The Psychological Challenges Of Rehabilitation For Injured Athletes

As a result of many athletes spending hours engaging in rigorous training programmes and competitions, the prevalence of sporting injuries has increased (Kraus & Conroy, 1984). Regardless of their level of involvement, a vast majority of athletes will experience an injury that will keep them away from their sport for an unwanted period of time, it is an evitable risk associated within partaking in sport. A general notion amongst most athletes suggests returning to sport sooner than later is the right course of action, due to a pre-existing stereotype challenging their competitive nature and willingness to sacrifice for the team (Weiss, 2003). Moreover, this sentiment is also portrayed in the current sports media, where an estimated recovery time for an injured athlete is always reported; highlighting the importance of their return to their respective sport and importantly team (David et al., 2018). Therefore, those athletes who take longer to rehabilitate can often be criticised; resulting in the athlete being questioned about their mental toughness, devotion to the sport and if their contractual salary is proportional to their diminished value (Meyers, 2015). However, a major factor of rehabilitation that an injured athlete is challenged with but is often overlooked, is the psychological aspect of injury. Some athletes have been known to rush their rehabilitation due to their competitive mindset, not placing importance on their readiness to return to action, affecting both performance and daily life. The psychological effects resulting from an injury can vary depending on an athletes’ mental approach and the severity of the injury (Taylor & Taylor, 1997). The rehabilitation process is a crucial period for an athlete to recover both physically and mentally. Therefore, this paper will delve into the psychological challenges’ athletes face when rehabilitating. This includes exploring effective approaches in mental rehabilitation post-injury, allowing for an athlete to achieve an efficient level of readiness and perform to the best of their abilities.

There appear to be a number of definitions for the term ‘sport injury’, which accounts for some disagreement in reported research findings (Pargman, 2007). However, some scholars emphasise sport injury as being defined as a major negative life changing event (Gould, Udry, Bridges & Beck, 1997). Whereas Lysens, Weerdt, and Nieuwboer, (1991) deem for an athlete to be injured, there needs to be only a one-day limit upon participation. Nonetheless, for this essay a sport injury will be when a trauma to the body of an athlete, or its parts, result in at least temporary and sometimes part damage to the body or a disability (Arvinen – Barrow & Walker, 2013). Although an injury is physically demanding, preventing an athlete from participating in their sport; fortunately, injured athletes today can expect a full physical recovery due to the development of surgical and rehabilitative technology (Taylor & Taylor, 1997). However, there has been a large amount of research investigating athletes’ psychological responses to rehabilitation from sports injury over the last twenty years (Bianco, 2001). Brewer (2003) suggested that psychological factors play an important role in the occurrence of and recovery from a sports injury. Moreover, it has been recognised that psychological and physical readiness to return to sport after incurring an injury are not always synonymous (Podlog & Eklund, 2006). Therefore, may be physically ready to return to sport after an injury, but not necessarily psychologically ready. Many clinical reports have determined that returning athletes often have concerns about reaching their pre-injury level or a fear of re-injury occurring (Crossman, 1997; Rotella, 1985). Furthermore, Taylor and Taylor (1997) stated that the sense of alienation is often felt by many returning athletes, which can result in a loss of confidence and decrease in performance due to the amount of pressure being felt. An example of such pressures being felt by returning athletes’ is the sample of Canadian national team skiers used by Bianco (2011). Several of the skiers felt pressure to prove that they deserved a place on the team to the coaches, therefore returned prematurely to competing. As a result, all skiers later developed further injuries due to their premature return.

There have been a number of conceptual models developed specifically addressing rehabilitation issues, such as those experienced by the Canadian skiers, including both the stress and grief process (Evans & Hardy, 1999). These issues have been divided into personal and situational factors which may influence an injured athletes’ behaviours, feelings or emotions, thoughts and rehabilitation outcomes (Wiese-Bjornstal & Smith, 1993). Within these personal factors include personality, psychological skills and age. The situational factors include treatment related variables e.g. facilities and time demands, injury related variables such as type and severity as well as various external factors e.g. social support and life stress (Evans & Hardy, 1999). Personal and situational factors are thought to affect an athletes’ response to injury (Larson, Starkey & Zaichkowsky, 1996). As a result, a stress process model was developed, suitable for understanding the sports injury process (Wiese-Bjornstal, Smith, Shaffer, Morrey, 1998). Stress has often been referred to as when the resources of the task don’t match the demand. This model of process advocates that sports injury is stress related and prompts appraisals of the injury situation, subsequently influencing emotional responses and having an affect on behavioural responses (Wiese-Bjornstal et.,al, 1998).

A few years previous, Kubler-Ross (1969) identified a five-stage grief reaction response, as a grief response was a consequence of sport injury. This consisted of denial, anger, bargaining, depression and acceptance or recognition. After the initial shock of an injury, an athlete may play down the injury and the severity of it as they are in denial. Anger then replaces the denial once the realisation of the extent of the injury kicks in. This level of anger may vary in intensity depending on situational and personal factors and can be directed at the self or others. This stage is followed by bargaining, this could be when an athlete will promise to train extra hard to recover sooner. After all the realisation and reality of the injury, it is common for an athlete to experience episodes of depression, believing they will never be the same athlete they were before and realising their inability to partake in sport which normally brings happiness. Finally, when the athlete recognises and accepts the reality of the injury and their losses, they become ready to rehabilitate and eventually return to sport. Kubler-Ross’ model was used within Gordon, Milos and Grove (1991) study, where sixty-six physiotherapists completed questionnaires. They claimed that amongst athletes they treated, bargaining and denial were reported frequently with anger and depression being less frequent. Although, the model has been successfully applied to athletes; it must be noted athletes may not necessarily follow the set pattern of the model or experience every stage (Brewer, 1994). Furthermore, the model was originally used for terminally ill patients, so care should be taken when applying to athletes’ experiences of injuries (Walker, Thatcher & Lavallee, 2007). Brewer (1994) reviewed stage-based versus process-based models and concluded that cognitive appraisal models seem to hold the greatest understanding of the sport injury process. However, grief process models and cognitive appraisal models are not mutually exclusive. It has been noted that the sense of loss in sport injury is a cognitive appraisal leading to emotions associated with grief (Evans & Hardy, 1995). Therefore, grief process models can be included by a broader stress process model.

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A broader integrated process stress model developed by Wiese-Bjornstal (1998) concerning grief process models in sport injury is known as the integrated model response to injury. This model posits that pre-injury and post-injury factors influence psychological response; this psychological response can change over time in a dynamic way. The process continuously in the background of the dynamic process is recovery – both physically and psychologically (Wiese-Bjornstal, 2010). Psychological and situational factors are incorporated throughout the model which continue to exert their effects throughout the dynamic process and influence the way the injured athlete cognitively appraises their injury. The normal route of the model displays that cognitive appraisals affect emotions, resulting in affecting behaviours, although certain mediators can make the direction of route reverse. The core of the model should be envisioned as spiral which if recovery outcomes appear negative it will go in a downward spiral. However, if the athlete appears to be having a positive injury outcome the spiral will go upwards in direction (Wiese-Bjornstal, 1998). However, a criticism of the integrated model is that Walker, Thatcher and Lavallee (2007) claim literature examining the model proposals has been scant and that their research offers further insight into the dynamic core of the model. Although, despite this the integrated model does have supporting research (Evans, Mitchell & Jones, 2006).

An injury specific model similar to Hardy, Jones and Gould (1996) integrated model of response has been developed to focus on personality type as an antecedent to the psychological response of an injured athlete. Certain traits can either reduce or increase the stress response and effect the cognitive appraisal of stress. A combination of pre-injury factors (interventions, history of stressors, personality and coping resources) and post-injury factors (team and coach influence) combine to affect cognitive, behavioural and emotional responses towards injury. Pre-injury negative mood state and risk-taking behaviours have been evidenced to be linked to increased injury incidence (Bovard, 2008). Furthermore, high self-motivation and excessive training behaviour was linked to a high chance of injury (McClay & Levitt, 1991). Having a history of life stressors have also been proven to have an affect on response to injury. This can include life stress, such as bereavement, a relationship break-up, illness etc. Life event stress has been measured by the social readjustment rating scale (Bramwell, Masuda, Wagner & Holmes, 1975). When categorised on a scale an athlete with low stress was found to have a 30% risk of injury, compared to an athlete with high stress has a 73% of injury occurring. This displays a positive relationship between life stress and injury. These stresses can also be classed as daily hassles, for example hassles with coaches, school or finances. However, Heil (1993) found daily hassles have not shown a direct link to risk of injury. Despite this Faulkner, McMurray and Summers (1999) found injured athletes had a significant increase in daily hassles in their personal life the week prior to obtaining injury, whereas there had been no changes in an athletes’ personal life regarding daily hassles who were not injured. Coping resources have also been identified as a mediator of an athlete’s psychological response to injury. An athlete who has low social support and coping tendencies are considered more vulnerable (Smith, Small & Ptacek, 1990). Johnson (2011) conducted interviews with twenty athletes about experiences of psychosocial risk factors and injury experiences. The qualitative research allowed for thematic content analysis, which revealed four risk factors: history of stressors, personal factors, fatigue and ineffective coping. The findings replicated existing research and three out of four core themes of the stress injury model became apparent. These three factors, as well as having reciprocal effects on one another, also have an influence on the rehabilitation behaviours and outcomes. Despite this research, there is limited understanding of an athlete’s appraisal of the initial injury or how they should cope with the injury, demonstrating the model can not be used to explain an athlete’s entire injury psychological injury process (Albinson & Petrie, 2003).

Within the integrated model of response, a coping resource that directly has an affect on injury outcome is social support. Danish (1986) stated an athlete with an injury is no less of an athlete, and no less of a person that they were before the injury. Therefore, a whole-person approach for an injured athlete appears preferable, due to most athletes’ main motivator for participating in sport comes from the social support they receive. Bianco and Eklund (2001) declared that social support induces positive experiences and outcomes, therefore is essential for an athlete to reach their pre-injury health both mentally and physically. This demonstrates that social support is crucial in the rehabilitation process, specifically for severe injuries. Social support uses an interactive method, influenced by both the provider and recipient, the socio-context the process is delivered in and the relationship of the two people involved (Bianco and Eklund, 2001). The role of social support can vary for individual athletes, depending on where the source of support comes from during the rehabilitation process (Taylor & Taylor, 1997). There are several sources of support on offer during rehabilitation including coach, teammates, family, friends, or people who have suffered similar injuries (Arvinen-Barrow et al., 2010). Injured athletes often experience low self-esteem, by having the presence of social support from significant others becomes an imperative source of confidence (Maygar & Duda, 2000). Athletes who at the beginning of their rehabilitation perceived that they had sources of social support utilised performance sources to aid restoring their self-confidence and esteem (Maygar & Duda, 2000). Physiotherapists provide immense informational and emotional support to an injured athlete due to their close relationship (Ford & Gordon, 1993). Instead of informational support, friends and family are a great source of emotional and instrumental support for the athlete, helping to increase self-confidence and reduce depression and anxiety. Subsequently, a great way to enhance coping mechanisms is to use other injured athletes who can provide appraisal support, this will also help encourage treatment motivation, satisfaction; reducing the fear of re-injury (Handegard et al., 2006).

Although having social support to aid rehabilitation useful for an injured athlete it is imperative that they learn psychological skills while rehabilitating, including goal-setting, imagery and relaxation training (Petitpas & Danish, 1995). Despite most athletes already using these techniques when participating in sport, it has been shown do not use the techniques to the same degree when injured (Sordoni, Hall & Forwell, 2000). Therefore, it is essential these skills are taught to be used to the same extent in rehabilitation as when they are competing. There is extensive support suggesting an increase in performance when using goal setting (Evans & Hardy, 2002). In regards to rehabilitation goal setting has been proved to be just as positive. Levleva and Orlick (1991) explore goal setting and recovery time. They concluded goal setting was associated with faster recovery in people who sustained ankle and knee injuries. Many athletes will describe “feeling the shot” or “seeing the shot” before they perform, displaying that imagery is often used within many sports, although is not used to the same extent when rehabilitating (Murphy & Martin, 2002). Driediger, Hall and Callow (2006) qualitatively explored how athletes used imager in injury rehabilitation. The athletes believed imagery served cognitive, motivational and healing purposes for example learning and performing rehab exercises, help goal setting and dealing with pain. Walker and Heaney (2013) stated that the aim of relaxation is to relax the whole body in a matter of minutes, so is a commonly used technique for injured athletes. Cupal and Brewer (2001) examined the effects of a relaxation and guided imagery intervention on knee strength, re-injury anxiety and pain following ACL construction. The results showed significantly greater knee strength and significantly less re-injury and pain for the treatment group 24 weeks post-surgery compared to the placebo and control group. Although these techniques appear positive, Heaney (2006) found physiotherapists believed managing stress and anxiety was important but using techniques such as imagery and relaxation were not. However, this lack of use of the techniques may reflect a lack of knowledge about how to use the skills or it is not the physio’s job to teach psychological techniques. Therefore, this does not mean the techniques are not successful.