Sports medicine has made great advances in the physical rehabilitation of injured athletes, but little attention has been given to the mental side of this recovery process. Rehabilitation is a process – both psychological and physical. Mental preparations in recovery are generally underused, because many athletes and rehabilitation professionals lack training and common utilization of psychological interventions are sporadic. Sports medicine specialists, trainers, and coaches would do well to identify certain behaviors indicative of possible psychological distress, especially when dealing with an injury. Once injured, an athlete must be aware of the severity of the injury, the length of time expected to be out of play, and what it will take for them to return both physically and mentally to their prior competition level.
For decades, interventions have been used to provide assistance to injured athletes who required surgery. At times sport psychologists have been utilized in interventions involving sport injury. These specific interventions are sometimes deemed necessary to accelerate the overall healing and rehabilitation process. Injuries in sport appear to be increasing in frequency and research into the psychological aspects of athletic injuries continues to gain popularity within the sport psychology and training literature. A serious injury can be both physically and psychologically debilitating for any sports participant, especially when an athlete begins to question their return to normal life and athletic activities.
The Role of Athletic Identity in Recovery
Individuals who stake claim in their “identity as athletes” tend to be less accepting of injury. These athletes are impacted greatly both emotionally and physically. They may try to keep their pain to themselves. They may neglect their support systems because their athletic identity is not consistent with those they view as needing caregiver assistance. Many of these athletes have said the period following surgery was like “being in their own personal hell”; a place where no one could possibly understand the physical and emotional work they have ahead of them to return to play. Athletes who are injured often feel tremendous loss – and – the uncertainty of their recovery can weigh heavily in their minds. To be injured is a great set back for that individual’s hopes, plans, lifestyle, physical environment and social contacts may all be altered. Injury triggers a wide range of emotions which progress through various stages similar to Elizabeth Kubler-Ross’s 5 stages of death. These concerns are also experienced by former athletes, who have maintained their athleticism, if they become injured in their late 30’s or 40’s. It seems that with any injury comes pain, and with pain comes fluctuating emotions.
One consistent emotion that definitely factors into the athlete’s recovery is anxiety. Anxiety can be conceptualized in a number of ways, and outcome variables typically include the psychological, behavioral and physiological. For example, stress may lead to an increase in muscle tension that can change flexibility, contribute to ischemia and poor circulation making it more difficult for the athlete to recuperate quickly.
Proper Screening Questions for PTs & ATCs
When an athlete comes into clinic and seems down or sad about their injury, the Physical Therapists (PTs) and Certified Athletic Trainers (ATCs) who are assisting them should take note. The first question that should come to mind is: “Will this athlete be hindered psychologically by this injury?” Studies have demonstrated that psychological well-being can play a large factor in adherence to the rehabilitation program.
The next question is: How do PTs and ATCs know when to ask for help when working with these athletes? Or perhaps, How can the athlete be convinced to speak to a sport psychology consultant? Many athletes feel that if they seek help they are being weak…another indication they will be viewed as vulnerable and not likely to ‘bounce back.’ Some may feel that there is really nothing mentally wrong with them, just the injury itself.
Athletes are quite often nervous about their injury, surgery and what rehabilitation may entail. Another reaction to anxiety can cause the athlete to retreat emotionally and become depressed. There are important warning signs to notice if you think an athlete you are working with is going through a depressive state:
1) loss of appetite
2) they withdraw emotionally
3) they withdraw socially
4) they seem to not care about their rehabilitation
5) they seem to stay in the training room longer each session
These are important signs to take notice of because anxiety and depression can cause distortions in the athletes thinking process. At times these cognitive distortions can seriously impair the recovery process. Some athletes may feel like they can no longer go on. They want to give up because they see no light at the end of the tunnel. They may feel “as if” they will never be physically healthy again. This train of thought can throw an athlete into serious depression. Cognitive distortions like this have been know to lead to substance abuse. If pronounced enough these distortions can become delusional and contribute to possible suicide….(every PT and ATC should have a certified sport psychology consultant at-the-ready for referral in this situation. Consultants are sometimes trained in sports sciences while others come from clinical backgrounds and are licensed therapists. This would be a situation where a licensed therapist is the preferred referral.)
It is more often the case when friends and family surrounding the athlete notice this emotional change before the athlete realizes it. This is the time when someone needs to step in and bring it to the athlete’s attention, which can be difficult and is sometimes not welcomed. The bottom line is this: Athletes need to focus on healing their mind first – emotionally prepare themselves for the trials ahead – and accept the rehabilitation process. Once they can get past that hurdle, the physical healing can begin. Too often, athletes are far into the rehabilitation process before they realize how much anxiety, depression, and frustration have sidetracked their focus. They may isolate themselves from friends and family and believe their rehabilitation is not progressing as well as initially hoped.
Questions Athletes Should Be Asking
The problem with this is: dealing and coping. Sometimes athletes do not ask enough questions because they do not want to know what is to come. Sometimes they are placed into a surgical situation so quickly they did not have the time to process what just happened, much less what lies ahead with regard to pain, rehabilitation and return to play. The main concern on most athletes’ minds are “When can I play again?” and “Will I ever be the same as I was?”
In the Journal of Athletic Training, there was a statement made suggesting that PTs and ATCs were in the “best position to educate athletes on the use of psychological interventions to enhance the recovery process.” (Hamson-Utley, et al., 2008 p. 258). This statement requires some clarification. It is true that PTs and ATCs have the most exposure to the emotional side of the athlete, however, unless they have been properly trained to address the emotional aspects of recovery, they should seek out a sport psychology consultant for this type of assistance. PTs and ATCs are clearly the best suited to educate and treat the athlete for their injury. Yet, it also makes sense for them to consult collaboratively with both the athlete’s coach and their sport psychology consultant so that they can employ goal setting and longer term strategies consistent with the athlete’s background. This can provide a structure and format familiar to the athlete so they have goals, learning objectives, training targets and more to look forward to each week.
“Tipping Points” in Recovery – Calling for an Assessment Tool
The most important moment in time for an injured athlete is when they first enter rehabilitation. At this juncture, it is difficult to determine how much that athlete may be affected by their injury emotionally and psychologically. Although assessment tools are used for many different situations – the rehabilitation process can be facilitated greatly through the use of targeted assessments. Just as the Borg Pain Scale has gained universal recognition in assessing the severity of pain, as more comprehensive tool that properly identifies how much the “athletic identity” of that individual may factor into their recovery, emotional state at the time of intake, previous experience with injury and rehabilitation, and what support system variables may make a difference.
An instrument that properly identifies athletes who may struggle emotionally and psychologically with their injury would likely prove quite helpful to a great many PTs and ATCs. The intention of this instrument would be for it to be used as a screening tool in orthopaedic sport medicine rehabilitation clinics to identify factors that might help or hinder the recovery process. Given the various stages in recovery, and the various benchmarks required both physically and mentally – a strong understanding of each athlete’s rehabilitative mindset can be pivotal in managing these “tipping points” in treatment.
For example, if athletes suffer from depression not only does this cause a possible set-back in adherence in rehabilitation, but it can greatly impact the emotional and psychological state of an athlete hindering recovery also adversely impacting their way of life. Currently, the Sport Injury Prevention Program Manager and Physical Therapy staff at Elite Sports Medicine (Connecticut Children’s Medical Center) are currently piloting such an instrument in which results of the instruments’ use can be reported in the near future. Stay tuned for more information on this instrument’s validation.
Sometimes athletes need to see a sport psychologist or consultant. Not only would athletes have a better chance in adhering to their rehabilitation program, but their exposure to mental strategies and systematic goals in the process of recovery would likely help them far beyond their recovery from injury. There is a great need for Sport Psychology consultants to be on staff or near by. It creates a comprehensive clinic for sports medicine practices. Sport Psychology consultants can assist athletes with mental strategies needed to overcome injury and return to play. They can assist athletes with situational depression at onset as opposed to being too far out and they could be lost. Sports Psychology consultants assist athletes not only in performing better, but assist in coping with injury, eliminating anxiety and to learn mental strategies to overcome specific situations.
Laura Miele, PhD is the Sport Injury Prevention Program Manager at Connecticut Children’s Medical Center/Elite Sports Medicine. Laura also is the Owner of Mind over Body Athletics, LLC where she consults athletes in sport psychology and trains athletes in various sports.
Laura can be reached at 206-339-0995 (voicemail) or via e-mail at [email protected]
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