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Psychosocial interventions in the rehabilitation setting

This is an excerpt from Athletic Training and Therapy With HKPropel Access by Leamor Kahanov & Ellen K. Payne.

By Paul Knackstedt, MS, Psy D, CMPC

The rehabilitation process can be a long and arduous journey for performers attempting to return from injury. Even the most determined can lose sight of their long-term goals, wane in motivation, and see a reduction in exercise adherence at certain phases of the return-to-play process. One way to address these issues is to apply psychosocial interventions in the rehabilitation setting, including effective communication, collaborative goal-setting exercises, relaxation training, mental imagery, and positive self-talk.⁴⁷

Effective Communication

The involvement of multiple health care professionals in the typical rehabilitation setting, often-intense emotions, and urgency of treatment may cause challenges for coordinating patient care. Effective communication between patients, health care professionals, and athletic personnel is essential in order to facilitate patient-oriented collaborative care and keep everyone on the same page throughout the duration of recovery.

To improve communication skills in the athletic training setting, use the Bayer educational model’s 4 Es:⁵⁴

1. Engage. In order to open a line of communication and relate to the patient, you must first engage the patient in a way that they can easily understand. During the initial engaging step, do your best to see the patient as separate from their injury and work on building personal connections.
2. Empathize. Empathizing with the patient involves getting perspective and attempting to understand their views on the situation. Work to stay in the moment and show the patient that you are interested in their world. Do your best to be aware of your body language, including your eye contact and gestures of affirmation (head nodding or shaking). Learn about the cultural and social influences that may result in differences between your patients. Within an athletic culture, typical standards of communication include direct eye contact and confirmation that verbal messages have been received and understood.
3. Educate. The patient must understand a great deal of information concerning their injury in order to recover well. The education phase includes specific details of the injury, the anatomical region affected, the rehabilitation procedure, and the prognosis. If the patient is given the opportunity to ask questions, they will begin to invest in the rehabilitation process and take ownership of their role in recovery. One of your tasks is to make yourself available to provide information and answer questions across multiple sessions.⁵⁸
4. Enlist. Finally, you should enlist the patient and the team of health care professionals in making decisions and constructing an adherence strategy for rehabilitation. Instead of assigning roles, allow members of the team to express their thoughts on how they can contribute their skills to the injury plan of care; this will ultimately improve motivation for patients and providers.⁵⁸ Allowing patients to contribute to their rehabilitation plans, set goals, and give feedback about their treatment increases their sense of control over the injury process.

Collaborative Goal Setting

Setting goals is important following injury once rehabilitation is initiated. Although goal setting comes easily to many successful athletes, it is a skill that can be improved through training and collaboration. Patients and health care professionals have reported that goal setting enhances patient motivation.⁵⁹ A study of athletic trainers found that goal setting was one of the top two psychosocial strategies that injured athletes used to address stress, anxiety, anger, and treatment adherence issues.⁶⁰

Consider these three main goals that directly apply to patient care in the rehabilitation setting:⁶¹

1. Outcome goals. Outcome goals are primarily focused on the result of the event, such as returning to play following an UCL rupture.⁴⁰
2. Performance goals. Performance goals focus on short-term objectives that need to be achieved to reach the overall outcome goal.⁴⁰ In UCL rehabilitation following Tommy John surgery, a performance goal may be to increase elbow flexion range of motion by 15 degrees compared to the week before.
3. Process goals. Process goals pertain to individual skills that, if present, aid in completing goals and performing skills well.⁴⁰ In the UCL example, a process goal would be to bring present moment focus to the rehabilitation session in order to help the patient complete all repetitions in all sets assigned that day.

Relaxation Training

Patients who are unable to fully clear their minds, relax, and focus their attention on the tasks of rehabilitation may be distracted by physical, social, and performance stressors associated with their injury. Stressful situations result in a narrowing of attention, higher levels of distractibility, and increased muscular tension, all of which contribute negatively to recovery.⁶⁵ You can use the following relaxation techniques during return to play to help reduce distress and excess tension that may be complicating rehabilitation:

• Diaphragmatic breathing. Diaphragmatic breathing uses slow abdominal breaths to stimulate the vagus nerve and lower the stress response. The diaphragm is the large dome-shaped muscle at the base of the lungs. Slow belly breathing reduces the fight-or-flight response by decreasing activity of the sympathetic nervous system and improves heart rate variability (HRV), a measure of minute variations between beats of the heart.⁷²
• Progressive muscle relaxation. Progressive muscle relaxation is an exercise that systematically tenses and relaxes individual muscle groups through directing conscious attention, active contraction, and relaxation. Jacobson provides a detailed script of progressive relaxation exercise that can be adapted for use in the athletic training room.⁶⁷
• Meditation. Meditation is a skill that helps patients during rehabilitation because it provides relaxation training (e.g., diaphragmatic breathing and mental imagery) and emphasizes remaining in the present moment with an attitude of acceptance and nonjudgment.

Emotional Intelligence

Emotional intelligence is a term used to describe a conglomeration of social skills, including the ability to identify, understand, and manage emotions to manage stress, communicate effectively, empathize with others, overcome challenges, and work through conflict.⁸ Emotional intelligence has received attention across various fields of psychology, including organizational and performance psychology. Emotional regulation is a related concept and is defined as the ability to monitor one’s own and others’ feelings and emotions, to discriminate between them, and to use this information to guide one’s thinking and actions to ultimately improve performance recovery.⁹⁴

Meta-analytic studies have shown that measures of emotional intelligence are associated with enhanced performance,⁹⁵ well-being, and stress management.⁷ Emotional intelligence has a more important role than general intelligence in various fields of study and attainment of competence.⁹⁷ Research is limited on the effectiveness of training programs that increase emotional intelligence, although this sort of training has been shown to be helpful in improving the efficiency of nursing care services and competence through decreased stress recovery.⁸⁹ Many emotional intelligence training programs have focused on sport-performance interventions, such as goal setting, self-talk, and mental imagery.⁹⁶ Developing effective and exciting ways to manage stress is vital to providing quality patient care and ensuring career longevity.

Mental Imagery

Imagery is a mental preparation technique used to create or recreate polysensory experiences within the mind to increase performance on subsequent efforts. It is also commonly known as visualization, mental rehearsal, simulation, and mental training.⁴⁰ People use mental imagery for a variety of reasons:⁴⁰

• Building confidence
• Increasing motivation
• Managing arousal
• Improving concentration
• Controlling emotional responses
• Developing sport skills
• Practicing performance strategy
• Coping with pain
• Problem solving

As a health care provider, you should educate injured patients on the potential for mental imagery to influence their rehabilitation outcomes. Mental imagery is a skill that can be improved with training. The two most important aspects of mental imagery training are vividness and controllability.⁴⁰ By focusing on controlling the image, the patient can learn to create a story pertinent to his sport and challenges; for example, he has the ball in his hands as the clock winds down in the fourth quarter with the game on the line. By learning to control the imagery, the patient can make sure he envisions himself winning the game for his team instead of accidentally losing focus and making a mistake that results in loss of confidence.

Patients can increase the vividness, or the realism, of the imagery by integrating as many of their senses as possible.⁴⁰ The PETTLEP model of motor imagery by Holmes and Collins has a checklist of important aspects to include in a mental imagery script: physical, environment, task, timing, learning, emotion, and perspective.⁶⁹ Focusing on these elements during the execution of a skill will create a functional equivalence between imagery content and actual performance. For an expanded explanation, see Holmes and Collins.⁶⁹

Self-Talk

Self-talk is anything that people say out loud or think about themselves.⁶⁸ There are three general forms of self-talk:

1. Positive self-talk is used in sport to help an athlete redirect attention toward a task, boost motivation and effort, and improve attitude (e.g., “Come on, you got this.”).
2. Negative self-talk typically negatively influences performance, increases anxiety, and destroys confidence (e.g., “I can’t believe you did that. You’re worthless.”).
3. Instructional self-talk does not have an influence on motivation and is meant to help improve focus on technical aspects of a movement (e.g., “Keep your knees shoulder-width apart, back straight, and head up.”).

You must identify negative self-talk with your clients at an early stage and work to increase positive and instructional self-talk to help them break bad habits, initiate action, sustain effort, and acquire new skills.⁴⁰ It is easy for patients to get down on themselves during rehabilitation from an injury when they feel isolated from their teammates, friends, and family. Due to this increase in social isolation, you need to be aware of the likelihood that patients will exhibit negative self-talk and feelings of low self-worth. This may manifest itself with self-deprecating humor where they make jokes about themselves that may be funny at first. This may be the perfect opportunity to ask them about their ratio of positive to negative self-talk responses and what effect they think the joking has on them. It may also be a time to connect them with local mental health resources.

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