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An athlete’s psychosocial response to injury

This is an excerpt from Clinical Foundations of Athletic Training and Sports Medicine 2nd Edition by Leamor Kahanov,Ellen K. Payne.

By Jennifer Ostrowski, PhD, LAT, ATC and Paul Knackstedt, MS, PsyD, CMPC-AASP

Sports medicine professionals tend to focus their attention on healing from the physical damage from injury, but there are important psychosocial implications to consider as well. Injury in physically active people can contribute to an already stressful lifestyle, and patients report feelings of tension, confusion, hostility, loneliness, fear, irritability, and anxiety^15,47 especially in patients following a concussion.^48-50 Research has demonstrated a positive relationship between injury severity and negative mood in patients.^51,52 ATs must understand how physically active people respond to injury and the rehabilitation process, both physically and psychologically, in order to facilitate holistic recovery from injury. Several theoretical models have been proposed, indicating that cognitive and affective elements may contribute to rehabilitation outcomes.

The integrated model of psychological response to sports injury and the rehabilitation process (figure 19.1) is a conceptual model that explores the interrelated psychosocial process of cognition, affect, and behavior.⁵³ Based on this model, rehabilitation outcomes are affected by the initial injury and the subsequent changes in the patient’s thoughts, feelings, and actions. Other contributions to the injury response are a variety of interacting personal and individual differences, such as gender, age, injury history, personality characteristics, and athletic identity. Postinjury cognitive appraisals are at the center of the model and involve the patient’s mental evaluation of aspects such as sense of loss, optimism, burnout, challenge, and self. Cognitive appraisals directly influence a patient’s affect-related psychosocial responses of emotion and behavior, as well as the patient’s physical recovery. Emotional or affective responses to injury include mood disturbances such as depression, anxiety, low vigor, fatigue, grief, burnout, and fear of reinjury.⁵⁴

Cognition and emotions directly affect the recovery process due to their influence on the person’s behaviors, including attendance at rehabilitation sessions, adherence to prescribed exercises, substance misuse, exercise dependence, and suicidal behavior.⁵³ Treatment adherence is largely determined by a person’s readiness and motivation to take on the rehabilitation of their injury.⁵⁵ Applying a behavior change model (typically used for increasing exercise behavior in sedentary people or eliminating substance use) for rehabilitation can help injured athletes increase self-efficacy, focus on positive instead of negative aspects of rehabilitation, and use behavioral processes instead of experiential processes.⁵⁶ One of these behavioral change models is the Transtheoretical Model (TTM) (figure 19.2).⁵⁷ Motivation is vital to a successful rehabilitation, so it is essential for ATs to keep patients engaged and in the action stage of change throughout the rehabilitation process, including updating goals and adjusting rehabilitation exercises. Focusing on the present moment in the athletic training facility through varied exercises and dynamic social relationships can help performers maintain motivation during their injury rehabilitation.

Due to the recurring nature of the behavior change processes, the TTM is conceptualized as a cycle rather than a linear process that has a distinct beginning and end. For example, many people struggle to make permanent behavior changes related to addiction, overeating, or gambling. Some make progress with strategies to change their harmful behaviors and develop motivation to grow in a new direction, while creating lasting change, while others relapse and return back to the precontemplation stage. The cycle of arrows in the model illustrates the frustration that many experience while working toward lasting behavior change.

Fear of Reinjury

Fear of reinjury may negatively influence the rehabilitation and return-to-activity process because patients may be concerned about returning to their preinjury level of performance. Typically, a patient’s fear of reinjury increases as they approach the scheduled return-to-activity date or sport.^58-60 It makes sense that a patient would be worried about performing all of the tasks of their activity at the same level that they could preinjury while testing the injured body part at game speed for the first time. ATs can help patients normalize and address this fear of reinjury as their return-to-activity date approaches by supporting open and honest communication about their worries and providing concrete examples of the physical healing that has taken place to increase the patient’s trust in the injured body part.

Fear of reinjury has been cited as contributing to lower sport confidence, difficulty giving maximal effort during rehabilitation or sport activity once the athlete has returned to play, or fear of being placed in an injury-provoking situation.^38,58 Fear of reinjury has also been noted as a common cause for retirement from athletic competition for athletes across all skill levels.^58,59,61 Psychosocial techniques that have been shown to assist patients with fear of reinjury include mental imagery.⁶²

Sociological Response to Injury for Athletes

Feelings of guilt for letting a team down, grief over the temporary loss of athletic identity, and isolation and estrangement from their teammates and sport often accompany athletic injury.^63,64 Some coaches limit injured athletes’ access to team functions and decrease their level of social support following an injury. Depending on the patient’s demographic and socioeconomic status variables, their coaching staff and teammates may represent their only source of support and may be even closer than family members. Injury is always about more than just the physical trauma that is endured; it is about what is lost and what could be at risk for the patient’s future. People with strong social support networks often see positive influences on their health. ATs should acknowledge the traumatic nature of injury and how the inability to engage in physical activity can affect their identity and should facilitate patient identification of social support resources.

More Excerpts From Clinical Foundations of Athletic Training and Sports Medicine 2nd Edition

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