Motivation and emotion/Book/2023/Sport injury recovery motivation

Overview


Fictional Case Study:

22-year-old Willow was being drafted into the AFLW team Adelaide Crows prior to rupturing her ACL in an interclub match before the season begun. Willow had heard the ACL recovery is tedious and painful, spanning up to 12 months. She was proud of the effort she made to get into the AFLW team and wanted to make her teammates proud so was easily motivated, she began physiotherapy quickly after the injury and prepared for her reconstruction surgery. After her reconstructive surgery her motivation decreased, feeling all the effort she put into her rehabilitation before the surgery meant nothing. She was in a lot of pain and the 12 month recovery felt almost impossible, furthermore she still had one more football season of sitting on the sidelines.

Injuries are an unfortunate but common factor within the careers of athletes. No matter which code or what level you are competing within, injuries of varying severities are bound to occur. A 2006 questionnaire found that 4.9% of top-level athletes reported a career ending injury (Ristolainen et al., 2012). Out of those individuals it was found that 70.4% of them experienced a mild to moderate permanent disability from their career ending injury.

There is an obvious association between significant sporting injuries and the termination of sporting careers. With such knowledge, how can athletes remain motivated with their rehabilitation? There is a large amount of research assisting in the physical rehabilitation of these injuries but only recently have rehabilitation programs included a psychological perspective. Many allied health professionals are shifting to take on a holistic approach to injuries and pain management to include space for the psychosocial change. Through this fresh approach to injury rehabilitation there is hope that people will have a better understanding and approach toward their injury management.

Theoretical underpinnings of the psychological impacts of injuries
The theoretical underpinning of the psychological impacts within sport injuries are crucial to implementing programs that will increase and sustain an individual's motivation. Such theories come from different fields of psychology, such as the Social Identity theory, which is a core theory within social psychology. These theories come together to create an overall understanding of how humans can remain motivated, what barriers can prevent motivation, and how we can overcome difficult situations such as enduring a traumatic injury.

Emotional states and phases of rehabilitation
When having experienced a significant sporting injury, individuals tend to undergo a range of emotions including depression, anger, anxiety, isolation, and low self-esteem. These emotions negatively impact the injured individual’s perspective on their progress and motivation towards rehabilitation.

Clement et al. (2015) conducted a study reporting the psychosocial responses within the different phases of sport injury rehabilitation. This study outlined the theoretical underpinning for the phases and psychosocial responses that are commonly experienced by injured athletes.



Phase one is considered the initial reaction and cognitive appraisal phase of the injury. This is where the injured athlete initially has a negative outlook and emotional response towards their injury. Clement et al. (2015) found the most common response was to seek out support from social groups such as family, friends or significant others, this continued to be the most conspicuous behavioural response (see Figure 3). Furthermore, the cognitive appraisal of the athlete was influenced by the perceived severity of the injury. This meant that individuals who were expected to be absent from their sport for a longer duration were more negative in their appraisals. As such, the emotional response of the athletes were all common in the way that the negative cognitive appraisal led to negative emotional states.

After diagnosis, individuals become aware of the severity of the injury causing their cognitive appraisal to alter depending on the diagnosis. If the news is less severe than initially appraised, the mindset will become more positive, and vice versa.



Clement et al. (2015) describes phase 2 as the “reaction-to-rehabilitation” phase, where individuals are described to experience varying cognitive appraisals. Mainly, individuals are concerned with questioning the rehabilitation and the common emotional response of frustration with the introduction of anxiety and self-esteem concerns once returning to their sport (see Figure 3 and 4). Cautiousness and questioning regarding rehabilitation emerged as a commonality within phase 2. These cautious and questioning thoughts caused a change in the athlete’s emotional response, which was mainly transformed to frustration, causing a further change in behaviour towards rehabilitation.



The final phase Clement et al. (2015) uncovered was the “reaction to return to sport”. In this final phase, athletes had a mixture of both positive and negative cognitive appraisals towards their perceived return to sport. Emotions such as anxiousness, positive excitement and cautiousness were reported. Athletes saw the injury as a time to reflect on the process of rehabilitation and their personal emotional response to the injury. Feelings of both excitement and anxiousness (specifically regarding reinjury) were another of the common negative emotion that athletes experienced (see Figure 5). The emotional responses of the athletes were directly related to their behavioural responses.

Overall, the understanding of the phases and psychosocial responses to athletes injuring themselves is crucial for success in the rehabilitation process. The insight gained for not only the athlete themselves, but their treating physiotherapist is crucial in understanding and utilising the psychoeducation when treating an injury. The emotional and behavioural responses allows treating specialists and athletes to work together to ensure motivation remains consistent in order to optimise rehabilitation engagement.

Self-determination theory
The Self-determination theory (SDT) presents a large fundamental basis for the research into human motivation. The quality of motivation, which is reflected within an individual’s purpose of engagement ultimately predicts behavioural dedication and persistence. SDT suggests that every individual has three basic psychological needs – autonomy, competence, and relatedness – all of which assist in the individual’s growth and development (Vlachopoulos, Karageorghis and Terry, 2000).

Autonomy refers to individuals having choice and are voluntarily supporting of the individual’s behaviour. Autonomy is supported by individuals within one’s environment attempting to understand the individuals wishes, perspectives, and providing an understanding of their behaviour (Vlachopoulos et al. 2000). Having your autonomy supported can assist in feeling that you have control over your actions and are therefore not pressured to behave or act in a particular way.

Competence refers to an individual’s experience of being effective in a specific activity. Competence can be supported by encouraging an individual’s skills, providing structure through evidence-based recommendations, and providing the individual with challenges and opportunities (Ntoumanis, 2001).

Relatedness refers to an individuals need to feel connected and having a sense of belonging with other individuals. Relatedness can be supported through individuals showing support and interest to another's activity, showing empathy to their specific circumstances, and ultimately conveying love and care (Moudatsou et al. 2020).

The individuals that one is surrounded by within their environment can influence or discourage their goals through the amount support given to the individuals fundamental psychological needs. SDT is a relevant theory within the realm of sporting communities. When an individual is experiencing a significant injury, their basic psychological needs can be impacted through a sense of disconnection to their environment. When suffering from a sport related injury, an individual can often feel withdrawn and isolated from one of their main supportive environments. For further information see: Long term injury in high performance field athletes and emotion

{Quiz

An individuals environment plays a large part in influencing or discouraging goals and ambitions: + True - False
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Social identity theory
Social identity theory (SIT) relates to the understanding of the psychology behind intergroup relations (Tajfel and Turner, 1970). SIT holds the view that part of an individual’s self-concept arises from their connections and relationships within social groups. This is something that motivates many people to begin participating in sport - feeling like they are a part of something. When an individual has their sense of belonging fulfilled, their ability to restore and maintain relationships is strengthened. Engagement within a sporting group allows individuals to have a foundation in which they can perceive and relate to others, this allows them to share a sense of social identity.



A study conducted in 2020 found that student athletes who remained in contact with one another during the social isolation period of the COVID-19 pandemic reported less dissolution of their social and athletic identity, and overall greater wellbeing (Graupensperger et al. 2020). This study highlighted the fact that athletes, despite not being able to partake in their sport during lockdown, were not as affected by the depressive symptoms of isolation because their social identity was stronger due to their connectedness to one another. These findings enhance the understanding that being a part of a social group such as a sporting community has overall benefits to ones mental and physical wellbeing.

Motivation and social identity are strongly correlated, meaning that when an individual has a positive sense of social identity, their motivation levels will be higher, and vice versa (Krane, Barber, & McClung, 2002). Being removed from ones social group can negatively impact one’s social identity and self-image. Therefore, when an athlete has been involuntarly removed from their sport due to an injury, self-esteem, social identity and motivation are all impacted. This plays a large role in the motivation to continue rehabilitation programs.

Practical approaches to sustaining motivation in injury rehabilitation
Motivation is explained as a psychological factor that is most impactful on adherence, meaning that even the best planned and structured rehabilitation program will have little effect if the injured athlete is unmotivated to adhere to the regime (Taylor and Taylor, 1997). Sports injury rehabilitation provides the injured individual with many setbacks include physical pain, emotional turmoil, fatigue and frustration; hence it is crucial to the outcome of the rehabilitation program that the individual remains motivated.

Taylor and Taylor (1997) suggested the following ways injured athletes can remain motivated throughout rehabilitation programs:

Focusing on long term goals
One main approach to sustaining motivation when undergoing rehabilitation is to focus on the long-term goals at play. Rehabilitation can be a long and draining process, stemming over 12 months in majority of ACL rehabilitation programs which can lead to phases in which an individual can be working on their program from over 6 months with another 6 to go.


 * Directing the individual’s attention to the benefit of staying motivated to their rehabilitation plan through constant reminders of why they are working hard to return to their sport can assist in sustaining motivation.
 * Another approach can be confronting the individual’s current competitor or goal within the rehabilitation program. Having a visual reminder and goal to work towards (i.e., beating a certain team or winning a championship) can take some of the negative energy directing toward to injury and recovery, and frame it in a more positive light.
 * Setting Rehabilitation goals is another common way to challenge an injuried athelete whilst keeping them motivated to continue their rehabiliation . This can be done through setting weekly or fortnightly goals such as being able to fully bear weight on the injured leg without crutches by week 4 post op. Setting this goal gives the individual the motivation to slowly make progress on their rehabilitation, but also holds them accountable to reach that goal.

Setting goals
Similarly to focusing on long term goals, setting goals that are reachable can allow the individual to shift focus away from the tedious exercises and focus on reaching their goals. These goals should be small, tanagable and realistic goals that can be marked off each week / fortnight. Allowing room for these smaller wins will make the individual feel like more meaingful progress is being made each week, and therefore will motivate them to continue to engage in their program.

Rehabilitation logs


One effect way to maintain and increase motivation is for athletes to keep a rehabilitation log (see Figure 7). Many individuals lose motivation as the progress made is not visual, from week to week it is hard to notice the changes that have occurred internally. A rehabilitation log allows the injured individual to have visual evidence of the progress they have made. This motivates them to continue being committed to their rehabilitation as they can watch their progress grow. A rehabilitation log can track different aspects of the rehabilitation program including:


 * Psychological progress
 * Physiology progress
 * Performance goals and progress
 * Motivation levels

Behavioural and emotional responses to injury and rehabilitation
After Willows ACL injury, she experienced overflowing guilt, hopelessness and diminished interest in activities. Willow had always experienced symptoms of depression but was able to cope through exercise. She felt she had let down her team by not being able to participate within the season and knowing she had little chance in playing in the next season. Despite the support her team showed, she felt that they were all secretly frustrated at her for not playing, and experienced large amounts of inappropriate guilt. Furthermore, due to her long recovery period, Willow felt hopeless that she would ever return to AFL.

Motivational Approach: Willow’s physiotherapist noticed her motivation decrease significantly. In order to increase her motivation toward rehabiliation, they asked her if she wanted to win a flag for the club which she was incredibly keen on. Once they set Willows directions on doing rehab to win a grand final, her motivation increased dramatically.

"The instant an athlete is injured, much of what he or she has worked for is taken away. This has a devastating impact, because, for athletes, physical condition and athletic ability are the major components of self-worth." (Faris, 1985, p. 545). Traumatic injuries can lead to involuntary termination of an athletes career or prolonged return to sport, both of which causes significant psychological distress. Through such emotional and difficult times, athletes may expreience a range of psychological and behavioural responses that differ to what they may normally expereince when uninjured.

Depression
Depression is a common symptom to experience after a major injury and subsequent surgery. Specifically, depression has been reported within 34% of ACL injuries (Crichlow et al., 2006). Exercise is a useful tool in combating depressive symptoms and can be a large part of athletes coping strategies. Furthermore, studies that investigated the relationship between removal of sport and depression found that sporting injuries are a large risk factor for depression in athletes. When unable to partake in their sport, depressive symptoms arise as part of the incongruence between who an athlete sees and believes themselves to be and their ability to behave and act in that self-appointed role, this is known as ego dissonance.

Further examples of depression in injured athletes can include:
 * Overall emptiness or hopelessness
 * Diminished interest in many activities
 * Reduction in social and atheltic identity
 * Unexpected weight loss or gain
 * Interrupted sleep
 * Fatigue
 * Inappropriate guilt

Isolation
After experiencing a traumatic injury, many people feel disconnected from their previous social lives as they struggle to go out in public when in pain or when using mobility assistance tools (i.e., crutches, casts, walking sticks or wheelchairs). Also contributing to the feeling of isolation is the management of appointments, time for recovery and rehabilitation (Graupensperger et al. 2020). Isolation can negatively impact an individual by:
 * Feeling disconnected from a main social system in ones life.
 * Detriating self image
 * Impacted sleep schedule
 * Increased stress levels

Anxiety
In many injury cases, anxiety is reported as a common psychological side effect. Increased anxiety can negatively impact ones motivation and ability in completing their treatment and, consequentially, can cause longer rehabilitation periods (Crichlow et al., 2006). Anxiety regarding an injury can also have impacts on:
 * Performance upon return to sport
 * Motivation to continue desired sport after rehabilitation.
 * Individuals outlook on health

Substance abuse

 * Substance abuse can be a risk factor for athletes who experience significant injuries. Severe pain experienced can lead individuals to rely on prescribed and non-prescribed drugs, alcohol and other addictive tendencies that relieves such discomfort (Cottler et al, 2011). Many injured athletes feel a certain loss of control after experiencing a traumatic injury. If an individual cannot adapt to changes in their life, they will struggle to adapt to such sudden and upsetting changes such as ceasing sport due to injury (Furie, Park and Wong, 2023). Once an individual feels out of control, they can often turn to substance abuse to feel more in control of their lives.
 * After an injury that shatters ones career or goals, there is a lack of self-worth and pride. Whether they were at the peak of their career or just the beginning, it can be hard to let go of any goals they had in mind, especially if they know they cannot return to their sport (Athanasou, 2015). Once this mindset has crept in, many turn to substance abuse to “drown out” the feeling of failure.
 * Furthermore, the use of illicit drugs act as a suppressor to motivation. Drugs such a methamphetamine and cocaine can cause symptoms of low mood, anhedonia and even after long periods of sobriety, a continued lack of motivation (Leventhal et al, 2008)

{Quiz

What are psychological and behavioural risk factors for injured athletes? + depression, anxiety, isolation, and substance abuse - depression, isolation, and agoraphobia - increased social life, substance abuse, mood swings, and increased activity
 * type="(+ True)"}

Conclusion
It is important to understand the relationship between motivation and the psychological underpinnings that come with rehabilitation. When individuals can establish a strong sense of motivation, their effort to reach their goals will increase and promote behaviours that enable faster healing.

The main theories that are associated with the psychological impact of ceasing sport due to injuries include emotional states and phases of rehabilitation, Self-determination theory, and the social identity theory. These theories explain the ways in which individuals seek social support, remain motivated and react to physical injuries.

When an athlete is removed from their sport and subsequent social group there can be dire consequences to their mental and physical wellbeing. As explained in the SDT, an individual’s environment and support system nurtures ones growth and development, and if removed suddenly can cause emotional turmoil. There are many motivational theories and approaches that can be used to ensure individuals remain motivated, including rehabilitation logs, setting goals, and keeping long distance and / or bigger picture ideas in the forefront of their mind. The psychological and behavioural responses to an injury can vary from psychological distress causing a rise in depressive and anxious symptoms, or a dependency on illicit drugs or alcohol. Majority of the subsequent responses can be reduced through the practical applications of motivational theories within the individual’s rehabilitation program, which stresses the importance of ensuring motivation through the rehabilitation stages.