REHABILITATION

enhance a patient’s confidence through the practitioner explicitly utilising the four proposed sources of efficacy information: 1) Reinforcement of previous experience (reminding the athlete of their previous recovery from similar injuries).

2) Vicarious experience/case studies (informing the athlete of the successful recovery from similar injuries of other athletes).

3) Verbal persuasion (the therapist using, and training the ath- lete to use, positive statements or positive self-talk relating to their likely recovery from injury).

4) Positive interpretation of symptoms (for example, training the athlete to interpret symptoms such as pain and inflammation as indicators of the appropriate immune response to the injury, as opposed to indicators of the severity of that injury).

Central to Bandura’s theory in this application is the proposal that athletes tend to be capable of being more positive than the general population (15).

Social support As stated above, Kiecolt-Glaser et al. (2) found that students reporting high levels of loneliness experienced significantly lower levels of natural killer cell activity. There are, or should be, clear professional boundaries in all therapeutic relationships. However, it may be argued that all too often the ‘medical model’ of treat- ment emphasises manipulation and medication at the expense of social support. The perception of social support may contribute to an individual experiencing a stressor as less overwhelming, and thus may limit immune system dysfunction. Therefore the use of, for example, injury support groups (allowing patients to discuss thoughts and problems) and other social support strategies such as keeping the injured sports performer with the rest of the team or training group, may help to maintain a positive outlook and guard against feelings of loneliness. Such psychological resources and a sense of meaning may be critical factors in stress/anxiety reduction.

Perceptions of control Psychosocial strategies can also be used to enhance the injured athlete’s perceptions of control over rehabilitation. Stowell et al. (16) reported that the use of active coping was associated with a greater immune system response among older adults with high levels of perceived stress, but not among older adults with low levels of stress. ‘Active coping’ includes techniques such as decision-balance sheets, whereby the athlete would outline positives, negatives and barriers to their rehabilitation. In conjunction with the therapist, coach and significant others, the athlete would then identify how to overcome the negatives and barriers. Positive self-talk and cognitive restructuring can be used to change negative thoughts into positive ones. Increasing the athlete’s sense of control leads to lower anxiety, depression and stress, therefore enhancing immune function.

Summary Evidence for neuro-immune interactions suggest that the physical health of athletes cannot be considered as independent from their mental state. In the rehabilitation process, emphasis should not simply be placed on the physiological or mechanical function of the injury site, but also on psychological factors such as the ath- lete’s appraisal of the pain, perceived stress, coping mechanisms and emotional responses, all of which might modulate the impact

22 of immune function on subsequent recovery.

Treatment of injury should thus be holistic not dualistic (ie. it should focus on the person as a whole not on the body exclusive of the mind). It is recommended that rehabilitation practitioners study the techniques of counselling psychology in developing more effective treatment modalities. It should be noted that such strategies should be used to complement evidence-based rehabilitation treatment regimes.

THE AUTHORS ■ James Hopker, BSc, is a member of the British Association of Sports Rehabilitators and Athletic Trainers. He is now a lecturer on the BSc Sports Therapy, Health and Fitness degree at the University of Kent. He also runs a sports injury and rehabilitation clinic at the University and provides training and injury prevention consultancy for athletes, sports teams and organisations.

■ Dr Chris Beedie, BSc, PhD, is a member of the British Psychological Society (BPS) and the British Association of Sport and Exercise Sciences (BASES). He is currently senior lecturer in sport and exercise psychology and programme director for the BA/BSc programme in sport and exercise psychology at Canterbury Christ Church University College. His academic interest and peer- reviewed publications focus on the effects of emotion, mood, and mind-body interactions on human performance. His consultancy work focuses on training practitioners in the field of health, fitness and sport, to better utilise psychological principles in their profes- sional practice.

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