The Psychology of the Injured Athlete

Does your mind slow down or speed up your recovery from an injury? Ian Craig thinks it does, and supports this theory with a convincing literature review..

Injury is one of the biggest challenges that an athlete (whether elite or recreational) will face in his or her athletic career. It is a barrier to successful athletic performance. The ability to resist injury and to rehabilitate well when injury occurs is fundamental to longevity in sport and to the full realisation of athletic potential.

Today sports psychologists are linking positive psychological strategies with a faster return to sport.

THE STRESS RESPONSE OF INJURY

The psychological state of the athlete is as important and sometimes more important than the athlete’s physical state¹ and, furthermore, his or her mental state can influence physiological function.

Athletes are very dependent upon their physical skills and because their identities may be very much intertwined with sport, injury can be an extremely threatening process. Athletes tend to be more motivated than the general population to undertake rehabilitation therapy, but since they perceive the injury as a bigger loss, they are more likely to experience a greater stress response.² Additionally, athletes low in self-esteem and those who have low expectancies of success in rehabilitation are more likely to experience high levels of stress.³

The work of Kubler-Ross4 on the emotional recovery from a loved one’s death (grief response) has been applied to the athletic setting: The emotional processes that were suggested to follow a sports injury include the following stages: denial, anger, bargaining, depression and finally acceptance. This progression was supported years later by McDonald and Hardy5 who demonstrated a progression from a negative to a more positive mood state as the rehabilitation process continued. The length of time it will take for the athlete to move through each stage depends on a number of factors, including emotional stability, importance of the injury to their career or life plans, severity of the injury, the time of season and the reaction of critical others.6

Vigorous exercise has been shown to decrease anxiety and depression and people who exercise regularly are thought to have better self-concepts than non-exercisers.7 From the exercise addiction literature, when runners were asked to miss a run or a series of runs, symptoms experienced as a consequence of the abstinence included irritability, anger, restlessness, frustration, depression, insomnia and muscle tension.8 It therefore appears that regular physical activity can play a central role in an individual’s psychological wellbeing. An athlete forced to stop exercise due to injury, or any other reason, may need to develop alternative means of dealing with their emotions.7

PSYCHO-PHYSIOLOGY OF INJURY

It has been suggested that for every physiological change that occurs in the body, there is an equivalent change in mental state and for every psychological change there is an equivalent physiological change: the ‘psycho-physiological principle’.9 It is quite clear now from the field of Psycho-neuro-immunology that the emotions of the mind, including feelings, attitudes and beliefs, can influence the physiology and therefore positively or negatively influence recovery from injury or illness. For example, very old studies revealed that chronic stress can suppress the immune system, which can inhibit the healing response to injury10 and that vasoconstriction in the vasculature that results from stress can interfere with the blood flow to the injured area, which is thought to prolong the recovery process.11

These thoughts are supported by a review by Ardern et al.12 The researchers considered 111 studies that had evaluated 983 athletes and 15 psychological factors in the recovery from injury. Motivation and confidence were strongly associated with a greater likelihood of swiftly returning to pre-injury levels of participation, whereas fear was a predominant negative response to returning to sport, although this generally decreased as recovery progressed. It has also been noted that greater confusion results at the onset of an injury in individuals more heavily involved in sport who have more to lose. These people also tend to perceive their recovery as slower compared to others who are not so intimately involved in sport.13 Additionally, research found that fear of re-injury was actually related to non-adherence to a rehabilitation programme.14

PSYCHOLOGICAL INTERVENTION STRATEGIES FOR INJURY REHAB

The psychological rehabilitation techniques that I will now discuss can all be inserted into position 1 of the mind-body model and should support the standard injury rehabilitation practices.

A study by Levleva and Orlick15 showed that athletes whose injuries healed very rapidly were more likely to use goal setting, positive self-talk, stress-control and healing imagery compared to athletes whose injuries healed more slowly.

According to Wiese and Weiss,16 there are four ways that a sport psychologist can motivate athletes to adhere to rehabilitation programmes. They are: goal-setting, self-talk, social support and imagery. All of these techniques can potentially help to facilitate recovery from injury and hasten the return to sport.

Goal setting

Goal setting provides the athlete with a sense of control and facilitates motivation, persistence and commitment7 rather than an over-reliance on their doctor or physiotherapist. In fact, the more problematic the injury and the greater the athlete’s commitment to his/her sport, the more intense the approach to goal setting should be.17

Writing down goals and planning a rehab strategy helps keep the athlete focussed on healing. It’s very important, however, to set modest short-term goals since athletes can often interpret small improvements as no or insufficient improvement.3

Sport and exercise psychologists Weinberg and Gould18 suggest that athletes should be given an approximate timescale for achieving certain intermediate goals during rehab to help the athlete stay focussed on the recovery process itself rather than simply waiting to get better.

Self-talk

Injured athletes have a tendency to dwell on negative and irrational thoughts about themselves, their injury, and their return to performance, creating emotional states such as fear, anxiety and depression – emotions shown to impair athletic performance19 and interfere with a successful rehabilitation.

Reframing negative statements into more optimistic positive ones that are rehearsed and spoken by the athlete as part of his or her own internal dialogue can lead to more positive approaches to rehabilitation.

Goal setting and self-talk are two of the most important techniques in the rehabilitation process.

Social support

In many cases in athletic situations, friendships may be suddenly ruptured because of the occurrence of an injury. Injured athletes may no longer be seen and may no longer see themselves as athletes. In a study by Fisher et al., support from significant others contributed most to the differentiation between adherers and non-adherers of a sport injury rehabilitation – athletes were more likely to keep a commitment to another person than to themselves.21 It may be a good idea to introduce the injured athlete to an injury support group which involves meeting regularly with a coach and other injured athletes to discuss thoughts and emotions.

The athlete’s physiotherapist or doctor also has a role to play – they should explain to the athlete why a particular form of treatment is being used since it is well known that belief in the treatment being given is critical to the healing process.3 It is difficult, if not impossible, for intelligent athletes to be positive and relaxed if they lack knowledge about the purpose of the rehabilitation process.

Imagery

According to the theories of imagery, the muscles being imagined become slightly innervated (stimulated/supplied with energy) during imagery practice, similar to innervations experienced during actual performance, meaning improved skills development.9 Also according to imagery theory, since the systems of the body consist of biological, psychological and social components, when two or more components interact, they regulate each other. It is through these regulations that systems become whole and ordered structures: Dysregulation at the physiological level can disrupt the psychological level and dysregulation at the psychological level can disrupt the physiological level.22 A major objective of healing imagery is to improve the connections between these components.

It has been suggested that positive visualisation eliminates the destructive panic-stress images in the mind which can cause vasoconstriction and reduced blood flow to the injured area – decreased blood flow is thought to be a precursor for muscle tension, 23 a negative outcome within rehab therapy.

CONCLUSIONS

To conclude, I quote one of America’s leading sports psychologists, Dan Gould: ‘Athletes who recover most quickly from injury tend to be highly motivated, take an active role in their recovery and adhere to their rehabilitation protocol. Goal-setting techniques, healing imagery, positive self-statements and stress-management techniques have also been associated with quicker recovery from injury.’24

Harness the power of your own mind and become commander of your own body, especially when it comes to recovering from injuries.

References

  1.  Rotella RJ & Heyman SR (1986). In JM Williams (Ed.), Applied sport psychology: personal growth to peak performance (pp. 343-364). Palo Alto, CA: Mayfield.
  2. Samples P (1987). The Physician and Sportsmedicine. 15(10):172-180.
  3. Weiss MR & Troxel RK (1986). Athletic Training. 21(2):104-110.
  4. Kubler-Ross E (1969). On death and dying. New York:Macmillan.
  5. McDonald SA & Hardy CJ (1990). The Sport Psychologist. 4:261-274.
  6. Nideffer RM (1989). International Journal of Sport Psychology. 20:241-255.
  7. Williams JM & Roepke N (1993). In Singer RN, Murphet M & Tennant LK (Eds.). Handbook of research on sport psychology. New York:MacMillan.
  8. Robins JM & Joseph P (1985). Journal of Sport Psychology. 7:23-39.
  9. Green LB (1992). The Sport Psychologist. 6:416-428.
  10. Simonton OC et al (1978). New York: Bantam Books.
  11. Lynch, GP (1988). The Sport Psychologist. 2:161-167.
  12. Arden CL et al (2012). Br J Sports Med.
  13. Johnston LH & Carroll D (2000). Br J Sports Med. 34:436-439.
  14. Pizzari T et al (2002). Journal of Sport Rehabilitation. 11 (2):90-102.
  15. Ievleva L & Orlick T (1991). The Sport Psychologist. 5:25-40.
  16. Wiese DM & Weiss MR (1987). The Sport Psychologist. 1:318-330.
  17. Heil J (1993). In J Heil (Ed.). Psychology of Sport Injury. Human Kinetics, Champaign, IL.
  18. Weinberg RS & Gould D (1995). Foundations of sport and exercise psychology. Champaign, IL. Human Kinetics.
  19. Woolfilk RL et al (1985). Journal of Sport Psychology. 7:191-197.
  20. Fisher AC et al (1988). The Physician and Sportsmedicine. 16 (7):47-51.
  21. Schwartz GE (1984). In A.A. Sheikh (Ed.). Imagination and healing (pp 38-50). Farmingdale, NY: Baywood.
  22. Sarno J (1984). Mind over back pain. New York: McGraw-Hill.
  23. Korn ER & Johnston K (1983). Visualization: The uses of imagery in the health professions. Homewood, IL: Dow Jones-Irwin.
  24. Gould D (2000). Psychology of Sports Injuries. Sports Science Exchange Roundtable 40. 11(2).
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The Psychology of the Injured Athlete

Ian Craig
About The Author
- BSc MSc, CSCS, INLPTA. He is a nutritional therapist, exercise physiologist, NLP practitioner and a lifestyle coach. He was a competitive middle-distance runner for 20 years and is now a more leisurely runner and cyclist. He runs a private nutrition practice in Johannesburg's Morningside Chiropractic Sports Injury Clinic, where he personalises nutrition and exercise strategies according to his client's genetic attributes and lifestyles. He also writes and is the editor for Functional Sports Nutrition magazine and he recently published his first book, Wholesome Nutrition, with co-author Rachel Jesson.