injury rehabilitation casebook

Mental Skills for Injury Rehabilitation

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Brennen Salmon, Psychology of Injury The University of Tennessee, Spring 2015

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THE UNIVERSITY OF TENNESSEE Spor t Psychology & Motor Behavior

Mental Skills for Injury Rehabilitation

Spring 2015

Brennen Salmon B.S. Psychology

The University of Georgia Master’s Candidate

Sport Psychology & Motor Behavior The University of Tennessee

404-610-8504 [email protected]

Table of Contents

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Sara Erdner: Lion Chaser 4

Sara’s Path to a Comeback 7

Introduction to Mental Skills 8

Maintaining Motivation 9

Goal Setting for Motivation 10

Self-Talk for Motivation 20

Sustaining Focusing 24

Relaxation for Focus 25

Imagery for Focus 30

References 35

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Sara ERdner: Lion Chaser

“Benaiah the son of Jehoiad was a man of Kabzeel with strength of heart. He had done powerful things…And he went down and killed a lion in a hole while the snow was falling.”

- 2 Samuel 23:20

In 2 Samuel, Benaiah leaped into a pit and took down a ferocious lion. In a situation where most people would flee, Benaiah chose instead to pursue. Benaiah’s courage in the face of death earned him favor with David, the King of Israel. As a result, Benaiah eventually became the chief of Israel’s army. While the average person will never come face-to-face with a fully grown lion, the obstacles in our lives present us with the same choice that Benaiah had to make: fight or flight. What we do not realize is that, often times, our biggest obstacles are also our biggest opportunities. We can choose to run from our obstacles and miss the opportunities that come with them, or we can choose to face our obstacles head-on and find out what opportunities await us. In order to become a triathlete, Sara Erdner has taken down a few “lions” of her own. Sara’s first career lion was actually deciding to compete in triathlons. Sara has been participating in sports all of her life - doing everything from softball and volleyball to basketball and intramural flag football. In 2013 she wanted to try something new. Sara exercised with women who competed in triathlons, and she joined them in their training sessions. Initially, Sara doubted her ability to complete a triathlon despite her athleticism and history of competing in sports. She eventually made the decision to compete in a triathlon, and she was able to finish - first lion slain. In the two years since becoming a triathlete, the list of lions Sara has defeated continues to grow and includes: becoming a swimmer, completing a 66-mile bike ride, finishing an Olympic race (a 1.2 mile swim, a 25 mile bike, and a 6.2 mile run), finishing first in a race, and completing as many as ten races.

At the end of the 2014 racing season, Sara encountered the next lion in her path. During the off-season, Sara began to increase the amount of strength training that she participated in. Sara’s sister-in-law asked Sara to run a half-marathon with her, and Sara agreed to. As Sara began training for the half-marathon, her body was unable to sustain the distances she was running with the additional muscle mass that she had obtained through her strength training. Throughout her training, bones in her foot began to degenerate. One day she ran six miles and did not realize she was injured until the next morning. The bottom of her foot was very tender and she hadn’t felt a pain like it before. The stress that her running and training regimen placed on her foot had caused the Sesamoid bone in her big toe to fracture. After seeing no improvement over the next three weeks, Sara had surgery on her foot, which included having bunions removed.

Initially after her surgery, Sara was not overly concerned with the injury and the recovery process. She was working on her thesis at the time so she used the recovery as an opportunity to get it finished instead of exercising or lifting weights. One evening she was going through her yoga routine, and she was able to see a clear difference in the muscular structure of her calfs. It was at this point that Sara had an emotional breakdown because she realized the extent of her injury. Sara deeply identified with her athleticism and the strength of her body. Perceiving herself as weak caused Sara to go through a mourning process during the early stages of her injury. It was at this point that Sara had to make the decision one has to make with all of life’s lions: fight or flight. Overcome or give in. Sara identified with the story of Benaiah in 2 Samuel. She recognized that her injury was a lion on her path to excellence in sport and in life, and this lion needed to be taken out. Instead of seeing her injury as a obstacle, she began to see it as an opportunity. Her injury was an opportunity to be a better student, an opportunity to develop her identity, an opportunity to become stronger, and an opportunity for spiritual growth. Sara knew that God’s plan for her is bigger than any injury, so she decided to live by faith and overcome this temporary setback. With this in mind, Sara used positive self-talk to embrace and nurture her injured leg. She even gave her injured leg a name - Benaiah. Sara began seeing a physical therapist early in the recovery process. She developed an outstanding relationship with her physical therapist whose empathy and light-hearted nature was critical to Sara’s rehabilitation. In addition to her physical therapist, Sara received great support from her friends, her family, and even her boss at work. It was difficult for Sara to ask people for help when she could not do things or get places on her own. Despite the difficulty of asking for help, Sara understood that asking for help developed her character. Sara said she learned that, “You cannot be someone’s helper unless you are humble enough to ask them for help.”

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Sara’s perspective, determination, and support system propelled her into an effective rehabilitation. Sara described her rehabilitation adherence as “100 percent. Maybe even more than necessary.” Sara went to the gym daily and always attended her physical therapy appointments. Sara had a confidence and belief in physical therapy. She knew that adhering to physical therapy religiously would get her back to her pre-injury form. In order to make her rehabilitation exercises part of her daily routine, Sara did additional exercises at home while reading or while watching television. Additionally, Sara will be able to swim before she will be able to run. Sara described swimming as her weakest leg of a triathlon. She plans on using her injury as an opportunity to become a better swimmer. When she returns to pre-injury form, Sara will be an even better triathlete because she was able to see the opportunity to become a better swimmer during her recovery. In a follow-up interview with Sara, she displays a lot of confidence in her foot and in her recovery. Sara is currently ahead of schedule in her recovery. She is completely out of her walking boot so she is re-learning to walk. Sara is really working toward regaining strength and flexibility in her calf, ankle, and foot. She has employed affirmations to aid in her recovery. When describing her foot, Sara says, “My foot feels strong. It is strong.” Looking ahead, Sara is excited about returning to competition. Sara’s first big test in her return to sport will be a 30-mile bike ride at the end of April. This bike ride will allow Sara to know that she is close to being “back”. Throughout rehabilitation, Sara has been motivated to return to sport by her internal drive to be successful and excel at anything she does. She wants to come back from her injury and come back stronger. When she does, Sara will be in a new age bracket for triathlons. Typically, the older age brackets present stiffer competition. Sara wants to prove that she can compete at a new age level. Sara is in the midst of a struggle with the largest lion she has faced as a triathlete. She is winning the battle, and she is going to win the battle. Throughout her life, Sara will be able to look back on this obstacle and see the opportunity that she was given to grow athletically, personally, and spiritually. She will have the confidence to face other lions in her life as well. The reality of life is that it is full of lions - obstacles - that we can choose to flee from or fight off. Sara has already shown that she is a fighter - a lion chaser.

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“It’s our past problems that prepare us for future opportunities. So someday we may be

as grateful for the bad things as the good things because the bad things helped

prepare us for the good things.” - Mark Batterson

Note: The remainder of this casebooks will specifically address and instruct Sara concerning the various mental skills and strategies that are presented.

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SAra’s path to a comeback

According to Khampoff, Thomae and Hamson-Utley (2013), there are three phases that an athlete typically goes through during the injury recovery. Phase one considers the athlete’s reaction and experience during the initial injury. Phase two considers the athlete’s reaction and experience during rehabilitation. Phase three considers the athlete’s reaction and experience when returning to his or her sport. The second, and most lengthy, phase of the stages of rehabilitation is typically characterized by the physical factors of strength, balance and mobility and the psychological factors of motivation and hardiness (Hamson-Utley, 2010).

Currently, Sara is in the later stages of the second phase. Sara is working to regain all of the strength and flexibility in her foot. She is learning to walk again and looking to make progress in her mobility. Physical therapy is still a primary aspect of her rehabilitation and she continues to stay committed to the various exercises prescribed by her physical therapist. This stage can be lengthy and challenging for athletes, so it will be critical that she maintain her motivation and focus.

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Mental Skills for injury rehabilitation

Although sport injuries are typically perceived as physical in nature, there is also a considerable mental component to injury. Mental skills training can equip you with a sense of control in a circumstance filled with uncertainty. Mental skills and strategies allow you to be an active agent in your recovery and leads to greater motivation and adherence to your rehabilitation regimen (Flint, 1998). Mental skills training can help you efficiently recover physically, in addition to preparing you to perform at a high level in your return to sport.

Sara, throughout the rest of this casebook, I am going to provide you with relevant mental skills and strategies which will assist you in your recovery from injury and your return to sport. Injury rehabilitation can be a long and formidable process, however, I know that you are more than up to the task! Thus, the two mental skills that we will be cultivating throughout this casebook are motivation and focus. My hope is that this casebook will equip you to return to sport physically and mentally stronger than you were before. Take advantage of the resources in this casebook, and enjoy the process of becoming a better - and healthier - athlete!

The key to successfully navigating the windy roads of rehabilitation is motivating yourself to keep driving! Sustaining a positive and healthy engagement in the recovery process will determine the quality of your motivation (Duda and Treasure, 2013). When you believe that you have the resources to meet the demands of the task at hand, you will feel and act more motivated (Ryan and Deci, 2002). Two relevant strategies for maintaining your motivation are goal setting and self-talk. The next section will provide you with goal setting and self-talk resources to assist you in meeting the demands of rehabilitation and return to sport.

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Maintaining motivation

Goal setting is the primary motivational mechanism to influence the degree of effort in striving toward a goal (Evans and Hardy, 2002). The main intent of goal setting should be to identify objectives for the rehabilitation process that allow you to return back to pre-injury form both mentally and physically (Arvinen-Barrow and Hemmings, 2013). Goals can also help you manage your time as the semester comes to a close. The increased utilization of goals leads to an increase in motivation, which leads to increased adherence to your rehabilitation regimen. As a result, the rehabilitation process becomes more manageable, and the healing process is aided.

Taylor and Taylor (1997), identified three types of goals that are specific to injury rehabilitation:

1. Psychological - psychological goals assist with issues associated with motivation, self-confidence, focus, stress, and anxiety.

2. Physical - physical goals give a clear direction for physical aspects of recovery.

3. Performance-related - performance-related goals identify potential areas of improvement for various aspects of successful rehabilitation (e.g., rehabilitation exercises)

Taylor and Taylor (1997), have also identified four different levels of goals that can be used to successfully achieve psychological, physical, and performance-related goals:

1. Recovery – associated with the final level of recovery (long-term goals).

2. Stage - consists of specific objectives for each of the different stages of rehabilitation (medium-term goals) - in your case phase two.

3. Daily - daily objectives and targets for each rehabilitation session (short-term goals).

4. Lifestyle - goals related to any lifestyle choices that can influence the quality of your recovery. For example, sleep, diet, alcohol and drug use, relationships, work, school, and commitments.

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Maintaining motivation: Goal Setting

A great way to begin the process of setting goals for rehabilitation is rehabilitation profiling. Rehabilitation profiling allows you to assess both the personal and psychological factors that influence the quality of your rehabilitation and your recovery (Taylor and Taylor, 1997). By completing a rehabilitation profile, you will create an awareness of your personal and psychological needs so you cater your rehabilitation goals around those needs. In addition to having an understanding of the factors that can help and hinder the rehabilitation process, completing a rehabilitation profile can give you a belief that you control your destiny and your recovery.

In order to complete the rehabilitation profile, it is important to understand each of the personal (Table 1.1) and physical factors (Table 1.2) that can impact your rehabilitation. Once you have an understanding of each factor, you can rate (on a scale from 0 to 10) how important each factor is to your rehabilitation and recovery.

After determining the importance of each factor, take a colored pen, pencil, marker, or crayon (whichever makes you happiest!) and fill in the personal profile (Figure 1.1) and physical profile (Figure 1.2) from inside to outside based upon the score that you gave each factor. For example:

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rehabilitation profiling for goal setting

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Rehabilitation profile: Definition of Personal factors

Table 1.1 Rehabilitation profiling: definition of personal factors

Source: Adapted from Taylor and Taylor, 1997

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Rehabilitation profile: Personal factors

Table 1.1 Rehabilitation profiling: personal profile


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Rehabilitation profile: Definition of Physical factors

Table 1.2 Rehabilitation profiling: definition of physical factors


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Rehabilitation profile: Physical factors

Table 1.1 Rehabilitation profiling: physical profile


Now that you have an idea of what personal and physical factors will influence your rehabilitation and recovery, you get to begin the process of developing the goals you want to achieve moving forward! When setting goals, it is important to follow a few guidelines to make them as effective as possible (Gould, 2013):

1. Goals should be specific - outline exactly what you want to achieve. It is better to have your goals be explicit rather than general.

2. Goals should be measurable - goals should be measurable numerically or by observable behaviors that allow you to assess the degree to which your goals were attained.

3. Goals should be attainable - make sure that you have the resources available to attain your goals.

4. Goals should be realistic - goals should be realistic based upon your past experiences/successes and your current capabilities.

5. Goals should be time-bound - you should have a target date for accomplishing your goals.

6. Goals should be stated in a positive manner - identify the behaviors you want to display rather than the behaviors you do not want to display.

7. Set both short-term and long-term goals - seeing success in your short-term goals will motivate you to continue working toward your long-term goal.

8. Goals should be somewhat flexible - it is better to focus on the degree to which you have attained your goal. Settling for nothing less than absolute attainment of your goal can result in feelings of failure (Arvinen-Barrow and Hemmings, 2013).

9. Monitor goals throughout rehabilitation - take the time to reflect on and evaluate your goals as you recover. It can give you an understanding and an appreciation for your progress which will lead to greater effort and motivation (Arvinen-Barrow and Hemmings, 2013).

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goal setting guidelines

The next few pages will provide you with tools for outlining and keeping track of the goals you want to achieve during rehabilitation.

The Goal Staircase (Gould, 2013) is a great visual tool that you can use to remind yourself of the importance of using short-terms goals (for example, comfortably riding on a stationary bike) as stepping stones toward achieving your long-term goal (for example, completing your 30-mile bike race). The first step should assess your current ability with the following three or four steps specifying what short-term goals you need to achieve to reach the top step - your long-term goal. Fill in your goal underneath each step then post the staircase somewhere visible or bring it with you to physical therapy. Let the Goal Staircase motivate you to a full recovery!

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Goal setting Activities

Present Ability

Short-Term Goal 1

Short-Term Goal 2

Short-Term Goal 3

Short-Term Goal 4

Long-Term Goal

An alternative to the Goal Staircase is a traditional goal recording worksheet. Feel free to write down any long-term recovery goals you may have along with some short-term daily goals (physical, psychological, or performance) that you can accomplish to reach your long-term goal!

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Once you have recorded your long-term and short-term goals for your rehabilitation, you can go through this checklist to ensure that your goals are equipping you for long-term motivation and a successful recovery!

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The thoughts and things that you say to yourself during your rehabilitation and recovery influence your emotions, behaviors, and recovery outcomes (Wiese-Bjornstal, Smith, Shaffer and Morrey, 1998). With this in mind, it is important to interrupt or change the negative thoughts that you have during rehabilitation, in addition to utilizing and fostering positive thoughts that you have during rehabilitation. The positive thoughts and self-talk create positive emotions that are associated with enhanced quality of rehabilitation (Udry, Gould, Brides, and Beck, 1997).

According to Hardy (2006), self-talk is:

1. verbalizations or statements addressed to the self 2. multidimensional in nature 3. has interpretive elements associated with the content of statements

employed 4. is dynamic 5. has intersectional and/or motivational functions for the athlete

Sara, for your stage of rehabilitation it will be beneficial to focus on the more motivational function of rehabilitation. Motivational self-talk is suggested to be more effective for the execution of strength and endurance-based tasks because it can increase effort, enhance confidence, and/or create positive emotions (Tod et al., 2011). As you regain strength in your foot and aim for participating in the endurance task of bike-riding, motivational self-talk should be a valuable resource for you.

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maintaining motivation: Self-talk

Motivational self-talk has been categorized into three primary, and more specific, motivational functions (Hardy et al., 2001):

1. Arousal - this function of motivational self-talk is used to psych up, relax, and control arousal. Motivational arousal self-talk allows you to control your arousal in a way that best suits your needs during rehabilitation. Maybe you are having a tough time motivating yourself to start an exercise, use self-talk to psych yourself up and get yourself in the right mindset. Maybe you are struggling with trying a new exercise or are attempting to get back into sport and anxiety is setting in. Use motivational arousal self-talk to relax yourself and lower your arousal levels.

2. M a s t e r y - t h i s f u n c t i o n o f motivational self-talk is used for mental toughness, focus of attention, confidence, and mental preparation. Mastery self-talk can be used to cope with difficult situations. In the rehabilitation setting, motivational mastery self-talk can help you push through the pain or exhaustion of an exercise or the conditioning that takes place as you ease yourself back into sport.

3. Drive - this function of motivational self-talk is used for goal achievement and maintaining or increasing drive and effort. On the days when the rehabilitation process is taking its toll on your psyche and you start to doubt your commitment to rehabilitation, utilize motivational drive self-talk. Motivational drive self-talk encourages you and increases your motivation and your effort levels.

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maintaining motivation: motivational Self-talk

Sara, throughout the duration of your rehabilitation, make use of motivational self-talk to keep yourself focused on your end goal of becoming the healthiest, strongest, and best athlete you can be! Below are a few examples of each function of motivational self-talk. Modify these or even change them completely so that the words and phrases you say to yourself have as big an impact and motivational effect as possible!

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Examples of motivational self-talk

Motivational Arousal Self-talk:

“Come on! You can do this!”

“Stay relaxed. Breathe deeply and slowly.”

Motivational Mastery Self-talk:

“My foot is strong like a mountain. I am ready!”

Motivational Drive Self-talk:

“Keep pushing! Only 2 more minutes!”

Another self-talk strategy you can use to increase your motivation is affirmations. According to Williams, Zinsser, and Bunker (2013), affirmations are statements that reflect positive attitudes or thoughts about oneself. They are statements of what you want, phrased as if you already had it. In order for an affirmation to be effective, they need to be realistic and vivid. Affirmations should also be in the present-tense and avoid perfectionist statements that include words like “always” or “never”. Some examples of affirmations that you can use are: “My foot is powerful! I will conquer this exercise!” or “I am a healthy and strong triathlete!”

Affirmations activity:

Write down two or three personal affirmations regarding your rehabilitation, recovery, and return to sport. Say these affirmations to yourself until you believe them. Additionally, you can post your affirmations in easily visible places that you are frequently nearby. You can also write them down on an index card and carry it around. Look at the index card as many times as you need to throughout the day in order to instill confidence in yourself and motivate yourself to continue rehabilitating with purpose!

1. ____________________________________________________.

2. ____________________________________________________.

3. ____________________________________________________.

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maintaining motivation: self-talk (AfFirmations)

When you you are fully focused or concentrating, you are able to selectively attend to appropriate environmental or internal cues, while blocking out irrelevant or distracting stimuli (Willaims, Nideffer, Wilson, and Sagal, 2013). Focusing enables you to completely engage in whatever activity you are participating in. For you, that could mean fully engaging in your strength and flexibility exercises, your conditioning exercises, or even having a complete awareness of how you are walking. In the next section of this casebook, information and strategies regarding imagery and relaxation will equip you to sustain your focus throughout the rest of your rehabilitation and recovery.

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Sustaining Focus

Flint (1998) divides relaxation into two categories: physical and mental. Physical relaxation is typically used to relieve the body of physical tension, while mental relaxation is used to relax and focus the mind, which will relax the body. Using relaxation techniques can reduce symptoms of stress and anxiety by focusing your attention to the task at hand, which will increase blood flow to your foot and aid in the healing process (Walker and Heaney, 2013; Taylor and Taylor, 1997).

The two relaxation techniques I want to introduce you to for the purpose of sustaining your focus during rehabilitation are: centering and mindfulness.

1. Centering is a conscious process used to adjust weight about your center of mass so you feel centered and in control (Williams, Nideffer, Wilson and Sagal, 2013).

2. Mindfulness is a mental state resulting from voluntarily focusing your attention on your present experience in its sensorial, mental, cognitive and emotional aspects, in a non-judgmental way (Cottraux, 2007).

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sustaining focus: Relaxation

Centering is all about focusing your attention on the task at hand. The primary means of centering is by focusing your attention from your head to your center of gravity which will give you a sense of control, stability, and relaxation. With practice, centering provides you with a means of relaxing almost instantly. When you become skilled at centering, a deep breath is all it takes to enter into a relaxed mindset so that you can focus your full attention on what needs to be done and how you are going to do it (Walker and Heaney, 2013).

You can also pair cue words with your centering exercises. For example, if you want to feel “loose” or “strong” while running, biking, or swimming, you can repeat those words to yourself while you are going through a centering exercise. Choose words that describe how you want to feel or how you want to behave while rehabilitating your foot or conditioning for your first bike race. With practice, similar to a deep breath, cue words used during centering exercises can also result in almost automatic relaxation and focus (Williams, Nideffer, Wilson, and Sagal, 2013).

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sustaining focus: relaxation (centering)

The following is an exercise adapted from Harwood (1998) that you can use to develop the relaxation technique of centering:

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sustaining focus: relaxation (centering)

❖ Stand with your feet shoulder-width apart and bend your knees slightly.

❖ Relax your neck, arms and shoulder muscles.

❖ Direct your thoughts inwards to check and alter your muscle tension and breathing, by focusing on the abdominal muscles and how they expand as you breath in. Try to feel the heaviness in your muscles.

❖ Take a slow, deep breath (from the diaphragm), trying to limit the movement of the chest cavity.

❖ Concentrate on your breathing and the heaviness of your muscles, clearing the mind of all irrelevant thoughts, and say ‘relax’.

❖ Now focus your attention on the rehabilitation activity and what you need to do to perform it.

Mindfulness is a distinct form of awareness or attention that uses breathing methods, guided imagery, and other practices to relax the body and mind and to help reduce stress (Walker and Heaney, 2013). Mindfulness allows you to stay focused on the present moment which is critical to producing the most beneficial rehabilitation and performance outcomes. Mindfulness during rehabilitation can help draw your attention to your various rehabilitation activities and promote the correct execution of physical movements (Mahoney and Hanrahan, 2011). Additionally, mindfulness allows you to objectively address any negative thoughts (boredom, frustration, anxiety, etc.) you may have during rehabilitation. You can mentally draw back, recognize these thoughts for what they are (just thoughts, not realities), and continue focusing on the task at hand.

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sustaining focus: relaxation (mindfulness)

The following is an exercise adapted from Williams, Nideffer, Wilson and Sagal (2013) that you can use to develop the relaxation technique of mindfulness and stay focused during your rehabilitation and return to sport activities:

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sustaining focus: relaxation (mindfulness)

❖ Sit quietly.

❖ Close your eyes.

❖ Begin breathing deeply in through your nose and out through your mouth.

❖ Breathe in slowly for four seconds and then breathe out slowly for eight seconds.

❖ See how long you can focus on a single thought.

❖ Become aware and mindful of your mission for today.

❖ What do you need to do to during this next rehabilitation exercise? How do you want to feel? Lock in on the task at hand.

❖ When you feel ready, become aware of your environment and bring yourself back.

❖ With your mindful state and focus, begin your rehabilitation exercise.

Imagery is an activity which involves creating a clear mental picture of the athletic situations, which can mean the environment, the performance, the conditions, the people, the emotions and senses. In the injury setting of sport, you can use imagery to create images of: the healing process, the injured body part fully healed and restored to desirable levels of functioning, the rehabilitation setting, successfully completing rehabilitation exercises, dealing with pain and any emotions associated with the injury and recovery process (Arvinen-Barrow, Clement and Hemmings, 2013).

This section of the casebook will guide you through how to make the most out of your imagery sessions, in addition to describing three types of imagery that will help you stay focused on your rehabilitation and recovery. The three types of imagery that will be discussed are: healing imagery, rehabilitation process imagery, and performance imagery.

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sustaining focus: Imagery

Now that you have an idea of some of the uses of imagery during injury rehabilitation, you get to begin the process of using imagery yourself! When utilizing imagery, it is important to follow these guidelines to make your images as effective as possible (Vealey and Forlenza, 2013; Taylor and Taylor, 1997):

1. Imagery should be a polysensory experience. When using imagery, you should incorporate as many of your five senses as possible to recreate a prior experience or create a desired experience. You can also include your kinesthetic sense (which involves the sensation of your body in motion) and the emotions that you felt or want to feel (e.g., confident, relaxed, focused, determined).

2. Related to imagery being polysensory is images being vivid. Vividness refers to your ability to see the image clearly and with detail. The more senses and feelings you can include in your images, the more vivid they will become.

3. As you practice imagery, your images should also be more controllable which means imaging exactly what you intend to and being able to manipulate those images as you please. The controllability of your imagery will take time, however you will find that you have more control with practice and patience.

4. Your images can also be from an internal perspective (the images are from your point of view) or from an external perspective (you are seeing yourself from an outsider’s point of view). Both perspectives are effective methods of using imagery so use whichever perspective is most natural and helpful for you!

5. When imaging, reproduce or create an entire experience. Use all of the physical and the psychological aspects of the injury rehabilitation process.

6. Use imagery when you are in a relaxed state. When your body is relaxed and your mind is calm, you will have the best physical and emotional experience.

7. Use imagery to facilitate physical and emotional wellbeing and feeling good.

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The three types of imagery that would be most beneficial to sustain your focus throughout the rest of your rehabilitation are rehabilitation process imagery, healing imagery, and performance imagery. Process and Healing imagery can help you remain mindful of the rehabilitation process and focus on gaining flexibility and strength in your ankle, calf, and shin. Additionally, as you prepare to compete in your first bike race since injuring your foot, it would be beneficial to utilize performance imagery as well!

1. Rehabilitation Process Imagery - rehabilitation process imagery equips you to create images of the many aspects of the rehabilitation process that you typically experience. For example, completing exercises, adhering to the rehabilitation program, overcoming setbacks and obstacles, maintaining a positive attitude, and staying focused (Heil, 1993; Ievleva and Orlick, 1991; Wiese et al., 1991).

2. Healing Imagery - healing imagery refers to images in which the athlete will see the injured body part healing. In order for healing imagery to be effective, you need to have a complete understanding of the injury and you must be able to create a picture of the injured area (Taylor and Taylor, 1997). Be sure to ask your orthopedic surgeon for more information about the sesamoid fracture, where your foot is currently at physically, and what it should look like when it is fully healed so that you can utilize healing imagery!

3. Performance Imagery - performance imagery entails mentally rehearsing sport-specific skills during rehabilitation (Walsh, 2005). You can imagine yourself participating in all three legs of a triathlon - successfully and strongly swimming, biking, and running on your fully healed foot. For your upcoming bike race take the time to image yourself completing the race and the emotions and feelings you want to have before, during, and after the bike race.

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In a study done by Cressman and Dawson (2011), athletes claimed that healing imagery encouraged more concentration toward and awareness of their injury. This led to improved adherence, focus, motivation and positivity during rehabilitation. The following is an imagery script adapted from the Cressman and Dawson (2011) study that you can use to stay focused on actively rehabilitating your foot and returning to sport:

Note: Be sure to follow the guidelines for imagery on page 31! Be patient and practice about 10-15 minutes a day!

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❖ Shift all of your attention toward your injury, it is the only thing on your mind now.

❖ Feel the tightness and resistance in your leg and foot releasing.

❖ Feel the tension around your injury releasing, your foot is becoming relaxed.

❖ See your lower leg, it is weakened but is ready for recovery.

❖ See the muscles in your lower leg and foot, see any loss of muscle mass.

❖ Feel the blood in your arteries pumping toward the injury, it is bringing new food and oxygen to your lower leg and foot.

❖ See the fresh blood circulating around the injury, strengthening the bone and muscles in your lower leg and foot.

❖ See new, strong, and indestructible muscle tissues coming to together and growing in your lower leg and foot.

❖ See the muscles coming together to make a strong, unbreakable band that is ready to run.

Sara, thank you so much for taking the time out of your semester to be interviewed and allowing me to be a part of your recovery! It has been a great opportunity for me to grow as a student and as an sport psychology consultant. I hope that this casebook is as beneficial to you as it has been to me. Please stay in touch and let me know how the rest of the recovery process goes. Keep chasing those lions!

Best, Brennen

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Thank you, Sara!

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Arvinen-Barrow & N. Walker (ed.), The psychology of sport injury and rehabilitation

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Cottraux, J. (2007). Therapie Cognitive et Emotions: La troiseme vague [Cognitive Therapy

and Emotions: The third wave]. Paris: Elsevier Masson.

Cressman, J. M. & Dawson, K. A. (2011). Evaluation of the use of healing imagery in athletic

injury rehabilitation. Journal of Imagery Research in Sport and Physical Activity, 6(1).

Duda, J. L., & Treasure, D. C. (2013). The motivational climate, athlete motivation, and

implications for the quality of sport engagement In J.M. Williams & V. Krane (7th ed.),

Applied sport psychology: Personal growth to peak performance (pp. 57-77). New

York, NY: McGraw-Hill.

Evans, L. & Hardy, L. (2002). Injury rehabilitation: A goal setting intervention study. Research

Quarterly for Exercise and Sport, 73, 310-319.

Flint, F. A. (1998). Integrating sport psychology and sport medicine in research: The dilemmas.

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