We all know the physical effects an injury can have on us and how hard they can be to overcome but recognising the psychological effects could be just as important. Recent research has identified key factors that can have a significant impact on whether someone returns to sport after injury and if they return to their previous level. Manage these factors and you can get back to running with a healthy mind and body.
Picture courtesy of James – AKA @Ablefeet
In March this year the British Journal of Sports Medicine published an article by Clare Ardern and colleagues which examined the psychological factors associated with return to sport. Ardern et al. (2012) completed a systematic review of the literature on the topic and included 11 studies involving nearly 1000 athletes. They concluded that positive psychological responses are associated with a higher rate of return to sport after injury and should be taken into account by clinicians during rehab.
Ardern et al. divided these factors into 3 main areas – autonomy, competence and relatedness which fit within the context of self-determination theory.
Refers to psychological factors that promote the perception that your actions are “self-authored or personally endorsed”. It links with motivation, independent choice and self-efficacy.
Ardern et al. found that athletes who returned to sport had higher levels of motivation and more positive perception of their return to sport.
Ardern et al. describe competence,
“Competence pertains to the cognitive and emotional responses (eg, fear and confidence) that contribute to an athletes perception of their proficiency or effectiveness in sports participation.”
I understand this as meaning, in a nutshell, how you feel about doing your sport.
Ardern et al. identified the following factors from the included studies – “confidence, emotions, mood, perception of negative influence of injury on current life situation, psychological readiness to return to sport, risk appraisal, subjective estimation of injury severity and competence needs satisfaction.”
Again athletes that returned to sport demonstrated a more positive psychological response in these areas and those with lower levels of fear of re-injury returned to sport more quickly.
Some factors were associated with not returning to sport – “female sex, not setting rehabilitation goals, negative outlook regarding injury and negative attitude toward rehabilitation…along with hedonic tone* were predictive of an athlete who was not likely to return to sport.”
* “Hedonic tone” refers to someone's ability to experience pleasure or satisfaction. Lower hedonic tone (i.e. difficulty experiencing pleasure) was associated with failure to return to sport.
Athletes who didn't return to sport rated their life situation as over three times worse than those who did return.
Refers to an athlete's “perception of connectedness or belonging in a social context.”
We're very fortunate as runners to have the support of a vibrant and caring running community that can help us to feel connected to others. Ardern et al. found just one significant relatedness factor – that athletes who returned to sport had positive perception of return to sport, which seems to be the case across all three main areas.
Thanks to the lovely Anji – AKA @enigmagirl81 for the photo!
What can you do to help yourself?
I should point out at this stage that I'm a Physio and not a Sports Psychologist!
If you have concerns about you mental health please ensure you speak to you GP or a qualified mental health professional.
These recommendations are taken from research findings and experience in managing patients within the Biopsychosocial model of care (that encompasses body and mind);
- Improve your understanding of the injury and how it heals – managing an injury is much easier if you understand it. It means you can make informed decisions about your rehab and this helps with autonomy. Research your injury, speak to your Physio or doctor or consult articles on this site for evidence based information. The best source of information is often your health professional who will have assessed you and knows your situation, make sure you discuss returning to sport with them and decide appropriate timescales. Be wary of internet advice if not provided by qualified health professionals.
- See running as helping healing and part of rehab – sadly many clinicians still view running as somehow damaging to the body. The result is many runners are told total rest is the only solution to an injury. In the early stages rest is often needed but so often I see these rest periods stretching long beyond the healing time of the injured tissue. Recently I treated a patient who had been told not to run over a year after a simple minor calf strain. My point here is that running can be a hugely helpful and important part of rehab if done at the right level. Loading of tissue stimulates healing and positive adaptations of those tissues. The art is finding the right level for you and your stage of injury. This can be done by setting a baseline and gradually increasing. Your baseline is the amount of running you can do at a comfortable pace with no symptoms. For more information see our piece on returning to running.
- Manage fear of re-injury – fear of re-injury is associated with slower return to sport and is often a reason why people are worried about returning to running. It is also totally understandable, especially when people have faced severe pain and a long time out from sport due to their injury. Two key areas are understanding and pacing yourself. As injuries heal the tissues gradually adapt and get stronger and more capable of dealing with stress and load. If you work within the limits of your tissues by pacing yourself and building up gradually it is less likely you'll suffer a setback. If you work over the limit of these tissues then you're more likely to have a flare up of your symptoms and have a setback. But here's the good news – these flare ups are usually temporary and often don't involve permanent damage to the healing tissue. In many cases after a few days or a couple of weeks you can return to your rehab and if comfortable, your running. If you know that you can prevent re-injury by pacing yourself and understand that any setback is likely to only be temporary then it makes it far less scary.
- Put yourself in control – find strategies you can do that help you reduce your symptoms and rehab towards recovery. This can be stretching, using a foam roller, self massage, self taping, home or gym exercise etc etc. This combined with pacing yourself means you're less likely to have symptoms but when you do you can manage it. Again this improves autonomy and reduces fear – you're likely to be afraid of things you can't control.
- Set goals – Ardern et al. recommend setting goals to build an athlete's confidence. They also help with motivation and give you a way of measuring your progress. In Physio we use “SMART goals” – Specific Measurable Achievable Relevant Timed. I like to make them SMARTI goals by adding an “I” for Inspiring. For example if my goal is simply to get back running it isn't very specific and how will I know when I've achieved it? When I can run for the bus? When I can run a marathon? A SMART goal would be to return to running 1 mile in 10 minutes or less within 2 weeks. To make it more “Inspiring” you could say run that 1 mile to a stunning view point (or cracking pub!). Goal setting is a learning curve – you might need to set both short term and long term goals and you may find a few turn out to be unrealistic but this improves with a little practice. With goals be kind to yourself – if you don't achieve 100% of your goal that isn't a failure. In fact even if you achieve less than 50% of it that's fine – anything is better than achieving 0% – it's all progress!
- Seek support from fellow runners – the running community is incredibly supportive and you can bet other runners will have had a similar injury and be able to share useful advice. Chat to runners online or at your local running club. Many running shops have weekly runs that are a good place to meet fellow runners and get involved with your local community. The online support is excellent too – tweet, blog, email and ask others and you'll find help for anything from blisters to bloating! It all helps with 'relatedness' and feeling connected with others in a similar situation. We encourage runners to share injury stories through 'guest blogging' with us – let me know via the comments section if you'd like to share your story with others.
- Envisage success – a consistent finding in Ardern's research was that the importance of a positive view of returning to sport. When fearful we tend to focus on negatives and get worried about what might happen if we try and run. Often this appears in the form of “what if”…what if I get injured again? What if I get stuck 5 miles from home? What if my leg actually falls off and I have to carry it home in a bag?! Think about the positives, how nice it'll feel to get out in the fresh air even if just for half a mile or how nice the views might be. Some athletes use positive mental imagery and imagine themselves running or competing and how much they will enjoy it.
- Have a plan to manage setbacks – you might expect the occasional injury setback, especially with long term problems. Have a plan to manage them. Make a list of things you know you can do to manage your pain and have anything you need close at hand. I keep an ice pack in the freezer, a roll or two of supportive tape, some massage oil and a foam roller to work on tight muscles. I know a swim and jacuzzi helps when I'm sore and plan one the day after each race.
- Manage overall mental health – many runners, myself included, have mental health conditions and exercise forms part of their management. When unable to run your mental health can get worse and some injured runners express greater concern over this than the injury itself. Seek support from your GP, family and friends and let them know if you're struggling. There are tools that assess your levels of stress, anxiety and depression. In physiotherapy we use the Depression Anxiety Stress Scale (DASS ) or Hospital Anxiety and Depression Scale (HADS) questionnaires and Pain Catastrophising Scale (PCS) which examines negative thoughts and feeling towards pain. You may choose to try these yourself but might need some help to interpret the results. I believe the free Cognitive Behavioural Therapy website Living Life To The Full uses HADS and is a good way to find free online help and monitor your mood. If exercise helps but you can't run then try cross-training with swimming, cycling or gym work. Try other activities that are good for mood and mental wellbeing such as relaxation and meditation and consider reducing your alcohol and caffeine intake. Don't underestimate the benefits of a good nights sleep too – it's thought to reduce stress, improve sports performance and decrease injury risk! The Mental Health Foundation and Mind are both excellent resources for more information on managing your mental health.
- Lean towards the positive – if there are two ways to look at something – the negative or the positive – lean towards the positive. Make a conscious choice to take the more positive approach. It's easy to dwell or negatives in life but ask yourself this question – when was the last time you let yourself dwell completely on the positives?
Closing thoughts: consider your psychological wellbeing in the recovery process after injury. Stay positive about your return to sport, set goals and seek support from fellow runners and you'll have a better chance of getting back to the sport you love.
If you need specific advice on when to return to running or on managing your mental health please consult your health professional. As ever on RunningPhysio if in doubt get it checked out.
Thanks to Clark (number 168) – AKA @thesasgeek for this picture.