Monday, March 25, 2013

Hockey Edge Newsletter: Psychological Recovery from Injury

This post comes from Dr. Dana Voelker sport psychology consultant and professor at Brockport State University.  Dr. Voelker provides a great recap of her own injury experience and what both players and coaches can expect.

My Injury Experience

I have always loved ice hockey and was fortunate enough to have played for the Penn State Lady Icers between 2003 and 2007. During all my years in competitive sport, I never sustained an injury that completely rocked my world. I had come out of years of lifting, running, mountain biking, skiing, competitive figure skating, and ice hockey without any major injuries – lucky me. Unfortunately, that came to an end a year following my last season at Penn State while instructing a college hockey class at Michigan State. What an unlikely scenario.

What I remember is that I got hit hard from the right, stepped awkwardly to left, and somehow fell face forward. Quickly realizing that I had just been knocked down, I got up and limped to the boards with the aid of my student hockey players. Something wasn’t quite right, but like many current and former competitive athletes do, I began convincing myself that I was perfectly fine. “Just a sprain,” I said as I began moving my left knee to show the class that I was pain-free – not quite. Unable to hide my grimace, my co-instructor urged me to get it checked out. Still convinced that I just needed some ibuprofen, I remember thinking that all the appointments would be a complete waste of time. “Anterior Cruciate Ligament,” the doctor said, “But we should do an MRI to verify.” Amazingly, I didn’t believe her, but went through the motions of an MRI anyway. The following was suggested: Complete ACL tear, partial PCL tear, torn meniscus, partially torn quadricep, bone bruises, and fractures to the head of the femur. Great - just what I had hoped for.

I finally came to grasp the severity of the injury and how my life would change during the recovery process at the meeting with the surgeon. He talked to me about surgical procedures, crutches, knee braces, and rehabilitation programs. What I really cared about at the time was how long until I could get back to sport and exercise participation. Statements like “6 to 9 month rehab” and “sometimes 3 years until the knee truly feels normal again” were pulsating in my brain. I thought I would never be the same and never get better. Let the catastrophizing begin.

Now I was angry. If I had just gotten more sleep the night before and if only I was more alert or had my head on a swivel like I was supposed to, this would have never happened. I remained in a straight-leg brace for 5 weeks waiting for the swelling to subside, and my leg atrophied to mush. That was hard for an avid exerciser. Eventually, I learned to face the music and made a purposeful decision to accept what was done and focus my energy on the things I could control to recover and move forward. My fear of surgery transformed into an eagerness to embrace the challenge of what I knew would be a long journey.

The post-surgery experience and rehabilitation process was nothing short of challenging. There were times when I handled pain well and other times I did not, times where I made progress quickly and other times slowly, times when I thought I would never reach pre-injury levels, and times when I thought I would come out stronger. The highs and lows really tested my patience, and I learned a lot about myself. For example, patience is indeed a virtue, I am mentally tougher than I thought I was, and I know it is ok to ask for help, among other lessons.

In addition to my personal experience, my education and professional expertise has allowed me to understand the psychology of injury and help athletes to optimize their recovery through mental skills training. The remainder of this article offers a sample of recommendations for the recovering athlete and their coaches in coping with injury. These best practices are based on scientific research, personal experience, and what I have found to work well when working with athletes and coaches. 

Recommendations for Injured Athletes

1. Understand that every athlete recovers differently
When I hit the 5 month mark and was still not cleared to begin running, I remember people being astounded at the long duration of my recovery. I often received unsolicited advice from unqualified friends and acquaintances about the activities I “should” be doing, and I felt terrible. Stay the course by remaining focused on your own recovery. Listen to your body and attend to the recommendations of the qualified professionals treating your injury.

2. Gain acceptance and think optimistically
After acknowledging and reflecting on what has happened, move towards accepting that the injury occurred and make a deliberate choice to focus on what you can control. Shift your attention from what could have been to what you can do to make the most of your circumstances moving forward, even when the injury is potentially career-ending or life-changing. Meaningful cue phrases such as “Look at life through the windshield, not the rearview mirror” (Byrd Baggett) can be helpful in honing your attention on forward-focused efforts.

Thinking optimistically can also go a long way in optimizing recovery. Decades of research suggests that self-deprecation and negative thought processes impair performance. When injury is seen as an impossible barrier, a useful way to facilitate positive thinking is to identify 8 to 10 ways your injury can also present opportunities. Although difficult, this exercise forces us to challenge our adverse thinking patterns. For example, my injury was an opportunity to accomplish the following:
* Practice, test, and develop my mental toughness.
* Increasingly focus on the mental aspects of sport and exercise participation.
* Rest and rebuild my body.
* Develop a greater appreciation for my body as well as sport and exercise participation.
* Learn about injury, recovery, and new forms of exercise.
* See another perspective of my sport (e.g., through a coaching and mentoring role).
* Share my experiences and help others struggling with similar adversities.
* Build my support network and develop stronger relationships.

3. Monitor your progress
Gather information from the professionals treating your injury to help you set realistic goals for your recovery. On days when I was only focused on the outcome of my rehab (e.g., return to sport and exercise), I felt like I would never get there. This was especially true at the beginning of rehab when I could barely contract a muscle. To keep myself going, I kept a daily log to help me acknowledge and appreciate the progress I was making, even when that progress seemed so small. Remember that recovery is seldom a linear process and that you may experience setbacks or plateaus. This is all the more reason to document those challenges and how you moved forward to overcome them.

4. Utilize social support
Initially, it was difficult for me to rely on others for support because I felt like a weakling whose independence had been stripped away. Still, I knew that social support was necessary. So I reframed my perspective - asking for help can been seen as a considerable strength during recovery because it means you are optimizing your resources to get better. Identify what type of social support you need at a given time (e.g., a listening ear, emotional support, information and practical suggestions) and seek out those resources. In addition to family and friends, it is often helpful to network with others who been through a similar experience.

Recommendations for Coaches of Injured Athletes

1. Provide support and maintain relationships
Injured athletes often feel isolated from their coaches and teammates and essentially forgotten. Help in optimizing recovery by maintaining contact with the injured athlete, demonstrating empathy and support, and including them in team practices, games, and other functions as much as possible. Give them active roles that they find meaningful to demonstrate their value both on and off the ice. For example, you might ask them to document their observations on specific plays or ask for their input during practice. Assisting the athlete in sharing their injury status and progress with teammates can be helpful in maintaining team rapport and keeping the lines of communication open. Finally, strike a balance between reinforcing the athlete’s progress while demonstrating patience and the value of a safe recovery.

2. Understand individual differences
Athletes view injury in many different ways. For example, injury may be seen as complete devastation, an opportunity to show courage, an easy way out of the sport, a chance to escape tedious practices, or save face for poor performance. The type, intensity, and order of emotional responses to injury experienced also vary, such as frustration, disappointment, denial, relief, and acceptance.

As a coach, it is imperative to recognize these individual differences and provide the appropriate support. For example, upon acknowledging my injury, I responded with emotional upheaval followed by an intense determination that actually led to over-adherence to rehab and risk for re-injury. If I had a coach at the time who reinforced that pain and injury are equated with weakness or who promised a starting position if I returned quickly would have likely done more harm than good. When it comes to optimizing recovery, understanding individual differences and an athlete’s perception of their injury, irrespective of severity, is what counts.

3. Look for signs of poor adjustment
Many athletes tend to cope with injury well, but a significant subset express more serious cognitive and emotional disruption. Coaches should attend to signs that an athlete may be poorly adjusting to their injury, such as prolonged denial, anger, withdrawal from important others, excessive guilt, and depressed mood. When cause for concern, refer athletes to a qualified mental health professional, preferably one with a specialty in sport and exercise populations (e.g., clinical or counseling sport psychologist).

4. Understand the importance of psychological recovery
Full recovery is often equated with medical clearance, while psychological recovery is largely ignored. Even when the physical injury is healed, psychological factors such as anxiety, fear of re-injury, and low confidence, may hinder an athlete’s ability to safely return to play. Discuss the athlete’s physical and psychological readiness with the professionals who treated the injury to develop realistic expectations for their return. Talk with the athlete to develop a safe plan for return in which all parties are comfortable.

While psychological recovery from injury is dynamic and complex, the process can be optimized with these recommendations. Importantly, injury is a challenge that can also be seen as an opportunity. Even in writing this article, my own injury experiences are continuing to pay themselves back in the form of an opportunity to help others.

About the Author

Dana K. Voelker, PhD, NCC, CC-AASP is an Assistant Professor at The College at Brockport, State University of New York where she teaches and conducts research on positive youth development through sport. She is a certified performance enhancement consultant for athletes and teams at the youth, high school, collegiate, and elite level out of DKV Performance Consulting in Western New York. Dana earned her bachelor’s in psychology with highest distinction from Penn State University as well as her master’s in counseling and doctorate in kinesiology from Michigan State University where she specialized in the psychosocial aspects of sport and physical activity. Dana has been the recipient of numerous awards, including the 2012 Ruth Abernathy Presidential Scholarship, the 2011 Outstanding Doctoral Degree Student Award, and was a University Distinguished Fellow at MSU. As a former figure skater and captain of the Penn State women’s ice hockey club, she has also been recognized for her many athletic accomplishments.

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