Part One Psych and Sports Injury

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An Investigation of the Psychophysiological Mechanisms of Sport Injury and Injury Recovery with Discussions in Psychological Perspectives, Behavioral Risk Factors, Psychological Injury Assessment, Psychological Treatments, and Biomedical Issues of Sport Injury.



By: Joe “Yu Yevon” King

Abstract: Injury is common in sports. An estimated 17 million sport injuries occur yearly among American Athletes (Booth, 1987). An estimates 1 million yearly injuries among high school athletes include about 10 fatalities (Mueller & Blyth, 1987). Almost one in two collegiate football players suffers an injury severe enough to lose playing time (Zemper, 1989). A third of the nations 15 million joggers sustain a musculoskeletal injury each year (Booth, 1987). Nearly half of habitual runners experience lower extremity injury every year (Macera et al., 1989). And each year, 1,000 spinal cord injuries occur when divers dive into pools and other bodies of water (Samples, 1989). Therefore it is imperative that the athlete recovers quickly and fully from an injury. Arguably the most important factor in injury recovery is also the most overlooked. It is the purpose of this article to investigate the importance of sport psychology in relation to sport injury and effective applications of psychology to injury recovery.

Since the late 1960’s, sport psychology has emerged as an interdisciplinary science within psychology and the biologically based sport sciences (Browne & Mahoney, 1984). As an academic discipline it is broadly concerned with the relationship between psychological behavior and sport and exercise. Sport psychology contains three focal areas of study; social issues, health and well-being, and performance enhancement. The use of mental training methods in association with performance has captured the interest of growing numbers of athletes, coaches and scientists as part of a trend of specialization in sport.

Phidippides



According to ancient Greek manuscripts from about 490 B.C., there lived a man named Phidippides. Phidippides was a messenger for the Greek army. Back then, the only way to effectively send messages from town to town was by men who could run great distances in a short time. Phidippides was arguably the best. In 490 B.C., the first battle for democracy was fought at the Greek village of Marathon. The Greeks were horribly outnumbered and the invading Persian army would surely destroy them. Phidippides was called upon to run to Sparta to ask for military aid to help combat the invading Persians who had just landed by the thousands on the beaches of Marathon. Before departing for Sparta, Phidippides stopped by his house in Colonos to take with him a small flask of water, some figs and a pair of sandals.







As we have shown you in JHR, water is imperative for myofibril hydration, and for removing large amounts of lactic acid from the muscles to prolong energy production. Figs have a high GI (about 103), therefore they will provide massive amounts of carbohydrates for further energy utilization. The figs will also elicit an insulin response, which will hasten the uptake of glucose to the muscles.

Phidippides ran along the Iera Odos (the “Sacred Way”) and took a short break to drink from his water flask at the town of Eleusis. After passing through Megara and reaching Isthmus, he turned to see all of Attica. He drank some more water and massaged his thighs before turning towards Sparta. He passed through Cornith and by the mountains near Argos. It was dark by the time he reached Arcadia. According to reports, his heart was of normal beat, his legs felt light and his soul was peaceful. He continued on into the night, passing Mycenae, Tiryns and Nauplion. As he was running he passed the time by reciting Homeric poems. He ran past the village of Taieatons and over the Eurotas river. As the sun began to rise, Phidippides entered Sparta. Upon entering the city, he stopped by a water fountain, not to drink, but to wash his brow. In the Spartan Senate (Gerousia), Phidippides announced himself and his mission. The Senate called the Archons to assembly to debate the matter as Phidippides patiently explained Marathon’s dilemma.

After about an hour of debate, the Senate concluded that they will send troops in 15 days, as the Spartan army does not initiate an action unless there is a full moon. Upon hearing the disappointing news, Phidippides began his journey back to Marathon. The distance from Marathon to Sparta is 140 miles. Phidippides ran a total of 280 miles in two days and two nights. Back in Marathon, the Athenians banded together with the Plataens and Thespians and drove back the invading Persians without the aid of Sparta. Upon victory, Phidippides was ordered to run to Athens to spread the good news. Athens was a mere 26.2 miles away (the standard distance of a marathon today). Upon reaching Athens, Phidippides shouted the good news of the victory at Marathon just before he collapsed of exhaustion and died.

Phidippides was not only an incredible distance runner (probably the best in his time), but he was also an unknowing master of psychology. Running the long distances, he would disassociate himself from the pain building up inside his legs and his lungs by reciting the Homeric poems. In fact, he was able to separate himself from the pain so much that he literally ran himself to death.

In sports today, we must learn to use psychology to increase performance, but we also must learn to use psychology to maintain a balance between performance and health.

There are a multitude of physical and psychological factors that influence the risk of injury and the effectiveness of rehabilitation and recovery. The loss of playing time and its potential impact on success as well as physical pain and the rigors of rehabilitation are major sources of psychological distress. This distress can also sensitize the athlete to pain, especially when the recovery from an injury is prolonged due to the severity or reinjury. Psychological stressors, such as the fear of injury during competition, may illicit a cycle of both physical and psychological effects that result in a decrease in physical performance (Nideffer, 1983). Fear can decrease concentration and self-confidence and can even produce physiological responses such as increased muscle tension and arousal levels. The athlete also tends to become preoccupied with physical sensations arising from the sight of injury. These sensations may be intensified by the psychophysiological dynamics of the fear response, and the athlete may perceive them as signs of injury or reinjury. These perceptions negatively effect performance through decreased efficiency in the biomechanics of skill execution, poor utilization of energy resources, and decreased attention to performance-related factors. There also appears to be an effect among physiological mechanisms as well as among psychological mechanisms. For example, muscle tension and autonomic changes may perpetuate one another as may the skill-based and interpretive psychological mechanisms.



Figure 1: The mind-body connection: a psychophysiological model of risk.

This phenomenon is usually manifested acutely, but can also be manifested in a more chronic form where the same psychological and physiological changes take place but in a more subtle and prolonged form. This is best conceived in the context of the general adaptation syndrome (Seyle, 1956), which explains the influence of stress on overall health.

Injury Perspectives

Injury obviously presents a physical problem, but it also presents a challenge to the maintenance of emotional equilibrium. Athletes are commonly encouraged both intrinsically and extrinsically to return to play as quickly as possible, therefore it is expected that they be mentally tough, maintain a positive attitude and play though pain. However, these expectations can discourage athletes from paying attention to emotional distress, which can impair the identification of injury adjustment problems.

Geoff Petrie, former player for the Portland Trailblazers and currently the V.P. of the organization discusses the meaning of an injury:

Serious injury is one of the most emotionally and psychologically traumatic things that can happen to an athlete. Injury can take away an athlete’s career at any time, and it threatens the feelings of invincibility and immortality that all young people have to some degree. Because athletes are so dependent upon their physical skills and because their identities are so wrapped up in their sport, injury can be tremendously threatening to them. There are some injuries from which a highly competitive athlete simply cannot recover, at least not to the point where he or she can return to a prior level of competition. In comparison, someone not involved in sports who sustains the same injury may be able to rehabilitate to the point of maintaining normal physical activity, and thus his or her life is relatively unchanged. The sense of loss is potentially greatest for top-level athletes at the peak of their competitive skills. The more time invested in sport and the greater the athlete’s success, the harder it is ultimately to face serious injury. As the athlete ages, it becomes more difficult to recover effectively.








One of the saddest things to see is an injured athlete who attempts to compete, only to do so poorly. Some athletes refuse to give up sport and keep searching for a solution to the limits posed by injury, a solution that unfortunately does not exist. In the process they experience tremendous frustration.





Dealing with minor injury presents special problems as well. Pushing oneself to the limit is an expectation that is very much a part of the heritage of sport. This means not only playing well but also playing through pain and tolerating injury. How effectively each athlete deals with pain and injury varies a great deal and relates to his or her psyche.

Whether injury is minor or serious, the challenge it presets goes beyond the physical aspect of rehabilitation. It is complicated by the expectations and reactions of others, including teammates, coaches, medical staff, and media. With the strong media presence in top-level sport, player behavior inadvertently becomes a part of the public domain. A negative reaction by the media, to a slow recovery from an injury, for example, can be a cruel blow to a player.

Petrie knows all about sport injury, having underwent five knee surgeries, which ultimately forced him to retire from the sport of basketball.

Living with an injury is an every day problem in sport. Bodybuilders especially have to deal with the pain of DOMS (delayed onset muscle soreness) nearly every day, which can be either entirely motivating or completely detrimental to the athlete’s mentality towards training. Bodybuilders must be able to discern between the beneficial pain of DOMS and the damaging pain of a muscle or tendon injury. However, in this article we will be focusing on the latter. Fundamentally, the best method of physical injury treatment involves a conservative approach in order to lessen the chance of reinjury.

Dealing with an injury can be a very personal matter. Some athletes find it beneficial to continue going to practices and conversing with their teammates during the injury rehabilitation process, while other athletes cannot bear to see the sight of their teammates competing without them. Every athlete has a slightly different approach to sport injury, which is why it is important to remain flexible during rehabilitation.

The decision to return to play is as important as it is complicated. There are three types of injury situations:

Self-limiting – An athlete with such an injury is physically unable to play, therefore there is no decision needed as to the return to play.

Borderline – The borderline injury involves a great deal of pain but little danger of reinjury.

The Gray injury – This type of injury involves a gray area where there is no clear best decision about whether to compete.

The athlete should not make the decision to return to play on his own, rather the coach and physician should play a role in the decision making process. In most cases, the athlete will want to compete sooner than he/she is physically ready. The coach and the physician can keep the athlete in check and advise a longer rehabilitation period.



Behavioral Risk Factors for Sport Injury



All athletes are susceptible to injury, but some more than others. A broad array of factors interact to influence the risk of sport injury. Some of the common and well established risk factors include the rules of the game and how they are routinely applied in a given setting, the nature and quality of equipment and facilities and the lesser known largely psychological risk factors such as training intensity, risk taking, attitudes towards pain and injury, life stress, substance abuse, and coping skills.

The risk factors can be subdivided into two fields of study, psychological risk factors and overtraining syndrome. Early work on the relationship between psychological factors and athletic injury risk was often a product of coaching or clinical experience (Ogilvie & Tutko, 1966). Recently, more scientific advances have been made. For example, Anderson et al. (1988) discovered the mechanism behind the life events-injury relationship has been found to lie within an individual’s stress responsivity (Andersen & Williams, 1988). The model which emerged from the aforementioned investigation provides a framework for assessing injury risk and suggests interventions for reducing the likelihood of injury. This model was largely built off of the research of Allen (1893) and Smith (1979). Central to the model is the stress response with its mutually influencing cognitive and physiological/attentional elements.




Figure 2: The stress response model of injury.

In any athletic situation, participants will experience different cognitive responses; for example, competition may produce positive feelings of challenge, excitement, and joy (eustress) or negative feelings of dread, anxiety, and discomfort (distress). The type of affective response an athlete experiences can easily influence their risk of injury. Distress is more likely to cause injury than eustress.

Physiological/attentional responses are rooted in endocrinological changes, such as elevated adrenocorticotropic hormone (ACTH) and catecholamine changes, such as activation of the sympathetic nervous system. Observeable changes in the sympathetic nervous system arousal includes an increase in respiration, pupillary dilation, increased sweating, piloerection (“goose bumps”), generalized muscle tension, tremor, increased distractibility, and emotional lability. Vasoconstriction in the viscera (causing “butterflies”) , nausea, tunnel vision, and increased adrenaline secretion are also experienced. From these physiological responses, attentional changes may follow.

The stress-injury relationship research has deep roots within the realm of athletics. Many studies have been conducted on football athletes and have empirically shown the relationship between life events, stress, and injury. High-stress athletes have a greater likelihood of injury than low-stress athletes (Bramwell, Masuda, Wagner, Holmes, 1975; Cryan, 1983; Passer, 1983). Outside of athletics, high levels of stress also contribute to a greater likelihood of accidents in the general population (Selzer, 1974; Stuart, 1981). Besides the history of stressors that contribute to injury (including life events, daily hassles, and previous injuries) there are two other broad categories of factors that may influence stress responsivity; personality factors (intrapersonal) and coping resources (behavioral and social).

The Stress Response

The way in which the cognitive and physiological elements of stress response interacts influences the likelihood of injury. The physiological/attentional changes during stress, as mentioned earlier, are generalized muscle tension, narrowing of the visual field, and increased distractibility, among others. Unwanted simultaneous contraction of agonist and antagonist muscle groups in generalized muscle tension can cause a severe injury such as strains, sprains and fractures. In an instant, flexibility, motor coordination and muscle efficiency is disrupted. A common example of this is a hamstring strain, which is caused by the simultaneous concentric contraction of both the quadriceps and the hamstrings groups.

Narrowing of peripheral vision during stress is often reported anecdotally. Research by Weltman and Egstrom (1966) demonstrated that novice divers, when placed in a stressful situation (in this case, swimming in an open ocean as opposed to a pool), showed greater peripheral narrowing than experienced divers. Substantial peripheral vision narrowing during stress has also been demonstrated in a laboratory setting with individuals who score high on life stress experiencing greater narrowing than individuals who score low on life stress (Anderson, 1989; J.M. Williams et al., 1990, 1991). This narrowing of vision could prevent an athlete from picking up peripheral cues that might otherwise enable the athlete to avoid an injurious situation).

The cause of peripheral narrowing under stress is still somewhat unclear. A possible explanation is that when the demands of a situation exceeds the athlete’s resources (behavioral, attentional, perceptual), available resources are allocated towards more central tasks, leaving the periphery with fewer resources for processing information (Kahneman, 1973). Recent investigations have shown that during times of peripheral narrowing, reaction time increases (Anderson, 1989). Attentional distractibility can lead to injury, when attention is turned from relevant cues to irrelevant cues.

Cognitive Appraisal

Intertwined with the physiological/attentional aspects of the stress response are the cognitive appraisals of the athlete. An athlete’s attitudes about competition can influence the likelihood of injury. If an athlete views a competition as challenging, exciting, and fun, the athlete tends to remain on task and stay focused which may decrease the possibility of injury. If an athlete views a competition as anxiety producing, a tribulation or potentially embarrassing, the chance of injury increases. If an athlete has low confidence, the athlete may feel that he or she does not have the required resources to meet the demands of the situation. This lowered confidence level can trigger the physiological/attentional changes that set up an athlete for injury. Individual differences in stress responsivity may either inoculate the athlete against injury or exasterbate his or her risk.

Psychological Factors and Stress



There are three major contributors to the stress response; the personal history of stressful experiences, personality traits, and resources that help in coping with stress (social and behavioral). The model also suggests that personality variables and coping resources act either directly or indirectly to the stress response.

History of Stressors: This includes life events and daily hassles. The previous injury history may also be of importance (an athlete may be physically ready for return to activity, but not psychologically ready). The study of the influence of life events began with studies on the relationship of major life events to illness outcome. T.H. Holmes and Rahe (1967) demonstrated a connection between the number of major life events and a person’s likelihood of developing illness. In 1970, Holmes again found a connection between major life events and injuries in football. Blackwell and McCullah (Dr. Penny McCullah is this authors professor) in 1990 demonstrated a high correlation between life stressors and athletic training. Generally, the 20 studies conducted on this topic since 1970 have shown that the risk of being injured increases in direct proportion to the level of life-event stress. However, the strength of this relationship can vary considerably across studies. Athletes with a high life-event stress are two to five times more likely to be injured than athletes with low-event stress.

Daily hassles are defined as the every day stresses and strains of living that may or may not be connected to major life events. These hassles have been shown to be predictors of health outcome in a clinical setting (Kanner et al., 1981), psychological distress (Monroe 1983) and stress responsivity (distress (Monroe 1983) but not injury vulnerability (Blackwell, 1990, Smith et al., 1990a). Daily hassles are thusly referred to as potential contributors to the likelihood of sports injury.

The general health literature has demonstrated that personality variables, such as hardiness (Kobasa, 1979), locus of control (Rotter, 1966), and sense of coherence (Antonovosky, 1985) are related to health outcomes. Competition anxiety (Martens, 1977), sensation seeking (Zuckerman et al., 1964) and achievement motivation are also included in the stress response model. Highly competitive athletes, when placed in stressful situations, exhibit strong stress responses and thus are more likely to become injured. These variables, however, are difficult to measure. Dr. Penny McCullah (1990) and Dr. Passer (1983) were able to measure sport specific anxiety and Dr. Dalhauser (1979) measured locus of control. Athletes with an internal locus of control were less likely to be injured, and athletes with a lower competitive trait anxiety were less likely to experience severe injury.

There is evidence that an athlete’s coping resources influence injury outcome both directly and indirectly. Williams et al. (1986) found that the strongest predictor of injury among volleyball players was a low level of coping resources. Smith et al. (1990) found that male and female high school athletes low in both social support and psychological coping skills exhibited the greatest risk of injury. Other studies found similar relationship between social support and athletic injury (Hardy et al. 1987).

To review:

It has been thusfar concluded in this investigation that in a potentially stressful situation, individuals with high life stress, many daily hassles, certain personality factors, and few coping resources will exhibit greater peripheral vision narrowing, more attentional distractions, and higher levels of generalized muscle tension.

Identifying and Classifying Overtraining Syndrome



In 1983, a round-table discussion was held by sport psychologists and other professionals to uniformly agree upon a definition of overtraining. The consensus was that overtraining cannot be accurately defined (Ryan et al., 1983) and this is still true today. Terms such as burnout, overreaching, overwork, overtraining, staleness and overtraining syndrome often are not uniformly used. Several working definitions have been brought forth. When heavy training work loads are applied for a long period of time the athlete is in danger of moving beyond a critical point resulting in a prolonged period of decreased performance and profound feelings of fatigue. These signs indicate overtraining syndrome (Kuipers, 1988).







Staleness is used either to describe the initial reaction to overtraining (Silva, 1990) or to define a prolonged state of overtraining syndrome (Kuipers, 1988; Ryan, 1983). An overtraining syndrome of lengthy duration can lead to the state of sysical and emotional exhaustion and frustration that characterizes burnout (Fender, 1989; Henschen, 1986; Smith, 1986). In contrast, overreaching or overwork means a short period of heavy training that deliberately exceeds the athlete’s coping capacity (Ryan, 1983). This intentional training overload is used as a stimulus (Harre, 1979) to speed processes of physiological adaptation that usually occurs more slowly during periods of normal training. Overreached athletes can fully recover after two to three weeks (Kuipers, 1988; Ryan, 1983).

Symptoms and Signs of Overtraining Syndrome

There is a variety of both psychological and physiological signs that characterize overtraining syndrome. Overtraining syndrome is characterized by distributed regulation of the central nervous system, with resultant physical symptoms and behavioral changes. The leading symptoms include decreased performance and rapid onset of fatigue during exercise. The athlete may also experience a general loss of motivation and diminished concentration. Additional diagnostic signs either may indicate general systematic disturbances (cardiovascular, digestive or nervous system) or, in contrast, may reflect a single organ dysfunction. Laboratory testing is necessary to assess whether the symptomatology is an organic disease or a psychophysiological disorder.

Clinical findings indicate that there are two types of overtraining syndrome: sympathetic and parasympathetic (Israel, 1976). The sympathetic type shows symptoms similar to those of hyperthyroidism and is characterized by increased activity of the sympathetic nervous system. The sympathetic type affects the state of health enormously and is clearly reflected in both objective signs and self-reports. This type of overtraining is common in bodybuilders. The parasympathetic type may show only nondescript sings and is difficult to recognize. Clinical observation (Israel, 1976) shows that parasympathetic overtraining syndrome is preceded by a short period of increased activity of the sympathetic nervous system.

Characteristics of overtraining syndrome include:

Common symptoms:
Decreased performance
Rapid onset of fatigue
Generalized pervasive fatigue
Loss of motivation
Emotional instability
Reduced concentration
Increased incidence of injuries
Increased susceptibility to infections

Sympathetic overtraining signs include:
Increased resting heart rate
Slowed heart rate recovery following exercise
Decreased body weight
Decreased body fat
Decreased appetite
Disturbed digestion
Insomnia
Short sleep intervals
Increased irritability and restlessness
Heart palpitations
Depression

Parasympathetic overtaining signs include:
|Quickened heart rate recovery following exercise
Increased sleep duration
Apathy
General disinterest

An important clinical feature of overtraining syndrome is increased susceptibility to infections with corresponding symptoms, which suggests some form of impaired immune system response. According to Ryan et al. (1983), chronic muscle soreness may also be a symptom of the overtraining syndrome, as may headaches or exaggeration in postural hypotension. Some cases of chronic fatigue syndrome in athletes appear to be related to overtraining syndrome (Eichner, 1989). Costill (1986) suggested that many athletes lose competitive drive and enthusiasm for training, developing aversions to the whole training program, training facilities, or athletes they regularly train with. In contrast, a strong desire to compensate for decreased performance with higher training workloads may actually mask the early signs of overtraining. Decreases in self-confidence is often evident and thus a consequence of the repeated experiences of weakness and failing. Psychological features such as mood disturbance appear to be sensitive indicators of the onset of overtraining (Druckman & Bjork, 1991, Silva, 1990). Israel (1976) suggested that disturbed coordination of excitatory and inhibitory mechanisms in the cortex may lead to dysphoria and may provoke conflicts in the social environment. Many authors agree that overtrained athletes may experience a typical clinical depression (Israel, 1976; Kindermann, 1986; Kuipers & Keizer, 1988; Ryan et al., 1983). Morgan et al. (1987) and Murphy et al. (1990) used standardized psychological assessment instruments to monitor the psychological impact of heavy training loads. In a series of studies, Morgan et al. (1987) administered the Profile of Mood States (POMS) to swimmers and wrestlers and found that mood disturbances increased with greater training loads. In a study of elite judo athletes, Murphy et al. (1990) used a series of psychological measures, including the POMS, and found increases in fatigue, anger, and anxiety with high-volume training loads. However, the results varied immensely in relation top the type of training.

The risk of injury is increased dramatically in overtraining syndrome. Two different patters appear to be involved: injury and overtraining occurring in parallel as separate consequences of the same underlying mechanisms, or injury occurring as a secondary effect of overtraining symptoms.

When injury and overtraining occur in parallel, all the factors contributing to overteraining syndrome may simultaneously affect the musculoskeletal system and result in overuse injuries (stress fractures, muscle pulls, fasciitis, etc) and other musculoskeletal problems (Stanish, 1984). Injury risk may also be directly related to excessive training or may be caused by a reduction in the body’s capacity to recover and repair tissue. According to Ryan et al. (1983), hormonal changes may be involved in this reduced recovery process. The authors also indicate that stress fractures can occur as reduced appetite and food intake result in substantially lowered blood levels of calcium. This is quite common in female ballet dancers and amenorrheic athletes across a broad range of sports (Lloyd et al., 1986; United States Olympic Committee, 1987).

When injury occurs as a consequence of overtraining syndrome itself, chronic muscle soreness in conjunction with mental and emotional instability may affect nervous coordination of working muscles and the perception of movement and fatigue. It is important to note that chronic muscle soreness alone is not a valid indicator of overtraining syndrome. Bodybuilders commonly experience this symptom without overtraining due to the demands of the sport. The assessment of overtraining syndrome should include not only chronic muscle soreness, but the other etymology as well.

Treatment of Overtraining Syndrome

Early detection for overtraining syndrome is the key to effective treatment. The syndrome can be alleviated within a few weeks, however extreme cases may last several months. For short term overtraining and overreaching, Costill (1986) recommended interruption (or cessation) of training for 3 to 5 days and resumption with lower total volume but maintained intensity. In order to allow necessary rest, the athlete should alternate each training day with a day off (Kuipers & Keizer, 1988). The athlete who has sympathetic overtraining syndrome needs to build up a sufficient aerobic base, beginning with low intensity endurance training and proceeding with slowly progressing workloads. Parasympathetic overtraining syndrome requires a cutback of high- and low-intensity endurance training and more emphasis on a few strictly limited, intensive, anaerobic workloads (Israel, 1976). Monotony of training and frequent repetition of single workouts must be avoided. Motivation is enhanced by the introduction of variety into training regimes. Treatment must consider both psychological and biological factors. Israel (1976) and Kindermann (1986) recommended sufficient rest, sleep, relaxation and proper nutrition.

Due to the complexity of overtraining syndrome, preventing measures require a multidimensional approach. One of the most important factors is a well-balanced training program, which gradually increases workloads in a logical progression (Kuipers and Keizer, 1988; Ryan et al., 1983). Because most of the cardiovascular adaptations seem to occur in 3-week cycles, the athlete can normally adapt to a certain percentage increase in workload within 3 weeks (Ryan et al., 1983). The risk of overtraining will be reduced if training follows the natural biological response of adaptation, with each cycle having a different main focus of intended adaptive change (periodization training). Athletes should also take care of disturbed relations in their family and social environments. Younger athletes need support from parents (Hellstedt, 1988). Enough rest and sleep are obligatory, and a well-balanced sports-adjusted nutrition program is also a preventative measure. Substrates of energy metabolism, such as glycogen, and fluid and minerals lost through perspiration require immediate repletion. Proper fluid intake should be observed.

Psychological Assessment and Mechanisms of Injury Rehabilitation

As hardcore athletes, the avoidance of injuries is of utmost importance. An injury can make or break an athlete, but more importantly, the athletes ability to recover from an injury, both physically and psychologically, will dictate the athletes future success. After an injury has occurred, the athlete must fight to recover from the injury as safely and effectively as possible. This writer has discussed the treatment of athletic injuries from a physical standpoint in-depth (see: A Comprehensive Physiological Breakdown of Acute Trauma). Now this writer will discuss the treatment of athletic injuries from a psychological standpoint.

Athletes are not to be compared to non-athletes. Athletes have a distinct and unique ability to cope with high amounts of stress. In short, it takes a special individual to become an elite athlete. Athletes tend to possess goal orientation, proclivity for physical training, strong motivation to return to optimal function following injury, and good pain tolerance. However, the athlete may be disadvantaged by having the aforementioned qualities after sustaining an injury. For instance, return to normal daily function is simply not good enough for the athlete, who obviously needs a longer recovery in order to meet the performance demands of sport. Due to a great investment of time, energy, and emotion in sport, the athlete experiences a greater loss with injury and a potentially greater threat to self-esteem than does the non-athlete. The relative balance of the positive and negative factors associated with injury will determine the speed and effectiveness of rehabilitation.

Figure 3: Psychological factors in rehabilitation of athletes.

Personal attitudes and behaviors as well as events in the recent and remote past reflect on an athlete’s ability to cope and his or her readiness to face the challenge of injury rehabilitation. Factors such as medical and psychological history and evidence of somatization (see below) provide insight to the strength of the foundation on which the coping ability is based. It is useful to be aware of preexisting medical conditions or a problematic medical history such as related injury, multiple surgeries, lengthy hospitalization etc. particularly if they were marked by difficulty in coping. An athlete’s first serious injury may be extremely disruptive with subsequent injury less so as the athlete learns coping skills. However, repeated injury may undermine the recovery process. Repeated or recent problems with psychological adjustment are also cause for concern, because there may be a reciprocally reinforcing relationship between injury and psychological difficulties. Evidence of poor adjustment is reflected by a prior psychological disorder, a history of substance abuse, or difficulty in psychological adjustment including trouble at school and with the law. It is also important to determine the relative balance of needs met through sport involvement and those met by other aspects of the athlete’s life. When an athlete’s sense of self-efficacy and self-esteem largely depends upon athletic performance and ability, the injury can be especially threatening.

Somatization is characterized by the inability to differentiate somatic sensations arising from physical illness and those that typically accompany emotional distress (Taylor, 1984). The somatic component of emotion is well conveyed in the body metaphors we use in speech (“butterflies in the stomach,” “pain in the neck,” “uptight,” “choking”). From this perspective, somatization may be viewed as an information-processing deficit whereby an individual overinterprets and mislabels somatic sensations. A small percentage of the population is prone to psychophysiological disorders and difficulty in coping with injury and illness (Ford, 1983; Fordyce, 1976). Following injury, an individual who is prone to somatization tend to focus on pain and somatic complaints while generally denying emotional distress. Somatization is most common among young athletes and among others whose sport participation is not truly elective.

There is growing evidence that life stress, in the form of either major life changes or chronic daily hassles, is predictive of injury. Risk that life stress will lead to injury is greatest in the segment of the athletic population characterized by limited psychological support and poor coping ability (Smith et al., 1990). Further, there are few setting in which the potential for a sudden and dramatic change is as ever-present as in sport. All athletes must cope with the fact that one day they can be winners and the next day losers. Within this context, change means challenge, whether it is following up on an outstanding performance or bouncing back from a poor one. As a consequence, even positive changes can be major stressors. Natural transitions in sport, such as a change in the level of competition from high school to college can bring new and greater challenges (Pearson & Petitpas, 1990). Movement to a higher competitive level brings increased mental and physical demands, and in addition the athlete often must adjust to a new social or geographic environment.

Investigators have observed increases in injury and illness as major competitions approach (Kerr & Minden, 1988; Nideffer, 1983). This is likely due to the combined effects of the heavy training load that often precedes major competitions and the psychological stress of the competition itself. Long-distance travel, which may influence sleep and diet, may also play a role. Factors such as attentional deficits, increasing anxiety, and a tendency to increase training load can all increase the risk of injury for an athlete.

Highly motivated marginal players may also be at risk of injury, as they are more apt to take risks in order to enhance their status and opportunities. They may be particularly concerned about losing opportunities as a consequence of injury and may even attempt to hide injury. They may also attempt to hide injury if they are sensitive to being labeled as “not tough” (Rotella & Heyman, 1986).

Athletes in general have been identified as a special population at risk for substance abuse and eating disorders, as well as problems related to competitive stress. Recreational and ergogenic drug use is widely noted (Tricker & Cook, 1990; Wadler & Hainline, 1989). Drug use has a broad variety of potential psychological and medical effects. Substances that may result in anxiety and other detrimental stressors include nicotine, caffeine, alcohol, cocaine, ginseng, antihistamines, ephedrine and steroids. The use of steroids and related agents in sports that place a premium on size, such as bodybuilding, and strength, such as powerlifting, is well recognized as are a variety of health-related risks (American College of Sports Medicine, 1987). The most immediately relevant of these is increased likelihood of soft tissue injury. Adverse psychological reactions including mood inflation, imperturbability, poor judgement, and aggressiveness (Gregg & Rejeski, 1990; Lubell, 1989) are being increasingly observed. Psychotic reactions may also be precipitated by steroid use (Stout, 1988). The use of diuretics, laxatives, fluid deprivation and other means of intentional dehydration are of major concern as well (American College of Sports Medicine, 1976). Participants in these sports appear to be at greater risk for bulimia or anorexia with consequent medical and psychological problems. Where extreme weight loss or heavy training result in amenorrhea there is evidence of increased risk for stress fractures (Lloyd et al., 1986).

Factors Associated with Injury

The greater the overall impact f the injury at the moment of its occurrence, the greater the emotional challenge the athlete faces during rehabilitation. The factors to be considered include emotional distress, the site of injury, and the immediate experience of pain, as well as the timeliness, culpability and unexpectedness of the injury. The greater the psychological trauma, the greater the likelihood of treatment and rehabilitation complications. Significant psychological impact is indicated by any of the following:

1. Extreme fear, anxiety, agitation, or hopelessness observed or reported at the time of injury

2. Catastophizing thoughts occurring at the time of injury, especially those that persist in spite of reassuring evidence to the contrary

3. A sense of derealization or depersonalization

4. Incomplete memory of circumstances of the injury

5. Retrograde or posttraumatic amnesia, of even a brief duration

The more extreme the emotional response relative to injury severity and the more limited the athlete’s coping resources, the greater the cause for concern. Reinjury especially following a difficult rehabilitation course can be incredibly disturbing if it calls to mind prior trauma or triggers persistent catastrophizing thoughts.

Injury to a part of the body that is highly prized (such as a pitchers throwing arm, or Kevin Levrone’s deltoids) or for which there is a special fear has greater psychological impact than other injuries (Eldridge, 1983). Injuries to the face, the genitalia, and the hand tend to be the most problematic (Chambers, 1963; Ford, 1983; Grunert et al., 1988), and injuries that cause significant disfiguration are also problematic. Traditionally, women are more sensitive to injuries that cause a loss of physical attractiveness while men are more sensitive to loss of function ability (Ford, 1983).

Pain as an immediate response to injury reflects not only the severity of tissue damage but also anxiety and expectations regarding the impact of injury on performance. Loesser (1991) offers an anecdotal case report to illustrate this concept. A collegiate quarterback who had returned to play following a severe knee injury stayed down after a tackle, apparently in severe pain. He was briefly examined on the field and reassured that the knee was still intact. His pain seemed to diminish quickly, and he was able to walk with assistance off the field. On the sidelines, this now reduced pain continued as tried with difficulty to walk it off. He eventually reached down to feel his lower leg and found a bone was fractured and pushing through his skin. At this instance, the pain once again became severe. Pain that appears out of proportion to the magnitude of injury may signify a breakdown of coping mechanisms. Pain response that appears mild relative to extent of tissue damage has often been noted and is attributed to positive mind-set (Beecher, 1956).

Even relatively minor injury at a key point in an athlete’s competitive season or career can be of tremendous consequence. Season ending injuries can create a sense of incompleteness that lingers into the next competitive cycle. There is evidence that injuries become more likely near the end of a natural cycle of activity – and that these injuries lead to more problems psychologically (Braveman, 1977). Individuals may hold superstitions regarding the timing of an injury. For example, there is a longwithstanding belief among soldiers that death or injury is most likely on the last mission before rotation of combat duty (Ford, 1983). There is also evidence to suggest that injury or illness is more likely on the anniversary of a significant prior trauma (Dlin, 1985).

In low- and moderate-risk activities, a highly proficient athlete may have a more troubled reaction to serious injury than one who is less skilled or experienced. Braveman (1977) noted this in ski and work-related injuries. In contrast, when athletes understand and accept high risks, distress may be less. Beecher (1946, 1956) observed dramatically greater pain tolerance and less need for medication in soldiers wounded in combat compared to general medical patients with injuries of comparable severity.

Factors Following an Injury

The greater chronically of injury whether due to severity or to rehabilitation complications, the greater the likelihood of psychological adjustment problems. Progress in rehabilitation, psychological status, and response of significant others to injury are all key factors. Where there is preoccupation with culpability for injury, whether attributed to oneself or another, adjustment problems are more frequent. If the injured athlete assumes responsibility for the occurrence of injury or interprets injury as a failure, feelings of guilt are likely. In team sports, injured athletes may also feel they have let their team down. Significant others who have an investment in the athlete’s competitive success may react in a way that enhances guilt. Anger may result if the athlete blames someone else for an injury (Ogilvie & Tutko, 1966), such as a coach for putting the athlete at unnecessary risk. Such anger may create problems in interpersonal relations between the athlete and the one being blamed.

The athlete is more likely to be disturbed by injury that occurs as a consequence of an intentional, calculated action to do harm than by injury that occurs during routine play (Ford, 1983). This can be all the more disturbing because of the tendency for such destructive behavior to go relatively unpunished.

Factors that can either be helpful or harmful to the psyche of the athlete during the rehabilitation process include:

- Compliance with treatment – How well the athlete complies with the treatment modalities

- Perceived effectiveness – How well the athlete perceives the rehabilitation process is progressing

- Treatment complications – The amount of treatment complications, or the way in which the athlete deals with complications dictates the athletes emotional recovery

- Pain – How well the athlete deals with the physical pain of rehabilitation

- Medication use – The amount of medication, the type of medication, and the potential misuse of medication can have either positive or negative effects on the athletes psychological state

- Social support – Positive social support can enhance both the physical and mental rehabilitation process while negative social support can hinder it

- Personality conflicts – The power driven athlete may feel helpless following injury, which may hinder recovery

Goal Setting for Injury Treatment

Goal setting for rehabilitation is the foundation of a good recovery program, and will help the athlete stay focused and motivated throughout the rehabilitation process. Goal setting after an injury is slightly different than the goal setting an athlete may be used to. To read more about goal setting for bodybuilders, read Muscle Mind Doctrine - Theoretical Concepts of Strategization .

The importance of setting and striving for goals has long been recognized in sport (Carron, 1984; Locke & Latham, 1985) and rehabilitation (Danish, 1986; Fordyce, 1976). Goal setting links motivation to action. In a rehabilitation setting, goal setting should parallel the treatment plan, establish an implicit statement of commitment by the athlete, and identify treatment as a collaborative process. In addition to setting goals, identifying barriers to goal attainment is also important. Factors that may interfere with effective rehabilitation include the following (Danish, 1986):

- A lack of knowledge about the rehabilitation process

- A lack of skill at a particular rehabilitation task

- A perception that the risks of treatment outweigh the benefits

- Lack of social support

For many athletes, goal setting for rehabilitation will be a novel application of a familiar concept. A goal program may be relatively simple and informal or complex and multifaceted. The specifics of a goal-based program will vary depending on the following:

- Length and intensity of treatment

- Urgency of speedy return to play

- Level of commitment to sport

- Initial psychological adjustment to injury

- Difficulties in rehabilitation

The more problematic the injury and the greater the athlete’s commitment, the more intense the approach to goal setting. Goal setting is most readily applicable to active rehabilitation; however, it can be extended to include any of the elements of rehabilitation. Goals may be set for medication use and modalities as well as braces or orthotic devices. They can also be set for important behaviors to avoid during the healing process. Goals do not have to be physical in nature. Goals can also be set for coping with psychological challenges that rehabilitation poses, such as boredom, impatience with maintaining activity limits, frustration with pain, or feelings of being down. Setting such goals implicitly acknowledges the suffering of injury, identifies it as a normal or ordinary behavior, and characterizes effective coping as an achievement. Where psychological adjustment problems are evident, training in coping techniques can be provided and goals set for their use. When progress is painstakingly slow, a more fine-grained approach to goal monitoring may be necessary calling greater attention to relatively small gains and demonstrating that progress is being made. Some rehabilitation gains are beyond the athletes ability to observe. When treatment plateaus occur, the athlete can supplement performance goals with effort goals using the Rating of Perceived Exertion Scale developed by Borg in the 1960’s, which continues to be investigated and refined (Borg & Ottoson, 1986). This scale has been used to measure a wide range of performance and rehabilitation activities (Monahan, 1988). Perceived exertion can safely guide those who adhere too vigorously to a “no pain, no gain” approach. Figure 4 represents a quick and easy guide to goal setting during rehabilitation.

Specific and measurable The athlete must know exactly what to do and be able to determine if gains are made

Stated in positive versus negative language
Knowing what to do guides behavior, whereas knowing what to avoid creates a focus on errors without providing a constructive alternative



Challenging but realistic
Overly difficult goals set up failure and pose a threat to the athlete. The lower the athlete's self-confidence, the more important success becomes and the greater the importance of setting attainable goals

Timetable for completion
This allows for a check on progress and evaluation of whether realistic goals have been set

Integration of short-, intermediate-, and long-term goals
A comprehensive program links day-to-day activities with expectations for specific competitions and with season and career goals



Outcome goals linked to process goals
Process goals (what to do) define the pathway to outcome goals. Outcomes are influenced by a variety of factors, many of which may be beyond the athlete's control. Process goals direct the athlete's focus to those factors most readily controlled

Personalized and internalized
The athlete must embrace goals as his or her own, not as something imposed from outside

Monitored and evaluated
Feedback must be provided to assess goals. Goals should be modified based on progress



Sport goals linked to life goals
This identifies sport and rehabilitation as life learning experiences and helps the athlete put sport in a broader perspective. This is especially important for athletes whose return to sport is doubtful


Figure 4: Guide to goal setting.

Social Support


Social support is a form of interpersonal connectedness. It encourages the constructive expression of feelings, provides reassurance in times of doubt, and leads to improved communication and understanding. Social support is one of many needs that can be met by sport participation, through camaraderie with other athletes and team membership. Social support is also a vehicle for increasing athletic performance as well as enhancing an athlete’s well-being (Richman et al., 1989). The general medical literature offers empirical endorsement for the psychological and medical benefits of various forms of social support (Taylor et al., 1986; Wallston et al., 1983; Williams et al., 1981). Social support buffers the effects of stress on health and enhances the prospects for recovery of those who are ill or injured. Those who possess a strong sense of social support demonstrate greater self-efficacy, lower anxiety, better interpersonal skills, and more risk-taking behavior (Sarason et al., 1990). The sport psychology literature constantly notes the benefits of social support in helping cope with injury (Danish, 1986; Rotella & Heyman, 1986). Research has also shown social support to be related to compliance with rehabilitation following injury (Duda et al., 1989; Fisher et al., 1988). Unfortunately, the injured athlete tends to be separated from their team after injury and lose this source of support at a time when it is most important.

Just as support is beneficial, pressure or confrontation regarding injury is potentially detrimental. In a study of over 500 intercollegiate female volleyball players from 65 schools (Hankins et al., 1989), researchers noted that challenges to the validity of the subjects’ injuries and pressure to return to play from coaches and other players produces psychological distress. In a well-researched journalistic look at youth tennis, McDermott (1982) graphically illustrated the devastating consequences for athletes with the absence of social support in times of emotional difficulty. Rosenfeld et al. (1989) identified a model that includes six forms of social support, listening, technical appreciation, technical challenge, emotional support, emotional challenge, and shared social reality.

Listening – Listening is a non-judgmental way to the concerns and feelings of another, as well as emphatic sharing of joys and sorrows.

Technical appreciation – Acknowledgement of good performance, based on technical understanding of the tasks in question.



Technical challenge – Encouragement to meet performance goals by those who have a technical understanding of the tasks in question.

Emotional support – Active support of an athlete through emotionally demanding circumstances (without necessarily taking his or her side).

Emotional challenge – Encouragement to meet and overcome obstacles that are emotionally demanding.

Shared social reality – Sharing of similar experiences, values, and views that provide a basis for self-evaluation through social comparison.

There are three distinct segments of the injured athlete’s support system: the sport team, the sports medicine team, and parents, spouses and friends. All of these people, by virtue of their knowledge and their relationships with the athlete, provide certain forms of social support; no single group appears to provide all forms of support in practice. Technical appreciation and technical challenge can only be provided by those with a significant understanding of sport performance or rehabilitation. Emotional challenge can be provided by those with personal concern for the athlete. Shared social reality can be provided only by those with similar life experiences such as friends and teammates. Rosenfeld et al. (1989) found that teammates and coaches provide little listening, emotional support, or emotional challenge and concluded that coaches believe that emotional distance is necessary to maintain the role of authority. Rosenfeld et al. (1989) speculate that competitiveness (of teammates with the injured athlete) and the task of orientation of sport shape the forms of support received from teammates. Richman et al. (1989) offered the following recommendations regarding social support:

“It (social support) is best provided by a network of individuals; it needs to be developed and nurtured; and it functions best as part of an ongoing program rather than simply a reaction to crisis. Specific recommendations offered for treatment providers include: be a willing listener, acknowledge both effort and mastery, and balance the use of technical appreciation and technical challenge.”

Social support is most needed and least available with injury requiring surgery and lengthy rehabilitation. The athlete is taken out of the sport system, limiting the opportunity for contact with coaches and fellow athletes. Visits by teammates to peers hospitalized for surgery are quite valuable, especially when family is not conveniently located. Continuing team contact is a natural way for the injured athlete to gain support and carries a host of other benefits. Attending practice and games keeps the athlete current with changes in plays and team strategies, helps the athlete stay in touch with the rhythm of the season, and continues established relationships with team members. It also provides the athlete an opportunity for continued visual learning, which can be supplemented by formal mental training. Continued involvement with the team has been reported to provide a feeling of being needed and a sense of security (LaMott & Petlichkoff, 1990; Wiese et al., 1991).

Injury support groups and peer modeling are useful interventions. An injury support group brings athletes together to deal with issues of mutual concern (Wiese and Weiss, 1987). Support groups can provide coping models in the from of athletes who have recovered from serious injury. Formal support groups are most appropriate for athletes facing long rehabilitation, especially those feeling depressed or isolated. A buddy system of peer modeling involved matching an injured athlete with one who has recovered from injury. This is particularly helpful when injury occurs at a sport-life transition. Flint (1991) created a videotape of athletes demonstrating coping behavior at various stages of recovery from serious injury. In related research, she found that injured athletes who viewed this videotape demonstrated more positive attitudes about recovery and better knowledge of rehabilitation. Where injury leads to career terminations, support is of great importance (Botterill, 1982). Social support can be provided in a variety of ways by a diverse group of individuals. Its effects, though intangible, are significant.