Psychological Aspects of Sport Injury Rehabilitation Presentation to the Sport Injury Special Interest Group – Singapore General Hospital 13 March 2002 By Daniel Smith, Ph.D. Physical Education and Sport Science National Institute of Education Nanyang Technological University

The Foundation of a Sports Medicine of the Mind The Psychological Process The Recovery Timeline The Way to Failed Rehabilitation The Way to Recovery The Aspects of a Remarkable Recovery Heil 2002

Psychological Process and Recovery Timeline Elizabeth Kubler-Ross (1969) On Death and Dying Her stage theory has been applied to athletic injury, however research has failed to demonstrate that injured athletes move in a predictable fashion through a series of stages on route to recovery (Brewer, 1994)

The Affective Cycle of Injury Distress (e.g. anxiety and depression) Denial (unacknowledged distress) Determined Coping (vigorous, proactive, goal driven) The goal is to help the athlete to progress from distress and denial to determined coping

The Way to Failed Rehabilitation Denial – Functional when it protects the athlete from being overwhelmed by negative emotions, Problematic when failure to recognize the severity of the injury results in low level of motivation for rehabilitation.

Pain – Pain is a whole brain experience derived from a summation of inputs from multiple brain centers including those that serve emotion and memory (Merskey,1986). Catastrophizing contributes to heightened pain (Sullivan et al., 2000). Cognitive Restructuring is necessary (attention diversion, rational emotive therapy, stress inoculation training).

Fear – A type of competitive anxiety related to injury risk. Fear can contribute to a respect for dangerous conditions and limit reckless behavior or undermine concentration and interfere with skill execution. Fear of re-injury was common in those rehabilitating severe knee injuries, with the fear inhibiting the recovery process in some cases (Mainwaring, 1999). Cognitive restructuring needed.

Culpability – When complications arise in rehabilitation, culpability may be directed to treatment providers (who may in turn, redirect blame to the athlete for failing to recover as anticipated). If the athlete assumes responsibility for injury, feelings of guilt may follow, especially if he or she feels the team or significant others have been let down. Attributing recovery to personal control (internal attributions) has been associated with greater rehabilitation adherence.

The Way to Recovery Education – About 50% of injured athletes felt their physicians were impersonal and did not provide enough information about their injury (Macchi & Crossman, 1996).

Goal-Setting – 5 Guidelines 1. Help develop management skills that are transferable between rehabilitation situations. 2. Help athletes establish rehabilitation schedules. 3. Provide opportunities for self-evaluation and recording. 4. Involve athletes in decision making. 5. Ensure individual progress is self-referenced.

Social Support 1. Athletes expect, but do not receive, sufficient social support and information from sports medicine professionals (Mainwaring, 1999). 2. Athletes lives are often intertwined with sport, with injury separating them from their teammates and coaches, thus they feel isolated. 3. Connections with other injured athletes, particularly those with similar injuries seems to be helpful (Granito, 2001). 4. Emotional support was especially important when the rehab process was slow, setbacks were experienced, or other life demands placed additional pressure on the athlete (Evans et al., 2000).

Mental Training 1. Imagery – Rehabilitation that includes imagery yields more effective healing than physical rehabilitation alone (numerous references). It represents a natural transfer of sport skills to rehab. 2. Relaxation – Conditioned Relaxation. When an athlete learn stress management techniques, the threat of injury becomes less.

The Aspects of a Remarkable Recovery The Quest for Competitive Excellence in Rehabilitation is built on: Heightened body awareness – Follows from quality rehabilitation that enhances fitness and a refined sense of biomechanics. Enhanced pain assessment – Develops out of a keener sense of pain awareness and a more informed decision making ability relative to pain per se and injury.

Psychological Momentum – Injury boosts negative emotion, demanding a corresponding increase in positive affect to maintain emotion balance. Maintaining positive affect as negative emotions diminish with recovery creates positive psychological momentum. Revaluing of Sport – When injury deprives the athlete of the opportunity to compete, it may have a paradoxical benefit – calling to mind all the good things that sport brings.

A Complete Sports Medicine Program Includes a Sports Medicine of the Mind