Emotional Effects of Sports Injuries: Implications for Physiotherapists

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RESEARCH REPORT

Emotional Effects of Sports Injuries: Implications for Physiotherapists Lisa Pearson Graham Jones Key Words Sport, injury, psychology, mood, emotional response.

Summary has been noted that injury can have psychological as we11 as physical consequences.This study was conducted to identify the emotional responses of sportsmenhomen to injury. An additional aim was to draw implications for physiotherapists who treat this group of patients. In Section A, 61 injured sportsmen completed two questionnaires: a Sportsmen’s Feelings After Injury Questionnaire (SFAIQ),and a Bi-polar Profile of Mood States (POMS-BI).A matched group of 61 non-injured sportsmen also completed the POMS-BI, the Feelings about Exercising Questionnaire and a Sporting Details Questionnaire. The SFAIQ revealed that many of the injured sportsmen were frustrated, depressed and bored. When their POMS-BI scores were non-statistically compared to normative data, injured sportsmen were found to have a more negative mood profile. T-tests revealed that injured sportsmen were significantly more tense, hostile, depressed, unsure, tired and confused than their non-injured peers. In Section B of the study, six of the injured sportsmen were interviewed to provide some additional in-depth data about the emotional effect of injury and the potential of physiotherapists to influence this. Their responses confirmed the detrimental emotional effect of injury. The sportsmen believed that physiotherapists had considerable potential to influence their moods during the rehabilitation period. Physiotherapists may be able to facilitiate their patients’ recovery from injury by considering the psychological aspect when they construct rehabilitation programmes. It

Introduction This paper examines the emotional effect of sports injury and highlights the implications for physiotherapists that can be drawn from the study. The psychology of sports injury has tended to lack rigorous study to date, but is rapidly becoming a ‘hot’ topic for research (Gould, 1990). A need for research into psychological apsects of physiotherapy was first documented by Worthingham (1965), but the continuing lack of activity in this area has been exposed in recent years by several physiotherapists including Dyer (1982) and Atkinson (1988). May and Sieb (1987) stated that ‘health professionals tend to be mechanistic and technical in their assessment and treatment approach or view the patient’s emotional responses as irrelevant’. They went on to list 40 emotional reactions to physical injury that have been observed clinically, including depression, restlessness, difficulty relaxing, reduced body image, reduced self-esteem, increased feelings of anger and inability to concentrate. Earlier, Schomer (1983) noted that it was important for a physiotherapist to monitor

patients’ mental health during treatment, while Ryde (1977) felt that many of the physical symptoms observed after injury were exacerbated by psychological factors. Furthermore, Yukelson (1986) stated that the goals of the rehabilitation process could be hampered by the emotional state of sportsmen. Recently, a survey of Australian sports physiotherapists revealed that 84% of them felt that their training in the psychological aspects of injury was inadequate, and 87% welcomed more applied information in this area in their training (Gordon et al, 1991). According to Weiss and Troxell (19861, incurring a debilitating sports injury can result in some of the strongest and most devastating emotions. Studies utilising questionnaires and the experimental withdrawal of exercise have indicated that an alteration in a sportsman’s exercise regime can indeed be detrimental emotionally (Carmack and Martens, 1979; Thaxton, 1982; Robbins and Joseph, 1985; Bahrke et al, 1986).Two studies relating specifically to the effect of injury on sportsmen’s moods are those by Chan and Grossman (1988) and Smith et a1 (1990a). Chan and Grossman (1988)administered the Profile of Mood States (POMS) (McNair et al, 1971) to 30 runners who were unable to run for at least two weeks because of injury. They were found to have a significantly greater overell mood disturbance when their mood profiles were compared to those of non-injured runners. Specifically, the injured sportsmen had significantly greater tension, depression, anger and significantly less uigour. Smith et a1 (1990a) administered POMS at two-weekly intervals to 72 injured sportsmen. Their scores at the first assessment were compared to college norms, and significant elevations were noted for depression and anger. No significant differences were noted on the subscales of tension and uigour, and the injured athletes actually experienced less fatigue and confision than college norms. Smith et a1 (1990a) stated that a limitation of their study was that they used college norms as the comparison group. As sportsmen have consistently been shown to have more positive mood states than the general population (Morgan and O’Connor, 19881, and as the age range of sportsmen is greater than that of college norms, it appears more valid to compare the mood states of injured sportsmen with those of their non-injured counterparts. The present study combined the methodologies of Chan and Grossman (1988) and Smith et a1 (1990a) by comparing the mood states of a group of injured sportsmen with those of a matched group of non-injured sportsmen, and also with normative scores for college students. The original POMS has been updated and the new version, the Bi-polar Profile of Mood States (POMS-BI), can be used ‘to identify and assess mood and feelings in normal subjects’ (Lorr and McNair, 1988). This study chose to utilise POMS-BI.

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€’OMS-BI was usefill t,o document the sportsmen’s general mood states, hut it is not injury-specific. In their study, Smith et a1 (1990a) administered the Emotional Responses of Athletes to Injury Questionnaire (ERAIQ) t,o index the sportsmen’s feelings relating to their injuries. Their questionnaire also collected basic demographic, sporting and injury information. A slightly modified version of the ERAIQ was created for use in the present study and was entitled: the Sportsmen’s Feelings After Injury Questionnaire (SFAIQ). POMS is relatively easy and convenient to adminster and, in their ‘test critique’ of the monopolar version, Peterson and Headen (1984) concluded that ‘it appears to provide a n important source of information in assessing mood states’. This also seems true of the POMSBI. However, lhylor (1987) questioned the validity of any test which is designed to measure a psychological attribute. Mood is an abstract concept, and it is doubtful that a rating scale can measure it accurately and fully. Indeed, Berger and McKenzie’s (1980) female jogger found that her exercise resulted in ‘a wide-ranging spectrum of emotions ranging from agony to ecstacy’ and, as has been mentioned, May and Sieb (1987) listed 40 emotions that have been observed clinically following physical injury. It is clear that a questionnaire could not have fully indexed these feelings. It seems likely that individuals will define their emotions in different ways, and will also interpret the rating scales differently. Any such scale is fraught with problems such as experimenter effects, individual biases and the ‘Hawthorne effect’ which may distort the responses elicited. Berger and McKenzie (1980) concluded that it was ‘necessary to postpone and also to forego absolute scientism for a nonreductionist, humanistic understanding of human behaviour. Reichardt and Cook (1979) first proposed t h a t quantitative and qualitative research could be effectively combined, and Shephard (1987)stated that this combined approach could ‘add tremendous richness and greater depth‘ to physiotherapy research. With their comments in mind, it was decided for the purposes of the study reported here to complement the quantitative data, from POMS-BI and the SFAIQ, with qualitative information. It is pertinent to realise that it is the sportsman’sindividual emotions that are important to him, his coach and the health care team, rather than any group generalisation. It was decided, therefore, to examine a cross-section of the injured sportsmen in this study in greater depth. The use of in-depth interviews has recently been highlighted as a developing research technique in the field of sport psychology (Gould and Krane, 1992). The present study, therefore, incorporated this research method to enrich and clarify the data from the athletes’ questionnaires. This permitted a more detailed understanding of the individual sportsmen’s emotions relating to their injuries, and examined factors inherent in the rehabilitation period; specifically, the effect of social support, and of physiotherapists and other members of the health care team, on the sportsmen’s emotions. The concept of psychological assistance as part of the rehahilitation programme was also considered.

physiotherapists surveyed by Gordon et a1 (1991) felt that their relationships with their patients affected rehabilitation performance. However, this suggestion has yet to be systematically studied and scientifically evaluated. Sports physiotherapists are always advised to be positive in their approach (May and Sieb, 1987) and to ‘treat the person, not just the injury’. It seems likely that this approach may improve athletes’ moods. Smith et a1 (1990a) suggested that their ‘most severely injured’ patients might require psychological support during rehabilitation, and some sport psychologists, especially in North America, are now starting to work in this field. Additionally, Kuland (1988) has suggested that other members of the health care team could learn to teach psychological skills to injured athletes in order to help them during the rehabilitation process. Several sport psychologists have written articles outlining this treatment (Weiss and Troxell, 1986; Yukelson, 1986; Nideffer, 1989; Smith et al, 1990b). However, athletes have not yet been asked in a n objective manner about their perception of the need for this service. In summary, this study attempted to highlight the emotional effect of sports injuries, by employing a combined quantitative and qualitative approach.

Hypotheses Due to the largely exploratory nature of this study, no rationale existed for specific hypotheses to be formulated about the emotional effects of sports injuries. However, there is sufficient literature for three general hypotheses to be proposed: 1. Injured sportsmen will have negative feelings associated with their injuries. 2. Injury will have a detrimental effect on the mood states of sportsmen. 3. Physiotherapists will have a n effect on the psychological status of injured sportsmen.

Methodology Section A

- The Quantitative Study

Subjects Sixty-one injured sportsmen volunteered to participate in a study determining how sporting people feel emotionally after injury. They were all patients attending a private orthopaedic medical centre in the south of England, during July and August 1990. The subjects comprised 41 males and 20 females. The mean age was 31.00 years (SD 11.58 years). The exercising group consisted of 61 non-injured sportsmen who were matched, a s far as possible, to the experimental group in terms of gender, age and three sport-related variables: sport played, amount of exercise undertaken weekly and standard achieved. This group also comprised 41 males and 20 females with a mean age of 29.82 years (SD 11.09 years).

Measuring Instruments

Weiss and ?Yoxell I 1986) suggested that sports medicine

Three questionnaires were used to index the sportsmen’s basic demogr.tphic and sporting inforinat ion, and to measure the emotional effect of a t h letrc irijurj

professionals could have a significant influence on their patients’ ability to cope with injury, and the sports

(SFAZQ) is a shortened version of the ERAIQ (Smith

The Sportmen’s Feelings After lryury Questiontinirc

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et al, 1990a). The first section of the SFAIQ provides demographic data about the sportman’s gender, age and sporting activity. The date of injury, and amount and type of exercise undertaken since the injury, are also noted. The second part of this form comprises three questions which index the emotional responses of the sportsman. He is asked how he feels because of the injury: first, he volunteers four words in order to determine the presence of any emotional response; and second, to determine the type of response, a list of words is provided from which the sportsman chooses the four which best describe his feelings. These words are: helpless, tense, bored, relieved, angry, frustrated, shocked, depressed, discouraged, frightened, optimistic, in pain. Finally, the magnitude of the emotional response is measured on a Likert scale. The sportsman is asked to rate his experience of each of the emotions from ‘absolutely’ (1)to ‘very much so’ (5).

injured sportsmen; people who regularly used the gymnasium at the clinic; and members of a local athletics club. They were administered the POMS-BI (‘during the past week’ version) and the Sporting Details Questionnaire. Some of them completed these questionnaires when the investigator was present, either on a training night or during a social visit. Others were sent the questionnaires and returned them by post.

The Sporting Details Questionnaire, completed by the non-injured sportsmen, is simply the sport-related demographic questions from the SFAIQ. This information was important in the context of attempting to match the two groups.

Procedure

The Bi-polar Profile of Mood States (POMS-BI)(Lorr and McNair, 1988) was used to index the subjects’ moods. The injured subjects were asked how they had been feeling ‘since the injury’. For comparison purposes the non-injured sportsmen were also administered this questionnaire, specifically, the ‘during the past week’ version. The bi-polar form of POMS lists 72 adjectives or phrases to measure six bi-polar mood states. Each mood state is defined by a scale comprised of 12 adjectives. One pole represents the positive aspects of the dimension while the other pole refers to the more negative aspects. The mood states are composed-anxwus, agreeable-hostile, elated-depressed, confident-unsure, energetic-tired, and clearheaded-confused. The respondent is asked to rate his feelings on a four-point scale where 0 indicates ‘much unlike this’, 1 indicates ‘slightly unlike this’, 2 indicates ‘slightly like this’ and 3 indicates ‘much like this’. Each scale’s total score is, therefore, the sum of all of the positive items minus the sum of all the negative items. A constant of 18 is added to make all possible scores positive. Thus each scale ranges from 0 to 36. Reliability studies have confirmed the test’s internal consistency (Lorr and McNair, 1988). Being fairly new, little research using POMS-BI has been published. However, the handbook (1988) provides normative scores for 432 male and female college students (age range 17 to 21 years) for comparison.

Procedure All of the sporting patients who attended the clinic were asked if they would be willing to participate in a research project. All of the sportsmen agreed to participate and each one was given two questionnaires to complete at the clinic, either before or after the first physiotherapy appointment that they attended after this study began. If time did not allow this, the patient took the questionnaires home and returned them, duly completed, when he returned for his next appointment. The questionnaires were the SFAIQ and the POMS-BI (‘since your injury’ version). The non-injured sportsmen were identified in several ways: they were exercising, non-injured friends of the

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Section B - Qualitative Case Studies Subjects Six of the injured sportsmen who had completed the questionnaires were randomly selected and agreed to participate in an in-depth interview which aimed to elaborate and expand upon the quantitative information elicited by their questionnaire responses.

Each interview followed a standardised format. The sportsmen were first read a standard protocol (McCracken, 19881, and they then responded to an identical list of questions which were recorded on tape. These were phrased so that they encouraged open-ended responses, and specific elaboration and clarification cues were used (McCraken, 1988; Scanlan et al, 1989; Jones and Hardy, 1991). The length of the interviews ranged from 30 to 60 minutes. The interview questions were designed to elicit more in-depth information about the emotional effect of each sportsman’s injury: how he had been feeling throughout the rehabilitation period; the effect of social support; if and how physiotherapists had influenced the emotional response; and whether psychological help would have been of any benefit.

Results Section A - Quantitative Results Emotional Response to Sports Injury The SFAIQ provided the sportsmen’s description of their general feelings since being injured. The words volunteered by the largest number of sportsmen were frustrated, annoyed, depressed and bored. When they were provided with a list of words describing possible feelings due to sports injury, the ones which most of the sportsmen ranked were frustrated, discouraged and bored. Similarly, as shown in figure 1, the emotion experienced with the greatest intensity was frustrated.

Comparison of Mood States of Non-injured Sportsmen, Norms and Injured Sportsmen Paired t-tests were carried out to examine the differences between the injured and non-injured sportsmen on the POMS-BI subscales. These showed that the injured sportsmen scored lower on all of the POMS-BI subscales than the non-injured sportsmen (all p < 0.001). These two groups were then compared descriptively with normative data (Lorr and McNair, 1988). The three groups’ means are plotted in figure 2. On all but one subscale, non-injured sportsmen were more positive than norms. Injured sportsmen, on the other hand, were more negative than the norms on every mood subscale.

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frustration, and she expressed surprise a t how depressed she was: ‘I still feel very frustrated and depressed . . . It’s quite a depth of depression which is alien to me because I’m such a positive person. I think five or even six weeks of being injured is acceptable but I don’t think it can go on much longer.. . I can’t see a n end to it. I tend to be an optimist and I’m beginning to get to the stage now where if I dm’t improve soon, I don’t know what I shall do.’

Frustrated In pain

Bored Depressed Optimistic Tense Angry

Helpless Relieved Frightened Shocked 0 Absolutely not

2

1

3

5 Extremely

4

so

-

Fig 1: AFAlQ Question 12: Athletes’ feelings because of their injuries - Group means

I

Confident Energetic

-ve affect Anxious Norms 4

Hostile

Depressec

Non-injured athletes

-a-

Unsure

I

1

1

headed Clear-

I

Tired

Injured athletes

Confused f

Fig 2: POMS-61 mood profiles - norms, non-injured Group means range athletes and injured athletes from 0 to 36 but the scores fell in this section only

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Section B - Six Qualitative Case Studies The analysis of the case studies was divided into two sections: (1) the perceived emotional effect of sports injury; and (2) the effect of other people, especially physiotherapists, on the sportsmen’s moods.

1. The Perceived Psychological Effect of Sports Injury On the Interview Day Sportswoman A, a junior international cross country runner with a chronic hamstring injury, stated that she was experiencing intense feelings of anger and frustration. It was particularly hard to see people whom she had beaten in the previous year being selected for teams which she would have been aiming for that season. She was also worried that the injury had appeared i n her final year as a Junior, because she would become unknown and therefore find it especially hard to establish herself as a Senior. Sportswoman B, a middle-aged show jumper with a traumatic elbow injury, also indicated her feelings of

Despite having recently improved quite considerably, sportsman C, an international athlete with a chronic hamstring injury, maintained that he was still worried ‘In the last month I’ve reduced the quantity of training, and I’m worried that when I go back to winter training and increase the quantity of hill, track and road work, that my pain may come back. In fact, I’m worried that it may be something that will bug me for the rest of my career’. The person who was most confident was sportswoman D who, on the interview date, indicated that she felt confident, because she believed that her chronic Achilles tendon injury would resolve. The emotion that sportsman E, a county cricketer, recognised in himself was that of being tentative. He identified two reasons for this. First, he was not totally confident about running because he occasionally experienced a sharp pain, and second, he was concerned about the cricket match that he was scheduled to play in the following week: ‘Because I’ve been out of the game for four to five weeks I’m going to feel a little bit tentative getting back into it.’ Sportswoman F had recently undergone major knee reconstructive surgery. She echoed sportsman A and sportswomans’ C feelings of worry and concern. She was worried about the fact that her knee was not able to bend as much as the surgeon’s programme had suggested it should, by that stage of rehabilitation. She feared that her replacement cruciate ligament was too short, and was concerned that she had lost a lot of power in some of her leg muscles. She also voiced frustration at ‘not being able to just get up and get on with life’. Despite these negative emotions, sportswoman F did state that she had ‘great expectations and was optimistic: ‘I’m always very constructive in my outlook and I try to think of the best things.’

Throughout the Rehabilitation Period Sportswoman A’s feelings had obviously followed the progress of her rehabilitation: ‘I tend to get mood swings. If I can get into a routine when I’m doing rehabilitation exercises and it’s going well, then I get happy and optimistic, but when it starts “breaking out” again I get pretty low.’ She noted that the failure of the injection to eliminate the pain had made her a bit disappointed. Sportswoman B stated that she had basically ignored the injury until she experienced the intense pain when she was weeding. At that point, she was annqyed with herself ‘for not having done something about it earlier.’ She felt that her arm was useless because she was able to do so little, and this made her feel ‘totally frustrated and depressed’. Sportswoman B’s feelings also seemed to follow the success of her rehabilitation. Her emotional state had improved as she had progressed physicaily.

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However, she noted a slight worsening in her emotions during the three to four days preceding the interview because her elbow problems had not improved for a few days. Again, it was the state of the injury that mediated sportsman C’s feelings: ‘My emotions have followed the amount of pain or problems I’ve had from my backside.. . Overall, my feelings go up and down, perhaps changing every couple of weeks depending on how training is going or how much pain I’m getting.’ He was in pain virtually all of the time during the previous athletics season and this had affected his outlook on his sport: ‘I just couldn’t enjoy my running.’ He also reported feeling helpless a t times, wishing there was something he could do to speed up his recovery. However, a t other times, when he was training and racing well, he had ‘very good periods’ emotionally. The long-term nature of the injury had enabled him to become more philosophical. He stated: ‘I’ve learnt to accept the fact that my bum’s going to be sore’. Sportswoman D’s comments revealed that her feelings had fluctuated and she too was largely influenced by the success of her treatment. She had experienced a large amount of depression and frustration since being injured ‘As the weeks went on, it got worse and worse and I started to feel worse and worse. I felt quite bad and I went through a few stages where I felt quite down, quite low, really depressed about it.’ She admitted to sometimes feeling isolated and envious of people who were out running, and was ‘disappointed and upset about missing competitions.’ Sportsman E described his initial feeling of depression, which had lasted for about five days. However, he quickly accepted what had happened and had been ‘quite lighthearted.’ His over-riding feeling was one of boredom. Like sportsmen C and E, sportswoman F had learnt to accept her injury: ‘I’m just resigned really. I tend to treat it fairly light-heartedly.’ However, she had experienced a whole range of emotions since she sustained the original injury. When she first injured her knee ‘it felt major’ and caused her frustration. She was unsure of her knee from then on, especially when it repeatedly disclocated. She described the hour before the operation as ‘the most doubtful hour of my life. He [the doctor] said it would be better, but you don’t know. Things can go wrong’. She had felt exhausted for a few weeks after the operation and her enforced inactivity had affected her post-operative emotions: ‘When you’re on crutches you can’t actually do anything . . . and that was the most frustrating thing. I felt so helpless.’ She also emphasised how much she was missing parachuting: ‘When I go and watch I’m just craving. . . I can cope at the moment but it gets worse and worse the more time I’m off.’

T h e Effect of Injury on the Sportsmen’s General Mood States At interview, sportswoman A stated that she had been experiencing general mood swings and, although she was fairly happy, everything seemed ‘a little bit empty’ without her running: ‘It’s as if there’s no direction.’ Sportswoman B felt that she had not been nearly such a positive person in general, but that otherwise there was no real difference in her moods. Similarly, sportsman C

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said that he did not observe a huge difference in his general mood states, but admitted that he had been getting ‘more irritable’ during this period. In contrast, sportswoman D identified a large change in herself since the injury. She seemed to be less happy, and more irritable: ‘I think that when I’m running, I’m a better, happier person. I don’t get so “wound up”. Things just seem to go over my head . . . But when I’m running, it really does affect me.’ Sportsman E noted he had been feeling ‘very lethargic and sluggish’, whereas when he was playing cricket, he would be ‘motivated and psyched up’. Sportswoman F reported being ‘generally quite happy’ and was enjoying her time off work. However, she had a cold sore during the week prior to the interview, which she said was a physical sign that she was a bit down. Certainly, she was more fatigued than usual, despite doing considerably less activity. Like the others, she admitted to being ‘more irritable, short-tempered and moody’. She got a bit wound-up when she was fussed over and sometimes ‘people’s lack of thought’ made her angry. She seemed to feel rather vulnerable a t times wanting to be left alone, and at other times wanting people to be there: ‘I feel like I need a good cuddle from somebody who cares, maybe more than I would normally do.’

2. The Effect of Other People on the Sportsmen’s Emotional Responses to their Injuries The S u p p o r t Given to the S p o r t s m e n by their

Families, Friends, Team-mates a n d Coaches

All of the sportsmen, without exception, admitted to being more moody and irritable with their families. Despite this, they were fortunate enough to have experienced a great deal of social support durin their 5 rehabilitation periods. There were two distinct types of support identified by the sportsmen. First, people had physically done things for the sportsmen that they were unable to do themselves due to the limitations of their injuries. The second type of support was that of a general positive and sympathetic attitude that the sportsmen’s families and friends had portrayed. Sportswoman B expressed the importance of this: ‘That [the social support] has been an absolutely critical part. Without that support, I couldn’t have got through the last five weeks.’ All of the sportsmen echoed this sentiment, though less strongly.

The Sportsmen’s Perception of Whether their Physiotherapists, a n d other H e a l t h Care Professionals, h a d Considered t h e Emotional Aspects of Sports Injury The sportsmen generally seemed to think that the physiotherapists and other health care professionals with whom they had been in contact had not consciously considered the emotional effect of their injuries. There was a general agreement that some of the health care professionals had sub-consciouslyconsidered this aspect. However, others had very poor ‘bedside manners’ and seemed entirely unaware of their patients’ feelings. T h e Effect of Health Care Professionals o n the Sportsmen’s Mood States There was a difference of opinion between the sportsmen over this issue. Sportsmen A and E did not think that

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the health care professionals had made any direct difference to them emotionally, whereas the others did think so.

The Validity of a Pyschologically-trained Physiotherapist Adding a Psychological Element to the Treatment Programme

Sportswoman D commented that her doctors had made her feel guilty - ‘I felt like I was wasting their time and should give up [running]’ - whereas sportswoman F said that she was not with her surgeon enough for him to affect her psychologically. Sportsmen B, C, D and F seem to have been helped, to some extent, by their physiotherapists. Sportswoman B stated that she had enjoyed her physiotherapist’s ‘nice sense of humour and lack of criticism’. Sportsmen C, D and F said that their physiotherapists were sympathetic and seemed to understand the sporting world, which helped. Sportsman C was a regular patient and was pleased that his physiotherapists had become interested in his running and racing. He thought that this made their help ‘all the more valid’. Sportsman F, another frequent visitor to the clinic, echoed these sentiments. Sportswoman D’s physiotherapist seemed to have decreased her uncertainty by explaining the injury’s cause and treatment in detail. She found his positive attitude helpful emotionally: ‘I started to feel a lot better. I thought there was hope to get back. . . I started to feel confident again.’

Sportswoman A was not certain how much a physiotherapist could help emotionally. Sportswoman F said that she would like to talk about the emotional aspect of her injury, but only if she felt that her physiotherapist could relate to well to her. She was unsure how well health care professionals could really get to know patients as individuals, but acknowledged that patients often tend to spend a lot of time with their physiotherapists. For her, the central issue regarding the possibility of being helped emotionally was how well she was known as a perscn. Sportsman C felt that it would be useful for physiotherapists to be able to help emotionally, but thought that they might find it hard to concentrate on their ‘normal’ physical treatment while, at the same time, following a psychological technique that might benefit the patient. He thought that it might be more useful if the physical and emotional aspects were two separate parts of the treatment, but noted that this would be time-consuming. He concluded: ‘I think that it’s a service that could be offered, but I’m not sure how many people would want to take advantage of it.’

The Possibility of a Sport Psychologist Helping Sportsmen During Their Rehabilitation Periods None of the sportsmen felt that seeing a sport psychologist would have been detrimental for them during the time that they had been injured, but they differed in their opinions as to how helpful one would have been. Sportswoman A stated that she was ‘not totally convinced how much one would have helped’, but did acknowledge that help with goal setting might have been useful for her. Sportswoman F echoed this uncertainty regarding the benefits that she may have gained from a professional: ‘I feel the benefit of being able to talk to someone who I’m close to, and is actually prepared to sit and talk and listen, and that knows the predicament. Whereas I’m a bit dubious as to the benefit of talking to someone who doesn’t really know you, because they don’t understand the way you work.. . . You’re just like a number. . . and then it’s on to the next patient. They aren’t close enough to really be able to help.’ Sportswomen B and D thought that ‘someone to talk to’ would have benefited them, and sportswoman B also thought that if she remained injured for much longer, her own coping skill would weaken, and that a sport psychologist’s help at that point might be particularly useful. Sportsman C stated that a sport psychologist might have been able to improve his motivation, thereby enhancing his physical rehabilitation: ‘I think that it might have helped me, in that it might have encouraged me to do more peripheral beneficial training, like swimming and cycling. Whereas it’s very hard sometimes, when you’re injured, to motivate yourself to do those sorts of things.’ Sportsman E felt that, for him, a sport psychologist would ‘most definitely’ have been beneficial in that, if he had seen one, he would have been better mentally prepared to resume playing cricket matches: ‘I don’t think that I would feel the tentativeness that I feel at the moment if I had had four weeks mentally being helped.’

Sportswomen B and D thought that it would have been helpful and valid for a physiotherapist to use psychological skills, with sportswoman B adding that a gradual introduction to this aspect from the start of treatment would be necessary. Sportswoman D actually thought that the physiotherapist would be the member of the health care team best equipped to help people emotionally: ‘I think the physiotherapist would be the best person to do it because I think if yau were to turn around to an injured athlete and say: “I think you should see an analyst”, they’d wonder if they were mad. If you could combine the two skills and, while treating, actually talk to them and explain the psychological situation, it would put their mind a lot more a t rest. If you could guide them, it would be good. Also, if you could let the athlete know that you understood their situation, and how they felt, it would be a lot better.’ Sportsman E felt that a physiotherapist with psychological skills would be useful a t his cricket club. The physiotherapist is a full-time employee at the club and, if he or she had additional psychological skills, Sportsman E thought that it would be ‘great’. He described cricket as a game where the players are just left to ‘get on with it’, and little attention is paid to psychological aspects. He suggested that a little more understanding of the cricketer and his psychology might be useful: ‘I mean, if the physiotherapist could just help you through your injury, and know what you’re going through and be understanding about it, it would be good.’

Discussion This discussion attempts to highlight aspects of the current results which may have implications for physiotherapists. It should be noted that further research is necessary before an exhaustive list of methods by which physiotherapists can help their patients emotionally, and ‘how to do it’ information can be created. A few possible limitations of the study will be addressed: First, it should be remembered that the athletes who

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participated were private patients. This might suggest that they had a greater motivation towards sport and, in consequence, were more emotionally affected than their NHS counterparts would be. However, it is felt that the mood disturbance experienced by the present patients was so marked that most athletes would have a similar response. A comparative study would be interesting. Second, practical limitations made it necessary for the patients to complete their questionnaires at different stages of treatment. It is likely that the diagnosis and prognosis of injury would have influenced their feelings and responses. A future study should attempt to control for this by administering questionnaires to all subjects at the same stage. Finally, the SFAIQ only has two positive mood words which may have biased the patients into negative responses. However the results from the POMS-BI, which has both negative and positive dimensions, confirm the athletes’ mood disturbance. It would be useful to construct and validate a new injury-specific mood scale which is bi-polar. The first hypothesis, that sportsmen will have negative feelings about their injuries, was supported. Two of the major post-injury emotions were frustration and depression. At interview, the sportsmen explained that their feelings about their injuries would revolve very much around the progress of their rehabilitation. They would not always have negative feelings; if the injury was improving then they would tend to become optimistic If the sportsmen’sperception of the success of rehabilitation has such a marked effect on their emotional states, then it is important that physiotherapists ensure that they highlight even the smallest progression. The strategy of goal setting may be helpful here: the resolution of the injury and return to full participation in sport will obviously be the long-term goal, but it would be useful to break this down into several smaller short-term goals which serve to mark progress through the rehabilitation programme. May and Sieb (1987) listed difficulty in goal setting as a possible problem associated with sports injury. This suggests that it may be advisable for physiotherapists to discuss the principles involved, and to work with sportsmen towards setting mutually acceptable goals.

Boredom was another feeling that many of the sportsmen identified. It is clear that an important and timeconsuming part of many of these sportsmen’s lives was suddenly removed from them. Physiotherapists could perhaps help to combat this boredom by ensuring that they provide their patients with alternative activities, such as swimming or selective weight training, which would also be beneficial in maintaining fitness levels. Earlier literature suggests that this alternative exercise may also help to combat the sportsmen’s depression. Arnheim (1989) stated that ‘exercise rehabilitation’ was important in ‘maintaining a good psychological climate’, and exercise therapy has been used successfully in treating clinically depressed people (Sachs and Buffone, 1984; Kircaldy, 1989). Perhaps, as Smith et a1 (1990a) also suggested, the rehabilitation period could also be used as a time to learn mental training techniques, such as visualisation (see Warner and McNeil, 19881, which might partly compensate for any loss of physical training.

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The injured sportsmen certainly did seem to experience a general mood disturbance, thus supporting the second hypothesis. A comparison of this study’s injured sportsmen with normative scores indicated that all of the mood dimensions were more negative in the injured sportsmen. The largest differences were in the mood subscales elated-depressed and agreeable-hostile. Smith and his colleagues’ (1990a) study was similar to this one in that the only two monopolar subscales on which their injured sportsmen scored significantly higher than norms were depression and angel: It was considered that the comparison of the injured sportsmen’s mood states following injury with those of the matched group of non-injured sportsmen was the most valid mood disturbance measure. This comparison revealed a significant difference between the two groups on every mood dimension. The results suggested that sports injury initiated a generalised mood disturbance; the whole profile simply moved downwards but kept a similar shape. Chan and Grossmads results (1988) are similar; their injured runners also experienced an increase in all of the monopolar POMS’ negative dimensions, and a decrease in the positive one. The slightly larger increases in Chan and Grossman’s (1988) study were on the subscales of depression and anger, and in the present study, the elated-depressed subscale was a little more affected than the others. Additionally, the injured sportsmen in this study experienced a larger decrease in their confidence. It seems, from these studies, that injury does indeed have a detrimental effect on sportsmen’s general mood states; in particular, it increases their feelings of depression and anger, and lowers their confidence. Smith et aZ(1990a)stated that their study did not support the suggestion that all sportsmen experience a typical grief reaction following injury, and the study presented here is in accord with these researchers. In fact, both of these studies support the suggestion by Weise and Weiss (1987) that the pattern may be far more complex. Some sportsmen may exhibit some of the signs of a grief reaction, but most seem to react as Yukelson (1986) suggested; by vacillating through emotional highs and lows. It will obviously be important that physiotherapists evaluate all sportsmen individually, and on a regular basis, to ensure that they are coping satisfactorily throughout the rehabilitation period. Social support, particularly from family and friends, was one factor which appeared, according to the interviewed sportsmen, to have a definite beneficial effect on their emotions. This appeared both as practical help with activities that the sportsmen were unable to do themselves because of their injuries, and as a general supportive and caring attitude. The present study, therefore, supports previous work professing the virtues of social support. According to May and Sieb (1987) ‘it is essential that the athlete feels supported throughout the rehabilitation process’. Yukelson (1986) said that the sport psychologist should encourage sportsmen to look for emotional support from family, friends, team members and sports medicine personnel. He, along with various other sport psychologists (Rotella and Heyman, 1986; Weiss and Troxell, 1986; Weise and Weiss, 1987; Nideffer, 1989; Smith et al, 1990b), has suggested that social support can have a positive emotional effect during

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rehabilitation. Thus, it will probably be useful for physiotherapists to encourage sportsmen to look for this support. In support of the survey of Gordon et aZ(1991), four of the six interviewed sportsmen believed that sports medicine professionals with whom they had been in contact had affected their emotional states. The effects seemed to be both positive and negative, depending on the professional’s ‘bedside manner’. The sportsmen considered that psychological assistance might have been helpful for them, but they differed in their belief as to how important this might be. They seemed to accept the concept of either a sport’psychologist, or a specially trained physiotherapist, providing this aspect of treatment. Although they had reservations, they believed that such a service might, a t times, be useful. Perhaps there is a need in Britain for this service to develop as it is currently doing in North America. While it is desirable that all physiotherapists should recognise that sportsmen are very likely to be affected emotionally when they become injured, it should be remembered that emotions such as frustration, mild depression and irritability are quite natural and expected responses, and are quite acceptable so long as the sportsman is able to cope. Five of the six interviewed sportsmen displayed strong coping skills; they threw themselves into alternative activities during the rehabilitation period. However, they stated that these activities did not entirely compensate for their loss of exercise.

To help injured sportsmen keep their emotions under

control, physiotherapists must be acutely aware of the manner in which they communicate with their patients; they should be understanding, positive but realistic, friendly and encouraging. Additionally, psychological factors, rather than physical ones alone, ought to be considered in the construction of a rehabilitation programme. This study has specifically suggested that the use of goal setting to highlight improvements, and rehabilitation exercise to combat boredom and depression, may be helpful. Ideally, all physiotherapists, and other members of the health care team, would be alerted to these suggestions and would start to implement them immediately. Additionally, the interviews suggested that it would be useful to have the option of referring some sportsmen to sport psychologists. However, it must be cautioned that there are relatively few of these professionals currently in Great Britain. The present study has indicated that the combined use of quantitative and qualitative research is an appropriate method of study in this field; large sample sizes, objective measures and statistical analyses allow general responses to be established; qualitative case studies, including interviews, provide rich in-depth individual data which are probably most relevant and interesting to practising physiotherapists, and indeed to the injured sportsmen themselves. Acknowledgments We are grateful to Neil Black and the rest of the staff at CitiSport Orthopaedic Medical Centre, Epsom, where the data collection phase of this research was undertaken. Thanks also to all of the patients who completed the questionnaires, especially to the six who were interviewed.

Authors

is a physiotherapist at Grande Prairie Physiotherapy Clinic, Alberta, Canada. Graham Jones PhD MSc BA is a lecturer at Loughborough University.

Lisa Pearson MSc Sports Science BSc Physiotherapy

Address for Correspondence Miss L Pearson MSc BSc, 11 Pentland Avenue, Edinburgh EH13

OHZ.

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Chan, C S and Grossman, H Y (1988). ‘Psychologicaleffects of running loss on consistent runners’,Perceptualand Motor Skills, 66, 875-885. Dyer, L E (1982). ‘Rock or sand’, Physiotherapy, 68, 6, 175. Gordon, S, Milios, D and Grove, J R (1991). ‘Psychologicalaspects

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HISTORICAL PERSPECTIVE

Those Vikings Again! Allen Mason ~~

~~~

~~

Although the German system of physical education was more generally used in Victorian schools, Dr Matthias Roth managed to persuade the London Schools Board to appoint a graduate of the Central Gymnastics Institute (CGI)of Stockholm as Lady Superintendent of Exercises. The Board invited Froken Concordia Lofving to take the post, which she held until succeeded by Martina Sofia Helena Bergmann Osterberg in 1881. Madame Osterberg was born in 1849 at Skane in Sweden. She attended the CGI for two years, graduating in 1881.While she was with the London Board, Madame Osterberg trained 1,312girls to undertake elementary free exercises. In 1884,however, she bought Reremonde, 1 Broadhurst Gardens, Hampstead, and opened it as a training college for gymnastic teachers. The Hampstead Gymnasium, as it was called, provided not only teacher training, but gymnastic classes for ladies and children, as well as some medical treatments. This was not unusual as she had been trained under the Ling system of remedial exercise. The College prospectus for 1885 noted that complaints such as spinal curvature, rheumatism, joint infections, paralysis, neuralgia, writer’s cramp, dyspepsia and chronic constipation could all be treated successfuly a t the Hampstead Gymnasium. Such was the demand that Madame Osterberg bought neighbouring 5 Broadhurst Gardens to house the medical gymnasium. A home visiting service could be provided if required, and there were also limited facilities for resident patients. The first such patient there was Nina Poore, later Duchess of Hamilton.

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Although members of the new Society of Trained Masseuses (founded 1894) were providing similar medical treatments, there is no evidence of any cooperation between hospital-based masseuses and gymnastic teachers. Not until 1903 did medical gymnastics make’its first tentative and unsuccessful appearance in the syllabus of the Incorporated Society of Trained Masseuses (ISTM); and the first formal examinations under its auspices were held much later in 1910, with the examination for teachers following a year later. Madame Osterberg’s contribution to physiotherapy as such is slight. Her major interest was in the training of gymnastic teachers by the Ling system. Some of her students, however, did leave to become masseuses. One of these, Miss Manley, was a n early leading figure in the ISTM. Neverthless, Madame Osterberg should be remembered for her promotion of career opportunities for women, an undertaking that was to influence recruitment in physiotherapy. Her contribution to the long struggle for women’s status in the late nineteenth century is something that deserves more recognition. Author Allen Mason MSc MCSP DipTP is a senior lecturer in the division

of health sciences, School of Health and Community Studies, Sheffield Hallam University.

Note ‘Historical Perspective’ is a regular feature anticipating the centenary of the founding of the Society of Trained Masseuses. Contributions which illuminate and colour the establishment and development of the profession are welcome and should be sent to the scientific editor.