Psychology of Injured Athlete
Dr. Duane Millslagle
Associate Professor
University of Minnesota Duluth
Outline
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Psychological Perspective of Athletic Injury
Patient-Practitioner Interaction in Sport Injury
Rehabilitation
Specialized psychological interventions in
Sport Injury Rehabilitation
The Bio-psychological perspective of pain
Integrated Rehabilitation Model:A Team
Approach
Psychological Perspective of
Athletic Injury
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Assessing and Monitoring Injuries
The Paradox of Injuries: Unexpected Positive
Consequences
Personality Correlates of Psychological
Processes During Injury Rehab
Stage Model Versus Cognitive Appraisal Model
Macrotrauma & Microtrauma: Different
Psychological Reactions
Assessing & Monitoring
Injuries
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Identify moderating variables that relate
to athletic injury
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Compare injured athletes to non-injured
athletes
Use of psychological inventories as the
primary tool
Severity of the injury
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Effects of psychological factors on injuries
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Effects of Psychological
Factors on Injuries
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Area of life stress
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Dealing with stress may affect the athlete
likelihood to become injured.
Life stress results from both within and
outside the athletic contest
Level of life stress is associated with the
injury
A proactive approach
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Periodic monitoring to assess one’s level
of life stress is necessary.
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Established psychological inventories
Interviews
With athletes who experience distress
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A need to reduce the stress to facilitate
restoration of psychological and
physiological states
Research Evidence
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Elite female gymnasts (Kerr & Minden,
1988)
Noncontact athletes (Hardy & Riehl,
1988)
Football players (Blackwell & McCullagh,
1990).
Adolescent sport injuries (Smith, Smoll,
& Ptacek, 1990)
Athletic Injury
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Being sport related
Results in a player’s inability to
participate on day after injury
Requires medical attention
Injury Frequency
Injury Rate
=
Definition of Injury
Population-at-risk
Severity of Injury
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No universal definition exists
Based on AMA Standards Nomenclature
of Injuries (1968)
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Depends on the time-loss
Depends on functional consequences of
participation or not participation
Psychological tests
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Profile of Mood States (POMs)-McNair, 1971
Eating Disorders Inventory-2(EDI-2)-Dean, et
al. 1990
Health Attribution Test(HAT)-Lawlis & Lawlis,
1990
Coping Resources Inventory(CRI)-Hammer &
Marting, 1988
Life Experiences Survey-Athletes(TESS)Morrow & Hardy, 1990
Paradox of Injuries
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“The injury made me a lot more
mature. I have a better grasp of reality
in life……I’m so much stronger
emotionally. (Lieber, 1991, p.44)
Are there ways to facilitate these
positive consequences with athlete
injuries?
Adversity & Stress
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General Adaptation Syndrome (GAS) by
Selye (1974)
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Alarm- injured person resists any additional
stressors
Exhaustion-additional stressors cause
injured person to succumb to stress
Adaptation phase-injured become stronger
and stressor acts as catalysts for higher
levels of functioning
Stress & Positive
Consequences
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Little research on how athletes come to view
there injuries in a positive manner.
One recently study by Udry et al (1997) did
involve 21 elite athletes on US Ski Team
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95% of the athletes reported more positive
consequences from their injuries
80% reported personal growth, psychological skill
enhancement,& physical-technical enhancement
from being injured
Recommendation
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Recognize that deriving positive
consequences takes effort
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Recognize different problem-solving strategies
can be used
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Injured athletes must not passively assume
positive consequence will occur
Use reversal strategies
Avoid Secondary victimization
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AT should not trivialize the experiences of the
injured athlete
Personality Correlates During
Injury Rehabilitation
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Neuroticism
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Explanatory Style
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Dispositional optimism
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Hardiness
Neuroticism
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Abundant evidence that injuries
produce generalized negative affect,
especially in severe injury.
Typical responses in athletes are:
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Disappointment
Frustration
Confusion and,
Depression
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There was pain because I had surgery;
pain because I knew my career was
over. It was probably the moment I
suffered the most in my life. It was
pain all over.”
Maladaptive Behavior &
Neuroticism
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Selective attention to the negative
emotions to injury
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Anger is exhibited (“I was not a nice
person when I was injured”)
Tendency to rely on inefficient coping
strategies
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Denial, withdrawal, selfblame, emotional
venting, disengagement
Explanatory Style
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Pessimistic explanatory style
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Personality caused:”It my own fault”
Stable over time: “I’m never going to play”
Global: “the rest of my life”
Health effects
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Immune system function
Poorer health
Dispositional Optimism
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Investigations are consistent
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Cardiovascular and,
Immunological function is associated with
optimism(Peterson et.al, 1991;Scheiver &
Carver, 1987)
Optimism mitigates the stress-illness
relationship
Link between optimism and recovery
Hardiness
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“Constellation of personality characteristics
that function as a resistance resource in the
encountering of stressful life events”-Kobass, et.
al. 1982. P. 169
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Components are
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Commitment-strong beliefs in one own value
Challenge-views difficulties to over come
Control-sense of personal power
Hardiness Link
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Kobasa (1979) linked hardiness to
physical health.
Mechanism underlying hardiness seems
to be cognitive appraisal and coping
processes(Florian et al, 1995; Gentry &
Kobasa, 1984)
Studies with Athletes
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Athletes who are high in neuroticism
and pessimistic explanatory style
display maladaptive behavior which
results in longer rehab or incomplete
recovery (
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Grove, Stewart & Gordon (1990) with
athletes with ACL damage
Grove & Bahnsen (1997) with 72 injured
athletes
Formal Assessment
Procedures
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Neuroticism
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Eysenck Personality Questionnaire (EPQN)-Eysenck & Eysenck, 1975
Explanatory Style
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Attributional Style Questionnaire (ASQ)Peterson et al., 1982)
Informal Assessment
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One-to-one visit & pay attention to the
athlete comments
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Fear, sadness, embarrassment, guilt &
anger, feelings of being over whelmed by
the demands of rehab—signs of
neuroticism
Ask the “why” statement….
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Insight into athlete’s explanatory style
Implications
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“the person that I wanted to talk to the
most was the person that was going to
help me get better…..We had the best
relationship. He/she knew what I was
thinking; he/she knew what I was going
through. He/she was my athletic
trainer.” (Quoted from elite skier,
injured athlete)
Implication
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Personality information helps AT to provide a
more complete service
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Highly neurotic athletes are prone to overreact,
denial, disengagement, and emotional venting.
AT need to:
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model rational behavior
well planned treatments
Maintain records of progress
Develop psychological skills of cognitive appraisal,
coping, and stress management.
Implications
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Injured Pessimistic Athletes feel helplessness
and depressed.
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These athlete fail to follow recommended
treatment programs(especially unsupervised
aspects).
Demonstrate a lack of persistence in the face of
poor or slow progress.
AT trainer should offer advise in how to cope,
prevent athletic isolation, & provide emotional
support.
Implications
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Injured athlete low in hardiness worry,
experienced depressed moods,&
overgeneralize negative aspects of their
character.
AT need to communicate clearly with the
athlete about the severity of injury, get them
actively involved in setting rehab goals, use
feedback of progress through charts or
graphs, and provide self-monitoring strategies
such as logs.
Psychological Reactions to
Injury
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Stage Model
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Cognitive Appraisal Model
Stage Model
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Based on death and dying literature
Relates to career ending injuries
Most important aspects is individuals
react differently across the stages.
Many AT reject the stage model
because each injured athlete act
differently.
Stage Model & Catastrophic
Injury
Denial
Anger
Grief
Depression
Reintegration
Cognitive Appraisal Model
Identified 5 components relevant to
psychological responses to athletic
injury
Based on stress and coping process to
athletic injury
Advantage of this model is it accounts for
individual differences in response to
athletic injury
Personal Factors
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Self-esteem
Neuroticism
Pessimism
Anxiety
Extroversion
Injury History
Sense of self
Sense of Self
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If someone has only one basis for a sense of
self, if that sense of self is threatened
(injury), so will the entire person……Erikson,
1968
If the athlete’s sense of self is threatened the
athlete will view the injury as severe loss
which results in anxiety, depression, or
hopelessness (Brewer, 1993).
Overestimators
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Athletes in general perceive injury as
more serious than it really is when
compared to the AT perception
(Crossman & Jamieson, 1985)
A group of athletes are overestimators
experience greater pain, more anger,
withdrawal, and show slow recover.
Situational Factors
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Post injury emotional adjustment is
positively related to situational variables
and social support.
AT needs to manipulate the situational
factors and enhance social support.
Manipulating the Situational
Factors
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Flexibility in rehab scheduling
Communicate with the athlete about
the seriousness of the injury
Provide a rehab center so it accessible,
safe, and friendly
Explain the purpose of each protocol
and goals of each rehab session
Response to Injury
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The athlete cognitive appraisal of the
injury interacts with the personality of
athlete and the situational factors
surrounding the injury.
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Perceived severity
History of Injury
Ability to Cope
Emotional Response
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After cognitive appraisal by athlete about
their injury, an emotional response will follow
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Perceived as threat the athlete will emotional vent,
become anger,experience high anxiety, denial,
disengagement, and depression
If pessimistic engage in negative self-talk, and
self-blame.
If neurotic engage in loss of self, withdraw, and
display changes in their personality.
If overestimator become irrational about the
severity of injury.
Behavioral Consequences
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After the emotional response the athlete will
engage in positive or negative coping
responses.
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Adopt healthy coping responses physically,
emotionally or psychologically.
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Learn new psychological skills and physiological
exercise…use injury as personal growth
Adopt maladaptive coping responses
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Career over, learned helplessness, blame others, use
other as the excuses, non compliance of rehab
Recovery or Delay in Recovery
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Length and degree of complete
recovery in reentry into the sport is
dependent upon:
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Severity and type of injury
Athlete’s cognitive appraisal and emotional
response to the injury
Athlete’s coping resources
Interventions both psychologically and
physiological
Types of Injuries
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Macrotrauma (acute trauma)
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Microtrauma (breakdown over time)
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Different psychological reaction to the
type of injury
Macrotrauma
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Rehab proceeds immediately
Usually results in clean progression of healing
AT and PT have clear cut rehab protocol
Athlete most certainly knows the injury could
not be prevented and it was caused by a
situation usually out of their control.
Athlete will bring closure to cognitive
appraisal and assume rehab as their rectifying
the situation.
Micotrauma
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Usually results from biomechanical
overloading
Recovery may be much longer with relapses
more frequent
Athlete experiences a great deal of distress
(frustration, anxiety, etc), second guessing,
and detachment for the sport is gradual.
Athlete will question the AT or PT skills and
protocol.
Psychological Perspective of
Athletic Injuries Summary
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Stress X Injury relationship needs to
assessed.
Once athlete are identified with high stress
levels there is need for proactive Approach
Injuries do have positive consequences if the
athlete has experienced a successful rehab.
Athlete’s personality is related to length and
degree of recovery.
Assess the athlete level of neuroticism,
explanatory style, optimism, and hardiness
Summary (continued)
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Athlete’s response to career ending injuries
reflect the stage model
Cognitive appraisal model provide AT why
some athlete behave differently when injured.
AT should assess the athlete cognitive
appraisal of injury through formal or informal
means.
Athlete’s respond differently when they have
macro versus microtrauma injuries.
PART II: Patient-Practitioner Interaction
of Injury Rehabilitation
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Patient Practitioner Communication
Patient-Practitioner Perceptions
Adherence to Rehab
Referral Process
Ethics & Legality
Patient Practitioner
Communication
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Received little AT empirical attention.
Studied extensively in medical literature
Results have indicated:
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Poor patient-practitioners communication
discourages future use of medical services
(Taylor, 1995)
Poor patient-practitioners communication
hampers adherence to rehab
(Meichenbaum & Turk, 1987)
Poor Communication
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Patient
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Anxiety
Inexperience with
the medical disorder
Lack of intelligence
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Practitioner
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Not listening
Using jargon
Technical language
Displaying worry
Depersonalize the
patient
Patient –Practitioner
Perceptions
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Rehabilitation Regimen
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Athlete and AT have significant disagreement
about rehab program (Kahanov & Fairchild, 1994).
Patients to expect to complete their rehab on an
average 42% quicker then AT estimates.
77% of sport injury patients who were prescribed
home rehab exercises misunderstood the rehab
program(Webborn, et al, 1997)
Patient-Practitioner
Perceptions
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Recovery Progress
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Perception of poor rehab is linked to negative
emotional responses in athletes (McDonad &
Hardy, 1990).
AT trainers and athlete’s rating of injury
disruptiveness is similar but athletes tend to
overestimate the severity (Crossman & Jamieson,
1985).
Athletes consistently perceive recovery as
complete well before AT perception.
Coaches do not see “eye to eye” with AT
perceptions the athletes return to competition
Attribution for Recovery
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Instilling a sense of self reponsibility for
rehab by the athlete (Gordon et al,
1991)
Depends on the rate of recovery
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Slow recovery are less likely to accept
responsibility
Faster recovery more likely they will
engage in their own self-recovery
Psychological Distress
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Emotional distress is inversely related to
rehab adherence and outcome.
Distress
Need to assess
distress
Adherence & Outcome
Adherence to Rehab
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Adherence rates range from 4091%(Brewer, 2002)
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Positive determinates of patient adherence:
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Self-motivation
Pain tolerance
Being involved and choices
Hardiness((Wittig & Schurr, 1994)
Negative determinates
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Ego involvement & Trait anxiety
Adherence to Rehab
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Environmental Factors
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Positive determinates
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Self-efficacy of the treatments(Duda, et
al,1989)
Comfort of rehab setting (Brewer, et al, 1994)
Convenience of rehab scheduling(Fields, et al,
1995)
Perceived exertion during rehab (Brewer, et al,
1988)
AT trainer expectancy of patient adherence.
Adherence-Enhancing
Strategies
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Based on previously injured athletes
and AT (Fisher, at al, 1993).
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AT who are caring, honest, & encouraging
At who educate the client
At who use goal setting and monitor the
clients progress
AT who do not use threats or scare tactics
in gaining adherence
Five Practical Suggestions for
Enhancing a Working Alliance
1.
2.
3.
4.
5.
Check preparations
Get specifics
Listen before you fix
Listen for the “but”
Value Patient Input
Referral Process
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5-13% of injured athletes experience clincially
meaningful levels of psychological issues
Before referring, consult with mental health
professionals about the athlete
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There is no perfect time refer
Need to explain to athlete why you are referring
them and to whom.
Always follow up about the athlete after referral
Using the Referral Process
Effectively
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Recognize there are certain conditions
which require referral
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Eating disorders
Depression
Establish a team of sport-medicine
professionals.
Team of Sport Medicine
Professionals
Primary Care Level
Secondary Care Level
Tertiary Care Level
Strategies in Referral
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Reactive referral
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Injured athlete shows signs of depression, eating
disorders, or anxiety.
Unfortunately, the majority of AT (76%) never
refer the athlete (Larson, et al., 1996)
Proactive referral
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Preventive approach
Provide tracking athlete nutritional requirements
for the sport
Provide psychological skills training related to
management of stress
Athlete Perception of Referral
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In reactive referral,
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athlete usually is in denial
Being referred to psychologist is perceived as
weakness
Goes against the norm of team and being an
athlete
In proactive referral,
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The sport-medicine team is part of the sport
Team is made up of specialist the athlete can go
to when having difficulty
Reducing Problems in being
Referred
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Introduce the sport-medicine team at the
beginning of the season
Discuss the roles of each member of the team
Emphasize that specialists is important in
achieving a complete recovery
Once referred, keep a complete history
including both psychological and medical
information
Eliminate the feelings of abandonment after
being referred
Ethical Issues
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Athletes using steroids
Athlete using nutritional supplements
Coaches who expect the injured athlete to
play in pain
Coaches who insists anti-inflamatory drugs
and cortizone are part of the training regimen
Athlete needs to “make weight” to
participate.
Ethical Status
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My belief is that if I had to take an
estimate, about 65% of the top five,
let’s say top ten in the world in every
event, are doing something illegal.
That is the growth hormones in the
ballistic events and blood doping for
distance events. (quote from athlete,
Ungerleider & Golding, 1992)
Ethics
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Dr. Park Jong Sei, director of Olympic
drug testing in Seoul stated that “as
many 20 athletes at the games turned
up positive but were not disqualified.”
Some coaches have been know to
refuse to train athletes who are clean
(Voy, 1991)
Legal Issues
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AT will regularly be confronted with evidence
of illegal and unethical practices to enhance
performance.
AMA now recognizes AT as allied health
provider.
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With increase professional status increases
vulnerability to lawsuits
With open-free standing clinics, AT are now are
expected to know more
Certification of AT was to protect the public from
incompetent and unethical sports professionals.
Moral Decisions
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Need to have a solid personal value system
Ask your self these questions:
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Is may decision compatible with my values?
Does it feel right?
What is usually done in past when making a
similar decision?
By doing this, what am I saying about myself?
(Simon, Howe, & Kirschenbaum, 1974)
These question will help you to establish
consistency and clarity!!
NATA Ethical Standards
5.
Prevention
Recognition and Evaluation
Management/Treatment
Rehabilitation
Organization & Administration
6.
Education & Counseling
1.
2.
3.
4.
TASK 3: NATA Education
Domain
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Directs the athlete to professionals in
order to receive consultation for social/
and or personal problems by
establishing a referral procedures.
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knowledge of situations requiring
consultation
Knowledge of available professionals
Knowledge of referral procedures
NATA Code
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AT who engage in counseling athletes with
social and/or personal problems would be
considered incompetent by the NATA
AT are expected
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to have knowledge in the area of phychological
readiness for the return to activity
skill in evaluating the athlete’s psychological
status,
And implication of unhealthy situations (e.g.
substance abuse, eating disorders, victim of
assault, abuse, etc.)
Penalty
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Violate the clients right of confidentiality
is extreme.
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Monetary damage
Loss of job
Loss of certification
Loss of Lesser ethical breaches
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Loss of certification
Censure to expulsion from AT organization
Physical Activity and Eating
Disorders
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Individuals often have unrealistic
expectations related to weight
management and PA.
Images of the ideal body
 thin
and fit for women
 fit and muscular for men
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Dieting is often used to attempt to
model these ideals.
Davis (2000) noted 80% of female with
eating disorders exercised excessively
Anorexia Nervosa
1. Refusal to maintain body weight at or above a
minimally normal weight for age and height
2. Intense fear of gaining weight or becoming fat,
even though under weight
3. Disturbance in the way in which one’s body
weight or shape is experienced, unduly
influence of body weight
Bulimia Nervosa
1. Recurrent episodes of binge eating.
a) a discrete period=more food than most people
b) a sense of lack of control over eating during the episode
2. Recurrent inappropriate compensatory behavior in order to
prevent weight gain
3. The binge eating and inappropriate compensatory behaviors
both occur, on average, at least twice a week for three
months
Comparison of Athletes to
Nonathletes
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Athletes as a population might be at-risk
1) Societal norms --favor a lean physically fit
physique -- these societal norms are salient
for athletes
2) Psychological characteristics consistent with
high-level athletic achievement
(perfectionism, motivation), are also
evident in individuals with eating disorders
Athletes experience more eating disorder
symptoms than do nonathletes.
Comparison of Athletes to
Nonathletes

Hausenblas and Carron (1999) metaanalysis
Female
athletes self-reported more
bulimic (ES = .16) and anorexic (ES =
.12) symptoms compared to females from
the general population
Male athletes self-reported more bulimic
(ES = .30) and anorexic (ES = .35)
symptoms compared to males from the
general population.
Comparison of Athletes to
Nonathletes

Hausenblas and Carron (1999) metaanalysis
Male
athletes in aesthetic and weightdependent sports self-reported more
bulimic and drive for thinness
symptomatology versus male comparison
groups.
Females in aesthetic sports self-reported
more of the tendencies to report anorexic
symptoms (ES = .38)
Steroid Abuse and Physical
Activity

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Steroids-- man-made versions of the
primary male sex hormone, testosterone
Athletes are not the only population using
steroids.
 Fireman
 Policemen
 Military
personnel
 Personal trainers
 Regular exercisers
Steroid Abuse and Physical
Activity

How prevalent is steroid use?
The
first nationwide survey of steroid
use among teenage boys 1988
About 7% of high school seniors had
used steroids.
Prevalent in wrestling and football
35% of steroid users did not
participate in any sport
Steroid Abuse and Physical
Activity

Reasons for use
 Improve
athletic performance (47%)
 Improve physical appearance (27%)
 Prevent or treat injury (11%)
 Fit in (7%)

The results of the Buckely et al. (1988)
study subsequently have been
confirmed by more than 40 national,
regional, and local studies
Steroid Abuse and Physical
Activity

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Pope & Katz (1994) examined the
psychological effects of steroid use
Urine samples were obtained to assess
actual steroid use.
23% reported experiencing major mood
disturbances (i.e., mania, anxiety,
depression, or major depression).
Muscle Dsymorphia

A large variety of terms have been used to
describe a form of body image distortion in
which the individual perceives him/herself
as unacceptably small.
(a) pathologically preoccupied with the
appearance of the whole body
(b) concerned that they are not sufficiently large
or muscular
(c) are consumed by weightlifting, dieting, and
steroid abuse.
Summary Part II

Poor communication between athlete
and AT & PT relates to:

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Athlete’s compliance of Rehab
Most athlete’s will have heightened levels
of anxiety
Depersonalizing the athlete, using technical
jargon, and not listening to the athlete are
poor communication strategies.
Summary II (Continued)
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Perception of poor rehab (time) is
linked to allot of negative responses
Most athletes overestimate,and
disagree with the AT or PT on when
they can return to play.
Most coaches disagree with AT or PT
when the athlete should return to play.
Summary II (continued)


The athlete who is self-motivated,
optimistic, high self-efficacy, high pain
tolerance, hardiness, and provided
choices rehab successfully.
Ego involved athletes highly neurotic,
pessimistic, lowly motivated, low pain
tolerance, and low self-efficacy rehab
will be longer and unsuccessful.
Summary II (continued)


AT must refer athletes if they experience
signs of depression, high anxiety, abuse,
assault, and eating disorders.
AT is required to develop and know their
referral procedures, the sport-medical team,
and knowledge in signs and assessment of
psychological disorders.
Part III: Specialized
psychological interventions





Social Support Interventions
Healing Imagery
Goal Setting
Positive self-talk
Stress-Management Strategies
Social Support Interventions

Supported athletes are generally more
mentally and physically healthy due to health
sustaining and stress reducing functions of
social support (Shumaker & Brownell, 1984)




Coach
Parents
Teammate
AT & PT
Social Support Interventions


Social support is critical in the rehab of
the injured athlete (Rotella & Heyman,
1986)
Social support is an effective
psychological technique that motivates
the athlete during rehab (Hardy &
Crace, 1990)
Social Support

Emotional support



Informational support


Behaviors that comfort and indicate that they are
your side.
Listening
Behaviors that acknowledge your efforts, helps
confirm your perceptions
Tangible support

Financial assistance, and rehab knowledge
Providing Emotional Support



Listen carefully
Keep in contact with coaches,
teammates, AT, PT, and parents.
Create an open environment
Providing Informational
Support





AT should develop a context expertise
in as many injuries as possible.
Deliver effective feedback
Use of technical modalities
Create sharing opportunities between
injured athletes
Have successfully rehab athletes with
similar injuries openly discuss the issues
Tangible Support




NATA trainer needs to know rules and
regulations of the sport about the type of
support from booster, alumni, coach, etc.
Let the athlete know exactly what you can
and will do as well as what you cannot and
will not do!
Best tangible support is services received at
the time it is requested.
Refrain from putting the athlete in a state of
indebtedness……give it freely.
Healing Imagery



Healing imagery in which athletes tried to see
and feel the body parts healing
Imagery during physiotherapy when they
imagined the treatment promoting recovery
Total recovery imagery in when they
imagined being totally recovered
Basic Components of Healing
Imagery




Relax mentally and physically
Mentally connect with the injured body part
and imagining healing taking place using all
the senses
See and feel how the body exactly as one
would like it to be.
Imagine the body fully functioning and
performing well in the sport or situation.
Healing Imagery


Arnheim (1985) had the athletes
imagine scar tissue being gobbled up by
“Pac Men”
Searingen (1984) had athlete draw
pictures depicting the healing process
around the factured site of the bone.
Healing Imagery

Create a series of imagines that are
progressional of one’s self from a
injured state to full recovery.

Process-oriented selves
Example of Process-Oriented Selves
(Markus & Ruvolo, 1989)







Self
Self
Self
Self
Self
Self
Self
#1:
#2:
#3:
#4:
#5:
#6:
#7:
Knee at 90 degrees
Strut your stuff
Hurt to get better!
Spring Forward
Let’s Play
Dribble, Drive, and Dive
No brace
Is Goal Setting Effective?
Research has shown that goal
setting is an extremely powerful
technique for promoting rehab,
but it must be correctly
implemented.
Why Goal Setting Works
Key:
Athletes who set performance
(rather than outcome) goals
experience less anxiety and more
confidence and satisfaction
during rehab
Principles of Goal Setting
1. Set specific goals. Specific goals, as
compared with general “do your best”
goals, are most effective for producing
behavioral change.
- I am going to my best in
completing all my exercisers.
-I am going to put forth 100%
each rehab session.
2. Set difficult but realistic goals. Goals
should be “moderately” difficult.
Principles of Goal Setting
3. Set long- and short-term goals.
Link long- and short-term goals to the
outcome which is full recover and return
to the sport.
4.
Set performance and process goals, as
well as outcome goals. For every
outcome goal, set several performance
and process goals that will lead to the
desired outcome.
Principles of Goal Setting
5. Set daily rehab session goals
6. Record goals. “Ink it, don’t think it.”
7. Develop goal-achievement strategies.
Develop specific goal-achievement
strategies that include how much
and how often things will be done in
an effort to achieve full recovery.
Be flexible, however.
Principles of Goal Setting
8. Consider participants’ personalities and
motivations. Consider factors such as
self-motivation, optimism, hardiness,
anxiety, ego involvement.
9. Foster an individual’s goal commitment.
Promote goal commitment by social
support, frequent feedback, and reassessment.
Ways that help athletes
commit to rehab goals





Write them down
State them to others
Keep a log
Provide the athlete constant feedback
about their rehab
Incorporate them into rehab session
Goal Setting System


Developed by Dr. Millslagle
Based on wheel of awareness model
used in athletic performance
Self-Talk

Key to cognitive control
How does positive self-talk
help?

It helps the injured athlete to:


Stay appropriately focused on the present
Foster positive expectations
Common Uses of Self-Talk

Skill acquisition
Changing bad habits
Attention control (being in present)
Creating mood
Controlling one’s effort
Building self-confidence

Injury rehabilitation

Exercise Adherence





What type of self-talk do you
use?

Positive or Negative?





What do you say to yourself after the
injury?
What thoughts appear during rehab?
When do you use self-talk?
Common themes that appear across the
rehab?
What cue words do you use in self-talk?
Cognitive Techniques to
Control the Mind





Thought stoppage
Changing negative thought to positive
thought!
Reframing
Rational thought
Designing coping and mastery self-talk
tapes
Measuring Anxiety
Physiological signs (heart rate,
respiration, skin conductance,
biochemistry)
Global and multidimensional
self-report scales
Trait and State
Anxiety Relationship
State anxiety: “Right now” feelings
that change from moment to moment.
Trait anxiety: A personality disposition
that is stable over time.
High versus low trait anxious people
usually have more state anxiety in
highly evaluative situations.
Recognize Symptoms of Arousal and State
Anxiety
Cold, clammy hands
Constant need to urinate
Profuse sweating
Negative self-talk
Dazed look in eyes
(continued)
Recognize Symptoms of Arousal and State
Anxiety
Feel ill
Headache
Cotton (dry) mouth
Constantly sick
Difficulties sleeping
(continued)
Recognize Symptoms of Arousal and State
Anxiety
Increased muscle tension
Inability to concentrate
What can the AT or PT do?


Change the athlete perception of
severity and importance of the injury
Reduce uncertainity about the injury
Anxiety and Rehab
How anxiety affects rehab depends on
an individual’s interpretation.
Anxiety can be interpreted as
pleasant/excitement or as
unpleasant/anxiety.
Anxiety interpreted as pleasant
facilitates performance.
(continued)
Anxiety and Rehab
Anxiety interpreted as unpleasant
inhibits rehab.
Bottom line:
Athlete’s interpretation of anxiety
determines it’s affect on rehab.
How the athlete should view anxiety
An athlete’s interpretation of anxiety
symptoms is important for understanding
the anxiety-performance relationship.
Viewing anxiety as a facilitator can
promote performance.
Significance of All these Anxiety–Performance
Views
Anxiety is multifaceted.
Anxiety
Physical activation
Interpretation of anxiety
Significance of All the Anxiety–Rehab Views
When anxiety is to high, athletes time
and extent of recovery is hindered.
• Lowly skilled, young athletes or
first time injured athletes are less
able to control their anxiety and
more apt to be overly aroused.
Anxiety Reduction
Interventions

Matching Hypothesis


Somatic anxiety
Cognitive anxiety
Anxiety–Reduction Techniques
Somatic Anxiety Reduction
Breath
control
Learn to control your breathing
in stressful situations.
When calm, confident, and in
control your breathing is smooth,
deep, and rhythmic.
When under pressure and tense
your breathing is short, shallow,
and irregular.
Center Breathing Session
Anxiety–Reduction Techniques
Somatic Anxiety Reduction
Progressive
relaxation
Learn to feel the tension in
your muscles and then to
let go of this tension.
Progressive Relaxation Session
Anxiety–Reduction Techniques
Somatic Anxiety Reduction
Biofeedback
Become more aware of your
autonomic nervous system
and learn to control your
physiological and autonomic
responses by receiving
physiological feedback not
normally available.
Anxiety–Reduction Techniques
Cognitive Anxiety Reduction
Relaxation response
Teaches individuals to quiet
the mind, concentrate, and
reduce muscle tension by
applying the basic elements
of meditation.
Anxiety–Reduction Techniques
Cognitive Anxiety Reduction
Autogenic
training
A series of exercises
designed to produce two
physical sensations—warmth
and heaviness—and, in turn,
produce a relaxed state.
Autogenic Relaxation Session
Anxiety–Reduction Techniques
Multimodal Anxiety Reduction
Stress–
An individual is exposed to
inoculation training (SIT) and learns to cope with stress
(via productive thoughts,
mental images, and selfstatements) in increasing
amounts, thereby enhancing
his or her immunity to stress.
Psychological Interventions for
AT Summary






Provide social support
“Time out” provides opportunities
Involve successfully rehab athletes
Set Rehab Goals
Mention to the athlete that imagery
promotes healing
Listen closely to the athlete’s needs
Psychological Intervention for
AT Summary



Be flexible in your attitude and
approach about the athlete path to
recovery
Mention that stress management
techniques help.
Mention self-talk promotes the time of
rehab
Psychological Interventions for
Athletes (Summary)








Stay involved in the sport
Set daily goals
Develop a physiotherapy plan
Do mental imagery
Use positive self-talk
Emphasize positive aspects of the recovery
Take advantage of the “time out”
Practice relaxation techniques
Part IV: Bio-Psychological
Aspects of Pain
Dr. Duane Millslagle
Associate Professor
University of Minnesota Duluth
Outline




Biological Factors
Psychological Factors
Pain Assessment
Pain Management
Biology of Pain

Pain is a “sensory and emotional”
experience (p.226; Merskey, 1986)



Medical community attempts to explain as
either mental or physical
Medical community view misleads the
athlete
One’s perception of their pain results in
many cognitive-emotional experiences
Pain Experience


Multistage process built on a complex
anatomic network and chemical
mediators that produce pain
This multistage process of the nervous
system is called Nociception.
Nociception
TRANSDUCTION
TRANSMISSION
MODULATION
PERCEPTION
TRANSDUCTION COMPONENT

Noxious stimuli (injury) are translated
into electrical activity at the sensory
endings of the nerves (site of injury)
Pain triggers two sets of receptors:
High threshold mechanoreceptor
Polymodal receptors
Transmission Component

The electrical activity (impulses) are
propagated (sent) through out the
sensory nervous system
Modulation Component

Sensory impulses are modified
(received, registered, and evaluated on
severity and site) neurally involving the
central cortical track and peripherial
sensory inputs.
Perception Component

Transmission, transduction, and
modulation culminates in a cognitiveemotional (perceptual) experience of
pain.
The Transduction Component
How pain is triggered?
Sensitization of Pain
Persistent Pain Syndromes
How is pain triggered?

Two sets of receptors are activated due
to a injury

Mechanorecptors


High threshold receptors (activated when high
noxious signal) which sends signals with
relative speed
Polymodal receptors


Respond to thermal, chemical and mechanical
stimuli and are relatively slow in transmission
Continue to fire after cessation of painful
stimuli
Sensitivity to Pain

Unfortunately these receptors have a
lower threshold of response with
repeated exposed similar stimuli.



Higher sensitivity to pain-producing stimuli
Pain occurs in ordinarily nonpainful stimuli
“This process is called Sensitization
Types of Sensitization

Occurs when there is repeated
exposure to severe pain over days and
weeks.

Persistent pain syndomes


Myofascial and
Sympathetical
Persistent Pain Syndromes

Myofascial pain syndrome



Musculosketal dysfunction
Indicated by points of tenderness when
activated triggers pain (Fine & Petty, 1986)
Sympathetical pain syndrome


Pain that occurs in the arms and legs
Characterized by hypersensitivity of the
skin and burning pain (Roberts, 1986)
Transmission Component




Pain is transmitted via peripheral nerves to
the spinal cord
Spinal cord acts as neurosensory switching
station
Information from periphery is received
centrally (spinal cord) and from the brain via
the descending track
All this information converges using similar
and common neurosensory pathways.
Gate Control Theory of Pain
(Melzack and Wall, 1965)
The processing center in the spinal cord
may either decrease or increase the
intensity of pain as a neuroelectrical
phenomenon and so result in the
perception of relatively lesser or greater
pain than initially signed.
Importance of Gate Theory

Explains why various therapeutic
modalities ranging from cryotherapy to
ultrasound to acupuncture to massage
control the efficacy of pain.
Modulation

The pain signal in spinal cord ascends
to the higher cortical centers of brain
which evoke a emotional-reaction.

One’s Perception of Pain
Perception of Pain




Based upon summation of inputs
Awareness of seriousness of injury
Meaning of the injury
Present state of mind
Once registered as perception, pain sets off a
cascade of electromechanical events via feedback
loop within the nociceptive system that influences
pain transmission and psychological status.
Reaction to Pain is Mystery?
One reaction to pain can produce a wide
ranging of psychological moods.
Sock………………..Enhanced Mood
May be due to the role of:
endorphins (pain inhibitor),
serotonin (pain intermediary),
sensitization and,
pathways that transmit pain & mediators
Psychological Factors


Goal of pain is to give it meaning
(perception).
Pain is interpreted due to:


Prior experience
Current context
Most Important Element



Most important element of meaning is
the assumed status of pain as benign,
or as a sign of injury.
No problem! This a routine pain.
Oh no! I’m really hurt!
Understanding Pain

Understanding if pain as an injury
triggers:





psychological coping,
Awareness of functional limits on athletic
ability,
Memory of similar painful events,
Self-assessment of injury and,
Social psychological reaction by
teammates, coaches, etc.
Pain Assessment

More complex and disstressing the
injury more comprehensive the
approach.


Injury may only involve the primary level
Injury may involve primary, and secondary
levels.
Proven Techniques in
Assessing Pain
1.
2.
3.
4.
Have the athlete rate on a scale 0-10 the
intensity of pain.
Have the athlete indicate the quality of pain
(burning, stabbing, aching, etc)
Daily self-report “pain at its worst” and
“pain at is least”
Indentify specific situations that increase or
decrease pain (specific movements or
exercises)
Pain Management

Common pain management treatments are:

Ice
Untrasound
TENs
Diathermy
Electrical stimulation
Acupressure,
Massage, and

Mobilizing coping resources.






Four Pillars of Psychological
Rehab
1.
2.
3.
4.
Education
Goal Setting
Social Support
Mental Training
The first three fall within the AT and
PT’s scope AMA responsibility and
ability.
Primary Responsibility of AT



Differentiate between benign pain and pain
associated with reinjury and to determine a
relatively safe level of physical activity.
Create a sense of calm and security in the
midst of pain and fear of further injury
Once in rehab, education



Nature of injury
Rehab strategies
Identify pain as a routine aspect of rehab
Part IV: Integrated
Rehabilitation Model:A Team
Approach
Dr. Duane Millslagle
Associate Professor
University of Minnesota Duluth
Psychological Model of
Psychological Response to
Athletic Injury and
Rehabilitation
Model of Postinjury Responses



Identifies the sports medicine team members
whom injured athletes at different levels of
sport participation may interact.
Identify the social-psychological impact of
athletic injury(Anderson & Williams, 1988)
Incorporated the stress model of injury
(Wiese & Weiss, 1987)
Ultimate Goal of the Model

Clinical Model in assessing postinjury
cognitive and emotional responses for
planning appropriate physiological and
psychological interventions.
Members of Sports Team by
Competitive Level

Who should be involved at each level.
Athletic Trainers Role

Controlled communication is a primary
responsibility during initial management
of injury (Wiese & Weiss, 1987)

Role of first responser




What they say
How they say it
Diagnoses must be avoided
Be reassuring, calm, and professional
Role of the Athletic Trainer

At High School and College level the AT plans,
monitor, and evaluates rehab programs this
means the AT has constant contact with the
athlete.


Rehab must be viewed as an educational process
Psychosocial role is vital



Support, encouragement, and reassurance
Positive communication that includes good listening skills
Focus is on adherence to rehag through praise, rewards,
and corrective feedback.
Role of Athletic Trainer



Trainers help the athlete set
performanced based goals
Trainers need to find appropriate
motivation strategies
Trainers need to provide social support

Athlete needs to maintain their social
support network (coaches, teammates,
etc)
Coaches Role

Coaches pay little attention to injured
athletes

The usual causes are the coach knows little
about the athlete’s life outside of sport, the
rehab required, athletes attempt to return
to competition, and stress response of
injury on a athlete.
Coaches Role



They need to care about injured athlete
Understand the rehab
Keep the injured athlete integrated with
the team




Attend practice
Use them as referee in scrimmage
Evaluate others performance
Keep score/times/statistics
Overall Summary

Discussed 5 areas





Psychological Perspective of Athletic Injury
Patient-Practitioner Interaction in Sport
Injury Rehabilitation
Specialized psychological interventions in
Sport Injury Rehabilitation
The Bio-psychological perspective of pain
Integrated Rehabilitation Model:A Team
Approach
Overall Summary

Psychological Perspective





Life stress X Injury Rate Relationship
Proactive Approach
Personality Affect on Injury Recovery
Stage and Social Appraisal Model
Type of Injury: Macro and Micro
Overall Summary

Patient-Practitioner Interaction


Communication
Adherence determinates





Positive: Self-motivation, pain tolerance, choice,
and hardiness
Negative: Ego involvement & trait anxiety
Referral Process
Sports Medicine Team
Ethical Issues
Overall Summary

Specialized Interventions




Goal setting
Social support
Healing imagery
Social support
Overall Summary

Psychology of Pain







“Sense and emotional experiences”
Nociception
Receptors
Sensitivity to Pain
Gate Control Theory
Pain Assessment
Pain Management
Overall Summary

Integrated Rehab Approach




Know the roles of each member
Preinjury factors
Personal history, situational factors, social,
and environmental moderators
Responses to injury


Cognitive, emotional, & behavioral
Physical & Psychological Recovery Process
The End

Areas which you should study about
are:


Using imagery in rehabilitation
Working with athletes with permanent
disabilities
Role of Sport Psychologist

Usually sees the player within a few days of
injury

First meeting



Interview the athlete alone about history and nature of
injury
Conduct it the ones office
Interview format of first meeting



Explain the role of sport psychologist
Qualification
Have the athlete complete the Emotional Response of
Athletes to Injury Questionaire (ERAIQ) –Smith, Scott &
Wiese, 1990)