The Way to Improve PsychologicalRehabilitation—Trust between Therapist and Injured Athlete

Ladies and gentlemen,

Good morning. Firstly, I want to thankISAKOS for inviting me to have the opportunity to communicate with all thesport medical experts here, and share my experience of the rehabilitation fromsport injury as one working in basketball field.

The topic of my presentation today is :Theway to Improve Psychological Rehabilitation—Trust between Therapist andInjured Athlete.

As we all know, injuries are an inherentpart of involvement in physical activity. Sport injuries threaten athletes’career and success. Some injuries are little and do not have any impact,instead others can end a career and have consequences on athletes’ quality oflife. Moreover, injuries determine rehabilitation costs, which concern athletesand sport organizations, in terms of monetary costs or lost time. An injurydoes not affect exclusively physical capabilities, but also psychologicalaspects. High performers experience major feeling of loss and mood disturbance.However, they also have a better reaction to the injury, probably because theyhave more psychological resources to cope the situation.

The main goal of sport injuryrehabilitation is to return an injured athlete to his/her prior levels offunctioning, particularly through the physical rehabilitation of damaged areas.Psychological factors, compared with the physical aspects, have long been asecondary concern within the realm of rehabilitation from sport injury. When anathlete gets injured, great attention is placed on appropriate methods ofphysical rehabilitation and the selection of appropriate rehabilitationprocedures. The psychological factors, which also affect the athletes, areoften overlooked. However, Rehabilitation from sport injury involves not onlyphysical, but psychological consideration. In addition, when all measurableindicators show that the injury is fully recovered; athletes still do notachieve the same results as before the injury, because physical andpsychological rehabilitation after injury are not necessarily synchronous.

Medical professionals also realize theimportance of incorporating psychological strategies into rehabilitation fromsport injury. Contemporary studies show that psychological factors play a majorrole in the rehabilitation process of athletes. Specifically, psychologicalfactors have been found to predict athletic injuries, vary the multiple psychologicalresponses due to sport injury, and also influence the process of recovery andrehabilitation from sport injury as well as athletes’ return to competitionfrom sport injury. It suggests the need for a more comprehensive treatment ofthe injured athletes.

The psychological burden of sports injuriesis so large that it may interfere with rehabilitation and recovery or evenprolong return to competitive sport. Physical injury is not only injury of aspecific part of the body, but it is primarily an injury to the entire body andathletes’ mentality.

The psychological research proposes threedifferent responses to the injury: denial, distress and determined coping. Wetalk of denial if the athlete refuses and negates the consequences of theinjury. Athletes may exhibit denial about severity of injury, about itsconsequences on sport career or on quality of life. Denial typically occurs inthe early stages of rehabilitation, immediately after the injury, but generallyit is not necessary to intervene at this time because this denial is adaptiveto the injury. If denial persists during the following stages and interfereswith the treatment, the psychological intervention is required.

Distress is given by negative emotionsderived from injury, such as anxiety, depression, anger, fear, feeling of lossand disruption of self-concept. Also distress is more present in the earlystages of rehabilitation, but it is more adaptive to the injury: in fact inthis phase it is possible to establish a relationship based on trust betweenthe injured athlete and the therapist. However, it is possible that the athleteexperiences distress also in other phases, for example during the latter stagesof rehabilitation the desire to return to sport may make the final steps of recoveryboring and frustrating. An athlete who can successfully manage thepsychological distress of being injured is likely to be motivated and show goodtreatment adherence. On the other hand, an athlete who has difficulty adjustingto the injury is likely to experience motivational deficits and show problemswith adherence. Failure to comply with the treatment protocol can slow recoveryand interfere with the healing process. The long term consequence ofnon-adherence is that it can leave the injured area weakened and vulnerable tofurther injury.

Determined coping is when an athlete hasovercome a passive attitude and starts to cope the new   situation. This includes: evaluatingresources, setting realistic goals, and maintaining commitment, focus on the programand cooperation with the therapist. Determined coping occurs generally in thelatter stages of the rehabilitation, when the athlete has overcome denial andhas become able to manage distress. This  attitude is the most functional to get success in the rehabilitation.

However, rehabilitation may be affected byproblematic emotional reactions, the most common of   which are fear and anxiety, and a loss ofconfidence. Warning signs characterizing poor adjustment to injuries include:Unreasonable fear of re-injury, continued denial of injury severity, Generalimpatience and irritability, Rapid mood swings, Extreme guilt about letting theteam down, etc. The levels and types of emotional reactions experienced alsochange over time from the initial onset of injury, through rehabilitation, toreturn-to-play.

A number of ways should be considered whenbuilding trust with injured athletes.1. Injured athletes often experience arange of emotions that make it difficult for therapist to establish rapport andbuild trust. Listening to the athlete is particularly important, not only tomake a medical diagnosis but also to assess and monitor their emotionalstate.  

2. Educating the athlete about the injury.Education can make athletes aware of their situation. Research has shown howthe athletes do not have a clear vision of the rehabilitation processimmediately after the injury and this can determine negative emotions anddemotivation. Moreover, athletes think a better knowledge of the rehabilitationprocess permits to see realistically the situation and reduce anxiety. Injuredathletes must understand and process  injury-relevant information, often at a time when they are experiencingemotional upheaval. It is critical that explanations of injuries be presentedin terms that the injured athlete can understand. An effective method to assessthis understanding is to ask the athlete to provide their interpretation ofinformation given to them. It is important that therapist provides ananatomical description of the injury and a timetable of the recovery.Afterwards, it is necessary that athletes know how the recovery processinvolves muscle soreness and stasis. They even should be aware that not onlyinjury produces pain, but also the rehabilitation. Athletes should learn to notuse excessive pain killers and recognize injury pains, which are negativesymptoms, and rehabilitation

pains, which are positive symptoms. Athletesshould be prepared also about their oncoming emotions, such as frustration,anger, or mood swings. It is also necessary that they are conscious of theirrole in the rehabilitation program, and the importance of their compliance withthe therapist. Education restrains emotions and attitudes typical of denial anddistress phases.

3. Identifying misinformation about theinjury. Injured athletes often obtain inaccurate   information from a variety of sources (e.g.parents, coaches, teammates, Internet) which  may contribute to confusion and emotional upheaval.

4. Preparing the athlete and coach (onlywith athlete’s permission) for the injury recovery process. The injury recoveryand rehabilitation process is variable due to characteristics of the injury,treatment provided, presence of complications and psychological issues. Therefore, the athleteand coach should be educated that an injury is best managed on anindividualized basis. In addition, therapist should be encouraged to help theinjured athlete avoid isolation from the team.

5. Encouraging the use of specific stresscoping skills. Injured athletes can experience considerable stress throughoutthe injury and rehabilitation process. Psychological as well as physicalstrategies will enhance the recovery process.

An important factor influencing the successof psychological rehabilitation is the athletes’ trust in the therapist and thetreatment program they offered. Athletes’ beliefs regarding the therapistinfluence the efficacy of rehabilitation itself. Those athletes who trust theirtherapists will perform prescribed exercises more effectively and will be morepositive about the exercises, which will in effect lead to fasterrehabilitation.

The rehabilitation therapist establishestrust through empathy, consistency, and reliability. While trust must be earnedover time, rehabilitation therapist begins by establishing a rapport with anathlete, including getting to know the individual on a personal level. Empathyis the ability to relate to someone who is suffering without feeling sorry forthem. It means conveying a sense of compassion without pity or judgment.

Therapist must be consistent in theirmoods, communications and behaviors. Keeping things simple and predictable foran athlete suffering from a sport injury is the best way to accomplish this.They learn to ask injured athlete questions about themselves, maintain eyecontact, and actively listen to their answers. Showing up on time, followingthrough on promises, and being dependable even under adverse circumstances areall part of being reliable and trustworthy.

Therapists also learn not to immediatelyassume that they have athletes’ trust. When injured athletes don’t respondwell, rehabilitation therapists remain kind, and refrain from anger orreturning unpleasantness. No one – including therapist - fully comprehends howothers are feeling, how much pain they are in, or what other emotional issuesare causing them to be unhappy at that moment.

  Asthe process of establishing trust evolves, the rehabilitation therapist willemploy different strategies to maintain relationships and motivate injuredathlete. It requires the ability to be flexible, patient, and honest throughoutthe duration of the rehabilitation plan. It means working hard to understandthe injured athlete, identifying each individual’s physical and psychologicalbarriers to trust, and finding ways to overcomethem.

    This is just the main content that I want to present today, and it isall from my personal experience of the sport injury rehabilitation process. Ihope it’s helpful to the athletes and therapists, and wish all the athleteshealthy. Thank you.

促进运动员心理康复的方式——康复师与运动员的信任关系

女士们、先生们：

 早上好！首先我想感谢大会的邀请，让我有机会在此与各位运动医界的专家一起交流，分享一些作为篮球工作者对运动损伤康复的体会。

今天我的演讲主题是促进运动员心理康复的方式—康复师与运动员的信任关系。

众所周知，运动伴随着运动损伤。运动损伤威胁着职业运动员的职业生涯和运动成绩。虽然一些轻微损伤对运动员未必会造成很大影响，但那些严重的伤病却可能会断送运动员的职业生涯甚至对运动员未来的生活质量产生极大影响。不仅如此，运动损伤也直接决定了恢复期所需成本，它包括资金成本和时间成本。这也是运动员和其所属运动组织十分关注的环节。运动损伤不仅仅影响了运动员的运动能力，对其心理方面也造成了创伤。运动表现更强的运动员在受伤时更容易产生较大的失落感和情绪不稳定。然而，他们对运动损伤的应对却更好，这是源于他们有更多心理学的资源来更好地应对伤病。

运动损伤康复治疗的主要目标是针对损伤部位进行物理治疗，从而将运动员的运动能力恢复到受伤之前的状态。在运动损伤康复领域，对运动员身体恢复的关注往往大于对其心理康复的关注。当一名运动员受伤时，大家对选择合适的身体恢复方法、制定恰当的身体恢复计划最为关注。但对运动员也有很大影响的心理因素却经常被忽视。然而，运动损伤的康复不仅仅包括身体的恢复，也包含心理方面的康复。有时即使所有指标都表明运动员已经从伤病中完成恢复，但他也却没有达到受伤之前的状态，因为受伤后的身体恢复和心理康复并不是完全同步进行的。

医学专家们也逐渐认识到在运动损伤康复过程中融入心理学干预的重要性。现代研究表明，心理因素在运动员康复过程中扮演着重要角色。具体来说，心理因素可以预测运动损伤、改变运动员对运动损伤的多重心理反应，并对运动员康复、重返赛场的过程有很大影响。研究指出，受伤运动员应得到更加全面的康复治疗。

运动损伤带给运动员的心理负担非常巨大。这种心理负担不仅影响康复过程，甚至会拉长运动员重返赛场的时间。可见，运动损伤不仅仅是对身体某个部位的伤害，更是对运动员全身和心理的伤害。

心理学研究提出了3种运动员面对运动损伤的反应：即否认、痛苦和决心应对。这里的否认是指运动员拒绝和否定受伤的结果，表现为否定伤病的严重性，否定对其运动生涯和生活质量造成的影响。这种否认反应一般发生在康复治疗的初期，即伤病刚刚发生时，此时基本不需要做过多心理干预，因为否认反应会自适应于伤病本身。如果否认反应在治疗过程中一直持续，则需要加入心理干预治疗。

痛苦反应是由伤病引起的负面情绪。包括焦虑、沮丧、愤怒、害怕、失落以及自我意识的丧失。痛苦反应也同样出现在康复治疗的初期，但比否认反应更具有对伤病的自适应性。在这个阶段，就是一个建立康复师与受伤运动员之间的信任感的好时机。当然，在康复治疗的其它阶段运动员也会产生痛苦反应，比如在康复治疗后期，运动员重返赛场的急切愿望会使得康复最后阶段变成一种煎熬。一名运动员如果能够成功控制伤病带来的心理痛苦，则更容易获得激励从而坚持康复训练。同样，如果运动员处理不好对伤病的心理反应，则无法得到有效激励，从而无法坚持康复训练。一旦运动员不能坚持康复训练，恢复就会减慢，康复过程就会受到影响。

当运动员能够克服消极态度，开始积极应对困难时，则进入了积极应对环节。包括：评估资源、设立目标、持续努力、专注康复并积极配合康复师。积极应对一般发生在康复训练的后期，此时运动员已经克服了否认反应并可以控制痛苦情绪。这种态度对康复训练最有效。

然而，康复过程很容易受到不良情绪影响，最常见的是害怕、焦虑、失去信心。无法正确认识伤病的心理特征包括：莫名担心伤病复发、持续否定伤病严重性、焦躁易怒、情绪不稳定、对影响团队而产生极度自责等等。不良情绪也随着康复过程的深入而变化，从受伤初期贯穿整个康复过程，直到运动员最终回归赛场。

康复师可以尝试一下几个办法与运动员逐步建立信任关系：

1.由于运动员受伤后会产生一系列情绪变化，从而不易与康复师建立密切而互信的关系。康复师尝试倾听运动员的心声是非常重要的方法，同时需要评估并跟踪运动员的情绪状态，而不仅仅是做医疗诊断。

2.向运动员介绍伤病情况，让运动员了解自己的伤情。研究显示，伤病发生后运动员对自身伤情的不了解容易造成不良情绪和负面动机。此外，运动员认为自己对康复过程的了解越多，焦虑程度就会相对降低。在负面情绪上升时，运动员更需要了解伤病的相关信息。康复师还必须确保用运动员可以理解的表达方法向运动员解释伤情，一种有效的方法是，康复师先倾听运动员对伤病的认知情况，再向运动员解释。康复师应向运动员透彻地描述伤病情况，并提供康复的时间表。之后，运动员也需了解在康复过程中可能会产生的肌肉酸痛等情况，不要使用大量的止痛药。运动员要理解伤处疼痛是不良症状，但是康复期的疼痛是积极的症状。运动员也要对自身情绪的不稳定、焦虑、愤怒等都要有所准备，对自己在康复计划中扮演的角色要清晰，并听从康复师的康复计划。康复师详细的介绍伤情会抑制运动员不良情绪的产生。

3.识别伤病相关错误信息，受伤运动员经常从不同来源获取不准确的伤病信息（如家人、教练、队友和互联网）,从而加深困惑和不良情绪。

4.让运动员和教练都了解康复过程（征得运动员同意），伤病在康复治疗过程中会有很多变化，康复师需向教练建议采用单独康复方式，但也要避免受伤运动员被运动队孤立。

5.康复师鼓励运动员运用应对压力的技巧。运动员在康复过程会产生很多心理压力，心理调节会加快康复速度。

影响受伤运动员心理康复的一个重要因素是运动员信任康复师以及康复计划。这种信任关系也影响到康复本身的效率。那些信任康复师的运动员会更积极有效地完成康复训练计划，这也会提高康复计划的最终效率。

康复师还应注意通过移情作用、一致性和可靠性等因素来影响与运动员的信任关系。获得运动员信任是需要时间的，康复师可以先从与运动员建立密切关系入手。移情作用是一种既感受到运动员承受的痛苦，而又不怜悯运动员的一种能力。

康复师需要保持情绪、沟通和行为的一致性。对于受伤的运动员，康复师需尽量将事情简化并且易于运动员预计。在与运动员一对一交流时，多询问关于运动员自己的情况，保持眼神的交流，积极地倾听运动员的回答。准时出现在康复训练时，言行一致，即使在恶劣的环境下也需让运动员感到可靠。这些都是提高信誉度的方法。

康复师也需注意不要轻易判断已获取运动员的信任。如果运动员回馈不佳，康复师也要注意态度，不要生气或发生不愉快。没有任何人包括康复师可以完全体会到运动员的痛苦。

当信任关系建立起来，康复师还需用不同办法保持这种关系并激励受伤运动员。这需要康复师在整个康复计划执行过程中保持放松、耐心、诚实的状态。努力倾听并理解运动员感受，识别运动员建立信任关系的障碍并克服这些障碍。

以上就是今天我想阐述的主要内容，也是我在经历运动损伤和康复过程中的一些感悟。希望可以给运动员和康复师能带去一些帮助。最后，祝愿广大运动员可以保持健康。谢谢!