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

•       Rebelliousness

•       Impatience and Irritability

•       Rapid mood swings

•       Hopelessness

•       Suicidal Ideation

•       Apathy

•       Panic Attacks

•       Depression

•       PTSD

•       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

PTSD

•       Intense memories, dreams, nightmares

•       Uncontrollable strong feelings

•       Flashbacks

•       Avoidance

•       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

•       Cognitive-restructuring

•       Coping skills training

•       Problem solving and planning

•       Self-management

•       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.

drjsquyres@mac.com

www.drjillsquyrespsychologist.com

Twitter: @drjsquyres    Facebook: JillSquyresPhD

Not to be copied without written permission.

Text copyright 2012 by Jill Squyres, PhD.  All Rights Reserved

Dear Dr. Jill on Summer Vacation

Originally published in Oak Meadow Elementary School Hoofprints Newsletter April 2004

Dear Mommy (even if everyone else calls you Dr. Jill),

How can we have the best summer ever?

Love Greg, Bradley & Nikki

My dearest children,

First I will tell you why we have such a long summer vacation.  In the olden days, back when your great-great grandparents were children, most people lived on farms.  Farm families had LOTS of children because more children meant more help on the farm.  Everybody knew school was important, but taking care of and harvesting the crops was even more important.  They couldn’t just go down to the grocery store for their food, so if they didn’t take care of the farm, they would be hungry.  For this reason, children didn’t go to school during the summer because this was the time they were needed to work on the farm.  Not much of a vacation, was it?

Children today have lots of time off during the summer and usually there are no crops to care for.    I want to get together one night, make some popcorn, and find out what everybody in our family likes doing best.  To have the best summer ever, we need to spend lots of time doing the things we like best.  I know we will want to do lots of swimming and bike riding.  Lets plan on some lazy breakfasts where we all help make the pancakes or eggs. I think this might be a good summer for you kids to learn some cooking.  Lets take the time to learn to bake a cake and make grilled cheese sandwiches.  Yum yum!  Spending time with friends sounds great too.  Sometimes your friends can come to our house.  Remember they must follow our rules about inside voices, walking instead of running, listening, sharing and keeping hands to selves.  Other times you can go to their houses to play.  Behave well and win the good guest medal by being invited back!  I think the best times are when you go outside and you run, feel the wind, giggle, roll in the grass, get sweaty and hot, and then drink something cold or have a popsicle.  Playing with the hose or in the pool are special summer treats too.

We are planning two very special vacations this summer.  We will go to Disneyworld and to the beach at South Padre Island.  We will spend lots of good times together.  At Disneyworld  we get to go on rides, eat interesting food, ride trams and see things we’ve never seen before.  We will take an airplane and stay in a hotel so we must remember to be respectful, polite and kind.  I will pack bags with treats and activities to keep you busy.  Traveling is a great time for gameboys, coloring or reading books.  When we go to the beach, we will drive.  Lets have a nice time in the car.  We can sing and talk and listen to music or books on tape. Looking at the scenery, animals, clouds, plants, houses and train tracks can pass the time quickly.  At the beach, you have to remember to always wear sun screen and stay where an adult can see you.  Don’t go in the water without permission! We will eat in lots of restaurants on both trips.  Talk in a calm, inside voice.  Order only what you plan to eat.  Sometimes we will get dessert but not every day so please don’t complain.  Complaints are never welcome, although suggestions usually are. 

Summer vacation is a long time away from school.  It is easy to forget the things you worked so hard to learn this year.  A good way to stay smart is to read.  We will try to read at least 30 minutes every day.  You are all good readers so I bet there will be many days you will want to read even more than that.  We can go to the library or bookstore to pick out some interesting books. We can play math games in the car or at dinner.  You can go to the store with me and help me pick out what we need and figure out what we are spending.  Computer math games are a good way to stay smart too.

Remember when I told you about the farm children earlier?  Summer vacation can be a good time to learn new skills and chores.  We all enjoy living in the house together so we all must pitch in and do our part.  Lets talk about chores AND allowances.  Its nice to have pocket money to buy what you want and to learn about responsible spending.  

The most important way to have the best summer ever is to enjoy time as a family and time by your self.  We have the most fun when we are kind and considerate and generous with each other.  We are happiest when we take turns and practice patience.  At night, we can sit outside and watch the stars and moon.  Maybe we will see constellations or planets.  Sometimes we can catch fireflies but we must always let them free before we go inside.  I also like to watch our pets playing.  It is so relaxing!  Our dog does funny things that make us laugh.  Our cats are so cute together and love to be petted gently.  We should spend time outside watching the clouds, blowing bubbles, playing games and walking in the woods.  Maybe we can go through some old photos together and talk about your grandparents and what life was like when Mommy and Daddy were your age. Quiet time spent thinking about our love for each other, what we are grateful for and how to be the best we can be is a good way to spend hot afternoons.  Its so easy to forget how nice it can be to do nothing.

Sounds like a good plan for the best summer ever doesn’t it?  I can’t wait!  

Check out my website: drjillsquyrespsychologist.com

Follow me on twitter @drjsquyres

Follow me on Facebook