Psychology of Injured Athlete Dr. Duane Millslagle Associate Professor University of Minnesota Duluth

Psychology of Injured Athlete

Dr. Duane MillslagleAssociate Professor

University of Minnesota Duluth

Outline Psychological Perspective of Athletic Injury Patient-Practitioner Interaction in Sport

Injury Rehabilitation Specialized psychological interventions in

Sport Injury Rehabilitation The Bio-psychological perspective of pain Integrated Rehabilitation Model:A Team

Approach

Psychological Perspective of Athletic Injury Assessing and Monitoring Injuries The Paradox of Injuries: Unexpected

Positive Consequences Personality Correlates of Psychological

Processes During Injury Rehab Stage Model Versus Cognitive Appraisal

Model Macrotrauma & Microtrauma: Different

Psychological Reactions

Assessing & Monitoring Injuries Identify moderating variables that

relate to athletic injury Compare injured athletes to non-

injured athletes Use of psychological inventories as the

primary tool Severity of the injury Effects of psychological factors on

injuries

Effects of Psychological Factors on Injuries Area of life stress

Dealing with stress may affect the athlete likelihood to become injured.

Life stress results from both within and outside the athletic contest

Level of life stress is associated with the injury

A proactive approach Periodic monitoring to assess one’s

level of life stress is necessary. Established psychological inventories Interviews

With athletes who experience distress A need to reduce the stress to facilitate

restoration of psychological and physiological states

Research Evidence Elite female gymnasts (Kerr &

Minden, 1988) Noncontact athletes (Hardy &

Riehl, 1988) Football players (Blackwell &

McCullagh, 1990). Adolescent sport injuries (Smith,

Smoll, & Ptacek, 1990)

Athletic Injury Being sport related Results in a player’s inability to

participate on day after injury Requires medical attention

Injury Frequency

Injury Rate

= Definition of Injury

Population-at-risk

Severity of Injury

No universal definition exists Based on AMA Standards

Nomenclature of Injuries (1968) Depends on the time-loss Depends on functional consequences

of participation or not participation

Psychological tests Profile of Mood States (POMs)-McNair,

1971 Eating Disorders Inventory-2(EDI-2)-

Dean, et al. 1990 Health Attribution Test(HAT)-Lawlis &

Lawlis, 1990 Coping Resources Inventory(CRI)-

Hammer & Marting, 1988 Life Experiences Survey-Athletes(TESS)-

Morrow & Hardy, 1990

Paradox of Injuries “The injury made me a lot more

mature. I have a better grasp of reality in life……I’m so much stronger emotionally. (Lieber, 1991, p.44)

Are there ways to facilitate these positive consequences with athlete injuries?

Adversity & Stress General Adaptation Syndrome

(GAS) by Selye (1974) Alarm- injured person resists any

additional stressors Exhaustion-additional stressors cause

injured person to succumb to stress Adaptation phase-injured become

stronger and stressor acts as catalysts for higher levels of functioning

Stress & Positive Consequences Little research on how athletes come to

view there injuries in a positive manner. One recently study by Udry et al (1997)

did involve 21 elite athletes on US Ski Team 95% of the athletes reported more positive

consequences from their injuries 80% reported personal growth, psychological

skill enhancement,& physical-technical enhancement from being injured

Recommendation Recognize that deriving positive

consequences takes effort Injured athletes must not passively assume

positive consequence will occur Recognize different problem-solving

strategies can be used Use reversal strategies

Avoid Secondary victimization AT should not trivialize the experiences of

the injured athlete

Personality Correlates During Injury Rehabilitation Neuroticism

Explanatory Style

Dispositional optimism

Hardiness

Neuroticism Abundant evidence that injuries

produce generalized negative affect, especially in severe injury.

Typical responses in athletes are: Disappointment Frustration Confusion and, Depression

There was pain because I had surgery; pain because I knew my career was over. It was probably the moment I suffered the most in my life. It was pain all over.”

Maladaptive Behavior & Neuroticism Selective attention to the negative

emotions to injury Anger is exhibited (“I was not a nice

person when I was injured”) Tendency to rely on inefficient

coping strategies Denial, withdrawal, selfblame,

emotional venting, disengagement

Explanatory Style Pessimistic explanatory style

Personality caused:”It my own fault” Stable over time: “I’m never going to

play” Global: “the rest of my life”

Health effects Immune system function Poorer health

Dispositional Optimism Investigations are consistent

Cardiovascular and, Immunological function is associated

with optimism(Peterson et.al, 1991;Scheiver & Carver, 1987)

Optimism mitigates the stress-illness relationship

Link between optimism and recovery

Hardiness “Constellation of personality

characteristics that function as a resistance resource in the encountering of stressful life events”-Kobass, et. al. 1982. P. 169

Components are Commitment-strong beliefs in one own value Challenge-views difficulties to over come Control-sense of personal power

Hardiness Link Kobasa (1979) linked hardiness to

physical health. Mechanism underlying hardiness

seems to be cognitive appraisal and coping processes(Florian et al, 1995; Gentry & Kobasa, 1984)

Studies with Athletes Athletes who are high in neuroticism

and pessimistic explanatory style display maladaptive behavior which results in longer rehab or incomplete recovery ( Grove, Stewart & Gordon (1990) with

athletes with ACL damage Grove & Bahnsen (1997) with 72

injured athletes

Formal Assessment Procedures Neuroticism

Eysenck Personality Questionnaire (EPQ-N)-Eysenck & Eysenck, 1975

Explanatory Style Attributional Style Questionnaire

(ASQ)- Peterson et al., 1982)

Informal Assessment One-to-one visit & pay attention to

the athlete comments Fear, sadness, embarrassment, guilt &

anger, feelings of being over whelmed by the demands of rehab—signs of neuroticism

Ask the “why” statement…. Insight into athlete’s explanatory style

Implications “the person that I wanted to talk to

the most was the person that was going to help me get better…..We had the best relationship. He/she knew what I was thinking; he/she knew what I was going through. He/she was my athletic trainer.” (Quoted from elite skier, injured athlete)

Implication Personality information helps AT to

provide a more complete service Highly neurotic athletes are prone to

overreact, denial, disengagement, and emotional venting.

AT need to: model rational behavior well planned treatments Maintain records of progress Develop psychological skills of cognitive appraisal,

coping, and stress management.

Implications Injured Pessimistic Athletes feel

helplessness and depressed. These athlete fail to follow recommended

treatment programs(especially unsupervised aspects).

Demonstrate a lack of persistence in the face of poor or slow progress.

AT trainer should offer advise in how to cope, prevent athletic isolation, & provide emotional support.

Implications Injured athlete low in hardiness worry,

experienced depressed moods,& overgeneralize negative aspects of their character.

AT need to communicate clearly with the athlete about the severity of injury, get them actively involved in setting rehab goals, use feedback of progress through charts or graphs, and provide self-monitoring strategies such as logs.

Psychological Reactions to Injury Stage Model

Cognitive Appraisal Model

Stage Model Based on death and dying literature Relates to career ending injuries Most important aspects is individuals

react differently across the stages. Many AT reject the stage model

because each injured athlete act differently.

Stage Model & Catastrophic Injury

Denial

Anger

Grief

Depression

Reintegration

Cognitive Appraisal Model

Identified 5 components relevant to psychological responses to athletic injury

Based on stress and coping process to athletic injury

Advantage of this model is it accounts for individual differences in response to athletic injury

Personal Factors Self-esteem Neuroticism Pessimism Anxiety Extroversion Injury History Sense of self

Sense of Self If someone has only one basis for a

sense of self, if that sense of self is threatened (injury), so will the entire person……Erikson, 1968

If the athlete’s sense of self is threatened the athlete will view the injury as severe loss which results in anxiety, depression, or hopelessness (Brewer, 1993).

Overestimators Athletes in general perceive injury as

more serious than it really is when compared to the AT perception (Crossman & Jamieson, 1985)

A group of athletes are overestimators experience greater pain, more anger, withdrawal, and show slow recover.

Situational Factors Post injury emotional adjustment is

positively related to situational variablesand social support.

AT needs to manipulate the situational factors and enhance social support.

Manipulating the Situational Factors Flexibility in rehab scheduling Communicate with the athlete

about the seriousness of the injury Provide a rehab center so it

accessible, safe, and friendly Explain the purpose of each

protocol and goals of each rehab session

Response to Injury The athlete cognitive appraisal of

the injury interacts with the personality of athlete and the situational factors surrounding the injury. Perceived severity History of Injury Ability to Cope

Emotional Response After cognitive appraisal by athlete about

their injury, an emotional response will follow Perceived as threat the athlete will emotional

vent, become anger,experience high anxiety, denial, disengagement, and depression

If pessimistic engage in negative self-talk, and self-blame.

If neurotic engage in loss of self, withdraw, and display changes in their personality.

If overestimator become irrational about the severity of injury.

Behavioral Consequences After the emotional response the

athlete will engage in positive or negative coping responses. Adopt healthy coping responses physically,

emotionally or psychologically. Learn new psychological skills and physiological

exercise…use injury as personal growth Adopt maladaptive coping responses

Career over, learned helplessness, blame others, use other as the excuses, non compliance of rehab

Recovery or Delay in Recovery Length and degree of complete

recovery in reentry into the sport is dependent upon: Severity and type of injury Athlete’s cognitive appraisal and

emotional response to the injury Athlete’s coping resources Interventions both psychologically

and physiological

Types of Injuries Macrotrauma (acute trauma)

Microtrauma (breakdown over time)

Different psychological reaction to the type of injury

Macrotrauma Rehab proceeds immediately Usually results in clean progression of

healing AT and PT have clear cut rehab protocol Athlete most certainly knows the injury

could not be prevented and it was caused by a situation usually out of their control.

Athlete will bring closure to cognitive appraisal and assume rehab as their rectifying the situation.

Micotrauma Usually results from biomechanical

overloading Recovery may be much longer with

relapses more frequent Athlete experiences a great deal of

distress (frustration, anxiety, etc), second guessing, and detachment for the sport is gradual.

Athlete will question the AT or PT skills and protocol.

Psychological Perspective of Athletic Injuries Summary Stress X Injury relationship needs to assessed. Once athlete are identified with high stress

levels there is need for proactive Approach Injuries do have positive consequences if the

athlete has experienced a successful rehab. Athlete’s personality is related to length and

degree of recovery. Assess the athlete level of neuroticism,

explanatory style, optimism, and hardiness

Summary (continued) Athlete’s response to career ending

injuries reflect the stage model Cognitive appraisal model provide AT

why some athlete behave differently when injured.

AT should assess the athlete cognitive appraisal of injury through formal or informal means.

Athlete’s respond differently when they have macro versus microtrauma injuries.

PART II: Patient-Practitioner Interaction of Injury Rehabilitation

Patient Practitioner Communication

Patient-Practitioner Perceptions Adherence to Rehab Referral Process Ethics & Legality

Patient Practitioner Communication Received little AT empirical attention. Studied extensively in medical

literature Results have indicated:

Poor patient-practitioners communication discourages future use of medical services (Taylor, 1995)

Poor patient-practitioners communication hampers adherence to rehab (Meichenbaum & Turk, 1987)

Poor Communication Patient

Anxiety Inexperience with

the medical disorder

Lack of intelligence

Practitioner Not listening Using jargon Technical

language Displaying worry Depersonalize the

patient

Patient –Practitioner Perceptions Rehabilitation Regimen

Athlete and AT have significant disagreement about rehab program (Kahanov & Fairchild, 1994).

Patients to expect to complete their rehab on an average 42% quicker then AT estimates.

77% of sport injury patients who were prescribed home rehab exercises misunderstood the rehab program(Webborn, et al, 1997)

Patient-Practitioner Perceptions Recovery Progress

Perception of poor rehab is linked to negative emotional responses in athletes (McDonad & Hardy, 1990).

AT trainers and athlete’s rating of injury disruptiveness is similar but athletes tend to overestimate the severity (Crossman & Jamieson, 1985).

Athletes consistently perceive recovery as complete well before AT perception.

Coaches do not see “eye to eye” with AT perceptions the athletes return to competition

Attribution for Recovery Instilling a sense of self

reponsibility for rehab by the athlete (Gordon et al, 1991)

Depends on the rate of recovery Slow recovery are less likely to accept

responsibility Faster recovery more likely they will

engage in their own self-recovery

Psychological Distress Emotional distress is inversely

related to rehab adherence and outcome.

Distress

Adherence & Outcome

Need to assess distress

Adherence to Rehab Adherence rates range from 40-

91%(Brewer, 2002) Positive determinates of patient

adherence: Self-motivation Pain tolerance Being involved and choices Hardiness((Wittig & Schurr, 1994)

Negative determinates Ego involvement & Trait anxiety

Adherence to Rehab Environmental Factors

Positive determinates Self-efficacy of the treatments(Duda, et

al,1989) Comfort of rehab setting (Brewer, et al,

1994) Convenience of rehab scheduling(Fields, et

al, 1995) Perceived exertion during rehab (Brewer, et

al, 1988) AT trainer expectancy of patient adherence.

Adherence-Enhancing Strategies Based on previously injured athletes

and AT (Fisher, at al, 1993). AT who are caring, honest, &

encouraging At who educate the client At who use goal setting and monitor the

clients progress AT who do not use threats or scare

tactics in gaining adherence

Five Practical Suggestions for Enhancing a Working Alliance

1. Check preparations2. Get specifics3. Listen before you fix4. Listen for the “but”5. Value Patient Input

Referral Process 5-13% of injured athletes experience

clincially meaningful levels of psychological issues

Before referring, consult with mental health professionals about the athlete There is no perfect time refer Need to explain to athlete why you are

referring them and to whom. Always follow up about the athlete after

referral

Using the Referral Process Effectively Recognize there are certain

conditions which require referral Eating disorders Depression

Establish a team of sport-medicine professionals.

Team of Sport Medicine Professionals

Primary Care Level

Secondary Care Level

Tertiary Care Level

Strategies in Referral Reactive referral

Injured athlete shows signs of depression, eating disorders, or anxiety.

Unfortunately, the majority of AT (76%) never refer the athlete (Larson, et al., 1996)

Proactive referral Preventive approach Provide tracking athlete nutritional

requirements for the sport Provide psychological skills training related

to management of stress

Athlete Perception of Referral In reactive referral,

athlete usually is in denial Being referred to psychologist is perceived

as weakness Goes against the norm of team and being

an athlete In proactive referral,

The sport-medicine team is part of the sport Team is made up of specialist the athlete

can go to when having difficulty

Reducing Problems in being Referred Introduce the sport-medicine team at the

beginning of the season Discuss the roles of each member of the

team Emphasize that specialists is important in

achieving a complete recovery Once referred, keep a complete history

including both psychological and medical information

Eliminate the feelings of abandonment after being referred

Ethical Issues Athletes using steroids Athlete using nutritional supplements Coaches who expect the injured athlete

to play in pain Coaches who insists anti-inflamatory

drugs and cortizone are part of the training regimen

Athlete needs to “make weight” to participate.

Ethical Status My belief is that if I had to take an

estimate, about 65% of the top five, let’s say top ten in the world in every event, are doing something illegal. That is the growth hormones in the ballistic events and blood doping for distance events. (quote from athlete, Ungerleider & Golding, 1992)

Ethics Dr. Park Jong Sei, director of

Olympic drug testing in Seoul stated that “as many 20 athletes at the games turned up positive but were not disqualified.”

Some coaches have been know to refuse to train athletes who are clean (Voy, 1991)

Legal Issues AT will regularly be confronted with

evidence of illegal and unethical practices to enhance performance.

AMA now recognizes AT as allied health provider. With increase professional status increases

vulnerability to lawsuits With open-free standing clinics, AT are now are

expected to know more Certification of AT was to protect the public from

incompetent and unethical sports professionals.

Moral Decisions Need to have a solid personal value

system Ask your self these questions:

Is may decision compatible with my values? Does it feel right? What is usually done in past when making a

similar decision? By doing this, what am I saying about myself?

(Simon, Howe, & Kirschenbaum, 1974) These question will help you to establish

consistency and clarity!!

NATA Ethical Standards

1. Prevention2. Recognition and Evaluation3. Management/Treatment4. Rehabilitation5. Organization & Administration6. Education & Counseling

TASK 3: NATA Education Domain Directs the athlete to professionals

in order to receive consultation for social/ and or personal problems by establishing a referral procedures. knowledge of situations requiring

consultation Knowledge of available professionals Knowledge of referral procedures

NATA Code AT who engage in counseling athletes with

social and/or personal problems would be considered incompetent by the NATA

AT are expected to have knowledge in the area of phychological

readiness for the return to activity skill in evaluating the athlete’s psychological

status, And implication of unhealthy situations (e.g.

substance abuse, eating disorders, victim of assault, abuse, etc.)

Penalty Violate the clients right of

confidentiality is extreme. Monetary damage Loss of job Loss of certification

Loss of Lesser ethical breaches Loss of certification Censure to expulsion from AT

organization

Individuals often have unrealistic Individuals often have unrealistic expectations related to weight expectations related to weight management and PA. management and PA.

Images of the ideal bodyImages of the ideal body thin and fit for women thin and fit for women fit and muscular for menfit and muscular for men

Dieting is often used to attempt to Dieting is often used to attempt to model these ideals.model these ideals.

Davis (2000) noted 80% of female with Davis (2000) noted 80% of female with eating disorders exercised excessively eating disorders exercised excessively

Physical Activity and Physical Activity and Eating DisordersEating Disorders

1. Refusal to maintain body weight at or 1. Refusal to maintain body weight at or above a minimally normal weight for age above a minimally normal weight for age and heightand height

2. Intense fear of gaining weight or 2. Intense fear of gaining weight or becoming fat, even though under weightbecoming fat, even though under weight

3. Disturbance in the way in which one’s 3. Disturbance in the way in which one’s body weight or shape is experienced, body weight or shape is experienced, unduly influence of body weightunduly influence of body weight

Anorexia NervosaAnorexia Nervosa

1. Recurrent episodes of binge eating. 1. Recurrent episodes of binge eating.

a) a discrete period=more food than most people a) a discrete period=more food than most people

b) a sense of lack of control over eating during the b) a sense of lack of control over eating during the episodeepisode

2. Recurrent inappropriate compensatory behavior in 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain order to prevent weight gain

3. The binge eating and inappropriate compensatory 3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a behaviors both occur, on average, at least twice a week for three monthsweek for three months

Bulimia NervosaBulimia Nervosa

Athletes as a population might be at-risk Athletes as a population might be at-risk 1) Societal norms --favor a lean physically 1) Societal norms --favor a lean physically

fit physique -- these societal norms are fit physique -- these societal norms are salient for athletes salient for athletes

2) Psychological characteristics consistent 2) Psychological characteristics consistent with high-level athletic achievement with high-level athletic achievement (perfectionism, motivation), are also (perfectionism, motivation), are also evident in individuals with eating evident in individuals with eating disorders disorders

Athletes experience more eating disorder Athletes experience more eating disorder symptoms than do nonathletes. symptoms than do nonathletes.

Comparison of Athletes Comparison of Athletes to Nonathletes to Nonathletes

Hausenblas and Carron (1999) Hausenblas and Carron (1999) meta-analysis meta-analysis

Female athletes self-reported more Female athletes self-reported more bulimic (ES = .16) and anorexic (ES bulimic (ES = .16) and anorexic (ES = .12) symptoms compared to = .12) symptoms compared to females from the general populationfemales from the general population

Male athletes self-reported more Male athletes self-reported more bulimic (ES = .30) and anorexic (ES bulimic (ES = .30) and anorexic (ES = .35) symptoms compared to males = .35) symptoms compared to males from the general population.from the general population.

Comparison of Athletes to Comparison of Athletes to Nonathletes Nonathletes

Hausenblas and Carron (1999) Hausenblas and Carron (1999) meta-analysis meta-analysis

Male athletes in aesthetic and Male athletes in aesthetic and weight-dependent sports self-weight-dependent sports self-reported more bulimic and drive for reported more bulimic and drive for thinness symptomatology versus thinness symptomatology versus male comparison groups. male comparison groups.

Females in aesthetic sports self-Females in aesthetic sports self-reported more of the tendencies to reported more of the tendencies to report anorexic symptoms (ES = .38)report anorexic symptoms (ES = .38)

Comparison of Athletes to Comparison of Athletes to Nonathletes Nonathletes

Steroids-- man-made versions of the Steroids-- man-made versions of the primary male sex hormone, primary male sex hormone, testosteronetestosterone

Athletes are not the only population Athletes are not the only population using steroids. using steroids.

FiremanFireman PolicemenPolicemen Military personnelMilitary personnel Personal trainersPersonal trainers Regular exercisersRegular exercisers

Steroid Abuse and Physical Steroid Abuse and Physical ActivityActivity

How prevalent is steroid How prevalent is steroid use? use?

The first nationwide survey of The first nationwide survey of steroid use among teenage boys steroid use among teenage boys 19881988

About 7% of high school seniors About 7% of high school seniors had used steroids. had used steroids.

Prevalent in wrestling and footballPrevalent in wrestling and football 35% of steroid users did not 35% of steroid users did not

participate in any sportparticipate in any sport


Reasons for useReasons for use Improve athletic performance (47%)Improve athletic performance (47%) Improve physical appearance (27%)Improve physical appearance (27%) Prevent or treat injury (11%)Prevent or treat injury (11%) Fit in (7%)Fit in (7%)

The results of the Buckely et al. The results of the Buckely et al. (1988) study subsequently have (1988) study subsequently have been confirmed by more than 40 been confirmed by more than 40 national, regional, and local studiesnational, regional, and local studies


Pope & Katz (1994) examined the Pope & Katz (1994) examined the psychological effects of steroid use psychological effects of steroid use

Urine samples were obtained to assess Urine samples were obtained to assess actual steroid use. actual steroid use.

23% reported experiencing major mood 23% reported experiencing major mood disturbances (i.e., mania, anxiety, disturbances (i.e., mania, anxiety, depression, or major depression). depression, or major depression).

Steroid Abuse and Steroid Abuse and Physical ActivityPhysical Activity

A large variety of terms have been used A large variety of terms have been used to describe a form of body image to describe a form of body image distortion in which the individual distortion in which the individual perceives him/herself as unacceptably perceives him/herself as unacceptably small. small. (a) pathologically preoccupied with the (a) pathologically preoccupied with the

appearance of the whole bodyappearance of the whole body(b) concerned that they are not sufficiently (b) concerned that they are not sufficiently

large or muscular large or muscular (c) are consumed by weightlifting, dieting, (c) are consumed by weightlifting, dieting,

and steroid abuse.and steroid abuse.

Muscle DsymorphiaMuscle Dsymorphia

Summary Part II Poor communication between

athlete and AT & PT relates to: Athlete’s compliance of Rehab Most athlete’s will have heightened

levels of anxiety Depersonalizing the athlete, using

technical jargon, and not listening to the athlete are poor communication strategies.

Summary II (Continued) Perception of poor rehab (time) is

linked to allot of negative responses Most athletes overestimate,and

disagree with the AT or PT on when they can return to play.

Most coaches disagree with AT or PT when the athlete should return to play.

Summary II (continued) The athlete who is self-motivated,

optimistic, high self-efficacy, high pain tolerance, hardiness, and provided choices rehab successfully.

Ego involved athletes highly neurotic, pessimistic, lowly motivated, low pain tolerance, and low self-efficacy rehab will be longer and unsuccessful.

Summary II (continued) AT must refer athletes if they

experience signs of depression, high anxiety, abuse, assault, and eating disorders.

AT is required to develop and know their referral procedures, the sport-medical team, and knowledge in signs and assessment of psychological disorders.

Part III: Specialized psychological interventions

Social Support Interventions Healing Imagery Goal Setting Positive self-talk Stress-Management Strategies

Social Support Interventions Supported athletes are generally more

mentally and physically healthy due to health sustaining and stress reducing functions of social support (Shumaker & Brownell, 1984) Coach Parents Teammate AT & PT

Social Support Interventions Social support is critical in the

rehab of the injured athlete (Rotella & Heyman, 1986)

Social support is an effective psychological technique that motivates the athlete during rehab (Hardy & Crace, 1990)

Social Support Emotional support

Behaviors that comfort and indicate that they are your side.

Listening Informational support

Behaviors that acknowledge your efforts, helps confirm your perceptions

Tangible support Financial assistance, and rehab knowledge

Providing Emotional Support Listen carefully Keep in contact with coaches,

teammates, AT, PT, and parents. Create an open environment

Providing Informational Support AT should develop a context expertise

in as many injuries as possible. Deliver effective feedback Use of technical modalities Create sharing opportunities between

injured athletes Have successfully rehab athletes with

similar injuries openly discuss the issues

Tangible Support NATA trainer needs to know rules and

regulations of the sport about the type of support from booster, alumni, coach, etc.

Let the athlete know exactly what you can and will do as well as what you cannot and will not do!

Best tangible support is services received at the time it is requested.

Refrain from putting the athlete in a state of indebtedness……give it freely.

Healing Imagery Healing imagery in which athletes tried

to see and feel the body parts healing

Imagery during physiotherapy when they imagined the treatment promoting recovery

Total recovery imagery in when they imagined being totally recovered

Basic Components of Healing Imagery Relax mentally and physically Mentally connect with the injured body

part and imagining healing taking place using all the senses

See and feel how the body exactly as one would like it to be.

Imagine the body fully functioning and performing well in the sport or situation.

Healing Imagery Arnheim (1985) had the athletes

imagine scar tissue being gobbled up by “Pac Men”

Searingen (1984) had athlete draw pictures depicting the healing process around the factured site of the bone.

Healing Imagery Create a series of imagines that

are progressional of one’s self from a injured state to full recovery. Process-oriented selves

Example of Process-Oriented Example of Process-Oriented Selves (Markus & Ruvolo, 1989)Selves (Markus & Ruvolo, 1989)

Self #1: Knee at 90 degrees Self #2: Strut your stuff Self #3: Hurt to get better! Self #4: Spring Forward Self #5: Let’s Play Self #6: Dribble, Drive, and Dive Self #7: No brace

Is Goal Setting Effective?

Research has shown that goal setting is an extremely powerful technique for promoting rehab, but it must be correctly implemented.

Why Goal Setting Works

Athletes who set performance (rather than outcome) goals experience less anxiety and more confidence and satisfaction during rehab

Key:

Principles of Goal SettingSet specific goals. Specific goals, as compared with general “do your best” goals, are most effective for producing behavioral change.

- I am going to my best in completing all my exercisers.

-I am going to put forth 100% each rehab session.

1.

2. Set difficult but realistic goals. Goals should be “moderately” difficult.

Principles of Goal SettingSet long- and short-term goals. Link long- and short-term goals to the outcome which is full recover and return to the sport.

3.

4.

Set performance and process goals, as well as outcome goals. For every outcome goal, set several performance and process goals that will lead to the desired outcome.

Principles of Goal SettingSet daily rehab session goals5.

6. Record goals. “Ink it, don’t think it.”

7. Develop goal-achievement strategies. Develop specific goal-achievement strategies that include how much and how often things will be done in an effort to achieve full recovery. Be flexible, however.

Principles of Goal SettingConsider participants’ personalities and motivations. Consider factors such as self-motivation, optimism, hardiness, anxiety, ego involvement.

8.

9. Foster an individual’s goal commitment. Promote goal commitment by social support, frequent feedback, and re-assessment.

Ways that help athletes commit to rehab goals

Write them down State them to others Keep a log Provide the athlete constant

feedback about their rehab Incorporate them into rehab session

Goal Setting System Developed by Dr. Millslagle Based on wheel of awareness

model used in athletic performance

Self-Talk Key to cognitive control

How does positive self-talk help? It helps the injured athlete to:

Stay appropriately focused on the present

Foster positive expectations

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

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! Reframing Rational thought Designing coping and mastery self-

talk tapes

Measuring Anxiety

Physiological signs (heart rate, respiration, skin conductance, biochemistry)

Global and multidimensional self-report scales

Trait and StateAnxiety Relationship

State anxiety: “Right now” feelings that change from moment to moment.

Trait anxiety: A personality disposition that is stable over time.

High versus low trait anxious people usually have more state anxiety in highly evaluative situations.

Recognize Symptoms of Arousal and State Anxiety

Cold, clammy hands

Constant need to urinate

Profuse sweating

Negative self-talk

Dazed look in eyes

(continued)

Cotton (dry) mouth

Constantly sick

Difficulties sleeping


Feel ill

Headache

(continued)


Increased muscle tension

Inability to concentrate

What can the AT or PT do? Change the athlete perception of

severity and importance of the injury

Reduce uncertainity about the injury

Anxiety and Rehab

How anxiety affects rehab depends on an individual’s interpretation.

Anxiety can be interpreted as pleasant/excitement or as unpleasant/anxiety.

Anxiety interpreted as pleasant facilitates performance.

(continued)

Anxiety and Rehab

Anxiety interpreted as unpleasant inhibits rehab.

Bottom line: Athlete’s interpretation of anxiety determines it’s affect on rehab.

How the athlete should view anxiety

An athlete’s interpretation of anxiety symptoms is important for understanding the anxiety-performance relationship.

Viewing anxiety as a facilitator can promote performance.

Significance of All these Anxiety–Performance Views

Physical activation

Interpretation of anxiety

Anxiety

Anxiety is multifaceted.

Significance of All the Anxiety–Rehab Views

When anxiety is to high, athletes time and extent of recovery is hindered.

• Lowly skilled, young athletes or first time injured athletes are less able to control their anxiety and more apt to be overly aroused.

Anxiety Reduction Interventions Matching Hypothesis

Somatic anxiety Cognitive anxiety

Anxiety–Reduction Techniques

Somatic Anxiety Reduction

Learn to control your breathing in stressful situations.

Breath control

When calm, confident, and in control your breathing is smooth, deep, and rhythmic.

When under pressure and tense your breathing is short, shallow, and irregular.

Center Breathing Session



Learn to feel the tension in your muscles and then to let go of this tension.

Progressiverelaxation

Progressive Relaxation Session



Become more aware of your autonomic nervous system and learn to control your physiological and autonomic responses by receiving physiological feedback not normally available.

Biofeedback


Cognitive Anxiety Reduction

Teaches individuals to quiet the mind, concentrate, and reduce muscle tension by applying the basic elements of meditation.

Relaxation response


Cognitive Anxiety Reduction

A series of exercises designed to produce two physical sensations—warmth and heaviness—and, in turn, produce a relaxed state.

Autogenictraining

Autogenic Relaxation Session


Multimodal Anxiety Reduction

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)

Psychological Interventions for AT Summary

Provide social support “Time out” provides opportunities Involve successfully rehab athletes Set Rehab Goals Mention to the athlete that imagery

promotes healing Listen closely to the athlete’s needs

Psychological Intervention for AT Summary Be flexible in your attitude and

approach about the athlete path to recovery

Mention that stress management techniques help.

Mention self-talk promotes the time of rehab

Psychological Interventions for Athletes (Summary) Stay involved in the sport Set daily goals Develop a physiotherapy plan Do mental imagery Use positive self-talk Emphasize positive aspects of the recovery Take advantage of the “time out” Practice relaxation techniques

Part IV: Bio-Psychological Aspects of Pain



Outline Biological Factors Psychological Factors Pain Assessment Pain Management

Biology of Pain Pain is a “sensory and emotional”

experience (p.226; Merskey, 1986) Medical community attempts to

explain as either mental or physical Medical community view misleads the

athlete One’s perception of their pain results

in many cognitive-emotional experiences

Pain Experience Multistage process built on a

complex anatomic network and chemical mediators that produce pain

This multistage process of the nervous system is called Nociception.

Nociception

TRANSDUCTION

TRANSMISSION

MODULATION

PERCEPTION

TRANSDUCTION COMPONENT Noxious stimuli (injury) are translated

into electrical activity at the sensory endings of the nerves (site of injury)

Pain triggers two sets of receptors:High threshold mechanoreceptorPolymodal receptors

Transmission Component The electrical activity (impulses)

are propagated (sent) through out the sensory nervous system

Modulation Component Sensory impulses are modified

(received, registered, and evaluated on severity and site) neurally involving the central cortical track and peripherial sensory inputs.

Perception Component Transmission, transduction, and

modulation culminates in a cognitive-emotional (perceptual) experience of pain.

The Transduction Component

How pain is triggered?Sensitization of Pain

Persistent Pain Syndromes

How is pain triggered? Two sets of receptors are activated

due to a injury Mechanorecptors

High threshold receptors (activated when high noxious signal) which sends signals with relative speed

Polymodal receptors Respond to thermal, chemical and

mechanical stimuli and are relatively slow in transmission

Continue to fire after cessation of painful stimuli

Sensitivity to Pain Unfortunately these receptors have a

lower threshold of response with repeated exposed similar stimuli. Higher sensitivity to pain-producing

stimuli Pain occurs in ordinarily nonpainful

stimuli

“This process is called Sensitization

Types of Sensitization Occurs when there is repeated

exposure to severe pain over days and weeks. Persistent pain syndomes

Myofascial and Sympathetical

Persistent Pain Syndromes Myofascial pain syndrome

Musculosketal dysfunction Indicated by points of tenderness when

activated triggers pain (Fine & Petty, 1986)

Sympathetical pain syndrome Pain that occurs in the arms and legs Characterized by hypersensitivity of the

skin and burning pain (Roberts, 1986)

Transmission Component Pain is transmitted via peripheral nerves

to the spinal cord Spinal cord acts as neurosensory

switching station Information from periphery is received

centrally (spinal cord) and from the brain via the descending track

All this information converges using similar and common neurosensory pathways.

Gate Control Theory of Pain (Melzack and Wall, 1965)

The processing center in the spinal cord may either decrease or increase the intensity of pain as a neuroelectrical phenomenon and so result in the perception of relatively lesser or greater pain than initially signed.

Importance of Gate Theory Explains why various therapeutic

modalities ranging from cryotherapy to ultrasound to acupuncture to massage control the efficacy of pain.

Modulation The pain signal in spinal cord

ascends to the higher cortical centers of brain which evoke a emotional-reaction.

One’s Perception of Pain

Perception of Pain

Based upon summation of inputs Awareness of seriousness of injury Meaning of the injury Present state of mind

Once registered as perception, pain sets off a cascade of electromechanical events via feedback loop within the nociceptive system that influences pain transmission and psychological status.

Reaction to Pain is Mystery?One reaction to pain can produce a wide

ranging of psychological moods.Sock………………..Enhanced Mood

May be due to the role of:endorphins (pain inhibitor),serotonin (pain intermediary),

sensitization and, pathways that transmit pain & mediators

Psychological Factors Goal of pain is to give it meaning

(perception).

Pain is interpreted due to: Prior experience Current context

Most Important Element Most important element of

meaning is the assumed status of pain as benign, or as a sign of injury.

No problem! This a routine pain. Oh no! I’m really hurt!

Understanding Pain Understanding if pain as an injury

triggers: psychological coping, Awareness of functional limits on

athletic ability, Memory of similar painful events, Self-assessment of injury and, Social psychological reaction by

teammates, coaches, etc.

Pain Assessment More complex and disstressing the

injury more comprehensive the approach. Injury may only involve the primary

level Injury may involve primary, and

secondary levels.

Proven Techniques in Assessing Pain1. Have the athlete rate on a scale 0-10

the intensity of pain.2. Have the athlete indicate the quality

of pain (burning, stabbing, aching, etc)3. Daily self-report “pain at its worst”

and “pain at is least”4. Indentify specific situations that

increase or decrease pain (specific movements or exercises)

Pain Management Common pain management treatments

are: Ice Untrasound TENs Diathermy Electrical stimulation Acupressure, Massage, and Mobilizing coping resources.

Four Pillars of Psychological Rehab

1. Education2. Goal Setting3. Social Support4. Mental Training

The first three fall within the AT and PT’s scope AMA responsibility and ability.

Primary Responsibility of AT Differentiate between benign pain and

pain associated with reinjury and to determine a relatively safe level of physical activity.

Create a sense of calm and security in the midst of pain and fear of further injury

Once in rehab, education Nature of injury Rehab strategies Identify pain as a routine aspect of rehab

Part IV: Integrated Rehabilitation Model:A Team Approach



Psychological Model of Psychological Response to Athletic Injury and Rehabilitation

Model of Postinjury Responses Identifies the sports medicine team

members whom injured athletes at different levels of sport participation may interact.

Identify the social-psychological impact of athletic injury(Anderson & Williams, 1988)

Incorporated the stress model of injury (Wiese & Weiss, 1987)

Ultimate Goal of the Model Clinical Model in assessing

postinjury cognitive and emotional responses for planning appropriate physiological and psychological interventions.

Members of Sports Team by Competitive Level Who should be involved at each

level.

Athletic Trainers Role Controlled communication is a

primary responsibility during initial management of injury (Wiese & Weiss, 1987) Role of first responser

What they say How they say it Diagnoses must be avoided Be reassuring, calm, and professional

Role of the Athletic Trainer At High School and College level the AT

plans, monitor, and evaluates rehab programs this means the AT has constant contact with the athlete. Rehab must be viewed as an educational process Psychosocial role is vital

Support, encouragement, and reassurance Positive communication that includes good listening

skills Focus is on adherence to rehag through praise, rewards,

and corrective feedback.

Role of Athletic Trainer Trainers help the athlete set

performanced based goals Trainers need to find appropriate

motivation strategies Trainers need to provide social

support Athlete needs to maintain their social

support network (coaches, teammates, etc)

Coaches Role Coaches pay little attention to

injured athletes The usual causes are the coach

knows little about the athlete’s life outside of sport, the rehab required, athletes attempt to return to competition, and stress response of injury on a athlete.

Coaches Role They need to care about injured

athlete Understand the rehab Keep the injured athlete integrated

with the team Attend practice Use them as referee in scrimmage Evaluate others performance Keep score/times/statistics

Overall Summary Discussed 5 areas

Psychological Perspective of Athletic Injury Patient-Practitioner Interaction in Sport

Injury Rehabilitation Specialized psychological interventions in

Sport Injury Rehabilitation The Bio-psychological perspective of pain Integrated Rehabilitation Model:A Team

Approach

Overall Summary Psychological Perspective

Life stress X Injury Rate Relationship Proactive Approach Personality Affect on Injury Recovery Stage and Social Appraisal Model Type of Injury: Macro and Micro

Overall Summary Patient-Practitioner Interaction

Communication Adherence determinates

Positive: Self-motivation, pain tolerance, choice, and hardiness

Negative: Ego involvement & trait anxiety Referral Process Sports Medicine Team Ethical Issues

Overall Summary Specialized Interventions

Goal setting Social support Healing imagery Social support

Overall Summary Psychology of Pain

“Sense and emotional experiences” Nociception Receptors Sensitivity to Pain Gate Control Theory Pain Assessment Pain Management

Overall Summary Integrated Rehab Approach

Know the roles of each member Preinjury factors Personal history, situational factors,

social, and environmental moderators Responses to injury

Cognitive, emotional, & behavioral Physical & Psychological Recovery

Process

The End Areas which you should study

about are: Using imagery in rehabilitation Working with athletes with permanent

disabilities

Role of Sport Psychologist Usually sees the player within a few

days of injury First meeting

Interview the athlete alone about history and nature of injury

Conduct it the ones office Interview format of first meeting

Explain the role of sport psychologist Qualification Have the athlete complete the Emotional

Response of Athletes to Injury Questionaire (ERAIQ) –Smith, Scott & Wiese, 1990)

Documents

Psychology of Injured Athlete Dr. Duane Millslagle Associate Professor University of Minnesota Duluth