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“The pain of an injury can be excruciating, mentally as well as physically.”- Earvin “Magic” Johnson, Former National Basketball Association star

and redirecting negative thinking toward the injured athlete’s progress will also help (see SportEX Health April ‘02). Relaxation training and biofeedback reduces the physiological arousal associated with stress and minimises its negative impact. These interventions can also benefit the athlete with mild depressive symptoms.

Depression increases sensitivity to pain and decreases motivation. Both reduce the effectiveness of rehabilitation. Depression is characterised by feeling down, discour- aged or sad. Poor adherence, poor effort or intensity in physical therapy and a loss of confidence could be symptomatic of depression. Negative self-talk, cata- strophising or expressions of doubt and uncertainty may be obvious. The depressed athlete may demonstrate low energy, loss of interest and pleasure from previously enjoyed activities and become socially withdrawn. Physically, he or she may com- plain of persistent fatigue, sleep or appetite disturbance or emotional distress expressed via pain and discomfort. If an athlete feels excessively hopeless, worth- less or helpless, particularly if suicidal ‘ideation’ is discovered, a referral to a clin- ical or counseling psychologist is warrant- ed.

Referral Common referral issues include: depres- sion, stress and anxiety, substance abuse, and eating disorders. Less common but equally important are compliance issues, persistent pain and conflicts with coach- es, treatment providers and others. When and how vigorously referral should be rec- ommended will be influenced by the severity and urgency of the problem and how significantly it is interfering with rehabilitation or the patient/athlete’s sporting and personal life.

Professionals qualified to treat injured athletes with psychological disorders (eg. major depression, post-traumatic anxiety, eating disorder, or substance abuse) will have a doctorate in clinical or counseling psychology. Ideally the psychologist will specialise in the treatment of athletes. In America, certification by the Association for the Advancement of Applied Sport Psychology (AAASP) identifies profession-

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als trained in performance enhancement techniques. A significant percentage of these professionals are licensed psycholo- gists. A list of certified consultants may be found on their website (www.aaasponline.org). In the UK the British Psychological Society is the best source of advice (www.bps.org.uk).

Physiotherapists rate communication and motivation as the most important psycho- logical skills/characteristics both thera- pists and athletes can possess (2,4). This is particularly true for a successful referral as the athlete must understand the need and perceive it as acceptable and credi- ble. When explaining to the athlete the reason for the referral, normalise the stressful nature of injury and emphasise the performance-enhancement focus of sport psychology. The purpose of treat- ment can be described as applying the mental skills of sport performance to rehabilitation in order to speed recovery. Simply stating that psychological treat- ment will help with problems of pain (or feeling ‘on edge’) is often sufficient.

It should also be noted that this is an opportunity for the athlete to speak with someone confidentially about worries and concerns associated with sport injury or other life situations. This helps mentally prepare the athlete by letting him/her know what to expect and it also express- es understanding and support of psycho- logical treatment.

Be clear about your enthusiastic support of psychology. The more comfortable and excited you are, the more relaxed but eager the athlete will be. Reinforce your continued care and concern. Let the ath- lete know she or he is not crazy and that the injury is real. Describing previous referrals and success associated with them is reassuring and encourages follow- through by the athlete.

The simplest way to assure follow-through is to immediately, in the athlete’s pres- ence, schedule an appointment with the psychologist. By also scheduling a follow- up with the athlete soon after she or he meets with the psychologist, the sports medicine team member will limit the ath-

lete’s fear of being ‘dumped’ or ignored. This also provides an opportunity to review the athlete’s experience with the psychologist, facilitating coordination of care and reinforcing the psychological treatment plan.

References 1. Ievleva L and Orlick T. Mental links to enhanced healing: An exploratory study. The Sport Psychologist 1991;5(1):25-40 2. Francis SR, Andersen MB and Maley P. Physiotherapists’ and male professional ath- letes’ views on psychological skills for rehabili- tation. Journal of Science and Medicine in Sport 2000;3(1):17-29 3. Gordon S, Milios, D, and Grove JR. Psychological aspects of the recovery process from sport injury: The perspective of sport physiotherapists. The Australian Journal of Science and Medicine in Sport 1991;23(2):53-60 4. Ford IW and Gordon S. Perspectives of sport physiotherapists on the frequency and signifi- cance of psychological factors in professional practice: Implications for curriculum design in professional training. The Australian Journal of Science and Medicine in Sport 1997;29(2):34-40 5. Daly JM, Brewer BW, VanRaalte JL, Petitpas AJ, & Sklar JH. Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. Journal of Sport Rehabilitation 1995;4:23-30 6. Brewer BW. Psychological applications in clinical sports medicine: Current status and future directions. Journal of Clinical Psychology in Medical Settings 1998;5(1):91-102 7. Heil J. Sport psychology, the athlete at risk, and the sports medicine team. In J. Heil (Ed.), Psychology of Sport Injury pp. 1-13. Champaign, IL: Human Kinetics. 1993 8. Brewer BW, VanRaalte JL, and Linder DE. Role of the sport psychologist in treating injured athletes: A survey of sports medicine providers. Journal of Applied Sport Psychology, 1991;3:183-190 9. Glaser R, Kiecolt-Glaser JK, Marucha PT, MacCallum RC, Laskowski BF and Malarkey WB. Stress-related changes in proinflammatory cytokine production in wounds. Archives of General Psychiatry 1999;56,450-456 10. Lieber J. Deeps scars. Sports Illustrated, 1990;75(5):36-44

Dr Edmund O’Conner, PhD is chief psy- chologist of the PEAK, Pain and Headache Programmes at Rehabilitation Professionals in Grand Rapids, Michigan, USA. He is a certified consultant through the Association for the Advancement of Applied Sport Psychology and member of the United States Olympic Committee