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Injury & the Mental Road less traveled...

Updated: Jan 18


When we suffer injury, there will be pain of a an acute nature that is considered to be more or less a normal presentation. The fact that tissue injury has occured means that the tissue is or will continue to be in danger for a period of time. This means that the brain will protect the tissue in a variety of ways. As mentioned in our previous posts, pain and abnormal movement are 2 of the more common methods by which our brains are able to protect our tissues while they heal.


Physical tissue injury isn't the whole story. There are always neurological or mental health sequelae that accompany physical injury. As we recently posted on our instagram feed @4th_corner_ptc there are several emotions or thoughts that you may encounter following an injury. Of those mentioned in the post, four are mental struggles that often occur after an injury; whereas, three are associated with mental struggles you may experience before and after an injury.


Those mental struggles that occur post-injury include:

  1. Kinesiophobia

  2. Depression

  3. Unrealistic Expectations

  4. Loss of Identity


Those mental struggles that may present before and after an injury include:

  1. Self-Efficacy

  2. Self-Esteem

  3. Internal Health Locus of Control


What we'd like to do is unpack these a bit more as well as provide a few examples of how these may be managed from an interventional standpoint. Before we dive into this, we'd like to make sure we are all on the same page. At 4th Corner P&T Concepts we believe each clinical presentation is likely very different and unique to the individual. We are in no way suggesting that some or all of this information is geared toward any one person in particular. In fact, if you identify with any one of these struggles related to a current injury, or even a past injury, we strongly recommend that you follow up with the medical provider of your choice to more fully explore your individual needs to determine what is best for your clinical presentation. To say it a bit more direct, this is not to be considered medical advice, but rather education that attempts to shed light on the mental struggles associated with injury. Our goal being to enlighten you so that you may become an informed consumer who is aware that these struggles do exist and are, more or less, abnormally "normal" in the context of injury.


Now that that's out of the way, let's get to the unpacking. Kinesiophobia is considered the fear of movement and or the fear that you are going to re-injure yourself which in itself promotes a level of elevated anxiety. Interestingly a fear of movement or reinjury has been significantly associated with a lack of activity or even a somewhat self-imposed inability to return to prior activity levels following injury. When we say "self-imposed" keep in mind this may be related to the decision not to return, but it also may be related to the decision, by the patient, not to perform the necessary work to actually return to the level needed to perform the activities they were once capable of performing.


Depression is an emotional state that is evidenced as a loss of interest or pleasure in daily activities, impaired function and or a change in behavior that is not considered "normal" for the individual. This negative emotional state can range from discontent to extreme feelings of sadness as well as despondency that interferes with one's daily life to varying degrees. We must admit that there is much more to the clinical entity of depression than what is presented in this humble narrative; however, it is such an ever present consequence of being injured that we would be remiss if we didn't discuss it within the current clinical context.

Depression is so prevalent that the World Health Organization considers it THE major cause of disability in people aged 15-44 years of age. Interestingly, following orthopaedic injury the prevalence of depression has been observed to be higher than the average adult prevalence of those suffering from in the US. In other words, injury can increase depression and anxiety more than what is considered to be the "norm" for adults within our country. Post-injury depression is associated with greater complications post-surgically and also with poor functional outcomes, post-surgical or otherwise, hindering the ability to return to work up to 7 years post-injury.


Kinesiophobia and depression can be further complicated by unrealistic expectations. In reality, there are a number of expectations that an individual may have that may be less than realistic based on the nature of a specific injury. In our instagram post, we mentioned the belief that healing is slower than what the individual may consider "normal" than they expect. However, it has been shown time and time again that the tissues of our bodies heal in a manner that is consistent across the human species. In other words, the time frame that human tissue heals is rather consistent regardless of our race.


Generally speaking, the timeframes for specific tissue healing are as follows:

  • Bone - 12 weeks

  • Ligament - 40-50 weeks

  • Muscle - 6 weeks to 6 months

  • Tendon - 40-50 weeks

It should be noted that the process of healing is further broken down into an acute, subacute and chronic stage. The timeframes above are consistent with "complete" structural healing of the tissue when it is considered as strong as it's going to become and not necessarily related to the length of time you might have pain.


Generally speaking, the different stages of healing are as follows:

  1. Acute Stage: 3-5 days (Inflammatory Phase)

  2. Sub-Acute Stage: 48 hours to 6-8 weeks (Proliferative/Fibroplasia Phase)

  3. Chronic Stage: 1-2 years (Remodeling & Maturation Phase)

As one moves through the stages of healing, pain normally begins to be less and less until finally an individual is able to move without pain and with the ability to use the injured tissue, more or less, as if tissue injury never occurred. It's during these stages of healing that mental sequelae may have a profound impact on your overall recovery. If your pain lasts longer than 3 months, though times vary, you are considered to have persistent pain. At this point, unless you have a genetic disorder or some other disease process that prevents your tissue from healing, your injured tissue has more than likely healed; and your pain experience is likely not associated with tissue injury. In other words, pain doesn't equal harm.


In our society we often, for better or for worse, define ourselves by what we do rather than who we are. This isn't meant to be a judgement, but rather a reality of our world today. The more we identify with what we do the greater the loss we might feel when we are no longer able to perform or participate in our chosen activity (e.g., job, sport, etc...). Now interestingly, the greater sense of identity you feel for your chosen activity the more beneficial this may be in your overall rehabilitation process. In fact, it's been observed that those with a stronger sense of activity related identity may actually adhere to their process of recovery more than those without a strong sense of identity. This in turn leads to a stronger desire to return to your chosen activity. One way to foster the benefits of a strong sense of identity is to stay engaged in the culture surrounding those activities we so choose. For instance, if you participate in a work or sport related activity, you may want to attend weekly meetings, events, practice or games, as appropriate, throughout your rehabilitation process.


Self-efficacy, self-esteem and your internal health locus of control are all factors that you may actually carry with you into your post-injury rehabilitation. That is to say, how you see yourself in the context of your environment may be more about where you resonated before injury rather than how your injury affects your mental health. In other words, your mental state before your injury will more than likely impact your overall recovery. Self-efficacy relates to your belief of how capable you feel you are at performing a given task. This doesn't necessarily speak to the reality of your actual capacity but rather how you "feel" or "believe" you are or aren't capable of performing. Self-efficacy tied to your overall identity can certainly promote a negative feedback loop that will significantly impact your recovery throughout your rehabilitation process.

Self-esteem, on the other hand, is related to your personal self-worth or belief in your overall abilities. Self-esteem and how you see yourself is beyond the scope of this blog post, but know it can indeed affect your overall recovery from injury, regardless of type. This brings us to your internal health locus of control. This has been defined as the degree to which you believe you have control over the events of your life. Admittedly somewhat abstract, the greater control you feel compared to what you believe is controlled by external forces, the more positive outcome you may experience throughout your recovery process. Conversely, if you lack a feeling of control over your life experiences, you will likely experience a more negative influence throughout your rehabilitation process.


We've covered quite a lot of ground throughout this post. We will conclude with a few common psychosocial interventions from the realm of cognitive behavioral psychology that are often used to intervene in those experiencing mental health struggles.


Common interventions include:

  1. Education

  2. Goal Setting

  3. Imagery

  4. Self-talk

  5. Graded exposure

  6. Social support

  7. Relaxation


Education is key! The more you know and understand about your clinical presentation the less prone to anxiety you are likely to become. That's why learning about injury and pain is SO instrumental in your recovery process. The less we know, the greater the possibility we may develop fear of the unknown. Knowledge truly is power, but without action, it's useless.


Goal setting is the method through which we put knowledge into action. Goal setting provides direction as well as allows you to measure your progress. In order to know how far you've come, you must know where you started. That's where goal setting becomes invaluable in the rehabilitation process. Goals that are S.M.A.R.T.-E.R. will have the greatest impact on your recovery.


S.M.A.R.T.-E.R. goals consist of the following:

  1. Specific

  2. Meaningful

  3. Achievable (& additive)

  4. Relevant

  5. Timely

  6. Evaluate

  7. Re-adjust


Specific goals are goals that promote action. If you set goals that are general or vague, there is no target to hit or outcome to achieve. If you measure something, then you can actually improve that measure. If you don't, you won't know if you've made improvements. However, if your goals aren't meaningful to you, then you buying into the process will be challenging at best. Rehabilitation goals shouldn't ever be viewed as taking away from your life but rather adding to the overall quality of your life (hence being additive). Your goals should be realistic, but they should also be rewarding and relevant to you. Again, if you don't see value in the goal, then it isn't the BEST goal for you.


Many goals are likely time sensitive (e.g., return to work or play), however you must remember you are a human who happens to perform whatever activity you'd like to return too and not the other way around. Life happens. Make sure your goals fit into your life, but also be sure to respect the stages of healing. You can't speed up the healing process, but you can certainly slow it down. Choose wisely.


Know that regardless of what life throws your way, you ARE capable and you CAN continue to make progress toward your goals. Something that is often lost in translation is that recovery is NOT necessarily a straight line. In fact, much like the image to the left, recovery is often not without its twists and turns. You may even appear to move backwards on occasion, but you ARE more than likely still making progress and you WILL continue making progress IF you continue working toward your goal. Breakdown your recovery process into steps (i.e., short term goals) that are manageable and you believe are doable. This will likely reduce anxiety as well as lay a clear step by step progression of actionable steps that move you toward your goal. That being said, don't hesitate to re-assess or evaluate your progress along the way. This ensures that you are indeed moving toward your overall long-term goal. When re-evaluating your goal, if you aren't seeing at least some progress in a positive direction it might be worthwhile to change your interventional approach. In fact, it just might be what you need to achieve long-term success.


Guided imagery is a technique that has been used for centuries in a variety of ways in a variety of cultures throughout time. This technique is a mind-body technique that utilizes specific mental images to improve an individual's sense of well-being as well as promote relaxation and anxiety reduction. It is believed that through the imagination an individual is able to overcome physical as well as mental symptoms through direct communication with the central nervous system. If you'd like to know more about the nervous system and how our brains affect our symptoms you might want to take a look at our recent blog post here. This direct communication and its effect on the CNS (and ultimately the body) is based on the principle that every thought results in a physiologic reaction; and that, along with specific mental images, come an associated emotional response that promotes a connection between your feelings and your mind and body. This can be further enhanced through relaxation techniques while performing imagery. Relaxation can help by reducing tension and anxiety which will diminish the "protection" output from the brain post injury or in those with persistent pain.


Another area of intervention that has been shown to be helpful when recovering from injury or living with persistent pain is that of self-talk. You may not realize it or not, but what you say matters. Self-talk can either promote healing or it can hinder healing. When we speak in a negative manner, we effectively increase what Moseley and Butler call "dangers in me" which can promote greater protection from our brains. This "protection" can come in a variety of ways with two of the more common being pain or altered movement. As we discussed in our last post, our brains reorganize based on the wiring or rewiring of neurons. That is to say, "the neurons that fire together, wire together." This is the essence of plasticity, or the ability of the brain to reorganize. It is important to know that post injury plasticity is going to occur. The question is will, this occur in a manner that is conducive for function or one that is not conducive for function. The good news is that you can certainly take steps to improve the outcome.


Your brain doesn't really know the difference between the real world and what you think. Your brain also doesn't really know the term "no" or "don't". Let's try a little experiment. What I want you to do is to NOT think of an orange. What was the first thing that came to your mind? If it was an orange, then you see the point. If we make statements that are negative in nature, those "modulation neurotags" will influence our "action neurotags" and create an output that is consistent with those "dangers in me". It's important to note that this is not about lying to yourself or making statements that aren't true. It's more about reframing the narrative in your mind to see it for what it is as well as for what it isn't. The fact of the matter is that there is always a more positive lens through which we can see our problem. In effect, there is a silver lining. If we look for that as well as focus our attentions there, this will improve our overall recovery process.


Graded exposure is an approach where patients confront their fear of movement or pain by being gradually exposed to movements or contextual situations where they believe they will experience pain or reinjury. It is through graded exposure where patient's teach their mind and ultimately their body, that movement is safe; and that they are capable of performing a given activity without harm. As tissues heal and or persistent pain persists through graded exposure, we effectively train or, in many cases, retrain the brain to allow the patient to create "safeties in me" that promote "modulation neurotags" that act on "action neurotags" in a way that promotes a more favorable outcome whereby the brain decreases "protection" of the body. This "opposite of protection" manifests as less pain, a more "normal" movement, and an overall improved function.


Lastly, it is very important for patient's to have a social support system that can help by enhancing the patient's coping strategies. This system not only provides encouragement, but also accountability. Accountability can promote consistency as well as perseverance toward a patient's long term goals. Knowing that you aren't alone can be extremely helpful throughout the rehabilitation process.


As we conclude our discussion, something that's worth mentioning and you may want to keep in mind throughout your recovery journey is that whether or not your symptoms came on quickly or over a period of time, they likely won't go away overnight. Be sure to give yourself some grace. Allow your body and your mind the time they need to rehabilitate, recover and restore.

We at 4th Corner thank you for taking the time to read this post. If you found this information helpful or you'd like more information regarding injury and or persistent pain please don't hesitate to reach out. We'd love to connect.


References:

  1. Andrews JR, Harrelson GL, Wilk KE. Physical Rehabilitation of the injured Athlete. 4th ed. 2012: ELSEVIER Saunders; Philadelphia, PA.

  2. Brewer BW et al. Pain and negative mood during rehabilitation after anterior cruciate ligament reconstruction: A daily process analysis. Scan J Med Sci Sport. 2007;17:520-29.

  3. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function. Wolters Kluwer; 4th ed; 2018: Chapter 11.

  4. Christino MA, Fantry AJ, Vopat BG. Psychological aspects of recovery following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2015;23:501-09.

  5. Christino MA, Fleming BC, Machan JT, Shalvoy RM. Psychological factors associated with anterior cruciate ligament reconstruction recovery. Orthop J Sport Med. 2016;4:1-9.

  6. Daley MM, Kelsey G, Milewski MD, Christino MA. The mental side of the injured athlete. JAAOS. 2021;29(12):499-506.

  7. Hsu CJ, Meierbachtol A, George SZ, Chmielewski TL. Fear of reinjury in athletes: Implications for rehabilitation. Sport Health. 2017; 9(2):162-7.

  8. Krau SD. The multiple uses of guided imagery. Nurs Clin Am. 2020;55:467-74.

  9. McCarthy et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003;85(9):1689-97.

  10. Moseley GL, Butler DS. Explain Pain Supercharged: The Clinician's Handbook. 2017. Noigroup Publications; Adelaide: Australia.

  11. Muscatelli S et al. Prevalence of depression and posttraumatic stress disorder after acute orthopaedic trauma. J Orthop Trauma. 2017;31:47-55.

  12. Otlans PT et al. Resilience in the orthopaedic patient. Bone Joint Surg Am. 2021;103:549-59.

  13. Woods MP, Asmundson GJG. Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial. Pain. 2008;136:271-80.



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