Recovering from Injury, Part 2

After you’ve been injured, it’s natural to focus on the physical side of recovery. But what about the mental consequences of injury, and the steps you can take to overcome them? We talk with Ted King of Liquigas-Cannondale and Dr. Renee Newcomer Appaneal of UNC Greensboro about their experiences. The mentally fit cyclist integrates a variety of mental skills into a complete recovery strategy.

By Marv Zauderer

Last month in this Sport Psychology column, we continued our series on Preventing and Recovering from Injury by exploring a challenge that all cyclists face: living with the risk of crashing. Our series has also included two articles on recovering from crashes: Part 1 related the post-crash recovery of pro Steven Cozza, and Part 2 provided recommendations on how you can recover from a crash.

This month, we return to the more general topic of recovering from any injury – incurred on or off the bike – that gets in the way of your riding. In Part 1 of Recovering from Injury, we identified a five-step process that can accelerate your recovery. Building on that, we discuss the topic with our guest experts:

Ted King, of the Liquigas-Cannondale Pro Cycling team, finished 3rd in the road race at the recent US Pro Championships in Greenville, South Carolina. He is a two-time finisher of the Giro D’Italia, has many successes in his palmarés, and writes a popular blog at Shortly after his podium finish in Greenville, Ted crashed while racing in Philadelphia when he rode into a shockingly-unmarked sewer grate, ending his plans to compete at the Tour de Suisse and for a place on Liquigas’ Tour de France team.

Dr. Renee Newcomer Appaneal, AASP-CC, Assistant Professor at The University of North Carolina at Greensboro, has been consulting with athletes, teams, and coaches for over 15 years. She is a Certified Consultant in applied sport psychology and a member of the USOC Sport Psychology Registry. In addition, she is a Licensed Professional Counselor in North Carolina and a National Certified Counselor. As an educator and consultant, she emphasizes health (stress management, injury prevention and recovery) as a prerequisite for performance excellence. She builds upon athletes’ existing psychological strengths and teaches specific mental strategies to manage stress, recover from injury, and ultimately achieve optimal performance.

Pez: Ted, what injury do you have, and what was your experience of having it repaired?

Ted King: A fractured left collarbone, the second time around…I did it once eight years ago as an amateur cyclist. At that time, I wanted to continue racing… and I didn’t have the surgery. I saw an orthopedic surgeon, and he sent me to one of the best upper extremity docs in the country [in Boston], and we agreed it wasn’t necessary at that time. And now, eight years later, I’ve seen the same series of doctors, and actually saw that doctor in Boston and he’s the one who repaired it this time around. A lot of that has to do with [the fact that] I’m a professional cyclist now, and it’s in my best interest to get back on the bike.

Pez: In the first hours and days after the crash, how were you affected?

TK: A lot of it was frustration, because it was so preventable. If it was a more foreseeable accident, I think I’d be OK with it, but to be frank, it’s the negligence of the race organizers….You elicit a lot of reactions from other people when you say you broke your collarbone. You hear a lot of horror stories. On the one hand, I’m incredibly thankful and grateful that I didn’t crack my head, I didn’t break my teeth, I didn’t have a TBI [Traumatic Brain Injury]. I know it could be worse, and I would prefer it to be better.

Pez: I’d think that part of the experience, given you were headed for the Tour de Suisse, was a sense of loss.

TK: Absolutely….I don’t believe in fate, I don’t believe in things happening for a reason…it’s not going to change what’s happening; accepting it is the best you can do.

Pez: What’s been hard about your recovery?

TK: You get stir-crazy pretty quickly, going from being on your bike 3,4,5,6 hours a day to virtually nothing – that’s tough. I’ve gone through accidents before, got a few broken bones before, so pain is a big aspect of it. This time around, the pain isn’t so bad, which certainly helps the situation.

Pez: Accepting what happened is one of the things you’ve been doing to cope. What else has helped?

TK: There are certainly worse places to be than at home with your family and friends in the middle of summer. This will be one of the first times I’ll be home for the 4th of July, so I really like that. I don’t want to sound cheesy, but [my advice is] just embrace what you have. I’ve accepted the situation and will make the best of it. It’s a beautiful 80-degree day in New England, and yet I’ll be on the trainer for the next few weeks before I get the nod to go outside. Things could be worse, things could be better, but accept where you are and make the most of it. As much as anything, it’s a head game. [But] compared to [early] this spring, when I had tendonitis in my knee, an overuse injury – that was really tough mentally. When you have a chronic injury like that, you don’t know what caused it, you don’t know how to prevent it. You drink your milk and eat your yogurt and cottage cheese, you do everything you can do, and presumably things will run their course. In that situation, you’re pretty heads-down and just sort of blast through that.

Pez: Renee, let’s start more general than crashing. What are the major psychological risk factors for injury in sports?

Renee Newcomer Appaneal: A lot of the research that’s been done has identified that your personality influences the way you cope with stress. The heightened stress response is what seems to be accounting for the psychological or mental influence on sport injury incidence. Obviously, there may be a physical impact of a trauma or collision, but the research over the past four-plus decades or so has shown a strong association between life stress, the presence of stress, and injury likelihood. So those who have a high degree of stress tend to get injured – either a greater degree of injuries or more severe injuries. There seems to be some connection there. Some of the additional research that’s followed that up [has shown that] it’s not just the presence of stress, it’s the presence of stress in addition to not having the coping resources to manage that stress.

Pez: So the higher the stress and the lower the coping resources, the more likely that the stress energy is going to fuel inattention or other risk factors that could result in a crash, or not managing the body’s warning signs effectively, or something along those lines?

RNA: Yes. There’s a pretty well-known stress and injury model [to explain the] mechanisms for how that happens. Your increased stress response can affect your attention, and that can interfere with coordination and movement. There have been some studies that have looked at attention, being able to recognize and identify relevant cues in your peripheral vision, and how that narrows under conditions of high stress. So there’s some consequences for focus and attention, and recognizing and reacting, in a stressful situation. There’s any number of things that can contribute, collectively and independently, to the likelihood of an injury.

One of the interesting things in health psychology that has occurred outside of sport that has just now started to show up in our field is the contribution to psychological stress to physiological healing and recovery. So even on a biological level, when the body needs to recover from trauma, even if it’s micro-trauma – an intense workout, travel – psychological stress will delay and prolong recovery. There’s an analogy where it extends your window of vulnerability.

Pez: What do we know about the personality factors that contribute to injury prevention?

RNA: A number of them focus on self-awareness of stress, and building/broadening the coping resources to manage that stress. Developing skills such as accessing social support, relaxation, cognitive skills such as focus and attention, to be able to buffer adverse consequences of stress. There are a few studies that have looked at stress-management interventions and the effectiveness of reducing injury risk. Those have all reflected a cognitive-behavioral stress-management program.

Pez: What are some of the key psychological consequences that we see athletes struggling with after they’ve had an injury?

RNA: One of the main things is that stress response. For injuries that are more severe, that preclude an athlete from participating in their sport or even being physically active, it can be incredibly challenging. For a lot of elite athletes, training and engaging in competition is actually how they cope with stress. You kind of get a double whammy: you get an injury that prevents you from doing what you enjoy, and also what you use to cope and manage stress in life or in your sport.

Pez: And then if your stress is increased, your recovery time may be longer.

RNA: Exactly. Psychological stress tends to interfere with the healing process – not just the biological and immune response systems, if you’re depressed, or anxious, or worried, or fearful about the injury, or in a lot of pain, you may have sleep disruptions, and a lot of the restorative recovery processes after an injury occur during sleep.

Pez: So unless you have other coping skills for the stress, you’re going to be more at risk.

RNA: Yes. It’s going to be a lot more challenging for individuals who use physical activity to cope with stress. With intervention following injury, the goal is to look at how they cope with stress, and try and develop their strengths, and adjust it to the kind of situation [they’re in]. So how can we use their approach, the way they might attack training, how can we use that to focus their energies and attack rehab and recovery.

Pez: Please go a little further with that – steps that help athletes recover.

RNA: One of the things that tends to be a focus of my work is building the coping resources. I do that in four areas. One is through social support: looking at how an athlete is using their resources. Are they engaged with their physician or their surgeon, maybe a physical therapist or trainer, are they actively involved in that program and asking questions? There are a number of ways to get social support, and the tendency is for the athlete say, “Oh, I don’t really need support.” When you’re injured, you need a lot of specific types of support that you may not have. I have to work with athletes to help them learn how to do that, similar to how they might reach out to a coach. If you don’t have experience being injured or dealing with this new stressor, you need input, just like you’d get input from a nutritionist or a specific sport trainer. Techniques and strategies – this is no different. We really work on building that social support network – existing support and also support in the medical community which they may not be used to dealing with.

Pez: It’s really about assembling the kind of team that you need.

RNA: Yes. And they may not have access or relationships with the medical community that focuses on rehab. [The medical people they know] might focus on training and performing at top levels, but not necessarily for rehab and recovery, which is a different goal.

The other thing is looking at coping and how they [the athletes] manage stress. If they use physical activity as a way to cope, are there ways to modify or use that – are there other things they can do to be active in coping with what they’re dealing with? If athletes have used mental skills, such as imagery or relaxation, then they have some foundation skills to develop some healing and recovery imagery, or even mental rehearsal, when they can run through long-term goals – where they hope to be. They can imagine being back in a particular race, or if they have goals, say, three months out, envisioning where they are [in three months] to help build confidence and maintain motivation. If imagery is something that an athlete is used to using, I’ll build on that existing strength and apply it to anything – from immediate healing imagery to focusing on developing confidence and mastery, seeing themselves recovered and strong and performing well down the line…figuring out what they use to perform well and what can apply to recovering well.

Pez: So social support is the first of the four areas, and stress-management patterns is the second….

RNA: We tend to think of coping as adaptive or maladaptive: avoidance or denial, venting, seeking information, or actively trying to solve problems. We all have different tendencies or preferences for how we like to cope with challenging situations. A lot of what I do is try to get a sense of – not just with the injury, but in life and other situations – how does the athlete typically cope, and is that something that’s appropriate for this situation that we can apply, or are there other choices that we need to be more mindful about.

The third area is the self-regulatory skills – the mental skills. The mental skills that they were already using, such as imagery, can be applied to recovering from injury. And then self-care: making sure they’re sleeping well, that they have adequate caloric intake, they’re hydrating, the kind of things that support healing and recovery, just as they would for training at top levels.

Pez: Unlike many athletes, cyclists live with the risk of witnessing or experiencing severe traumatic injury, even death. For those of us who follow pro cycling, that’s been on our minds recently. Given that reality, what unique considerations might there be for cyclists after a traumatic injury?

RNA: I like to find out more about how they experienced fear and anxiety before the injury became their focus. Fear is actually a good thing – one of the things I try to help athletes understand and recognize is that the goal is not to have no fear, but to have a healthy respect for it. If you recognize fear and anxiety, you can look at that and examine it: does this mean there’s something I need to be paying attention to that I’m not? Is there a decision I can make, do I need to be more vigilant, do I need to be more focused on being relaxed? The idea is to be able to recognize an appropriate, normal, transient fear versus the exaggerated, emotionally charged, fear of reinjury after being injured or after seeing a [traumatic] injury….the exaggeration is the reaction to the [normal] fear.

Pez: What are the biggest missteps athletes make when they’re trying to come back from injury?

RNA: The tendency is to not recognize or appreciate the impact of the mental recovery. There’s a tendency to just focus on the physical recovery – that’s more easily observable. If you’ve been able to get back on the bike, to get back into competition, to return to participation in whatever sport you’re engaged in, the sense is, “allright, I’m back.” We unintentionally send a message that if physically you’re able to do it, you should just be able to do it. We know that there are mental, psychological, and emotional things that can interfere with your ability to perform, let alone the emotions, reactions, or sensations that you’re trying to manage when you’re coming back from an injury.

Many thanks to Ted and Renee for sharing their experiences with Pez, and I encourage you to click on the links in this article for more tips on building the mental skills you need to accelerate your recovery. Be well!


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