REHABILITATION PSYCHOLOGY “I CAN’T STOP THINKING ABOUT HOW MUCH IT HURTS”

CATASTROPHISING IN REHABILITATION

By Dr Edmund O’Connor, PhD, sport psychologist

The International Association for the Study of Pain defines pain as both a sensory and emotional experience. Pain does not occur in the body without the mind reacting and con- tributing to the experience. Your self-talk and feeling states modulate every pain sensation. An adaptive thinking style minimizes pain and improves coping, while negative think- ing styles increase pain and interfere with adaptive behav- iors. Pain intensity is one of the most powerful predictors of activity tolerance, particularly within rehabilitation (1). Developing a positive thinking style regarding pain improves your chances for a successful rehabilitation.

Catastrophising defined Catastrophising is a thought process characterised by an excessive focus on pain sensations (rumination, "I can’t stop thinking about how much it hurts") with an exaggeration of threat (magnifica- tion, "something serious might happen") and the self-perception of not being able to cope with the pain situation (helplessness, "there is nothing I can do to reduce the pain") (2).

Sport-specific examples include, "My athletic career is over," and "I can’t go through more rehab." Unfortunately, catastrophic thinking is a common reaction to athletic injury (3). Nearly 100 studies have been published on catastrophising; consistently find- ing it associated with a more intense pain experience and increased emotional distress (4).

Catastrophising increases pain Catastrophising boosts anxiety and worry, which stimulates neur- al systems that produce increased sensitivity to pain (hyperalge- sia) (5). Anxiety makes it difficult to think and problem solve. The anxious athlete doesn’t make the best behavioural decisions and may not follow through with treatment recommendations (eg. do more exercises than prescribed in an effort to get better faster). This can worsen the injury. Physically, catastrophising increases muscle tension which creates excessive wear-and-tear on the muscles and decreases blood flow to the injured area. This in turn increases pain intensity and slows rehabilitation.

Control the athlete’s self-talk The excessive focus on pain sensations and the exaggerated threat involved in catastrophising, limit an athlete’s activity levels (1). Individuals better able to minimise pain may be able to persist longer in painful activities such as rehabilitation (6).

As a result, pain management becomes an important rehabilita- tion goal, beginning with controlling the athlete’s self-talk.

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Catastrophising thoughts may feel as if they enter the mind auto- matically. A conscious effort to change the focus and self-talk is necessary. Positive self-talk can increase rehabilitation perfor- mance (7), however, statements that are simply optimistic are not effective. Self-talk must be realistic and said with meaning and attention.

An accurate injury assessment provides the evidence-based mean- ing from which self-talk develops. Education about the injury and rehabilitation is the key. Self-talk is then ‘realistically positive’ and not merely encouraging. When confronting the pain and injury with medical facts it becomes more difficult to focus on the nega- tive. Pay close attention to why these statements are true. Distracting from these realistically positive statements and choos- ing to dwell on the negative undermines the effectiveness of self- talk. This process may be initially difficult. Negative thinking can become a habit. Fortunately, it can also be unlearned with con- scious attention and frequent challenging for skill development.

Take an athlete who tears his ACL during the soccer preseason as an example. An initial catastrophising reaction my be, “This is it. I’ll never play again.” These thoughts increase anxiety, frustration and pain. Compare this with the athlete who realistically assess- es the situation and remains optimistic, “I’m injured and it’s serious. I’ll be out for a while, but let me wait to see what the doc has to say. We’ve got a great sports medicine team. Maybe I can make it back for the playoffs.”

Catastrophising during rehabilitation includes thoughts like, “I’ll never recover,” “I’m progressing too slowly” and “I can’t get the pain out of my mind.” The emotional distress associated with cat- astrophising can inhibit the athlete’s motivation to follow through with treatment recommendations. It is better to focus on progress and say, “I’m getting stronger every day. I can do this.” Realistically positive self-talk brings the intensity necessary for a remarkable recovery.

Other strategies to challenge catastrophising Ruminating thoughts may be interrupted by planned distractions. Advise the athlete to surround themselves with positive people and use social support. Music and books can help keep an ath- lete’s mind off the pain and injury.

Relaxation and imagery are

excellent mental skills that help with pain management and can facilitate return to play.

Magnification of the threat of the injury is best challenged by education. The doctor and physiotherapist has a responsibility to provide information regarding the seriousness of the injury, the rehabilitation timeline, potential pitfalls and setbacks, prognosis