Identify your fear of re-injury and overcome it!

Unfortunately injury is a common threat when it comes to both elite and non-elite sport. How we cope with it may determine our path to either full recovery or re-injury. We often participate in major competition despite ‘having a niggle’ or carrying a larger injury and passing it off as nothing much (Lopez & colleagues, 2012). The extent of the injury and injury situation are less transparent when it comes to our ability to cope psychologically (Walker, Thatcher & Lavalle, 2010).

Our psychological responses to injury comprise of cognitive (thought based), emotional and behavioural reactions (Tripp & colleagues, 2007). It is inevitable that the psychological responses to injury such as negative emotions and a reduction in confidence occur in the face of injury, resulting in the development of re-injury fears (Johnson, 1997; Heil, 1993).

In an attempt to avoid pain athletes may develop inaccurate ideas of their physical ability thus preventing some rehabilitation activities, which they deem unnecessary (Lethem & colleagues, 1983). This may be through hesitation in technique or movements, holding back in training or competition, lack of effort, or a high dependence on equipment such as taping of previously injured areas (Johnston & Carrol, 1998). Therefore anxiety can develop through repetitive and long-term injuries aiding to the fear of re-injury upon resumption of activity (Cassidy, 2006). Various academic models may help to better describe this.

Fear Anxiety Model

The Fear Anxiety Model depicts that those who were previously injured follow a pattern of,

1. Catastrophising or extreme negative evaluations of the experience
2. Escape and avoidance behaviours in the anticipation of pain
3. De-training effect due to fear of exercising the injured area
4. Inability to remove attention away from pain related fears
5. Increased mental and physical reactivity when confronted with situations that are appraised as dangerous

(Vlaeyen & Linton, 2000).

According to research by Lethem (1983) the model highlights that fear of pain can lead to two coping mechanisms,

1. Confrontation – leads to a desensitisation in the face of similar events
2. Avoidance – leads to an elevation of the fear to a phobia

However the fear avoidance model is not sport specific so the following two models may be more applicable to athletes.

Stress Injury Model

Anderson and Williams’ (1988) stress-injury model highlights that athletes react to personal or situational stress with muscular fatigue, reduced concentration, which may elevate the chance of injury (Podlog and colleagues 2011). As such in the face of a perceived threat athletes’ attention is disrupted with a narrowing of peripheral vision, subsequently increasing distractibility and chance of re-injury (Podlog et al., 2011).

Are you now thinking how exactly might this happen? Research by Heil and the Psychophysioogical Mechanism of Risk might shed some light.

Psychophysioogical Mechanism of Risk (PMR)

This model demonstrates the psychological and physical responses to injury in sport. Fear of re-injury appears as:

1. Reductions in concentration and self-confidence
2. Coinciding responses of increased muscle tension, guarding or bracing of injured areas.

(Heil, 1993)

According to Heil, a negative mood state may increase heart rate subsequently elevating an person’s distractibility. As such an awareness of pain is intensified which then initiates a reduction in self-confidence.

These serve to affect performance through the observation of:

1. Reduced biomechanical ability and skill
2. Poor use of energy resources,
3. Decreased attention to performance related cues
4. Specific fears of re-injury

(Heil, 1993)

Unfortunately this is a poor use of energy resources, which creates a continual cycle of possible re-injury (Heil, 1993).

Identification and Maintenance of Re-Injury Fears

The thoughts and feelings observed in the models above may develop in rehabilitation through

• Perceived lack of progress
• Inability to partake in training and competition
• Reduction in fitness
• Comparison with uninjured athletes
• The timing of rehabilitation relative to competition
• Perceived lack of rehabilitation progression

(Wadey and colleagues, 2012).

As such it is important to consider research which highlights that athletes who have a strong correlation with their athletic identity are more likely to suffer mood disturbance during injury and rehabilitation (Asken, 1999). Key to this is the identification of high-standard athletes who function in a highly structured and controlled emotional environment compared to lower-standard athletes (Woodman & Hardy, 2003). This may exacerbate the athletes’ inability to identify and release re-injury anxieties. Extensive analysis has shown that this presents in the form depression with symptoms in athletes including anger frustration, anxiety, sadness and hopelessness (Woodman & Hardy, 2003).

According to Wadey (2012) the reduction in self-confidence and increase in anxiety elevated levels of negative self-evaluation. In turn this lowered confidence in the injured body part thus inhibiting the return to sport (Wadey et al., 2012). Therefore it is highly important to evaluate any levels of decreased confidence and increased anxiety upon return to competition as observed by Bianco and colleagues (1999).

Furthermore with regard to Self Determination Theory, Podlog (2011) highlights that if the needs of competence (the ability to do a task efficiently), autonomy (freedom from external control) and relatedness (feeling connected with others) are not met in rehabilitation and return to competition, motivation will decrease followed by heightened stress and anxiety.

heightened stress and anxiety.

Therefore with reference to this and other research these steps can aid athletes in returning to competition post injury:

1. Increase personal reflection and confiding in others to allow more understanding of stressors and enable the creation of solutions.
2. Establish regular and graduated opportunities to experience success in ability and to increase confidence through positive self-evaluation in rehabilitation (Podlog et al., 2011). This may be achieved through Positive Performance Indicators depicted in http://www.thesportinmind.com/articles/applying-positivity-in-sport/. Simply put this asks athletes and coaches to highlight three good things that they have achieved each day in rehabilitation/training and life as a whole in a diary.
3. Utilise process goals to build and develop a structured path in which concentration is maintained. As each process goal is achieved there are more opportunities to congratulate oneself. Process goals should be set regularly in association with your physiotherapist/coach. They should increase in difficulty yet be achievable. The use of these goals enables a sentiment of returning to pre-injury levels for athletes in rehabilitation, subsequently increasing their competence and enabling a return to competition (Podlog & Eklund, 2009).As well as building competence this allows for more autonomy as it builds a sense of controllability in the rehabilitation process.
4. Provision of relatedness through positive feedback from coaches. Social support will increase self-confidence and reduce re-injury anxiety. This will increase athlete self-satisfaction and feelings of competence in rehabilitation/return to competition.