Psychological considerations for rehabilitation of the injured athlete

1. Psychological Considerations
for Rehabilitation of the
Injured Athlete
PRESENTED BY:
DR RAHMAN SHEIKHHOSEINI
ASSISTANCE PROFESSOR AT ALLAMEH TABATABA’I UNIVERSITY
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2. Introduction
• The negative effect of fear of injury in athletes
• The importance of psychological aspects in sport related injuries and
return to sport
• Early writings often mention that one should never attempt to cure
the body without curing the soul.
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3. ACCULTURATION
The moving of the injured athletes
from the familiar sport culture to
the unfamiliar rehabilitation
culture.
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4. ACCULTURATION
• Most athletes have the self-confidence to adapt to a mild or moderate injury,
and most have the support, understanding, and proper encouragement to
adapt to more severe injury, but even the most self-confident athletes have
their doubts.
• Athletes don’t all deal with injury in the same manner. one might view the
injury as disastrous, another might view it as an opportunity to show courage,
whereas another athlete might relish the injury as a means to avoid
embarrassment over poor performance, to escape from a losing team, or to
discourage a domineering parent.
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6. The Injury-Prone Athlete
• Some psychological traits might predispose the athlete to a repeated injury cycle.
• No one particular personality type has been recognized as injury-prone.
• The individual who likes to take risks seems to represent the injury-prone athlete.
• Predisposing an athlete to risk of injury are being reserved, detached, tender-
minded, apprehensive, overprotective, or easily distracted.
• These individuals usually also lack the ability to cope with the stress associated
with the risks and their consequences.
• Some other factors leading to a propensity for injury: attempts to reduce anxiety
by being more aggressive, fear of failure, or guilt over unobtainable or unrealistic
goals.
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7. Stress and Risk of Injury
• Stressors are both positive and negative.
• Stressors that seem to predispose an athlete to injury are the negative
stressors.
• Negative stressors lead to a lack of attentional focus and to muscle
tension, which in turn lead to the stress-injury connection.
• Loss of attentional focus can cause the athlete to miss cues during a
play, setting the stage for a possible injury.
• Muscle tension leads to reduced flexibility, reduced motor
coordination, and reduced muscle efficiency, which set the athlete up
for a variety of injuries.
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8. Stress and Risk of Injury
Stress measurement tools:
 Likert-type 8-point scale
 Social and Athletic Readjustment
Rating Scale (SARRS)
 Profiles of Mood States (POMS):
(Five negative and six positive
scores)
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9. Interventions for Stress Reduction
• Not all athletes need or want counseling, and the close relationship between the
athlete and the athletic trainer is invaluable in making this decision.
• Few athletes react to stress events by verbalizing their feelings of stress, yet most
handle them very well by themselves.
• Unfortunately, many coaches do not have the interest or ability to work with athletes
who need help.
• The use of buffers might be all the athlete needs to handle the stress of injury and
rehabilitation.
• Several buffers that can be beneficial in reducing the stress of injury and
rehabilitation are progressive relaxation with or without imagery, aerobic exercise,
diet modifications (e.g., reduction of caffeine), treatment of sleep disorders, and time
management programs.
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10. Interventions for Stress Reduction
Abdominal Breathing:
• Lie on your back in a quiet place with one hand on chest and one hand
on your stomach. Inhale through your nose and have the air fill up your
belly without your chest moving. Now breathe out through your mouth
and feel your belly go down. Breathe slowly and pay attention to the air
moving in and out of your lungs. During the exhale phase feel your pain
and tension being ‘blown out’ of the body with the exhaled breath.
• Once the athlete has mastered the lying-down position, move on to
sitting and then standing positions.
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11. Interventions for Stress Reduction
Relaxation Techniques: (Jacobsen’s progressive relaxation technique)
• The relaxation method involves the tensing and relaxing of muscles in
a predetermined order. The arm and hand are done first because the
difference in tense and relaxed muscles is more apparent in these
muscle groups.
• The repetitions should last approximately 10 to 15 seconds for the
tension segment and 15 to 20 seconds for the relaxation segment,
with about three repetitions for each muscle group.
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14. Interventions for Stress Reduction
Imagery:
 After the athlete is comfortable with the relaxation training, then imagery can be
introduced.
 Imagery is the use of one’s senses to create or recreate an experience in the mind.
 Visual images used in the rehabilitation process include visual rehearsal, emotive imagery
rehearsal, and body rehearsal.
Visual rehearsal :
 Coping rehearsal: athletes visually rehearsing problems they feel might stand in the way of
a return to competition. They then rehearse how they will overcome these problems.
 Mastery rehearsal: gaining confidence and motivational skills. Athletes visualize their
successful return to competition, beginning with early practice drills and continuing on to
the game situation.
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15. Interventions for Stress Reduction
Emotive rehearsal:
• The athlete gains confidence and security by visualizing scenes relating to
positive feelings of enthusiasm, confidence, and pride. The emotional rewards
of praise and success from participating well in competition.
Body rehearsal:
• Empirically helps athletes in the healing process. It is suggested that athletes
visualize their bodies healing internally both during the rehabilitation
procedures and throughout their daily activities.
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17. PROGRESSIVE REACTIONS DEPEND ON LENGTH OF
REHABILITATION
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18. DEALING WITH SHORT-TERM INJURY
• Less than 4 weeks
• Short-term injuries can include, but are not limited to, first- or second degree
sprains/strains, bruises, and simple dislocations.
Reactions to Short-Term Injury:
Shock: The primary reaction to these injuries is the shock of surprise—the
shock that the injury cannot be just “walked off ” or “shaken off.”
Relief: secondary reaction, relief that it is not something really major, given
that it couldn’t be discounted as just a “nick” or “ding.” The sense of relief is
contingent on the patient’s trust in the athletic trainer.
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19. Reactions to Rehabilitation of Short-Term
Injury
Impatience:
• an impatience to get started, to do something, to get on with the program as
quickly as possible.
• The athletic trainer can reassure the patient that the phases are necessary and
that to push it could set back the rehabilitation time.
Optimism:
• secondary reaction in this phase
• Optimism is due to the confidence and trust established between the athletic
trainer and the patient.
• It is important that compliance be consistent with the athletic trainer’s treatment
plan and that the injured patient does not try to return to practice or play too
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20. Intervention for Short-Term Injury
 Allowing the patient to vent frustrations and reiterating that there
is a light at the end of the tunnel.
The injured athlete should be encouraged to:
• Remain involved with the team
• Attending practices while performing rehabilitation
• Attending team meetings
• Interacting with teammates after hours.
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21. Reactions to Return to Competition after
Short-Term Injury
Eagerness: the primary reaction, usually eager to begin to practice
and play.
Anticipation: Secondary reaction, They anticipate that they will
return to their preinjury competence the first day back.
 The patient and the athletic trainer must agree on a realistic
plan for return to activity so that the transition will be safe and
satisfactory for all concerned.
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22. Reaction to Long-Term Injury
More than 4 weeks, Long-term injuries include, but are not limited to, fractures, orthopedic surgery,
general surgery, second- and third-degree sprains/strains, and debilitating illness.
Reaction to Long-Term Injury:
Fear:
• Primary reaction, fear that they will never get better, fear that they can never play again, fear
that they cannot handle a long rehabilitation period, fear of pain, and fear of the unknown
• At this point the athletic trainer must allay the fear with pertinent information (But not so much)
in terms that are easy to understand.
Anger:
• Secondary reaction, anger that the injury happened, that it happened to them, that it happened
at the time it did
• Anger cannot be reasoned with, and the sports medicine team must understand and not react to
the patient’s anger.
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23. Reaction to Long-Term Rehabilitation
Loss of vigor and irrational thoughts:
• Primary reactions
• Athletic trainer needs to be aware that a loss of vigor can be
masked as depression, although depression can also be a possible
reaction.
• If signs of clinical depression (loss of appetite, sleep disruption,
withdrawal, change in mood state, thoughts of or plans for
attempting suicide, etc.) are present, then the possibility of
attempted suicide must be addressed.
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26. Reaction to Long-Term Rehabilitation
• If irrational thoughts are persistent, interfere with the normal
routine of daily life, and disrupt the rehabilitation process, then
psychological intervention is recommended and is frequently
effective.
Alienation:
• Secondary reaction, the athlete often feels that the coaches have
ceased to care, teammates have no time to spend with them,
friends are no longer around, and their social life consists of time
put into rehabilitation.
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27. Intervention for Long-Term Rehabilitation
• Whenever possible, anger should not be challenged.
• It is as important to listen to what the patient is feeling in addition
to what the patient is saying.
• One of the more difficult aspects of adjusting to injury is stopping
negative thoughts, which are devastating to a successful
rehabilitation process.
• Lost social support can be replaced by organizing support groups
or similar injury groups or mentoring by athletes who have
completed rehabilitation successfully.
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28. Reaction to Return to Competition for Long-Term
Injury
Acknowledgment:
• Primary reaction
• Acknowledgment that the rehabilitation process is completed.
Trust:
• Secondary reaction
• Trust that everything has been done to be as prepared as
possible to return to play.
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29. DEALING WITH CHRONIC INJURY
• Chronic injury can be defined as an injury having a slow,
insidious onset, most often starting with pain and/or signs
of inflammation that might last for months or years and
giving the impression of recurring over time.
• Can include tendinitis, stress fractures (shin splints),
compartment syndrome, and other second- or third-
degree injuries.
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30. Reaction to Chronic Injury
Anger:
• Primary reaction, Often the patient has done everything the athletic trainer
suggested as far as rehabilitation and even maintenance rehabilitation, and
still the injury recurred.
• Such repetition is necessary (Identifying mechanisms of recurred injury and
possibility of recurrency with training) because an angry patient has selective
hearing and a short attention span.
Frustration:
• Secondary reaction,
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31. Reaction to Rehabilitation of Chronic Injury
Dependence and independence:
• Primary reaction
• Dependent patients don’t take part in the decisions of rehabilitation, they don’t give their
input concerning what did, or didn’t, work before and they often leave all decisions up to
the athletic trainer or team physician.
• The independent reaction: these patients want to call all the shots and are up-to-date on
the latest fads. They are likely to change the treatment plan—or the athletic trainer—if
progress is not as fast or as productive as they expect or want.
Apprehension:
• Secondary reaction
• Patients with chronic injuries know that although they might get through this flare-up, there
is a strong possibility that the injury will return, for in fact it never completely heals.
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32. Interventions for Chronic Injury
• If dependent: the athletic trainer needs to head off this response
by firmly explaining the restrictions on time and what is required
of the patient in terms of rehabilitation.
• The independent: is encouraged to develop a relationship with the
athletic trainer that is one of respect and trust.
• All patients are participants in the rehabilitation process, but they
must be active participants and become engaged in the process.
• All efforts should point toward a positive result, with the patients
working with what is available and not with wishful thinking.
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33. Reaction to Chronic Injury Recovery
Single level reaction
Skeptical reaction:
Confident reaction:
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34. DEALING WITH A CAREERENDING INJURY
Reaction to a Career-Ending Injury:
 Isolation: primary reaction
 Grief: secondary reaction
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35. Reaction to Rehabilitation for a Career-
Ending Injury
Loss of athletic identity:
• Primary reaction
• Baillie and Danish 3 suggest that athletes have taken anywhere from 2 to 10
years to adjust to termination from sport.
• Referral to psychologist or…
• Intervention can have the nature of psychological counseling (stress
management, alcohol or drug counseling, etc.), career counseling (school
enrollment, job placement, etc.), financial planning (investments, tax shelters,
etc.), or whatever the patient needs.
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36. Reaction to Recovery from a Career-Ending Injury
• Closure and renewal are
intertwined, with closure being
necessary to give full energy to
renewal.
• Once they reach the acceptance
stage, these athletes can put
closure on a career that has
ended and focus their other
talents, long overshadowed by
athletic prowess, toward a new
career.
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37. COMPLIANCE AND ADHERENCE TO
REHABILITATION
 Compliance is a term from the medical profession and means obedience of
the patient to the physician’s or health caregiver’s instruction. More passive
than active.
 Adherence is a term from the exercise discipline and carries the meaning of
active voluntary choice, a mutuality in treatment planning. Adherence
involves long-term change on a more voluntary basis and suggests a
behavioral change sought by the participant.
 The term compliance will be discussed because there are certain guidelines
for treatments that produce the desired esult of rehabilitation of an injury.
 In rehabilitation, a comply now — adhere later approach is the best descriptor
for successful return to the previous level of fitness.
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38. Factors Influencing Compliance
• Athlete should be support from peers, coaches, and rehabilitation staff.
• Attitude: (patient’s belief in the efficacy of the treatment).
• The coach must support the rehabilitation concept.
• To motivate patients to do their best in the rehabilitation process.
• Lack of commitment might indicate frustration, boredom, or feelings of a lack
of progress.
• To do with patients’ perception of their ability.
• Etc.,
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39. PAIN AS A DETERRENT TO COMPLIANCE
• Painful exercise, therefore, is
not only harmful but also
reduces compliance,
especially in the nonadherent
athlete.
• The cause of pain needs to be
addressed.
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40. Goal Setting as a Motivator to Compliance
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41. Reference:
William E. Prentice, Rehabilitation Techniques in
Sports Medicine. McGraw-Hill Humanities/Social
Sciences/Languages; 5 edition (January 8, 2010).
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