A Pain in the Brain: The Psychology of Sport and Exercise Injury

It is estimated that 3 to 5 million people in the United States are injured from recreational, exercise and sport-related activities each year. While the primary causes of these injuries are physical, psychological issues can also contribute—and impact recovery as well.

Fitness professionals need to recognize the signs of impending injury, notice clients’ psychological reactions to injuries and know mental strategies to improve the recovery process. This article will explore the role that psychological factors play in injuries and rehabilitation and explain how to use sports psychology techniques to prevent future injury.

The psychological factors that contribute to injury are viewed primarily as stress related (Williams & Andersen 1998). Research has demonstrated that a direct relationship exists between life stresses and injury rate. The types of stresses referred to stem from major life changes, such as losing a loved one, getting a promotion, having a baby or going through a divorce. If a circumstance is viewed as stressful or threatening, an individual may experience an increase in anxiety, which can cause a variety of changes in focus and muscle tension. These changes in focus and muscle tension are at the heart of the two theories used to explain the stress-injury relationship.

ATTENTIONAL DISRUPTION

When an athlete’s focus is disrupted by stressors not related to the activity at hand, injury can occur because the athlete is not aware of peripheral activities or misses adjustment cues (Williams et al. 1991).

Examples. A participant in a step class is so preoccupied with her ill mother that she does not hear the instructor’s directions, misses a step and sprains her ankle on a riser. An executive, distracted by an argument with his coworker, misses a step on the treadmill and is thrown from the machine.

What the Instructor Can Do. Exercise is a great stress management tool as long as you help your clients remain in the present and on the equipment. Exercisers need constant reminding to “focus” and attend fully to the activity at hand. Have them check their problems at the door and commit to being in the present moment for the duration of the activity. It’s good to have casual conversation while exercising, but cue your clients firmly when it is time to focus on a new movement or exercise.

MUSCLE TENSION

High stress levels can be accompanied by considerable muscle tension, which can interfere with normal coordination, increasing the opportunity for injury (Nideffer 1983).

Examples. A client who manifests stress in the trapezius may risk neck or shoulder injury owing to excessive muscle tension and restricted range of motion. A client with excessive muscle tension in the low back risks injury during leg exercises.

What the Instructor Can Do. Know when your clients are expe-

riencing life changes, assess their impact, carefully monitor and adjust training regimens and provide support as needed. Be aware of flexibility and range-of-motion changes in clients during stressful periods, and spend more time stretching and warming up. Periods of high stress are not good times to introduce new exercises or movements.

Psychological risk factors that can contribute to injury include the following, in varying combinations:

• high levels of negative and/or positive life changes
• high levels of type A or type C behavior (See “The ABCs of Personality” sidebar above.)
• high levels of anxiety
• exhibition of poor reaction and movement time, due to poor attentional focus
• high or low pain tolerance
• high levels of either extroverted or introverted behavior, which may lead a client to inaccurately perceive a situation, environmental stimuli or signs of impending injury
• behavior associated with insecurity, overprotection and
  dependency
• behavior reflecting that the client feels little control over the athletic situation at hand
• behavior reflecting a poor self-concept and low self-esteem
• high levels of depression

(Kelley 1990)

A number of traits can cause clients to become more accident prone. These traits include aggressiveness, anger, attention getting, the tendency to be easily offended, bereavement, boredom, competitiveness accompanied by an inability to lose, excitement, feelings of inferiority, a pattern of frequent conflict with authority, frustration, guilt feelings and an unconscious need for self-punishment as a result of stress or a life situation (Nideffer 1981).

Elite Athletes and Exercise Addicts. David Parker, PhD, executive director of the Washington Institute of Sport Medicine in Kirkland, Washington, sees certain similarities in behavior between elite athletes and exercise addicts when it comes to injury. Both groups are often obsessive-compulsive in their exercise behavior and can experience high levels of denial. When an injury occurs, they are afraid it is going to “shut them down,” and they don’t want to deal with that possibility. It is easier for them to exercise through the pain than to deal with the psychological issues associated with the obsessive behavior. Furthermore, Parker sees a lot of women in their late 20s, 30s and early 40s who have exercise addictions and eating disorders and feel a need to exercise even when injured, believing the injury will go away on its own. Parker refers to the female athlete triad (disordered eating, amenorrhea and osteoporosis) as a risk factor for injury. Depriving oneself of calories, expending more calories than one consumes and overtraining on consecutive days contribute to injury. Personal trainers can exacerbate the problem by feeding the fire of an overtraining exerciser, viewing that person as highly motivated rather than recognizing obsessive-compulsive, physically destructive behavior.

Signs of obsessive-compulsive behavior include the following:

• rapid and/or excessive weight loss
  

• more than two hours a day of exercise
• performance decrements from lack of recovery
• acid etching on the teeth, and receding or bleeding gums
• lack of gluteal muscles

What the Instructor Can Do. Exercise professionals need to take some responsibility for knowing when to push someone and when to rein a person in. Prior to starting your training sessions, survey clients on how they are feeling and find out where your clients, especially those with eating disorders or exercise addictions, are in the rest-recovery continuum. Use this information to structure each workout.

Sue Matyas, MS, fitness director at the Bellevue Club in Bellevue, Washington, has no hard-and-fast policy to deal with exercise addicts or members with eating disorders. She addresses these clients discreetly on a case-by-case basis. Because an
eating disorder or exercise addiction is a very sensitive issue, she invites the member in for a consultation. She first lets the client know that the trainers are concerned for her well-being and then tries to educate the client on the dangers of overtraining. If the behavior persists, Matyas refers the member to a physician, who must give her medical clearance to exercise before she is allowed to return to the fitness center. Matyas has had only two such instances in her nine years at the Bellevue Club, and in both cases the exerciser never returned. Often, once exposed, exercise addicts will just find a new venue for their obsessive behavior. Such a response is a typical part of the disorder and not necessarily a reflection of the fitness professional’s approach. (For additional information, see “Facing Eating Disorders” in the May 2000 issue of IDEA Health & Fitness Source and “Demystifying Muscle Dysmorphia” in the March 2001 issue of IDEA Health & Fitness Source.)

Pain is a protective mechanism the body employs to warn of possible trauma or to indicate that further injury may occur if precautions are not taken. Pain can be categorized as “positive” or “negative.” Positive pain is discomfort associated with physical conditioning; negative pain is discomfort associated with injury. Pain that continues beyond seven to 10 days is negative pain and an indicator that medical attention is needed.

Pain lets one know when the body is stressed beyond its normal limits. Most exercise-related pain is due to the accumulation of lactic acid and other metabolic waste products and their effects on pain receptors located in the muscle tissue. Tonic reflex muscle contractions—caused by sustained, localized spasm of motor units—are responsible for delayed soreness, which is experienced 24 to 72 hours after unaccustomed exercise (Kelley 1990).

Many athletes are socialized into believing that they must train through pain, and that more is always better. This mind-set can lead to overstraining and injuries like shin splints, swimmer’s shoulder and tennis elbow. Hard physical training does not have to involve excessive discomfort. Athletes and exercisers need to be taught to distinguish between the normal discomfort that accompanies overloading and increased training volume, and pain that indicates the onset of an injury (Weinberg & Gould 1999). Highly motivated clients may want to achieve a goal so badly that they cannot differentiate between good and bad pain.

Healthy athletes learn to distinguish between beneficial and damaging pain, or they do not remain healthy for long. Trainers, group exercise instructors and coaches need to be aware of how they motivate their participants. Asking clients to “give 110 percent” or “go hard or go home” may reinforce an overactivation response that can push people to injury, especially if they are new to exercise. Clients not completely aware of their bodies and physical capabilities rely on a trainer or an instructor to be the barometer by which they measure how much effort their bodies can sustain. Make sure your clients understand that “you can train up to, but not into, pain.”

Athletes and exercisers who take pain medication prior to physical activity may mask the natural sensations that stem from an injury and indicate that a physical problem exists. Failure to pick up these signals can lead to further trauma and possibly permanent injury. Know when your clients are self-medicating for pain and inform them of the potential hazards.

Even with the best training regimen and psychological preparation, injuries happen. They are an inherent risk in all physical activity, but how individuals react to an injury can effect their rehabilitation and subsequent return to sport and exercise. It is important for fitness professionals to understand their clients’ psychological reactions. Injured exercisers and athletes often experience a five-stage grief response, originally described by Elisabeth Kübler-Ross, MD, in her 1969 book, “On Death and Dying.” Kübler-Ross identified these stages of grief:

• denial
• anger
• bargaining
• depression
• acceptance and reorganization

This multilevel grief response to injury is widely recognized, although experts debate whether all these stages are experienced in the sequence shown above. Rather, it seems that many people feel the various emotions and thoughts simultaneously or revert back to categories once they have gone through them. Fitness professionals should not try to pull clients out of the stage they are in, as this can cause resentment. The key lies in recognizing the current stage of grief response and being sensitive, supportive and aware of what clients are experiencing.

Jim Gavin, PhD, professor in the Department of Applied Human Sciences at Concordia University in Montreal and a sport psychology counselor, says, “When athletes have strong identity ties to their physical activity, they are thrown into a state of shock or disorientation [when an injury occurs]. It is in this state that they will experience many of the emotions referred to in the Five Stages of Grief. They can ‘spin’ in this cycle of disorientation for extended periods of time. It is not until they can view the injury without blame—i.e., not blaming themselves, circumstances or somebody else for their injury—that they can move forward in the recovery process.”

Fitness professionals are by and large very optimistic, and they may tend to overmotivate recovering clients, when good listening skills and empathy are what are needed early in the recovery process. Gavin says, “A person fresh into injury needs to go through the emotions with a compassionate listener, someone able to be empathic without rushing in to give advice or motivating pep talks. If after a significant period of time (perhaps 3 months, depending on the injury’s severity) the competitor is still ‘spinning,’ it would be advisable to discuss it with the person. Let him know that he appears to be stuck and that talking with a mental health professional could help break this unproductive cycle.”

Be prepared to supply clients with a referral or recommend they get one from their primary injury care provider. Provide the information, but let the clients decide to follow through, making sure they know you will remain supportive. If they are not receptive to counseling, recommend they talk with someone they respect and feel is credible—for instance, someone from their church, a business mentor, a teacher or a person they trust who is not directly or indirectly involved in the injury.

Remarkable gains have been made in the rehabilitation of exercise-related and athletic injuries. Among the advances in methods for rehabilitation are active recovery and weight training. Active recovery allows an athlete to work around the injured body part. For example, a runner with a knee injury can work on upper-body conditioning with weights and do some prescribed stretches during recovery, as long as the activities are cleared by the athlete’s medical professional. Furthermore, less invasive surgical techniques have inadvertently helped shorten recovery times. Innovative psychological techniques, using more holistic methods of healing both mind and body, also facilitate the injury recovery process. According to a national survey of athletic trainers, they refer 8 percent of their clients to psychological counseling (Larson, Starkey & Zaichkowsky 1996). The majority of athletes and exercisers who sustain an injury work through their response with little or no difficulty adjusting. However, the fact that a client doesn’t go into counseling is not an indicator that she has no such difficulty.

Although the psychological process is not fixed or orderly, you can expect an injured client to experience three general stages of response:

Injury-Relevant Information Processing. The injured athlete focuses on information such as the pain of the injury, awareness of the extent of the injury, questions about how the injury happened, and the negative consequences or inconvenience of the injury. Three primary emotions reported shortly after injury are frustration, depression and anger.

Emotional Upheaval and Reactive Behavior. Once the athlete or exerciser realizes he is injured and must stop his activities to recover, he may become agitated; vacillate among different emotions; feel depleted, isolated and disconnected; and experience shock, disbelief, denial or self-pity.

Positive Outlook and Coping. The athlete accepts the injury and deals with it, initiates positive coping efforts, exhibits a good attitude, is optimistic and feels relieved to sense progress. Keep in mind that some people never make it to the positive outlook phase. The injury may be so severe that the athlete can never return to his favorite activities.

The speed at which athletes move through these stages varies. One person may move through the process in a day or two while others may take weeks or even months (Gould et al. 1997b).

Some injured exercisers experience fear and anxiety. They worry about whether they will recover and if re-injury will occur. Lack of self-confidence becomes an issue as exercisers lose physical conditioning, and lowered confidence can result in decreased motivation, substandard performance or additional injury. Many athletes and exercisers have difficulty lowering their expectations after an injury. They may expect to return quickly to a pre-injury level of performance, and if this does not happen, they tend to push too hard, exposing themselves to chronic or recurring injury.

Fitness professionals should be alert to signs that a client may be having a problem coping and could require special attention. (See “Symptoms and Warning Signs of Poor Adjustment to Injury” on page 43.)

Building rapport is a crucial skill when dealing with injured athletes. They often experience frustration, vulnerability, anger,
confusion and disbelief. These emotions can make a working
relationship difficult to establish. Rapport building includes:

• showing emotional support and trying to be there for the
  injured client
• showing empathy by trying to understand how the person feels
• showing concern by visiting, phoning or e-mailing the client (This is especially important after the novelty of the injury has worn off and the exerciser or athlete feels forgotten.)
• being careful not to be overly optimistic about a quick recovery; instead being positive and stressing a team approach to recovery (“Your injury was unfortunate, but together we will do our best to get you up and going again.”)
• not repeatedly mentioning the injury during training

Research the injury and become familiar with the rehabilitation process. Often, injured athletes will avoid learning about their injury because they would rather not know how bad it is or how long the recovery process is likely to be. Describing what to expect is especially important when clients are dealing with their first injury. Help them understand the injury in practical terms. If an athlete has an anterior cruciate ligament (ACL) tear in the knee, bring in a diagram of the knee and explain in very basic terms what the injury is and how it affects movement in the athlete’s sport or activity. Explain how long the client can expect to be out of commission and encourage her not to resume normal activities until medically cleared to do so. Stress that setbacks are not uncommon during rehabilitation and not a cause to panic. It is important to prepare for possible setbacks, while also encouraging the client to keep a positive attitude.

Laying out the specific recovery process is very important. If injured exercisers can see that a plan exists to help them get back to an activity, they will feel more confident and capable. For example, let the client with the injured knee know when she might be able to start some light weight-bearing activities or perhaps some upper-body weight training while her knee is healing. Doing some kind of training is much more positive and proactive than just sitting at home and feeling depressed.

Highly motivated individuals tend to do more than is required, potentially setting themselves up for re-injury. Ask these clients to adhere to their protocol and not force recovery. Periodically reevaluating goals and redefining recovery timelines is part of the process. Inform clients during the rapport-building phase that they may improve faster than expected or may fall prey to unforeseen obstacles. Being up front in the beginning will eliminate resentment later if recovery does not proceed as planned.

Gavin warns fitness professionals against “taking responsibility” for someone else’s injury or recovery. This can become a terrible burden for an exercise specialist and will prove counterproductive to recovery. Fitness professionals who feel guilty or frustrated over a client’s slow recovery are being hard on themselves and not allowing the injured person to take responsibility for the recovery.

Know your personal and professional boundaries, be consistent and keep the overall long-term wellness of your clients as your primary objective. In an ideal rehabilitation scenario, the injured individual takes responsibility for his own rehabilitation. Athletes who successfully rehabilitate from injury are willing, not only to be motivated and determined, but also to listen and learn (Crossman 1997).

The most important psychological skills for fitness professionals to learn and share with clients going through rehabilitation are goal setting, positive self-talk and relaxation training (Hardy & Crace 1990).

Goal Setting. Helping injured participants set personal performance goals and adopt strategies to enhance self-efficacy will facilitate performance. Setting performance goals can be especially helpful in decreasing recovery time. Encourage injured athletes to reward themselves for progress made in rehabilitation. Rewards should be significant to the clients themselves and given often enough to be motivating. Short-term rewards keep individuals on track to achieve long-term goals (Crossman 1997). Try using these goal-setting strategies with injured athletes, always remembering to adhere to the guidelines set by the medical professional supervising the rehabilitation program:

• Set a date to return to the gym or a group exercise class.
• Set the number of rehab sessions to attend per week.
• Set goals for increasing range of motion, strength and endurance. Be sure to be specific and quantitative. For instance, “Increase range of motion by x degrees, complete x sets of strengthening exercises and spend x amount of time on endurance activities.”

Positive Self-Talk. Self-talk is important in counteracting the diminished self-confidence that can follow an injury. The injured exerciser needs to stop negative thoughts and replace them with positive ones. For example, encourage clients to replace, “I’ll never be 100 percent again” with, “I’m still on target with my rehab, and I just need to be patient and positive and I’ll make it back.”

Relaxation Training. Relaxation training can be useful to relieve the pain and stress that usually accompanies severe injury and can persist through the recovery process. Athletes can use relaxation techniques to aid sleeping and reduce general levels of tension (Weinberg & Gould 1999).

Whenever possible, make a personal connection between the injured athlete and someone who has successfully recovered from the same injury. This relationship can become an important bond and an invaluable learning experience for the injured person.

Successful Coping Techniques. A survey of athletic trainers revealed that athletes who successfully cope with their injuries differ from their less successful counterparts in the following ways:

• They comply better with their rehabilitation and treatment programs.
• They demonstrate a more positive attitude about their injury status and life in general, and they are more motivated, dedicated and determined.
• They ask more questions and become more knowledgeable about their injuries.

Matyas attributes the low incidence of injury at the Bellevue Club to the trainers’ general workout philosophy, which focuses on core stability training. Bellevue trainers focus on establishing a strong functional core for their members, and this in turn minimizes injuries, especially in recreational pursuits (e. g., skiing, basketball, tennis), where most of the injuries Matyas sees occur. This core approach to training integrates strength work on a ball, balance work and medicine ball exercises with traditional weight training. Matyas also attributes the club’s low injury rates to the education and experience of her trainers and group exercise instructors. Besides maintaining their required continuing education credits, they receive quarterly in-service trainings. Matyas also encourages her trainers to work closely with their physical therapy associates. She believes the club’s open relationship with a nearby sports therapy clinic is pivotal to her facility’s successful record of injury prevention and rehabilitation.

When assembling a team of exercise professionals, it is important to include a trainer with a strong background in physical therapy, injury reconditioning and/or cardiac rehab. This person will be, not only an asset for your members, but also an in-house resource for other trainers who want to discuss injury cases.

Dealing with a competitor or an exerciser who is in denial of an obvious injury and continues to train with you puts you in an ethical dilemma. Gavin believes you must not continue to enable destructive behavior and should use your professional integrity to say, “I won’t work with you in your present state of injury.” Establishing a contract is one way to resolve this issue. Contract with your client by setting a time frame for measurable improvement. Stipulate that if the client does not meet specific criteria within the designated time frame, she must receive a medical consultation for the injury before you will continue to work with her.

As interest in athletics, exercise and recreation continues to rise, it is safe to assume that the number of people injured while participating in these endeavors will climb. Early detection of the emotional responses to injury may allow for prompt appraisal of coping strategies and appropriate intervention to aid in rehabilitation and a safe return to activity. By applying basic psychological strategies, exercise professionals can make a tremendous difference in the speed and completeness of recovery.