Wednesday, 22 April 2015

Overcoming Injury - Mind over Matter?

This essay by Anna Reynolds was a finalist in this year's Ithaka Prize. 

You may think your body’s failed you, but behind every injury there is psychology. My initial thoughts on this subject were that the only thing that can help recovery in the rehabilitation process is advice from doctors and physiotherapists on exercises and physiological strategies to overcome the injury. However, more recently sports psychologists have identified that the main hurdles when facing an injury are athlete’s psychological responses. Physiotherapists, doctors and nurses can work their magic and do everything possible for an athlete, however if that individual does not have the right mind-set for recovery, then that injury will continue to loom over them.

I intend to discover the role of sports psychologists within elite sport and how they can help athletes’ recover from injury as well as aiding their performance on and off the pitch. Firstly I will consider the main causes of injury through the use of several case studies. These highlight the causes and show that they can have a serious effect on an individual’s sporting career.

Injuries occur for a number of reasons; there are four main causes: physical, environmental, socio-cultural and psychological. Physical causes include fatigue, overuse and muscle imbalance. Environmental causes involve things such as unsafe or broken equipment and slippery surfaces.

Socio-cultural causes are the attitudes and philosophies of teams and cultures that cause injury e.g. the idea that pain tolerance shows strength and resilience and seeking medical attention is a weakness and inferior to fighting through the pain, the notion that injury is a part of sport. Dan Pfaff, the American athletics coach who trained Donovan Bailey, Greg Rutherford and Jonnie Peacock believes that in elite sport there is a mentality for athletes to push their bodies and keep on pushing. Pfaff believes there is a breaking point and often athletes overwork their bodies and end up with an injury, which could have easily been avoided. In our sporting society many of us adopt the “no pain, no gain” attitude, however Pfaff believes that this can do more harm than good.

Finally there are psychological causes; evidence suggests that there are two main categories: stress and personality. Psychological research has suggested that risk of injury is in proportion to levels of stress, so when more stressed, you are much more likely to suffer an injury. This is due to several factors; firstly the stress acts as a distraction so an athlete is less likely to focus on their sport, and risk of injury is enhanced. Secondly, stress narrows an athlete’s attention so they could miss important cues and stimuli. Finally, stress increases an athlete’s muscle tension; this inhibits the coordination of movement, therefore increasing risk of injury.

One example of an elite athlete coping with high levels of stress and the detrimental affect that had on their performance is Sir Steve Redgrave. Having already won two rowing Olympic gold medals previously in his career, in 1992 Redgrave was diagnosed with ulcerative colitis. Throughout the 1992 season there were only two months when Redgrave was fit and healthy; during this time he completed one of the best races of his life and managed to win his third Olympic gold medal with Matthew Pinsent in Barcelona.

The second hurdle Redgrave had to overcome had a detrimental effect on his mental state. In November 1997 he was diagnosed with type 2 diabetes, Redgrave thought this was the end of his career. He believed there was no way he was going to be able to compete at such a high level with the condition; he thought it was all over. However when he spoke to his specialist they came to the conclusion that the journey was going to be very bumpy, however there was no reason why Redgrave should not aim to go to Sydney and try and win a fifth gold medal. Redgrave was stepping into the unknown; no professional rower had ever juggled a high performance training programme with type 2 diabetes.
Just before Christmas 1997 there were signs of the colitis returning, Redgrave had several tests to discover the severity of the situation, however with the diabetes and the potential return of colitis, everything was getting a bit much for the Olympic champion. Whist waiting for the results of his tests, he missed his first ever training session without telling his coaches and team mates and went for a skiing holiday with his family. This is a classic sign of someone dealing with illness by avoidance; he wanted to escape and leave all his troubles at home and have a nice happy holiday with his family. This coping strategy works in the short term, however is very ineffective in the long term, since you are not dealing with any issues; you are dodging, ducking and diving away from them. During the holiday Redgrave discovered that he had colitis. This added another major obstacle in the path to his main goal – a gold medal at Sydney 2000. However he succeeded in juggling diabetes, colitis and a full time training programme and achieved this goal winning his fifth and final gold medal.

Overall Redgrave dealt with his illness very well. He had a very strong mind, never gave up, kept fighting and eventually all the effort paid off. However, during his training sessions he felt very isolated from his fellow team mates, which did not help the recovery process. He felt different and not part of the team. Here Redgrave showed enormous mental strength; other athletes may have isolated themselves further, however he kept going and tried to be as involved with the team as possible.
Redgrave concluded that the overall cause of his colitis was stress. He seemed very calm before and during races, however subconsciously he was unable to cope with the expectation and pressure. Additionally up until 1992 Redgrave had financial problems, which added to his levels of stress. Finally his diabetes was a very stressful experience and this was the cause of the return of colitis.
This case study shows that stress is a major cause of injury and illness and an athlete may not know they are feeling stressed but deep down their body is failing them due to the added pressure and anxiety.

The second psychological cause of injury is an athlete’s personality. There may be some aspect of their character which inhibits performance and increases recovery time. For example, Kelly Holmes had two major flaws to try an overcome in her career: injury and lack of confidence. Holmes had serious mental health pain and had vast amounts of self-doubt. A lack of confidence was part of Holmes’ character. She had feelings of frustration, separation and as if she was an outsider; this led to Holmes self-harming and feelings of despair. She got trapped in a viscous circle; being injured meant she trained less, which reduced her confidence, and limited confidence meant she’d need to be patient and take training gradually. However eventually she broke out of this circle and was able to gradually build her confidence and her risk of injury diminished.

Having identified the causes of injury, I will now reflect on the psychological effects of injury. Sport plays a crucial and major part in athletes’ lives; it is what they devote all their time to. Therefore if they experience an injury there are bound to be serious psychological consequences.

I have experienced this in my hockey career; I developed an injury before a major international event. I was in the England U16 hockey squad, however wasn’t selected for the Four Nations tournament in April. After this, I began to train extremely hard to make sure I would be selected to go to Hamburg and play against Germany. I worked on my fitness and strength and conditioning off the pitch, as well as developing my aerial skills on the astro. In June I was told that I was selected to go to Hamburg, however a week later I started to feel pain in my left knee. This was very hard for me to cope with, since I had trained so intensely for such a long period and had devoted so much time to ensure I would make the cut. I thought I wasn’t going to be able to go to Hamburg and I was never going to achieve the cap I had been working so hard to achieve. However, I discussed the injury with my physio (Lynn Booth) early on when I first started to feel the pain and she reassured me that with the right recovery process, I would still be able to go to Hamburg. I spoke to Lynn everyday for a week to see how my rehab was going and to get all the frustration I was feeling, in the early stages of rehab, off my chest and eventually I was fit and well, and ready to go to play against Germany. I was extremely pleased with the end result, however it was very difficult for me, when I realised I had the injury to stay positive and optimistic. 

Firstly a major consequence of injury is athletes feel a loss of identity; their sport makes up who they are. Without it, they feel they are worthless and have nothing to offer. They also feel immense feelings of self-doubt; their sport is the only thing they are good at; if that is taken away what do they have to offer? They have nothing left. As well as a loss of personal identity, athletes very often lose their identity on the team, they feel isolated and different to all the people they should be training with. This adds to the stress levels and causes them to isolate themselves further and recovery takes much longer.
Realising you have an injury can be one of the most stressful times of an athlete’s career. The way most athletes deal with stress usually, is through their sport; as soon as they step onto the pitch they forget all their worries and problems and focus entirely on the match. If you pick up an injury, athletes no longer have that coping strategy; they are left to deal with large amounts of stress with no way of dealing with it. This stress can build up and cause serious injury or illness, which we have seen through Steve Redgrave’s career.
Finally an athlete’s physical health and sense of invincibility begins to diminish. They can longer do things they were perfectly capable of doing in the past. They feel their body has failed them and they become dependent on others. This causes vast amounts of frustration and anger in an athlete since they have lived their whole lives being independent and helping others; they can start to feel pathetic and weak.
All these feelings are perfectly normal for any athlete who is recovering from injury; it is their body and mind’s coping strategy. However the road to recovery can be a lot shorter if an athlete controls their feelings of anger and frustration and shows mental toughness and willingness to accept their injury and start the rehabilitation process.

Some sports psychologists believe the psychological stages that an athlete experiences when coping with an injury are very similar to Kubler-Ross’ five stages in her discussion of death and dying. This relates to Jess Ennis’ feelings of bereavement (referred to in later example), as if you’ve lost a part of what makes you. The first stage is denial; athlete’s downplay the injury and try to continue training. This has a detrimental effect on their performance and only makes their injury worse. Secondly they feel anger; they are frustrated with their situation so the only way they can take out that anger is through the people around them (usually they would deal with it through their sport). Next they come to a phase of internal bargaining; athletes try to avoid or undo the situation by thinking “if I do this, I’ll be able to play again”; they try to negotiate their way around the injury. When any athlete discovers an injury they will most likely go through a stage of depression; they start to realise the seriousness of their injury and recognize their loss. They may suffer sleeping and eating disturbances and become disinterested in things they once loved. Eventually any athlete will accept their injury and have a more rational opinion on recovery and rehabilitation. They will accept they have to stop for a while, but will try to get around this by doing other things.

Having looked at the psychological effects and consequences of injury, I will now consider injury prevention and its place in sport. Prevention of injuries has become very prominent in elite sport. Many National Governing Bodies now encourage their athletes to step out of training as soon as they feel a slight niggle or twinge.
England Hockey is educating all of its talent development athletes in the importance of injury management in order to enable a fruitful and long career. They are stressing the importance of the individual recognising that it will be more beneficial to their career if they tackle an injury early, rather than playing through it and causing more harm. However this depends on the athletes stepping up, being assertive and going to the physiotherapist to deal with an injury rather than continuing to play on. There are many cases of young athletes who are too eager to keep playing rather than seek medical attention. Many athletes, when going through the trialling process for England Hockey, think that stepping out and seeing the physiotherapist shows weakness and will have a negative effect on their selection. However many coaches feel the contrary; it shows good initiative, injury management and confidence; coaches will be more likely to select this athlete than one who plays through injury. The principle of injury management and prevention is trying to be portrayed to the young players so they can take this into their future hockey careers, and suffer as little injury as possible.

Another key form of injury prevention is perfection. If an athlete’s technique is flawed in anyway, this may cause a serious injury. Before improving an athlete’s strength and power, strength and conditioning coaches and physiotherapists must ensure that the athlete has the technical aspects of the skill in the bag. They may receive the correct outcome in the short term, however if the technique is incorrect, later on in their careers they will pay the price with a major injury. The key to this it to tackle bad habits and imperfections early, so the athlete has time to change and develop the correct technique. Coaches and physiotherapists need to have an incredible attention to detail; if something is slightly out of line then performers could suffer.
Alison Rose, physiotherapist who has worked with Jess Ennis and Kelly Holmes, helped Alistair Brownlee overcome an Achilles tear six months before London 2012. Brownlee’s medical team realised that he had slightly locked arms whilst running; this caused slight niggles in his Achilles. They highlighted this to Brownlee and he was able to change his running technique to make it smoother with a lot more loose rotation in his arms. This helped cure his Achilles pain and he went on to win gold at the London Olympics. This is a clear example of attention to detail and correct technique having an immense benefit to performance.
There are also arguments to suggest that injuries can be prevented due to state of mind. If the athlete is constantly worrying and tense then they are more likely to get an injury, opposed to a performer who is relaxed and calm.

When an athlete picks up an injury the main challenge is dealing with the psychological journey that is ahead of them. An athlete’s physical injury is mainly in the hands of physiotherapists and doctors, however their mental state is completely down to them. People can listen and support the athlete through the journey but no one can affect the psychological state of the athlete more than the athlete themselves. All athletes who discover injuries have to deal with the psychological consequences.
One example of this is Jess Ennis; she discovered she had stress fractures of the navicular and metatarsal of her right foot, just months before the 2008 Olympics in Beijing. She was the favourite for the games, so was absolutely devastated when she found out she’d be out of competition for a year. Ennis said “to devote your life to something and then have it snatched away is a bit like suffering a bereavement. You’ve lost something that’s part of you.” However on the whole Ennis coped very well with her injury; she learnt to jump off her right foot for long jump. She was enhancing other areas of her performance rather than sulking and losing her fitness. Moreover Alison Rose was key to her recovery; Rose phoned Ennis every day and Ennis was able to just talk to Rose about anything and clear her head. This shows the importance of support and encouragement of the people around you when you are suffering from an injury.

It is very well recognised around sports rehabilitation that the main obstacles are psychological. If an athlete has high levels of mental strength, a positive and proactive mentality in which they are confident they are going to recover, they are the athletes which cope with injuries the best and are more likely to recover quicker. All these aspects of an athlete’s mind can be strengthened and enhanced with the use of sports psychologists. In elite sport, most teams will have sports psychologists who help all the athletes with their mental game, which will aid their physical performance. They focus on several main themes: arousal regulation, self-talk, goal setting, imagery, performance routines, motivation, confidence and rebounding from injury. Since the advancement in research concerning the importance of athlete’s minds; sports psychologists have become crucial in elite sport.

Another good coping strategy for injuries is focussing on the other aspects of your life, when you are not spending hours everyday training. Chrissie Wellington, ironman champion says when she sees her family and friends she is reminded that there is more to her than an athlete. She said “If that were all I saw myself as, my emotional and physical well-being would be determined by my sporting performance, with debilitating consequences should that facility be taken away by injury or illness.” When she sees herself as more than a performer, her happiness and self-esteem is maintained. This is an excellent way for athletes to cope with injury; initially they may feel as if their life is falling apart around them, however realizing there is more to life than their sport helps to restore their physical and emotional well-being.

Overall, there may be many physiological reasons why an athlete picks up an injury, however with the wrong mentality the recovery process will be greatly increased. Furthermore, athletes are human beings with lots of emotion and feeling; at times they may feel like a cog in a well oiled machine, however coaches, physiotherapists and doctors need to understand that every athlete is a person. Sports psychologists can help this process by informing the coaches, doctors, managers and parents about athlete’s mental state and how their psychology will be affected by injury or similar stressful situations. Sports psychologists are essential in guiding and facilitating athletes, to try to make their careers as fruitful, long and intrinsically nourishing as possible.

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