Biopsychosocial cycle of a sport injury

An injury can sometimes be just that, an injury. You get unlucky, get injured, go to a physiotherapist, recover, and return to climbing.

Sometimes, this experience can be a bit trickier.

If that is the case, and you struggle to deal with the injury in some way, these are some tips on psychological tools that can be helpful.

DEFUSION

PROGRESSIVE MUSCLE RELAXATION

Defusion

Cognitive Defusion is a technique often used in Acceptance and Commitment Therapy (ACT) that involves learning to perceive thoughts as simply what they are—words—rather than what they seem to be: threats, facts, or deep truths about ourselves. Thoughts can influence our emotions and behavior and are, therefore, very relevant to recovering from a sports injury.

If you recognize being fixated on a particular thought cycle (script, image, memory, self-judgment, or fortune-telling), you can use Defusion techniques to “unhook” from those thoughts.

How can Defusion help?

It can help you take a step back and create a small distance from persistent thought cycles. It can help you recognize thoughts as something you don’t have to give in to or act upon, that thoughts can exist without necessarily being true, and that you have a choice in how much attention you pay to them.

Exercises:

The setting is the same for all three exercises. Find a spot where you can relax and not be disturbed. It is best to do it sitting to maintain a wakeful state. Take a few deep breaths and then return breathing to normal. You can focus on your breathing or one of your senses – what you hear, keep a soft gaze if your eyes are open, what you feel (contact with the chair or a floor, soft breeze or warmth), smell or taste (even though a bit more rear, for some it works best). When you feel ready, you can apply one of the following techniques.

I am having a thought…

Suppose you notice an unnerving thought, for example, a self-judgment. Make a note of it. Say to yourself (silent or out loud), “I am having a thought that I am stupid and reckless,” or, “… it was all for nothing”. Then, give yourself a chance to redirect your attention back to breathing until you notice another thought that is causing some disturbance, and repeat the same technique.

Name the story

Notice some of the persistent, repetitive thoughts. Is there a theme? It can be the “I should/shouldn’t have,” “I always/it always,” “If only,” “It’s no use,” “What would others think,” “This means I am,” and all the similar sticky thoughts. Name the story you are telling yourself. You can silently say, “Oh, it’s the -I always get injured- story or -I will never get better at climbing- story.

Radio mind

Whatever thoughts appear, let them chatter away as if you were listening to the background radio while doing something else. Focus on breathing or one of your senses.

Skills: Stress regulation/coping, Motivation, Acceptance, Self-awareness, Flexible attention

Pain Coping

Understand your pain. Ask your doctor or physical therapy professional everything you want to know about the nature of your injury.

Ignoring pain can naturally have clear physical consequences, but it can also make it a scary monster in your head. You feel it, all the alarms go off, it creates chaos. By learning more about the pain, understanding it and giving yourself a chance to feel it, you can start recognizing what signals damage and what is tiredness, discomfort, worries, and any other meaning pain might hold for you.

When you learn to distinguish between pain and discomfort, you can alternate using associative or dissociative strategies for pain coping.

Associative strategies

Tune into the pain. Breathe into it, lean into it. Whether you're meditating or doing rehabilitation exercises, focus on allowing yourself to feel it and make a conscious decision about how far to push and when to stop.

Sometimes, having a “pain log” or a “pain journal” can help. Tracking the pain intensity 0-10 in relation to your activities can not only help you have a better overview but can also be very useful in consultations with your physical therapist.

Perhaps you were asked once (or more often) by a physiotherapist to rate the pain on a scale of 0-10, or got instructions that feeling 2 or 3 on a scale of 0-10 is acceptable for continuing the exercise (this is a fictive number randomly chosen to illustrate the technique; please do not take it as a guidance and consult your doctor/physical therapist for personal advice and evaluation). If you feel a psychological block from pushing through discomfort, you can use a sentence (sort of a mantra) to help you stay committed. Staying in tune with the amount of pain you feel, you can say to yourself, “This is ok, this is 2 out of 10,” or “Lean into it,” “I am in control,” “I can always stop,” etc.

Dissociative strategies

Sometimes, with bigger and more painful injuries, pain can be exhausting. Besides finding ways to soothe the pain, you can find out which strategies work for you to take your mind off it. The same way you would, for example, re-direct your attention while meditating from your thoughts back to your breathing, you can use music, recall soothing images, have a bath, or ask a friend to hang out to direct attention away from pain.

Skills: Self-awareness, Body-awareness, Acceptance, Flexible attention, Stress regulation/coping

Emotional Regulation

The RULER approach, developed by Dr. Marc Bracket, is an informative and thorough method of learning emotional skills. It stands for:

R - recognize emotions

U - understand the causes and consequences of emotions

L - label emotions accurately

E - express emotions appropriately

R - regulate emotions effectively

It was initially created to promote the development of emotional intelligence in schools, but it is very useful for anyone of any age. To help you get started, I recommend the app How We Feel, created by Dr. Marc Bracket and the Yale Centre for Emotional Intelligence. It can be downloaded for free.

If you wish to read more about emotions in the context of climbing, you can read the article I wrote for the Strong Mind (you can find it in -in the media- section).

Skills: Emotional granularity, Self-awareness, Body awareness, Acceptance

Journaling

Writing simple, regular check-ins in a journal can be very useful for managing emotions and creating awareness of specific thought patterns (helpful or unhelpful). It can also help you understand the relationship between your feelings, thoughts, behavior, and recovery.

As mentioned in the section about Defusion, some repetitive thoughts can become overwhelming. Writing them on paper can help create some distance.

Answering a few simple questions, such as, “How am I feeling?” “How energized do I feel?” “How motivated am I?” Each day or before a recovery session, training, or climbing can help you create a better overview and understand yourself and your state of being better.

Skills: Self-awareness, Body-awareness

Imagery

Mental imagery (creating mental representations of certain skills, performances, strategies, or recovery) is a widely applied, well-researched, and proven effective method in sports psychology.

It is an “as-if experience,” a technique that may be better known to climbers as visualization. This method involves vividly picturing your performance or recovery in your mind, engaging as many senses as possible. Doing so can enhance your memory, motor skill learning, and confidence.

For injury recovery specifically, you can utilize a technique called healing imagery. This involves creating mental images of the healing processes occurring in your damaged tissue, whether these images are symbolic or realistic. It’s important to note that while healing imagery can have many positive effects, it can not and should not replace physical therapy.

To make a visualization as effective as possible, write a script for what you want to visualize with the guidance of the PETTLEP acronym. It stands for:

Physical—Include physical sensations in the script. It can be as simple as imagining the feel of your shoes, the amount of tension in your body, chalked hands, dampness in the air, feeling the structure of the rock under your fingertips, etc. You can go as far as wearing all the gear or embodying the Adam Ondra floor routine (if you know, you know).

Environment – Include more input from the environment where you wish to perform, rock, or a gym. What’s the temperature, sounds, atmosphere, amount of people?

Task—Be accurate about the task you wish to perform. Perform all the moves in a correct sequence without skipping anything, including rests.

Timing—Aim to set the duration of the visualization in real time without speeding up through “easy” sections or doing cruxes too quickly and easily.

Learning – If it happens that you can start attempting this task in real life, rewrite the script if it needs to be adapted to the new situation. Maybe you tweaked some beta, stayed less long in a rest, or became a bit more pumped than in previous sessions/seasons.

Emotion—If any emotions can or did come up in real life while performing this task, include them in your visualization.

Perspective—It is considered more effective to use the first-person perspective, meaning you imagine it as if you would see it when performing the task in reality. Other options are to imagine it as seeing yourself by someone else (third-person perspective), or you can alternate between the two.

See the PETTLEP as a guide instead of in all-or-nothing terms. The acronym could be a bit easier to apply when using it as a tool for working on a project than for a healing imagery script.

To help you create a script for Healing imagery, you can think of the following question:

What images do I associate with healing, getting stronger, and gaining confidence in recovery? They can be literal and realistic or weird and silly; it doesn’t matter much as long as you (your mind and body) associate those images with healing and repair.

Approach Imagery techniques as you would meditation. Find a quiet spot where you won’t be disturbed and get comfortable. Take a few deep breaths and give yourself a moment to focus on the here and now. With Healing imagery, starting by feeling your body's state and then imagining the script of healing and repair can be helpful.

Skills: Body awareness, Motivation, Self-efficacy

Goal Adjustment

Take the time to intentionally readjust your goals instead of getting stuck in a status quo. You may think, “Of course, I know that I need to readjust and postpone my goals if I get injured”, but it is different if you put it down on paper. It makes sense always to have some hopes or unrealistic expectations about recovery and the “what ifs.” If they stay lingering in the back of your mind, they can be a cause for doing too much too soon or for later dissatisfaction, lack of motivation, and disappointment.

You can even have two categories on paper: hope goals and realistic goals. In this way, you acknowledge the most audacious wishes about your recovery and give them space to be while refocusing on smaller steps in recovery, which will help you maintain your motivation.

Skills: Goal setting, Self-awareness, Acceptance, Motivation, Flexible attention

Locus of Control

Understanding attribution—the reasons you give to explain certain outcomes or behaviors—can help you manage motivation more effectively. The first step is to recognize what is within your control and what is not. The second step is to learn how to use this understanding to positively influence the areas you can control and let go of the ones you can not.

One of the dimensions of attribution (reason-giving) is locus of control. It describes to what extent you feel you can influence the outcome of an event. Is it in your hands? Or do you depend on the mercy of external factors (e.g. luck)? In this case, you can think of the recovery or, later, chances of re-injury.

Understandably, not everything can be controlled. For example, you can’t control the amount of pain you feel, but you can control how you approach it. You can’t control the speed of recovery and progress, but you can control the quality of exercise, sleep, rest, and nutrition.

Practicing acceptance and letting go of the things outside of your control, and redirecting attention to the actions within your control can help you feel in charge of your recovery process. When returning to climbing, this sense of agency helps manage the fear of re-injury. If it was you who committed to the recovery and ensured the quality of it, not just that the time passed and the tissue somehow healed, then the confidence and motivation have a stable foundation for growth.

The need to explain the reason and cause of injury can be another source of troubling thoughts. It can be challenging because what has happened can’t be changed. There is value in the analysis of what happened to see if it could’ve been avoided and use that knowledge in the future. That is different than letting the rumination take over. Rumination can cover anything from how you could’ve prevented the injury, blaming yourself for not preventing it, thinking it’s not fair, and wishing it hadn’t happened.

To help you get unstuck, you can do a little investigation:

How much did you train/climb last weeks before the injury?
Were you improving and getting stronger?
Were you motivated?
Too motivated?
Was there a specific goal that was really important?
Did you feel any signs of a possible injury (be honest)?
What happened just before?
Is there any particular style of climbing or a move that caused the injury?
Does that mean climbing in that style, or doing that move will always cause an injury?
What can I change next time? What is ok to keep doing in the same way?

After the investigation, you can let go of your regrets and judgments and redirect your attention to the here and now.

Skills: Attribution, Acceptance, Self-efficacy, Motivation

Progressive Muscle Relaxation

Constantly experiencing mental tension can impact your physical state and coordination. Even small changes can lead to significant effects. Additionally, experiencing pain during injury recovery can create tension throughout your entire body. Progressive muscle relaxation is one of the muscle-to-mind relaxation techniques. It helps release both mental and physical tension by systematically tightening and relaxing different muscle groups. It can be as general or specific as needed.

Here is a short example of a script for progressive muscle relaxation. Skip injured or painful parts of your body and work on the rest.

Find a spot where you can relax and not be disturbed. You can do it sitting or lying down. Take a few deep breaths and then return breathing to normal. You can focus on your breathing or one of your senses – what you hear, keep a soft gaze if your eyes are open, what you feel (contact with the chair or a floor, soft breeze or warmth), smell or taste (even though a bit more rear, for some it works best). When you feel ready, you can start with the script.

Take a deep breath. Feel your abdomen raise, your lungs fill up with air. Hold your breath for a few seconds and then release it slowly. Feel the tension leave your body. You can repeat this cycle two or three times.

Now direct your focus to your feet. Bring as much tension to your feet as you can without tensing the rest of your body (squeeze, curl up your toes). Hold for a few seconds. Keep breathing normally. Release and feel your feet relaxing. Again, repeat this cycle two or three times.

You can move in this way throughout your whole body. You can pick to focus on body parts such as feet, lower leg, upper leg, torso; or be more specific and think of specific muscle groups.

Stay in tune with your body during the whole exercise, and be careful not to tense, squeeze, or push to the point of strain.

At the end of the exercise, give yourself some time to feel the relaxation in your whole body. Start moving slowly until you are ready to sit up or stand up.

You can record the script for yourself, or find a suitable one online.

Skills: Stress regulation/coping, Body-awareness

Resources

Bakker, F. C., & Oudejans, R. R. D. (2019). Sportpsychologie. (5de, herziene ed.) Arko Sports Media.
Brackett, M. (2019). Permission to Feel. Quercus Publishing.
Britton W. Brewer, Charles J. Redmond.(2016). Psychology of Sport Injury
Cheadle, C. J., & Kuzma, C. (2019). *Rebound: Train Your Mind to Bounce Back Stronger from Sports Injuries.
Harris, R. (2019). ACT made simple: an easy-to-read primer on acceptance and commitment therapy (2nd ed.). New Harbinger Publications.
Wiese-Bjornstal, D. M., Wood, K. N., & Kronzer, J. R. (2020). Sports Injuries and Psychological Sequelae. doi:10.1002/9781119568124.ch34

DISCLAIMER: This text is meant for informational purposes only. Some techniques mentioned might not be suitable for everyone. If you are struggling with your mental and/or physical health, please reach out to your general practitioner, physical therapist or a mental health professional