PERFORMANCE

and low self-esteem (9). These may certainly have a negative impact on immune function, but should not be seen as being limited to the sports injury domain; the ramifications in rela- tion to illness and even disease are also evident. Figure 2 below illustrates how psychological appraisal of the stressor (eg. the injury) may modulate immune function and wound healing.

Note: Cytokines regulate wound healing by control- ling cellular growth, differ- entiation and metabolism

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Sympathetic spinal nerves

Stressors ▼

Hypothalamus ▼ Anterior pituitary

Adrenal glands

▼ cortisol ▼ ▼ Spleen, thymus and other immune organs

Figure 2: Stress and the immune system (from The Unknown Mechanism of Overtraining Syndrome. Sports Medicine 2002;32(3):185-209)

STRATEGIES TO MINIMISE THE ADVERSE EFFECTS OF NEGATIVE PSYCHOLOGICAL STATES It is briefly described above how many psychological processes may interact with immune processes and it is suggested that, to optimise recovery from injury, the practitioner should attempt to minimise any negative effects of psychological processes. To illustrate this, consider an athlete who is anxious about her rate of recovery from an injury. The processes described above infer that this anxiety is not only about her slow rate of recovery, but is also perhaps a contributory cause of this slow rate of recovery. Consequently the injured per- former may enter into a cycle in which injury and cessation of participation leads to anxiety, anxiety increases healing time, increased healing time leads to greater anxiety ad infinitum, via what is effectively a positive feedback loop.

Injury ▼ Anxiety Positive feedback loop ▼ No intervention ▼ Anxiety reduction intervention ▼ Enhanced immunity Figure 3: Injury, anxiety and psychological intervention

In such a situation, the practitioner who prescribes an inter- vention or strategy that reduces the (psychological) anxiety is likely to enhance recovery from the (physical) injury (see Figure 3 above). Practitioners in clinical, counselling and sports psychology have developed a number of anxiety-reduction interventions, ranging from the psychodynamic through the cognitive, behavioural, and cognitive-behavioural (CBT). This

www.sportex.net Impaired immunity

Relaxation Kiecolt-Glaser (13) and Fawzy (14) demonstrated how relax- ation interventions (progressive relaxation and guided imagery) were effective when used in visits to healthy geriatric patients (3 x 1 hour visits per week). At the end of the one month inter- vention, and one month after the intervention, an approxi- mately 30% enhancement of natural killer cell lysis was evident compared to a control group. Several relaxation strategies may be used by practitioners, from the use of music, guided imagery, progressive relaxation, and even yoga and meditation (11).

Confidence building Confidence is often proposed to be the conceptual opposite of anxiety. Confidence is the perception of having sufficient mental/physical resources to achieve a certain outcome, while anxiety is the perception of insufficient resources. On that basis, any increase in confidence may have the effect of decreasing anxiety. However, confidence,

like imagery, is in

many respects a trainable skill for both the practitioner and the patient. Bandura’s (15) self-efficacy model can be used to

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Immune cells ▼

Cytokines

paper cannot hope to address even a small percentage of these, but some ideas are outlined below.

Imagery Simonton and Matthews-Simonton (11) used imagery to try and combat illness and fight infection. They developed a method of imagery in which cancer patients were taught a simple form of relaxation, imagining a pleasant place and holding it in their consciousness. They were asked to imagine their illness in the way that it appeared to them and to imagine the form of treat- ment they were receiving. They found clients’ images of their cancer or pain provided invaluable information regarding their beliefs. Those clients who succeeded in overcoming their cancer usually employed imagery with certain features, for example, the cancer cells were weak or the body’s immune system was an aggressive army of white blood cells eager to do battle with the invading organisms and destroy them. This form of fighting imagery may be particularly useful if patients are angry and need a release of this emotion - they are able to channel it into a more intense support of the healing process.

Transposing the approach above to the injury rehabilitation setting, it could be suggested that the injured athlete should imagine the tissues of the body healing the injured area. To achieve this, the injured sports performer may focus on the injury and create a healing image, for example blood vessels sending out healing roots, or particles of calcium forming like building blocks. Note that imagery is not a simple process that can be adopted overnight. Aspects of the imagery process, such as the controllability and vividness of an image, take practice to master. We recommend that the interested reader refer to one of a number of psychology texts for imagery strategies - a good example is Morris and Summers (12). We are not suggest- ing that the imagery process may directly promote these heal- ing mechanisms (although neither do we discount this possi- bility), but that the reduction in anxiety resulting from this process may do so indirectly via reducing the negative impact of the anxiety on immune function and recovery.

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