Psychology of Injury Steven Sutherland, MD, & Rick LaCaille, PhD Primary Care Orthopaedics Conference March 23, 2012 Learner Outcomes 1) Define physiological & psychological stress responses to injury 2) Develop strategies for mental health assessment of physical injury 3) Identify the roles of the clinician & non clinician in the mental health assessment of physical injury 4) Discuss successful management of stress response and adaptation to injury 1
Prevalence of Injuries Over 23 million sport injuries per year Nearly 50% of all amateur athletes suffer an injury that precludes participation About 25% of these requiring > 1 wk of non participation 4.3 million annual visits to ER for sport & recreation related injuries Cited in Williams & Andersen (2007) Psychology of Injury As much as you love to play a game, there comes a time to face reality. When things are going well, you don t see it coming. When you are forced to change your plans, to look to the next phase of your life, it s very hard, but my body was not answering anymore. I finally had to say that s enough. My reputation was as a good, hard worker, who had some good stats, but when you re injured, no one wants to take a chance on you. Junior Lessard DNT (2/10/2012) 2
Psychology of Injury Increased emphasis on understanding the relationship between injury & psychological issues related to injury. Team Physician Consensus Statement (2006) American Academy of Family Physicians American Academy of Orthopaedic Surgeons American College of Sports Medicine American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Sports Medicine Psychology of Injury Mann et al. (2007): Survey of sport MDs (n = 857) 80% discussed injury related psychological issues 54% agree completely it is their role/place/responsibility to discuss with pt athletes Frequency (%) Suspected Their Pt-Athletes Having Difficulties Often / Sometimes Stress / Pressure 88% Anxiety 84% Family / Relationship Problems 74% Disordered Eating / Body Image 70% Depression 69% 3
Psychology of Injury Psychological aspects of sports injury split into two broad categories: 1. Psychological antecedents that increase an athlete s risk of developing an injury, 2. Psychological reactions to injury & their impact. Diagnosis & treatment of mental health conditions, regardless of injury status, are important. Comparable prevalence to non athletes, though some may be higher in some sports (e.g., eating disorders) Nathan s Story Sections 0:18 2:30 & 5:30 6:45 4
Psychology of Injury Biological (e.g., conditioning, biomechanics, overtraining) Physical (e.g., weather, equipment, playing surface) Sport Injury Risk Psychological (e.g., life event stress, risk taking, mood states, beliefs) Sociocultural (e.g., sport norms / rules, officiating / coaching quality, medical interactions) Adapted from Wiese Bjornstal (2009) Psychology of Injury Psychosocial factors influence injury through linkage with stress & resulting stress response Stress response: Greater physiological activation & attentional disruptions Bi directional relationship between cognitive appraisal of stressful situation & physiological / attention aspects of stress 5
Stress Injury Model History of Stressors Coping Resources Personality Stressful Situation Stress Response Cognitive Physiological/ Appraisals Attentional Changes Injury Interventions Adapted from Williams & Andersen (2007) Athlete Scenario: J.R. is a senior starter on the high school soccer team and has been wanting to be seen by college coaches. Consequently, he is feeling an increased pressure to perform and take chances on the soccer field. He reports chronic anxiety, particularly in games and competitive situations, and often shows physical signs ranging from sweaty palms to muscle tension. High levels of perceived stress, including frequent daily hassles and some more significant negative events (relationship breakup, performing poorly academically) have also been present over the past year. The combination of these pressures have resulted in J.R. finding it more challenging to maintain his focus and concentration on the game, which he admits has led him to fail to identify some cues and avoid risky situations, such as blind side tackles. 6
Response to Injury & Rehabilitation Injury Personal Factors Cognitive Appraisal Situational Factors Behavioral Response Recovery Outcomes Emotional Response Adapted from Wiese-Bjornstal et al.(1998) Response to Injury & Rehabilitation Personal Factors Psychological: Traits Mood states Identity Physical, Injury severity, etc Demographics Situational Factors Sport type level of competition, ii etc Rehab environ. & access Cognitive Appraisal Self perception Rate of perceived recovery Beliefs & attributions Goal adjustment Social: Team mates Coach Providers Behavioral Response Adhere to rehab Effort & intensity Use of social network Risk taking Malingering Emotional Response Frustration, boredom Depression, anger Fear, anxiety Relief Optimism, 7
Predictors of Rehabilitation Outcome Brewer s (2010) review: 26 correlational studies (Predominantly ACL injuries) Positive predictors PT attendance Use of Goal setting, healing & recovery imagery Active coping direct addressing of emotions, as opposed to avoidant coping Internal health LoC Negative predictors Psychological distress/ anxiety/ depression 10 20% of disabling injuries result in clinically significant symptoms Avoidant coping External health LoC Role of Practitioner Screen for MH & factors Education: Oral & written material Communication & active listening Social support Enhance athlete s efficacy beliefs: Self & rehab Using short & long term goal setting Enhancing pain tolerance Refer & consultations 8
Assessment Preseason screen for psycho social factors SF 36 Mental Health subscale (8 items) Center for Epidemiological Studies Depression (CES D) Scale (20 items) Self Presentation in Sport Questionnaire (33 items) Performance/Composure Appearing fatigued/lacking inadequacies energy Physical appearance Appearing athletically untalented Assessment Recognize stress related symptoms: Selected Signs & Symptoms of Stress Behavioral Physical Psychological Difficulty sleeping Feeling ill Negative self-talk Lack of focus / overwhelmed Profuse sweating Self doubt Cold, clammy hands Consistently performs better in Uncontrollable Headaches practice / training than in intrusive & negative Increased muscle competition thoughts / images tension Substance abuse Altered appetite Inability to concentrate Consensus Statement (2006) 9
Assessment Recognize problematic emotional response to injury: Doesn t resolve, worsens over time, or severity seems excessive relative to other injured athletes Problematic Emotional Reactions (Examples) Persistent Symptoms Worsening Symptoms Excessive Symptoms Alterations of appetite Alterations of appetite into disordered eating Pain behaviors Sleep disturbance Sd Sadness into it depression Excessive anger / rage Irritability Lack of motivation into apathy Frequent crying / emotional outburst Disengagement into alienation Substance abuse Consensus Statement (2006) Interventions Research supports use of both prevention & rehab. Improved strength, endurance, recovery time Techniques / Strategies Social Support Somatic-based Cognitive-Behavioral Rehab team provide informational & emotional support Models successful rehab athletes Team-mate contact / ensure stays involved with sport Biofeedback* Slow, deep, or centered breathing* Thought stopping* Thought replacement & guided imagery* Mdl fl Progressive muscle Positive self-talk* tlk* relaxation* Goal setting* Brewer (2010)*,Consensus Statement (2006); Podlog et al. (2011) 10
Interventions: Somatic Sample Progressive Muscle Relaxation Script (handout): Sit or lie down in a comfortable position & try to put yourself in a relaxed state. Close your eyes & take a long, slow, deep breath through your nose then exhale slowly & completely, feeling the tension leaving your body. Take another deep breath relax as much as possible remember not to strain to relax. Just let it happen. During the session, try not to move any more than necessary to stay comfortable. Particularly, try not to remove muscles that have already been relaxed. As we progress through each of 12 muscle groups, you will first tense the muscle group for approximately 5-7 seconds and then relax for 20-30 seconds Williams (2006) Interventions: Cognitive Behavioral Practitioners may help reframe athlete s perspective via shifting focus onto: 1. Intrinsic reasons for sport involvement ( love of the game ) 2. Personal satisfaction in learning new skills 3. Social benefits of sport involvement Example 1 Negative statement: I m concerned that I may let my team-mates down if my fitness isn t what it used to be. Replacement: Stop. I ve worked hard in rehabilitation to get my fitness where it is & it will only continue to improve with time. Ultimately what counts is that I get to do something I love & I m excited to play again. Podlog et al. (2011) 11
Interventions: Cognitive Behavioral Example 2 Negative statement: I m worried about what the coach (or others) will think if my skills & ability aren t as good as before the injury. Replacement: Enough. What the coaches think of my skill level isn t under my control. I know I ve been practicing my skills while injured & my technique has only gotten better. It s great that I get to compete again. Podlog et al. (2011) Interventions: Cognitive Behavioral Guided Imagery Example 1 Golfer & torn rotator cuff: Cannot play for the duration of the healing process & having problems consistently driving the ball. Visualize a proper swing via going through the entire routine before a drive, visualizing his feet correctly aligned & his hands gripping properly He can walk through h each second of the drive focusing on the placement of his head, shoulders, arms, & legs The golfer can imagine how the club feels, how his body is oriented, how a good drive sounds, & how a course smells Williams (2006) 12
Interventions: Cognitive Behavioral Guided Imagery Example 2 Runner with foot injury: Undergoing a lengthy recovery & unsure of ability to succeed upon her return. Imagine herself as through a video camera on track, hearing crowd, feeling ground beneath spikes, smelling turf & rubber Visualize pack entering last 100m & in 3 rd place see determined gleam in eyes & bulge bl in muscles as legs propel forward See smooth stride as overtakes 2 nd & heads for 1 st see her sweat & quick but steady breathing Williams (2006) Interventions: Cognitive Behavioral Goal Setting Staircase format: easy / attainable harder / longer term Realistic, specific, measurable vs. Vague, easy, do your best I.D. clear objectives for rehab process through different goals & levels (4). Recovery goals Stage goals Daily goals Lifestyle goals Taylor & Taylor, 1997; Weinberg & Gould (2007) 13
Interventions: Cognitive Behavioral Recovery Goals (Long Term) Stage Goals (Medium Term) Daily Goals (Short Term) Lifestyle Goals Sleep, diet, alcohol use, work/school, relationships Physical Goals RoM, strength, coordination, stamina Performance Goals Technical skills Psychological Goals Confidence, focus Taylor & Taylor (1997) Interventions Referrals Licensed mental health practitioners are typically y more easily accessed (or, at least, the referral patterns are more clear) in college health service settings In other populations, referral patterns may differ between each Primary Care Provider, family, insurance network 14
Interventions Mental Health For those who meet criteria for: Mood disorder (esp. Major Depression) Anxiety disorder Substance use disorder Eating disorder Clinical care is necessary not just for accommodation to injury, but to reduced risks & disability associated with mental health disorder Interventions Mental Health Treatments include: Psychotherapy Office based Intensive (Partial Hospitalization / Intensive Outpt) Medication Most commonly, SSRI antidepressants Athletes often express appropriate concern re: side effects affecting performance Of the medications commonly used in psychiatry, only anticholinergic medications (e.g., tricyclic antidepressants, mirtazapine), Beta blockers, & benzodiazepines have been shown to predictably impair athletic performance. 15
Citations American College of Sports Medicine, et al. (2006). Psychological issues related to injury in athletes and the team physician: a consensus statement. Medicine and Science in Sport and Exercise, 38, 2030-2034. Brewer, B.W. (2010). The role of psychological factors in sport injury rehabilitation outcomes. International Review of Sport and Exercise Psychology, 3, 40-61. Mann., B.J., Grana, W.A., Indelicato, P.A., O Neill, D.F., & George, S.Z. (2007). A survey of sports medicine physicians regarding psychological issues in patient-athletes. American Journal of Sports Medicine, 35, 2140-2147. Podlog, L., Dimmock, J., Miller, J. (2011). A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. Physical Therapy in Sport, 12, 36-42. Taylor, J., & Taylor, S. (1997). Psychological Approaches to Sports Injury Rehabilitation. Aspen Publishers: Gaithersburg, MD. Weinberg, R. S., & Gould, D. (2007). Foundations of sport and exercise psychology (4th ed.). Champaign, IL: Human Kinetics. Citations Wiese-Bjornstal, D. M. (2010). Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: A consensus statement. Scandinavian Journal of Medicine and Science in Sports, 20, 103-111. Wiese-Bjornstal, D. M., Smith, A. M., Shaffer, S. M., & Morrey, M. A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10, 46-69. Williams, J. M. (Ed.). (2006). Applied sport psychology: personal growth to peak performance (5th ed.). Boston: McGraw-Hill. Williams, J.M., & Andersen, M.B. (2007). Psychosocial antecedents of sport injury and interventions for risk reduction. In G. Tenenbaum & R. C. Eklund (Eds.), Handbook of sport psychology hl (3rd ed., pp. 404-424). 424) New York: Wiley. 16