Psychology of Injured Athlete

Mark E. Lavallee, MD, CSCS, FACSM February 2016

Director, York Hospital Sports Medicine Fellowship, York, PA Head Team Physician, Gettysburg College, Gettysburg, PA

Chairman, USA Weightlifting, Sports Medicine Society, Colorado Springs, CO Medical Director, International Weightlifting Federation, Masters World Championships, Budapest,

Hungary

Disclosures • Do not have any financial disclosures to reveal

Jerrad’s Story

• 24y.o. Olympic Hopeful in Weightlifting. • Educated Physical Therapist who curtailed career for

last 3 years preparing for Olympics.

• At Worlds Weightlifting Championship in Houston in November 2015

• Was expected to do very well (PR and score USAW team points.

• Earn spot on Olympic Team for Rio 2016 (FYI: had injury just before 2012 Olympics forgoing his participation on Team USA)

Jerrad’s Story

• His Exam immediately after before he was going to try a second attempt was +Varus Stress (LCL), No pain, but could not prefer split jerk without feeling right knee giving out.

• Withdrew from competition in TEARS • Let team done, by NOT scoring much need team points in

order to earn slots for more Team USA to go to Rio (ASHAMED)

• Second time an injury has occurred just before an Olympic year. (LOSS)

• Uncertainity of injury: if ACL ruptured, no chance for Olympics (ANXIETY)

Jerrad’s Story • Jerrad’s MRI confirmed LCL grade 2 injury and ACL

rupture • He had ACL reconstruction surgery and is on road to

recovery. • MOOD-

• Initially: sadness, bargaining, fear, self-pity • Within hours: acceptance of injury, anxiety, fear, loss, pain • Within days: acceptance, rare anger, pain

• WHY was Jerrad successful in navigating this? • Tremendous Family, Coaching, Friends, and USAW support • Goal Shifting from Rio 2016 to Toyko 2020 • Spiritual focus • Sense of humor and humilty

Goals and Objectives

• Understand the psychology of the injured athlete • Understand psychological barriers to recovery from injury • Review potential interventions

Athletes are Different!!

The Goldman Dilemma • Would athletes pursue sporting success (an

Olympic Gold Medal) via an undetectable performance enhancing drug that would kill them in five years time;

• 52% reported they would take the drug (Goldman et al, 1984).

• Only 3% of regular population answered yes.

• Dr. Conner repeated survey among elite T&F

athletes (119 men 93 Women) mean age 20.9(2012)

• Only 2 out of 212 athletes reported that they would take the Faustian bargain offered by the original Goldman dilemma.

• However, if there were no consequences to the (illegal) drug use, then 25/212 indicated that they would take the substance (no death condition).

• Legality also changes the acceptance rate to 13/212 even with death as a consequence.

• Regression modelling showed that no other variable was significant (gender, competitive level, type of sport)

http://sportingphysio.files.wordpress.com/2013/07/genedoping3_widec.jpg

Injuries + Loss of Performance=> Mood + Personality

• Types of Injuries • EARLY IN CAREER

• Concussion • Injury

• MID CAREER

• Injury • Concussion

• END OF CAREER

• Chronic health concerns • Loss of performance • Injury • Loss of Focus/Mental toughness

Note: he is looking at his front tooth sticking in the floor

Early in Career

• Concussion • Relationship established with

repeated TBI risk of the following increases:

• DEPRESSION • ANXIETY

• MSK Injury

Middle of Career

• MSK injury • Divorce/ Family strife • Change in notoriety/income

End of Career • Ending a career in sports is a very significant

time an athlete’s life. This includes many transitions as athletes often follow a very structured routine.

• Adjustment often includes change in diet, daily routine, self-perception, perception of control, social environment, emotions, and relationships.

• End of career issues happen from “normative” (routine transitions) and “non-normative” transitions (injuries).

• 14-42% of athletes retire due to serious injuries

• Athletes reactions to a career ending injury may include: grief, identity loss, loneliness, anxiety/fear, loss of confidence, depression, alcohol abuse, and even suicide.

End of Career • Kleiber, et al (1992) showed that the sole

predictor of life satisfaction 5-10 years after departure from formal sport participation was whether one had sustained a career-ending injury

• In a previous study of psychosocial factors on injury response, the most significant predictor of post-injury depression was severity of injury

• The higher the level of the athlete and lower the education, the higher the risk for emotional difficulties following a career ending injury.

• Coping strategies for stress, social support, life planning, and alternative activities are important topics for discussion.

B. Jaroni (HUN) dislocates right elbow at 2008 Olympics, thus ending his career.

How shall we look at the Injured Athlete? • Mood disorders

• Depression • Anxiety

• Personality disorders • Narcissitic PD • Borderline PD • Obsessive-Compulsive PD • Bipolar PD

Degenerative Conditions Cognitive decline-Dementia Eating Disorders Anorexia (restrictive) Bulima (Purging) Body Dysmorphic Syndrome

Athlete Response to Injury

• Common athlete responses Tension

• Low self-esteem • Depression • Anxiety

• Ability to cope with stress improves outcomes

• Clearance to return may evoke negative responses

• Emotions may vary: • Anger early in rehab • More positive emotions late in

rehab/RTP

Common Athlete responses to Injury

• Early response • Stress/anxiety • Anger • Treatment adherence problems

• Positive traits for recovery

• Adherence to plan/rehab • Having a positive attitude

Glazer DD. J Athl Train. 2009 Mar-Apr;44(2):185-9.

Three Levels of Stress

Positive Stress: Brief increases in heart rate, mild elevations in stress hormone levels

Tolerable Stress:

Serious, temporary stress responses buffered by supportive relationships

Toxic Stress:

Prolonged activation of stress response systems in the absence of protective relationships

Adapted from the Center on the Developing Child Working Paper Excessive Stress Disrupts the Architecture of the Developing Brain

Dr Ron Wade’s Lecture on ACE 11/19/15, York College, York, PA

How does Youth respond to PPEs

• In realm of EKG screening during Pre-Participation exams

• Would screening cause negative stress/impact on youth

• Just being screened, though NEGATIVE EKG screen (Normal)

• POSITIVE EKG, though follow-up confirmatory test NEG (False Positive)

• POSITIVE EKG, with POSITIVE confirmatory tests (True Positive)

• Screened 1,516 HS students • 59% male • 56% White, 26% AA • Seattle, WA Area

• Normal Screening: 1116 • False Positive: 333 • Trues Positive: 13

Asif et al, Clin J Sport Me 0(0) 2015 1-8

Demographics of High School Students study for Anxiety due to EKG during PPEs

Asif et al, Clin J Sport Me 0(0) 2015 1-8

Youth response to EKG

• RESULTS: • EKG screening does NOT cause

excessive anxiety in HS youth • Though males and African-

American race are at higher rate of SCD, they had lowest anxiety scores.

• Asif argue that anxiety is not an argument against doing EKGs at PPEs on youth

• COMMENTS • WHY did those at higher risk had

lowest anxiety?? • Teenage Boys are CLUELESS • “10 feet tall and Bulletptoof”

• Cost (financial/time) seems prohibitive

• Only NW part of USA • Gold Standard is ECHO, which is

quicker if doing limited-view echo, thus would decrease false positive.

Factors that may affect Recovery

• Motivation • Intrinsic > extrinsic • Positive versus negative

perceptions about return to sport • POSITIVE

• Return role with teammates • Performing sport them love

• NEGATIVE • Loss of self without sport • Self worth issues • Sports was their main stress reliever

• Confidence • Greater confidence in athletes

who have return to sport

Fear

• Fear-Avoidance • Avoiding activity for fear of re-

injury

• Psychological

• Fear of not returning to previous level

• Fear that teammates, coaches will think less of them (weaker cause of injury)

• Athletes with greater fear of re-injury have delayed return to sport

Anxiety/Depression

• Depression and anxiety are common after injury

• If athlete has greater than 3-6 months

• chronic pain • Until return to sport (not necessarily

their level of training) • “Career-Ending” Injury

• These Athletes have shown a 82% chance of developing depression

• Generally Mood improves during recovery course

• Athletes mood affects return to sport

• Profile of Mood States ( POMS) measurement significantly related to time to return to sports from medical clearance

Other risk factors for NOT returning to sport • Female sex

• Higher rates anxiety/depression? • Certain Personality Disorders

• Bipolar, Borderline, OCPD, • Not setting rehabilitation goals • Negative attitude toward

• therapy • life

• Lower hedonic tone • Ability to experience pleasure or

satisfaction

“Retired” Bodybuilder due to right Rectuas Femoris tear!!

Measurements

• Emotional Response of Athletes to Injury Questionnaire (ERAIQ)

• ACL Return to Sport after Injury scale (ACL-RSI)

• Injury Psychological Readiness to Return to Sport Scale (I-PRRS)

• Beck Depression Scale

What Should I do?

• Understand that psychological factors play a role in athlete recovery

• Team vs individual sport • Family involvement • Friend’s involvement • Financial implication • Scholarship/Sponsor

• Monitor for factors that may be associated with worsening outcome

• Persistent negative attitudes • Persistent anxiety/depression

• Address musculoskeletal related issues

• Persistent instability • Ankle sprain • Patellar dislocation

• Strength/Neuromuscular deficits

• Athrogenic Muscle inhibition

• Inappropriate preparation for return to play

• Acute moving to Chronic Pain

How can you help the Athlete

• Availability • Compassion • Hope (when appropriate) • Counselling • Advocate for their health and

wellness- you may be the only “Voice of Reason!”

• Being ‘POSITIVE!” • Humor when appropriate

Cheering up a Depressed Teen with a Glow-in-the-dark spiral colored a cast

Chronic Pain– The GREAT mood changer

• If someone suffers from chronic (>3 months), unrelieving pain

• 82% mood alteration • Higher rates of depression (suicide

if neurologic issues persists. • Avoid Narcotics

• Dependence, mood issues, declining efficacy on pain control

• Consider • Ketamine, tramadol, Notriptyline,

Lidoderm patches, SSRIs NSRIs.

• Suggested reading

• PAIN: The gift Nobody Wants by Dr. Paul Brand

Arthrogenic Muscle Inhibition (AMI) • AMI is caused by a change in the

discharge of articular sensory receptors due to factors such as swelling, inflammation, joint laxity, and damage to joint afferents

• Most commonly described in the • quadriceps muscle • post & anterior cruciate ligament

• Likely a component in all joint injuries

• ? Contribution to decreased confidence and fear-avoidance “ Own” the knee

Conclusion

• Psychological factors may play a role in recovery

• Unclear what interventions may have an effect

• Many may be intrinsic to the athlete

• Addressing barriers/assessing readiness for RTP may improve return to sport

• Control those factors that you can

• Pain • Strength • Return to play progression

DENG, Wei after WR C&J of 146 kg at 63 kg, IWF Worlds, Nov 2015

Selected References

• A systematic review of the psychological factors associated with returning to sport following injury.Ardern CL, Taylor NF, Feller JA, Webster KE.Br J Sports Med. 2013 Nov;47(17):1120-26

• Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010 Dec;40(3):250-66

• Development and preliminary validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. Glazer DD. J Athl Train. 2009 Mar-Apr;44(2):185-9.

• Asif IM, Price D, Harmon KG, Salerno JC, Rao AL, Drezner JA, Psychological Impact of Cardiovascular screening in Young Athletes: Perspective across Age, Race and gender” Clin J Sports Medcine 0(0) 2015 pp1-8.

• Roy Wade, MD, personal communitation,”Adverse Childhood Events and their Impact on Health,” Grand Rounds, York Hospital, November 19th, 2015.

• Stoltenburg AL, Kamphoff C, Lindstrom Bremer K, “The psychosocial Effects or Collegiate Athletes’ Career-Ending Injuries.” The Online Journal of Sport Psychology, 2011.

Psychology of Injured Athlete�DisclosuresJerrad’s StoryJerrad’s StoryJerrad’s StoryGoals and ObjectivesAthletes are Different!!Injuries + Loss of Performance=> Mood + PersonalityEarly in CareerMiddle of CareerEnd of CareerEnd of CareerHow shall we look at the Injured Athlete?Athlete Response to InjuryCommon Athlete responses to InjuryThree Levels of StressHow does Youth respond to PPEsSlide Number 18Youth response to EKGFactors that may affect RecoveryFearAnxiety/Depression�Other risk factors for NOT returning to sportMeasurementsWhat Should I do?How can you help the AthleteChronic Pain– The GREAT mood changer�Arthrogenic Muscle Inhibition (AMI)ConclusionSelected References