Sunday, November 18, 2012

Helping the Injured Athlete Return to Play

The Injured Athlete: Getting Back: in the Saddle, on the Slopes, on the Field, on the Track (You Get The Idea!): A talk presented at the Vail Summit Orthopedics CATA conference, Edwards Colorado, November 17, 2012

Take a moment to imagine the following: You've been playing your sport as far back as you can remember. You’ve built strength, and endurance and you’ve perfected your technique. Your entire life revolves around practice, performance and competition. You love your sport. It’s who you are! It’s the most important part of your life and your identity.  Its how you spend your time and what you’ve built your plans and dreams around. 

Then the unimaginable happens. Suddenly you're injured and you can’t play.

For a serious athlete the physical pain of an injury is only one VERY small part of the suffering experienced as a result of that injury. The severity and impact of the emotional pain and the temporary or permanent loss of your sport can far exceed any physical discomfort from the physical injury. Emotional suffering must be addressed for rehabilitation to be successful. Coaches, trainers and rehab professionals who are sensitive to these issues facilitate the rehab process. Professionals and loved ones who don’t recognize the importance of emotional issues in recovery can further traumatize the injured athlete and may compromise the healing process.

To better understand what happens psychologically when an athlete is kept out of action because of an injury, it's important to consider three major roles that sports play in the life of a serious athlete.
       Sports fulfill multiple needs for athletes
       The injured athlete experiences multiple losses:
       Sense of identity / role / teammate
       Loss of physical health / invincibility
       Loss of Independence
       Sense of alienation and isolation
       Loss of recognition / esteem
       Loss of major way they spend time
       Loss of constructive outlet for stress
       Sports fulfill multiple needs for athletes

Identity – For serious athletes the sport is their life. They’ve invested years of time, energy and pain. It's how they see themselves and how others see them.

Self-esteem - For most dedicated athletes, sports provide ongoing positive reinforcement and feedback. The enjoyment and self-satisfaction that come from mastering new skills, overcoming new challenges and progressively growing stronger and better is a central source of self-esteem. The recognition of your accomplishments by friends, family and members of the community feed the athlete’s sense of joy and accomplishment. A well-played game, race or match feels fantastic and provides tangible evidence that the athlete’s hard work has paid off.

Stress-managment - Physical exertion is a great stress reliever. When people have no physical outlets they tend to internalize their stress, often leading to headaches, GI complaints or other physical symptoms. Many athletes find that their involvement in sports also provides an escape from family, school or relationship problems. Participation in sports is also a healthy way for athletes to manage frustration and anger.

Normal Reactions to Injury may include: Initial denial / minimizing  - Grief and mourning - Sadness - Anger - Questioning - Frustration- Loneliness- Helplessness - Disillusionment - Boredom - Anxiety - Fear

Worrisome Reactions to Injury
       Prolonged denial of the injury itself, injury severity and / or response to recovery or limitations
       Obsession with return to play
       Extreme guilt
       Impatience and Irritability
       Rapid mood swings
       Suicidal Ideation
       Panic Attacks
       Aggression and Raging

Depression: What to Watch For: Low self-esteem - Sadness - Irritability - Hopelessness -Tearfulness - Indecisiveness - Difficulty Concentrating - Guilt - Lack of Motivation - Agitation/anxiety - Loss of sex-drive - Suicidal thoughts - Loss of interest - Lack of Energy - Unexplained Aches and Pains - Disturbed sleep or appetite - slowed speech or movement - Social withdrawal - impaired school or work performance

Negative thoughts often accompany depression: Why me? -  It’s not fair - Why now? - If only… - But now I can’t / won't - I’ve worked too hard for this to happen to me! - I’ve let everybody down - Nobody cares - Nobody understands - Nobody can help me - I can’t handle this -  It will never get better - I’m being punished for my sins -  I’m a loser - It’s hopeless - I can’t take it anymore - Everyone would be better off without me - I’m a burden -The future holds nothing. - What now?

Depression in Athletes after Injury: Statistics
      Over half become depressed
      10-15% seriously depressed
      80 % experience symptoms of depression
      Suicide is rare
      Time frame determined by physical recovery time frame
      Highly treatable with psychotherapy

       Intense memories, dreams, nightmares
       Uncontrollable strong feelings
       Pushing people away
       Negative thoughts
       Hyper-arousal and agitation
       Concentration problems
       Sleep disturbance
       Fear of re-injury

Substance Abuse Issues in Athletes Recovering From Injury
Alcohol abuse
Illicit drug abuse
Prescription drug abuse: easy for professionals, coaches and trainers to be complicit in prescription drug abuse or even encourage it.  Must challenge the athlete about abuse

Psychotherapy can be highly effective in helping people cope with injuries, overcome depression or PTSD from their injuries and recover more quickly and completely from their injuries.  Of course, psychotherapy is very cost-effective too.  A course of psychotherapy to assist an athlete in recovering from injury will often cost less than a single MRI.

Psychotherapy techniques to assist athletes in recovery from injury
       Supportive listening
       Coping skills training
       Problem solving and planning
       Relaxation skills
       Communication skills
       Mood regulation
       Visualization and hypnosis to facilitate recovery and return to play

Advice for the Athlete Recovering From Injury
       Accept your feelings
       Learn about your injury
       Learn about your treatment
       Be an active participant in your care
       Take responsibility
       Set achievable goals
       Maintain a positive attitude
       Follow treatment recommendations
       Self monitor
       Work hard within guidelines
       Practice patience, with yourself and with your body
       Seek and accept social support

Social Support after Injury Can:
       Maintain a connection with the team during rehabilitation and recovery
       Help with treatment
       Help with daily tasks
       Make the athlete comfortable asking for help
       Provide education and answers
       Offer empathic listening and opportunity to vent
       Be encouraging
       Provide a positive opportunity for distraction / fun / pleasure

Suggestions For Recovering Athletes
       Bring a list of questions to your doctor’s appointment or therapy sessions
       Participate with your team in non-active ways
       Have friends / team mates / coaches check in with you
       Schedule activities with friends
       Plan ahead and ask for help if you will have mobility issues
       Get assistance with transportation needs

Set Appropriate Goals
       Injury can be another training challenge
      Focus on recovery rather than performance
       Maintain motivation
       Focus on small incremental improvement
       Work closely with therapist or doctor
       Obey doctor’s orders about pace of rehab
       Accept injury and know your limits
       Maintain fitness while injured
       Knowing what to expect can facilitate sense of control and agency

How can medical professionals facilitate recovery in injured athletes?
       Build trust and rapport with the injured athlete
       Listen to concerns and provide honest answers
       Assess and monitor the athlete’s emotional state
       Educate the athlete about the injury
       Identify misinformation
       Involve the athlete’s family, coach and trainer
       Prepare the athlete and coach for the recovery process
       Encourage the development and use of coping skills
       Recognize return to play issues
       Screen for depression and other mental health concerns
       Refer to a psychologist with expertise in sports psychology and / or rehabilitation psychology     if needed

How can Trainers and Coaches Facilitate Recovery?
       Be empathic and caring
       Build up the athlete’s self-esteem
       Discourage self pity
       Take an interest in the recovery process
       Encourage realistic goals
       Offer general encouragement and emotional support
       Listen to the athletes concerns and feelings
       Encourage optimistic ways of thinking and discourage pessimism
       Discourage maladaptive ways of thinking such as “no pain-no gain” or “suck it up”
       Monitor athlete for depression, substance abuse or other mental health problems
       Encourage acceptance of help from a psychologist if indicated
       Encourage patience and realistic expectations

How can Trainers and Coaches Facilitate Recovery?
 Reach out to the athlete, do not wait for him to reach out to you
      If the athlete is in the hospital, visit, bring greetings from the team
      Participate in family conference if invited
      Visit at home during recovery
      Accompany to physical therapy if appropriate
Keep the athlete involved with the team
      Keep athlete in touch with team activities and issues
      Give the inured athlete achievable team related tasks
      Have the injured athlete participate in team activities in non-injurious ways
      When appropriate expect the athlete to participate in practice (with modifications) 
Do not allow social isolation and withdrawal
      If necessary assign team mates to check up on or provide practical help
Make the athlete accountable for participation in rehab
Participate in return to play issues and decisions
Encourage athlete to maintain fitness during rehabilitation

How can Trainers and Coaches Facilitate Recovery?
Gently help the athlete get in touch with other areas of personal strength, creativity, interests and ways to participate in their sport in new ways if they are faced with a long-term recovery or permanent disability

I hope you help the athletes you work with fulfill their dreams.  I hope some of the information I’ve shared today will help you do that even better than you might have imagined. I will end with another quote from the same person who’s quote introduced this talk.

Wise words for recovering athletes:
 “Speak quietly to yourself and promise there will be better days. Whisper gently to yourself and provide assurance that you really are extending your best effort. Console your bruised and tender spirit with reminders of many other successes. Offer comfort in practical and tangible ways — as if you were encouraging your dearest friend. Recognize that on certain days, the greatest grace is that the day is over and you get to close your eyes. Tomorrow comes more brightly.”
 *** Mary Anne Radmacher:

I hope in your work you help athletes have tomorrows that come more brightly.
That is the most precious gift you have to give.  Thank you for your attention and may your tomorrow burn more brightly too.

Twitter: @drjsquyres    Facebook: JillSquyresPhD

Not to be copied without written permission.
Text copyright 2012 by Jill Squyres, PhD.  All Rights Reserved

What One Jill Learned From Another: on Skiing and Recovery from Spinal Cord Injury

What one Jill learned from another: on Skiing and recovery from Spinal Cord Injury

“Courage doesn’t always roar. Sometimes courage is the little voice at the end of the day that says, ‘I’ll try again tomorrow.’” Mary Anne Radmacher

When I was a teenager, I was looking through the TV Guide and saw that the Sunday Night Movie was about a teenager named Jill who suffered a ski accident.  I’d never been skiing but I didn’t know too many other Jills so I thought I would watch the movie.  It was a life changing experience.  As some of you may guess, the movie was called “The Other Side of The Mountain” and it was about a skier name Jill Kinmont. 

Jill Kinmont Boothe was the national women's slalom champion and on the cover of Sports Illustrated when she competed in a 1955 race to qualify for the U.S. Olympic ski team. Speeding down an icy Utah ski slope, she lost control, struck a spectator, crashed and hit a tree. She broke her neck and suffered high level quadriplegia.
I was transfixed by her story.  She suffered multiple tragedies beyond her initial injury and yet her strength and resilience kept rebounding and she found ways to go on with a meaningful and productive life, although she never skied again.  I read her books and watched the movie’s sequel.  I thought she was amazing.  Whenever I felt like I couldn’t do something because it was too hard, I imagined how she pushed herself and I pushed myself too.  I also became fascinated with skiing, which I’d never tried.  I learned to ski and fell in love with the sport.

In 1982, I was spending a research year at Stanford while getting my doctorate from USC.  I was driving my car on El Camino Real in Mountain View California.  The person driving the car behind me didn’t realize I was stopped at a red light.  He slammed into me going 35 miles per hour.  Initially, I thought I was fine and I went home.  In the morning, I awakened with pain and numbness in my hands and arms.  X-rays at Stanford University Hospital (this was pre-MRI) revealed a C-7 “clay-shovelers” fracture.  I cried when I thought about skiing and the bike that I might never ride again.  And then I remembered Jill Kinmont.  If she could prevail I could too.
This sparked my lifelong interest in behavioral medicine and rehabilitation psychology.  By the end of 1983, I was back on my bike and the following winter I was back on my skis.  I chose to specialize in spinal cord injury psychology and chronic pain management during my psychology residency.  In 1990, I took a job as the psychologist on the Spinal Cord Injury Unit at the VA Hospital in San Antonio, TX.  In 1997, I spoke at the American Association of Spinal Cord Injury Psychologists and Social Workers conference.  The speaker who followed my talk was Jill Kinmont Booth.  After she finished, I walked up to her put out my hand to shake hers (she had learned a graceful way to do this, as many people with quadriplegia do).  I said “Hi Jill, I’m Jill and I’ve been wanting to meet you since I was a young teenager.”  I got to spend time with her and her husband, snapped some priceless photos and was able to share my story.  It was a wonderful moment for us both. 

Jill Kinmont Boothe (who sadly passed away this February at the age of 75) and I were both featured speakers at the American Association of Spinal Cord Injury Professionals conference in September 1997 in Las Vegas, NV

On Christmas Eve 2001, I suddenly experienced the spontaneous rupture of two discs in my cervical spine at C4-5 and C5-6.  I had an emergency discectomy and fusion the first week in January and had to start my rehabilitation from scratch with significant weakness, some neurological symptoms and pain.  I was able to see and read my MRIs so I knew what damage Dr. Swan had to fix.  Little pieces of the ruptured discs had to be delicately extricated from my spinal cord before the fusion could take place.  I adjusted my attitude in the positive direction and spent the time prior to my surgery visualizing the upcoming repair and restoration of my spinal cord. 

Post-up, Dr. Swan came to check on me shaking his head.  When he realized he’d frightened me he quickly clarified my misperception.  He said “Its remarkable.  What I saw when I went in bore only slight resemblance to what the MRI showed.  I actually made them pull a fresh copy of the films to verify I had the right patients films and I did.  The site I was operating on was much cleaner and easier to work with than I had been lead to believe from the imaging studies.  As a result, a projected 4+ hour surgery was successfully completed in 90 minutes.” 

When I had awakened from the anesthesia, I could move my arms and feel my fingers again.  And Dr. Swan had (appropriately, given his name) appreciated the importance of a lovely neck so he brought in a top plastic surgeon to close my incision.  Usually a dry pragmatic man, my neurosurgeon was floored by my amazing recovery.  I went through extensive PT (at Health South where the San Antonio Spurs go) to overcome weakness in my arms and a drop foot on the right.  Once again, I had been told “no more skiing”.

I finally got to test my compliance to the doctor’s order last year when we came to use our time share in Avon Colorado and ski at Beaver Creek.  I was apprehensive.  I relished the cold smoothness of my skis as I put them on and the satisfying snap as the boots locked into the bindings, I took it easy and only got a bunny slope ticket to give a nod to caution.  I got to the top of the slope, pointed my skis in the right direction and ‘woosh', I was flying.  For the first time in over 20 years I have my own equipment again and nothing except common sense will hold me back.  I’m a skier again and I’m a skier who now lives in the Vail Valley.  A dream come true!

Twitter: @drjsquyres    Facebook: JillSquyresPhD

Not to be copied without written permission.
Text copyright 2012 by Jill Squyres, PhD.  All Rights Reserved