Psychology of Injured Athlete Dr. Duane Spike Millslagle Professor Motor behavioral Specialist University of Minnesota Duluth

Part I Introduction & Personality Correlates

Introduction Athletic injuries are increasing despite safer equipment and rule changes. In secondary and collegiate levels in U.S. Athletic Injuries are estimated at: 750,000 per year (Bergandi, 1985) 850,000 or more (Noble, et al, 1982) The causes of athletic injury range widely. Accident, Aggressive behavior, overtraining, high-risk sports, et al.

Introduction Psychodynamic dimension of sport injuries may explain why: Some athlete become injured Some athlete do not recover from an injury Some athlete rehab is shorter than others. Some athlete adhere to their rehab schedule and other do not.

Personality Correlates related to Athletic Injuries Personality Determinates During Injury Rehabilitation (Wittig & Schurr, 1994) Neurotic behavior Pessimistic Explanatory Style Overestimator Dispositional optimism Hardiness Stress Depression Attitude

Neurotic Behavior Selective attention to the negative emotions to injury Anger (I was not a nice person during rehab) Emotionally venting on the PT Self-blame for the injury Withdrawal (e.g., not coming to rehab) Tendency to rely on the following ineffective coping strategies Denial that they need rehab, Withdrawal and disengagement from the program, 6

Pessimistic explanatory style Im never going to _____ the rest of my life Considered to a stable disposition across other situations not just the injury or recovery. Health effects Immune system function Poorer health 7

Overestimators Non athletes and athletes in general perceive injury as more serious than it really is when compared to the PT perception (Crossman & Jamieson, 1985) There are a group of non-athletes and athletes that are overestimators: Perceive greater pain, and shows slow recover. 8

Dispositional Optimism Investigations are consistent Cardiovascular and, Immunological function is associated with optimism (Peterson et.al, 1991;Scheiver & Carver, 1987) Link between optimism and faster recovery 9

Hardiness Constellation of personality characteristics that function as a resistance resource in the encountering of stressful life events- Kobass, et. al P. 169 Components are Commitment-strong beliefs in one own value Challenge-views difficulties can be over come Control- strong sense of personal power 10

Stress and Depression levels High stress and being depressed are non compliance determinates of rehabilitation and exercise. You need to be certified to counsel these areas but we can screen the clients level of stress or depression.

In summary Non athletes and athletes who display neurotic behavior, over estimators tendencies, report being stressed out, show signs of being depressed, and/or display pessimistic attitude will adopt maladaptive behaviors (e.g., withdrawal, anger) which results in longer rehab or incomplete recovery Grove, Stewart & Gordon (1990) with clients with ACL damage Grove & Bahnsen (1997) with 72 injured athletes 12

What can one do? Conduct an informal one-to-one visit & pay attention to the Athletes comments: Fear, sadness, embarrassment, guilt, anger, and feelings of being over whelmed by the demands of rehabsigns of neuroticism & over estimator Ask the client Why do you feel rehabilitation will help? statement…. Insight into athletes explanatory style 13

Then what? Keep them involved in some form of rehabilitation by providing them meaningful incentives (e.g rewards). Provide them regular steady feedback on their progress whether it verbal or recording their progress. Maintain their fitness level by redirecting them to another physical area such as swimming, cycling, walking, etc. They need social validation by significant others, spouses, and relatives. Attempt to remove perceived barriers such as providing a flexible scheduling of appointments, providing access to rehab center, and transportation resources. Provide strategies or techniques to cope with pain or rehab (e.g. goal setting, attentional focus) 14

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Psychological Skills Training & Rehabilitation PART II

Psychological Skills & Rehabilitation Brewer (2000) investigated the effects of psychological skills on rehabilitation adherence and outcome 95 patients at sport medicine clinic with ACL knee surgery Motivation, reducing stress, and enhancing adherence produced better outcomes in the patients.

Psychological Skills & Rehabilitation Scherzer (2001) involving 54 patients undergoing ACL reconstructions were studied. Found that goal setting was significant predictor of rehabilitation aherence Positive self-talk was associated with completion of home exercises

Psychological Skills & Rehabilitation Johnson (200) study of 54 national and international injured athlete who were involved in long-term rehab after athletic injury. One group of injured athletes were involved in 3 mental training sessions of stress management, goals setting, and imagery. Results found that short-term psychological skill training enhanced mood in the injured athletes This group showed high self-rated perceptions of physical readiness to return to sport

In Summary Psychological Interventions that target Motivation Reduce psychological stress Goal setting Imagery, Self-talk, and Techniques that enhance adherence should be used to better rehab outcome.

Stress Management

SIT (Stress Inoculation Training) Cognitive-affective stress management Training (SMT) Systematic Desensitization Self-talk strategies Stay physically active

Coping Techniques An individual is exposed to and learns to cope with stress (via productive thoughts, mental images, and self- statements) in increasing amounts, thereby enhancing his or her immunity to stress. Stress– inoculation training (SIT)

Stress Inoculation Training Kerr & Gross found that SIT was effective in helping athletes cope with the stress of injury. SIT teaches skills for coping with psychological stressors.

Three Phases of SIT Conceptualized stage. -Awareness of the effects of positive and negative self- talk Rehearsal stage -Injured athlete learns to use healing imagery and positive self-talk Application stage -athlete practice imagery and positive self-talk in low stressful situations -gradually progress to applying positive imagery and self-talk in more stressful situations

Cognitive Affective Stress Management Training (SMT) Most comprehensive stress management approach SMT involves - coping response using relaxation and cognitive components to control emotional arousal. -Injured athlete are an ideal population for SMT because they face stressful rehab and return to competition problems

SMT Phases Pretreatment Assessment Treatment rationale Skill acquisition Skill rehearsal

Pretreatment Assessment Phase Conduct personal interviews to assess the injured athletes stress: -circumstances that produces stress -Their responses to stress -How their responses affect their behaviors

Treatment Rationale Phase Focus is on helping the injured athlete: - Educate the athlete - Help them understand their stress response - Increase self-control The emphasis is education, not psychotherapy

Skill Acquisition Phase Develop coping responses by: -Relaxation training -Cognitive intervention skill training Cognitive intervention skill training involves: -irrational to rational self-talk -reconstruct self-statements I wont be worth anything to Ill be good person no matter wether I win or lose

Skill Rehearsal Use the coping skills of relaxation and cognitive strategies: -During early training when one just returns to activity or sport use coping skills and cognitive strategies -Gradually increase the intensity of training (stress) and have the athlete use the coping skills.

Self-Talk Where the mind goes so does the body! Usually mind will fail you before the body! The key to controlling the mind is self-talk!

Common Uses of Self-Talk Skill acquisition Changing bad habits Attention control (being in present) Creating mood Controlling ones effort Building self-confidence Injury rehabilitation Exercise Adherence

Self-talk and Injured Athlete More self-critical thoughts than positive talk. Negative thoughts were associate with ability to return to competition. Injured athlete exhibited little change in their thought patter unless taught

How does positive self-talk help? It helps the injured athlete to: Stay appropriately focused on their rehab Foster positive expectations

What type of self-talk do you use? Positive or Negative? What do you say to yourself after the injury? What thoughts appear during rehab? When do you use self-talk? Common themes that appear across the rehab? What cue words do you use in self-talk?

Cognitive Techniques to Control the Mind Thought stoppage Changing negative thought to positive thought! Rational thought Designing coping and mastery self-talk tapes Parking

Thought Stoppage Negative thought come into your mind….you stop it! Cue or trigger word that snaps you back to positive thought Snapping your finger Hitting your hand against your thigh

Changing Negative Thought to Positive Thought List all the types of self-talk that you associate with the injury Try to substitute a positive statement for each negative statement. Create a chart with negative thoughts in one column and your corresponding positive self- talk in another.

Negative Self-talk to positive Self-Talk You idiot-how could you get injured Ill never recover from this injury I cant do my rehab Everyone get injured-just concentrate on rehab Healing takes time. Just take one day at a time and make rehab fun

Rational Thought Irrational thought I am never every going to play again. I am not good injured, so what is the point! My season is lost, so what is the point. Rational thought The trainers and physical therapist told me that I will recover from the injury quicker if I complete the rehab exercises correctly.

Master Self-Talk Tape With pleasant or motivational music With positive cue words or statements Positive Self-affirmation statements - You can do it! - Just do it! - Feel it! See it! Perform it! - No pain, no gain!

Parking While performing and negative though intrudes your thought. Park it and then deal with it after the performance is over! One of the distinguishing factors between a good athlete and poor athlete is: - good athlete are able to deal with set backs while poor athlete cannot. Park it

Healing Imagery Imagination is more important than knowledge – Albert Einstein

Mind-Body Integration -Facilitates the healing process -Increased immune response between imagery and lymphocyte function. -Immune system is triggered by imagery

History Ancient time the removal of pathogenic image was necessary for a cure. - images led to pathology (Aristole) - images were movement of the soul Middle Ages - Vital spirits traveled between the heart and brain - Imagination became a predominate role in pathology

History Pre modern times - All illness were regarded as psychosomatic - Blindness was a loss of sensation of reality - Imagery was a key interventions

History Imagery ended in 17 th century as predominate intervention due to dualism (mind and body are separate) -bleed became popular In the 18 th & 19 th century, imagery was defined as the content of the mind and end product of sensation. -Illness that had no explanation were imaginal

History 20 th Century -Link between imagination and pathology -Edmund Jacobson work in relaxation -Cancer research

Mental Imagery Positive imagery are useful in enhancing ones believe and mobilizing ones own healing powers. Simonton, et al (1978) cancer patient study found relaxation and imagery showed 41% improved, 22.2% had total remission, and 19.1 tumor regression. Hull replicated Simonton study and found similar results.

Ievleva & Orlick Study 35 injured athletes used 3 types of imagery -Healing imagery (see and feel the body part healing) -Imagery during physiotherapy (imaged the treatment promoted recovery) -Total recovery imagery (imaged total recovery)

Results Injured athletes with knee and ankle injuries participated in the study. Mental imagery was a focus of the study 19% of these athletes had exceptionally fast recoveries that used any form of imagery Recovery time was significantly shorter for those athletes that used imagery than athletes that did not.

Healing Imagery Defined as visualizing and feeling the healing taking place to the injured area. Imagine the clot formation around the fracture, the change of the clot into fibrous tissue lattice, calcium crystallization on the latticework, and restructuring of new bone around the fracture.

Injury Use During Rehab From Injury Evans, Hare, & Mullen (2006) Journal of Imagery Research Sport & Physical Activity.

Purpose Greater understanding of injured athletes across the phases of their rehab

During the first week Athletes experience intense feels of depression & frustration Imagery was used for healing and pain management purposes Rehearse and maintain skills enhanced self-confidence

Mid-Phase Athlete wanted to see progress in their rehab Maintain their performance levels Increases their use of healing and pain imagery Used imagery to motivate them to complete rehabilation

In Final Phase Primarily concerned with returning to sport Used imagery to foster their self-confidence Overcome fear on re-injury Cope with the return to sport

Ive done so much imagery between getting injured and now…Im still a lot closer to the real performance than I would be if I had not done nothing. I think that maybe the reason behind the successful performance in the competition last week, in that I mean even though Id been 2 months without any training at all, you known it just kinda came naturally to me, it was amazing, technically, I hadnt lost a thing. (Evan, Hare, & Mullen, 2006)

Healing Imagery First relax then image. Imagine the mending of the injury Imagine the body being repaired by the treatment Internal imagery Practice imagery daily Involves all the senses not just vision

Final Note on Imagery Winners see what they want to happen, losers see what they fear Linda Bunker

Return to Sport Part III

Return to sport is both the ultimate goal of rehab A source of doubt and worry about the uncertainty of injured athletes abilities to return to a level at or above where they performed prior to the injury

Approaches It can be threat Low confidence Decreased adherence to rehab Increase in pain Display avoidance behaviors Increases anxiety Reduced motivation It can be challenge Positive attitude High motivation Excitement Increased effort in rehab Greater desire to return to sport Overadherence to rehab Greater risk of reinjury due to permature return

Stages of Return to Sport Initial Return to Sport Recovery confirmation Return of Physical & Technical Abilities High Intensity Training Return to Competition

Initial Stage Considered to be the most difficult Athlete quickly determines the effectiveness of the rehabilitation Entire stage should include a series of tests of the healed area Athletes expectation are: They will perform at the same level as prior to the injury Pain will not be present Discussion with the athlete are needed to examine their expectations. A concern of AT is that athlete become overzealous in their approach to train and compete.

Recovery Confirmation More psychological than physical Involves the athletes obtaining evidence from initial stage that the injury is healed and ready to face the demands of the sport participation This is considered the make or break period Athletes initial play will confirm their attitudes and approaches Success will lead to higher levels of self-confidence and motivation Injury does not swell, no pain, full range of motion, Self-confident and motivated Not being successful will lead to doubt if they will be able to return. Swelling occurs, unexpected pain, little range of motion, decrease strength Highly anxious and depressed

Return of Physical & Technical Skills High intensity training marks the absolute conclusion of athletes identification that they are fully healed. Re-establishment of their regimen of physical conditioning and technical training Major psychological concern is their level of perceived preparedness: -Provide a safe, -progressive conditioning program developed by the AT or physical trainer

Return to Competition First post-injury competition is key concern: Athlete is usually more anxious than at any other time Initial uncertainty Athlete may have a distorted perception of the probability of the injury occurring again. Need to discuss with the athletes their attitude and feeling about the upcoming competition Athlete should not be thinking negatively Athlete needs to redirect their focus to their skills, game strategy, and goals.

Fear of Injury: A Major Concern Perception that recovery is incomplete, returning to sport to soon, impatient in returning to sport, lack of acceptance of the risk of the sport, low confidence, highly anxious, and preoccupied with being re-injured

Prevention of Fear of Reinjury Continue involving in the sport during rehab View rehab as a form of athlete performance Becoming involved with a coping model Performance imagery Give the athlete time to progressively regain their physical, psychological, and technical skills.

Treatment of Fear of Injury Need to take a proactive approach to alleviate the fear Athlete needs to face a similar situation as when the injury occurred. Rational self-talk helps the athlete refocus Simulation practice Relaxation techniques Athlete establish pre-competition and competition routines

Self-Determination Model & Return to Sport Ryan & Deci (2000) focused on: Competence, Autonomy, and Relatedness in explaining the athletes return to sport. From the self-determination perspective, the success of an athletes return to sport from injury is related to meeting these psychological needs

Competency Issues Athletes fear and concerns of returning to sport Loss of enjoyment because they could not participate in the sport Injury blocked their short & long term goals Letting down others, teammates, and coaches

Issues Competence Relatedness Autonomy Competence Issues - Fear related to returning to sport - Injury blocked their sport goals - Overcoming their fear of reinjury Relatedness Issues - Feels of separation from team - Support in re-entry into sport - Having role models Autonomy Issues - Sense of personal control - Pressure to return to sport

Implications Competence Relatedness Autonomy Regarding the assistance and management of athletes returning to sport following an injury: -Rehab environments should: 1)Set goals 2)Giving the athlete choices when to return to sport 3)Provide role models 4)Rehab should be safe

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