Recovery From Physical Injury: Don’t Overlook the Mind

Editors Note: Sports psychologist Jonathan Brain contributes his blog on the physical and mental aspects of injuries.

By Jonathan Brain

Recall a time when you got injured and could no longer participate in your sport for a period of time. How did you feel?

  • What was your reaction when you were told the news that you would have to miss the rest of the season?
  • How did you feel seeing your teammates training and winning games without you?
  • Did you feel sad, frustrated or angry for not being able to play or exercise?
  • If you haven’t experienced an injury yet, how do you think you would react?

I certainty felt frustrated and angry when I got injured and was told I would have to stop participating in sports for at least 6 months. I honestly hated everything about being injured (despite the smile on my face in the picture). Looking back, I realize that I learned a lot from my injury, although it certainly did not feel like a positive experience at the time.

I often questioned myself whether I was overreacting, being too grumpy or frustrated during my recovery. Knowing what I know now, I don’t blame myself for having had these types of feelings and reactions, it was completely normal given the mental implications sustaining an injury entails. However, I do wish I had had some strategies which could have helped me better manage and cope with my injury at the time.

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Me after my second surgery after sustaining a torn patellar tendon from a bad football tackle

 

 

This blog aims to help those of you who:

  1. Haven’t experienced an injury yet, to prepare yourself and become more aware of what you could potentially expect psychologically, if and when injury does happen
  2. Are currently experiencing an injury, by explaining different types of strategies you could use to better cope with and manage your recovery from injury
  3. May know someone who is struggling with their injury and you want to help them cope and provide useful support

No matter which of these three scenarios you find yourself in, whether you are a recreational exerciser who enjoys a Sunday morning run, a competitive amateur football player, or an athlete competing at the highest level in your sport, this blog will help in some way, shape or form.

Right, enough waffle and let’s get to the interesting part.

SPORTS INJURIES? TELL ME MORE

Simply put, a sports injury refers to damage to bones, ligaments, tendons and nerves caused by sport participation (i.e. musculoskeletal damage). Unfortunately, injuries are inevitable and tend to occur quite frequently in sports, no matter a person’s experience or level, as demonstrated by the bubbles below (1,2,3).

I included these numbers not for the purpose of comparing amateur vs professional athletes’ incidence of injuries but rather to show how relevant injuries are to ALL athletes.

HOW DO ATHLETES PSYCHOLOGICALLY RESPOND TO THEIR INJURY?

Injured athletes face problems not only from the actual painful and unpleasant physical repercussions of sustaining an injury, but also other hurdles such as enduring tedious, repetitious and sometimes painful rehabilitation exercises (3).

Whilst the physical repercussions are usually easily apparent, those of a psychological nature are less obvious. Injured individuals tend to experience many different negative psychological responses (4).

I) Emotional = ‘‘how you feel about the injury’’
II) Behavioural = ‘’how did you act and react to the injury situation’’
III) Cognitive = ‘’how you viewed the situation of being injured’’

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Some examples:

Depression: It’s not surprising that when an athlete’s primary source of enjoyment is no longer accessible to them due to injury, their mood is affected. This type of reaction is particularly evident when an athlete truly identifies with their sport and it plays a big part in their life (e.g. their career/full-time job or a way to escape from daily stressors (5)).

Fear & Anxiety: Injured athletes can feel fearful and/or anxious for different reasons; because they don’t know how fast they will recover from their injury, or because they wonder if they will re-injure themselves during their rehabilitation or upon their return to sport (5,6).

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Some Examples:

Seeking Social Support: Injured athletes tend to seek social support from their social support circle (family, friends, teammates, coaches, physiotherapists etc.). Social support provides athletes with crucial reassurance, comfort and encouragement for them to successfully manage their emotions, thoughts and feelings during their recovery. They may initially resist help but will certainly be grateful for it when they seek it (7).

Non-Adherence to Rehab Program: Rehabilitation programs can be long, monotonous and repetitive, with only little or slow progress evident and it can therefore be hard for injured athletes to adhere to it. The temptation to return and compete in their sport prematurely can be overwhelming, despite the risk of re-injury or causing new injuries (5,7).

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Some Examples:

Alienation & Social Isolation: Injured athletes can feel isolated and lonely, particularly if they train and compete in a team sport from which they may now feel disconnected. They may also feel envious of those who are able to continue participating in their sport or activity (8).

Low Self-Esteem & Perception: Self-esteem can suffer in injured athletes, leading them to feel worthless which is highly correlated with an individual’s athletic identity. The more the athlete is committed and devoted to his/her sport or if it’s their job, for example, the higher his/her athletic identity will be (5).

SUSTAINING AN INJURY ISN’T ALWAYS BAD

A common misconception that athletes frequently have when sustaining an injury is that it is ONLY negative. However, once recovered, athletes, (including myself), may be able to perceive the experience in a totally different manner. I certainty experienced negative feelings, but going through my injury experience was definitely insightful and I grew as a person. This way of responding is also known as post-traumatic growth (9).

After experiencing an adversity such as an injury, the positive outcomes can include:

1. Enhanced Relationships: Post injury, athletes may value friends and family highly and feel more compassion towards others, demonstrating their appreciation for all the support they received from their support circles.
2. Changed Self-Perception: Recovered athletes can develop wisdom, personal strength and gratitude and may have a greater acceptance of their vulnerabilities and limitations. Any athlete, no matter the level or their current form can easily get injured. No one is invincible.

3. Changed Life Philosophy: Spending time away from sport enables athletes to reflect upon their life in general and current circumstances, to put things (e.g. minor life issues) into perspective and to appreciate things they didn’t before. I know this may sound a bit cliché, but you would be surprised how much this is actually the case, especially when you are deprived of something you thoroughly enjoy.

4. Other Responses: Being injured can also lead to the development of new skills such as time-management and goal setting, which can be applied outside of sport. Additionally, overcoming such a difficult experience undoubtedly strengthens an individuals’ character, self-confidence and resilience (5,10,11).

If I didn’t perceive my injury experience as being a positive and insightful experience, I probably wouldn’t have written this blog. Don’t’ forget, there’s always light at the end of the tunnel.

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Tiger Woods’ comeback win in 2018 after Spinal Fusion Surgery

SO, WHY DO ATHLETES RESPOND IN THESE WAYS?

Well, the best way I can explain this to you is by sharing with you a model which was developed by sport injury researchers.
It has a long name (The Integrated Model of Psychological Response to the Sport Injury and Rehabilitation Process) but the important thing to understand is how different factors interact with each other to determine how an athlete can potentially react to their injury.

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The Integrated Model of Psychological Response to the Sport Injury and Rehabilitation Process (adapted) (12).

The model suggests that both personal and situational factors influence the way an athlete perceives his/her injury (i.e. cognitively respond). This influences the way he/she will emotionally respond which will in turn affect the way he/she will behaviourally respond.

These factors combined with the different responses, will determine if an athlete will have a positive or negative injury experience and recovery.

For example:

If Cristiano Ronaldo sustained an ACL injury, which is a severe injury, and given the fact that he has a competitive, ambitious and determined personality (personal factors) combined with the fact he is at the highest level, he trains every day, plays competitive matches every week (situational factors) he is highly likely to have negative thoughts concerning the injury. As a consequence, his cognitive responses (e.g. social isolation and low self-esteem), will influence his emotional responses (e.g. fear, anxiety and depression) and his behavioural responses (e.g. seek social support and difficulty to adhere to his rehabilitation program). These factors combined (either being positive or negative) will determined his recovery outcomes.

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What does this mean?

The key takeaway from this model is that the way an athlete responds to his injury is entirely individualistic, as there can be many contributing factors. There isn’t a ‘’right way’’ to feel, think or behave when it comes to enduring and coping with injury (12).

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It is NORMAL and OK to feel the way you are feeling; no one should decide for you.

HOW CAN I BETTER COPE WITH MY INJURY?

Now, this is the part you are probably most curious about.

There are various psychosocial strategies you can learn, practice and apply to yourself to better manage and cope with your injury. Don’t be put off by the word ‘’psychosocial’’, it’s just the name of the type of intervention sport psychologists use.

These specific ones are designed to promote positive factors such as self-efficacy, confidence and athletic identity and reduce negative factors such as anxiety and depression which majorly influence the recovery process and an athletes’ successful return to sport (13).

Let’s have a look:

I) Goal Setting: As an athlete you may tend to reflect upon your training or game performances and establish clear short-term or long-term goals. When faced with your injury, the route to achieve these goals is put on hold, providing a great opportunity for you to set new ones. You can use the SMART acronym to help you set your injury recovery goals. For example, a recreational runner may use this strategy in the following way (14):

S = Specific – Get 5K running time as I did pre-injury (e.g. under 20 mins)

M = Measurable – I can track my time using Strava, Apple Watch etc.

A = Attainable – I know I’ve achieved this time before so I can do it again

R = Relevant – I love running and I want to continue to do so

T = Time-bound – In the meantime I’m going to take time to heal from my injury and undertake the necessary rehab exercises, go for shorter runs to then be ready for the 5K race I signed up for in 2 months

II) Positive Self-Talk: This process will allow you to shift your negative thoughts concerning your injury into more positive ones. Saying positive affirmations verbally out loud or internally to yourself can help provide you with direction and motivation throughout your recovery period. Cues such as ‘’I can overcome this’’, ‘’I can do anything’’, ‘’I have to work to get my leg as strong as my left one’’ are all useful positive self-talk techniques you could employ. Of course you can come up with your own ones (15).

III) Mental Imagery: Mental imagery allows you to connect your mind and body whilst imagining performing a movement. Using imagery actually slightly activates the muscles you would usually use to undertake the actual movement. For example, you can use imagery to visualize you successfully completing your rehabilitation exercises that you didn’t think you would be able to achieve or that you’re currently struggling with, boosting your confidence. Lastly imagining plays, drills, movements and techniques allows you to not only sharpen your skills by reminding you of what needs to be done once fully recovered but also to overcome fears of re-injury(16). Once successful example of the use of this strategy is Vincent Kompany:

“When I was injured and when I was watching the games, I visualised how I would have tackled this or that attacker, what pass to make. I realised that I could progress without even being able to train”

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IV) Emotional Written Disclosure: Write down your emotional feelings related to your injury in a journal, as doing so with commitment and consistency can be an extremely helpful way to cope and manage with your emotions. It can also be a useful future resource you can refer back to if you experience another setback (e.g. getting re-injured) (7).

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I can appreciate it may be a bit daunting reading about these different techniques and no one expects you to be an expert right away. The idea of this blog is to raise your awareness and let you know that these are some of the ways that you can help yourself.

If you would like to learn more about these techniques, there are various resources online to help you learn and practice them. Alternatively, if you would like to apply these techniques, working with a qualified sport psychologist to support you with this process will be beneficial.
Just know you don’t have to be a professional athlete to learn, practice and apply these strategies, anyone can do it.

TAKE HOME MESSAGES:

· Injury affects EVERYONE taking part in sport, regardless of your level or experience

· It is ok to not feel 100% when you’re injured, it’s not an easy experience, be kind to yourself

· Sustaining an injury isn’t ONLY negative and great things can come out of it.

· There are various strategies available you can use to help you cope better with your injury

· Don’t be afraid to ask for help from family, friends, coaches, physiotherapists, sport psychologists; that’s what we’re all here for

I hope you found this blog interesting or helpful whether or not you’re currently injured. I hope that I have shed light on some of the implications sustaining an injury can induce, allowing us to be more aware, kind and empathic to ourselves and others.

REFERENCES:

1. T, Gangcuangco J. (2019, August) Premier League clubs score record injuries and costs in 2018-2019 season. Insurance Business. https://www.insurancebusinessmag.com/uk/news/breaking-news/premier-league-clubs-score-record-injuries-and-costs-in-201819-season-175242.aspx

2. Ekstrand, J. (2008). Epidemiology of football injuries. Science & Sports, 23(2), 73-77. https://doi.org/10.1016/j.scispo.2007.10.012

3. Fernandes, H., Alves, J., Reis, V., & Saavedra, F. (2014). Social support and sport injury recovery: an overview of empirical findings and practical implications. Revista De Pscicologia Del Deporte, 23(2), 445-449. https://psycnet.apa.org/record/2014-30540-023

4. Clement, D., Arvinen-Barrow, M., & Fetty, T. (2015). Psychosocial Responses During Different Phases of Sport-Injury Rehabilitation: A Qualitative Study. Journal Of Athletic Training, 50(1), 95-104. https://doi.org/10.4085/1062-6050-49.3.52

5. Podlog, L., Gao, Z., Kenow, L., Kleinert, J., Granquist, M., Newton, M., & Hannon, J. (2013). Injury Rehabilitation Overadherence: Preliminary Scale Validation and Relationships With Athletic Identity and Self-Presentation Concerns. Journal Of Athletic Training, 48(3), 372-381. https://doi.org/10.4085/1062-6050-48.2.20

6. Ardern, C., Taylor, N., Feller, J., & Webster, K. (2012). A systematic review of the psychological factors associated with returning to sport following injury. British Journal Of Sports Medicine, 47(17), 1120-1126. https://doi.org/10.1136/bjsports-2012-091203

7. Arvinen-Barrow, M., Massey, W., & Hemmings, B. (2014). Role of Sport Medicine Professionals in Addressing Psychosocial Aspects of Sport-Injury Rehabilitation: Professional Athletes’ Views. Journal Of Athletic Training, 49(6), 764-772. https://doi.org/10.4085/1062-6050-49.3.44

8. Podlog, L., & Eklund, R. (2010). Returning to competition after a serious injury: The role of self-determination. Journal Of Sports Sciences, 28(8), 819-831. https://doi.org/10.1080/02640411003792729

9. Joseph, S. (2012, November) What doesn’t kill us… The Psychologist, 25, 816-819. https://thepsychologist.bps.org.uk/volume-25/edition-11/what-doesnt-kill-us

10. Podlog, L., & Eklund, R. (2006). A Longitudinal Investigation of Competitive Athletes’ Return to Sport Following Serious Injury. Journal Of Applied Sport Psychology, 18(1), 44-68. https://doi.org/10.1080/10413200500471319

11. Wadey, R., Evans, L., Evans, K., & Mitchell, I. (2011). Perceived Benefits Following Sport Injury: A Qualitative Examination of their Antecedents and Underlying Mechanisms. Journal Of Applied Sport Psychology, 23(2), 142-158. https://doi.org/10.1080/10413200.2010.543119

12. Wiese-bjornstal, D., Smith, A., Shaffer, S., & Morrey, M. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal Of Applied Sport Psychology, 10(1), 46-69. https://doi.org/10.1080/10413209808406377

13. Gennarelli, S., Brown, S., & Mulcahey, M. (2020). Psychosocial interventions help facilitate recovery following musculoskeletal sports injuries: a systematic review. The Physician And Sportsmedicine, 1-8. https://doi.org/10.1080/00913847.2020.1744486

14. Heaney, C. (2020) Exploring the psychological aspects of sport injury. The Open University https://www.open.edu/openlearn/ocw/mod/oucontent/view.php?id=85698&section=4

15. Pillow, D. (2019, June) 7 Tips for Recovering Mentally After a Sports Injury. Henry Ford Health System. https://www.henryford.com/blog/2019/06/7-tips-recovery-after-sports-injury
16. Durden, M. (2017, January) Utilizing Imagery to Enhance Injury Rehabilitation. The Sport Journal. https://thesportjournal.org/article/utilizing-imagery-to-enhance-injury-rehabilitation/

17. Duncan, E., Gidron, Y., & Lavallee, D. (2013). Can Written Disclosure Reduce Psychological Distress and Increase Objectively Measured Injury Mobility of Student-Athletes? A Randomized Controlled Trial. ISRN Rehabilitation, 2013, 1-8. https://doi.org/10.1155/2013/784249