emotional response to injury as we explore this topic we will look for the following things we will look to integrate applicable theoretical models of emotional responses to injury enforced inactivity we will look to identify what may affect athletes post-injury emotions and subsequent behaviors including personal situations and injury characteristics we should learn to describe the cognitive and emotional impacts of catastrophic and career-ending injuries by the end of this section we should be able to summarize the unique emotional impact of concussive injuries and describe the influence of athletic identity on appraisal and emotional and behavioral responses to injury we should also be able to implement strategies designed to Aid in managing emotions and facilitating positive responses to injury including emotion focused and instrumental coping strategies we should be able to describe the concepts of post-traumatic growth and understand the potential for developing it within the rehabilitation environment we should be able to identify athletes who may be intentionally or even unintentionally prolonging the injury process and then implementing strategies to help athletes maintain athletic identity through the injury and Rehabilitation process and finally identify scenarios in which maladaptive emotional responses necessitate psychosocial referrals so let's get started emotional disturbances are common following injury but the extent to which emotional disturbances affects the injured athlete varies greatly the common nature of emotional disturbances might lead to under attention by the Allied Health professional or athletic trainer who is treating the athlete we will focus on common emotional responses of patients following injury we want and need to understand a typical response so that if an atypical response occurs we can quickly identify it and refer the individual for additional resources the psychological complexity of injuries most coaches athletes and athletic trainers accept the fact that injury is a natural part of athletic participation but we need to consider the impact each injury has on an individual so some food for thought I want you to think about this as we talk about this lecture how many ankle sprains knee sprains or even shoulder injuries such as labral injuries have you seen as an athletic training student now think about those individuals for how many of those athletes was that their first experience with injury does that change the way they respond we also have to think about how much of their response is based upon the culture of the sport we see this come up in sport mantras and even in advertising I love Rodeo but how does this impact an individual when they actually are injured think about other sports as we talk about this as well things like they say it's not when you get hurt bull riding it's how bad or these advertisements from Ariat pain is guaranteed suffering is up to you a broken arm is a small price to pay for reputation you don't get overtime you just get over it or Time Heals all wounds especially a really good time you win some you lose some teeth thumbs are like kidneys you only need one a partially collapsed lung is nothing all I need is eight seconds of air think about the impact of these advertisements on the sport culture the psychological complexity of injury some injuries that our patients encounter may be the first time the individual has ever been injured although many individuals cope well with the injury process some individuals will experience significant cognitive and emotional disruption there is not necessarily a right or wrong way to deal with injuries however some individuals will view injuries as either positive or A negative experience for some this is a disappointment While others will view their injury as an opportunity to show courage and come back stronger some common issues that athletic trainers May encounter in our patient population include fear anxiety identity crisis confusion isolation and even depression emotion is defined as an episode of interrelated synchronized changes in the state of all or most of the five sub-systems in response to the evaluation of an external or internal stimulus event as relevant to Major concerns of the organism or the individual there are eight primary emotions that have been identified and they are the basis for all other emotional subgroups these eight primary emotions are grouped into Polar Opposites such as joy and sadness acceptance and disgust fear and anger and surprise and anticipation elements of this wheel looking at the wheel we notice three main characteristics the color the layers and the relationships the colors the eight emotions are arranged by colors that establish a set of similar emotions primary emotions are located in the second Circle emotions with softer colors are a mix of the two primary emotions there are layers moving towards the center of the circle intensifies the emotion so the colors intensify as well for instance at the center of the wheel the primary emotions change from anger to rage anticipation to vigilance joy to ecstasy trust to admiration fear to Terror surprise to Amazement sadness to grief and disgust to loathing moving to the outer layers the colors become less saturated and the intensity of emotion lowers their relations the polar opposite emotions are across from each other the space between the emotions demonstrate combinations when primary emotions mix we see the emergence of emotions like love submission optimism aggressiveness contempt remorse disapproval ah and even submission emotions often form a U-shaped pattern with the periods of greatest emotional disturbance occurring immediately after injury and just before return to play for most of us the high emotional disturbance at the time of injury makes sense however when an individual goes to return to play anxiety may be high and confidence in the body part that was injured or in the individual's overall Fitness or performance maybe low athletes moods tend to parallel their perception of their recovery status it is vital for athletic trainers to understand and recognize typical emotional reactions so that we can help to facilitate emotional recovery at the same time physical recovery is occurring additionally we should be able to identify when an athlete or patient may benefit from referral there are additionally some issues that we need to be aware of including the failure to adapt post-concussion syndrome concerns malingering or even career ending or catastrophic injuries the theories concerning the emotional responses following injuries have evolved over time the Kubler-Ross model is also called the grief response model this was developed in 1973. this model focuses on loss such as death job loss or even marital Separation and suggests that grief is an active process that follows a specific sequence of events or stages sometimes the stages are called dabda d-a-b-d-a and start with denial anger bargaining depression and finally end with acceptance this model was based upon the observations of terminally ill cancer patients and therefore this response may be significantly different for injured patients Brown and studemire had a theory in 1983. from this early model Brown and studemeyer developed their own three-stage model of the typical grief process they theorize that an athlete enters a shock-like stage immediately after injury followed closely by a stage of intense preoccupation with the injury and its effects once athletes are able to accept the injury they enter a reorganization state although researchers applied this model successfully in the past it is not generalizable enough to all injured athletes it is through the work of brown and sudimir that we get our first glimpse into potential variations of these strict stage-like models however these Concepts were not applied within an injured athlete context for another decade Hardy and Grace in 1990 they modified the original grief response model resulting in four stages with extremes that better reflected the typical magnitude of emotional response from athletic injury this Theory suggests that athletes progress from initial denial it's okay I'll run it off to anger I wasn't supposed to be in that play in the first place to sadness now that I have this injury I'm not going to be able to play for weeks two finally and finally progress to acceptance and reorganization I cannot change the fact that I got hurt but now what am I going to do to help myself however research within an athletic population has been unable to identify such stage-like emotional patterns stage like models have received criticism because they do not consider individual differences that may affect how an individual reacts to injury nor do they address potential cognitive disruptions in the response to stress an alternative to the stage models was developed by Heil in 1993 in his description of the effective cycle of emotional response the sequential nature was replaced by a cyclical process for which injured individuals could maneuver back and forth the components include distress denial and determined coping the distress element acknowledges the disruptive aspect of an injury and how it can place an emotional imbalance such as anxiety depressed mood or helplessness denial involves a sense of lacking acceptance of the severity of the injury and the subsequent Rehabilitation involved denial is complex because it can both be adaptive serving as a protective mechanism to limit overwhelming emotions or maladaptive if emotions are ignored and not processed determined coping implies a perspective whereby athletes not only accept the severity and the prognosis of their injury but proactively incorporate coping strategies to process through the recovery process at the onset of injury it is understandable to experience the distress and the denial elements but as their Rehabilitation progresses generally athletes develop determine coping the unique feature of this effect cycle is the potential to repeat or cycle back and forth with all three elements Brewer's cognitive appraisal model in 1994. is a significant deviation from the previous stage like models that attempted to predict the sequence of emotional responses to athletic injury personality and situational factors can be antecedents to injury these factors can also influence an athlete's perception of the meaning of an injury Brewers model focuses on attention of the role and the power of cognitive appraisal and how the individual's perception of the injury affects the subsequent emotions and actions this model also allows for the influence of situational factors such as the Time of the Season and whether the individual is a starter or non-starter and the injury characteristics such as the severity of the injury initially the appraisal determines the emotional reaction which then influences the subsequent behavioral response the foundation of this model is that although athletes cannot change the fact that the injury has occurred they can change their appraisal of what the injury means to them as you consider this model it is important to understand that interventions can happen at specific stages of this model udri at all in 1997 was working within an athletic population and developed a model that attempts to sort emotions into three General categories of response to injury in the first category injury relevant information processing the focus is on the pain in the extent of injury the athlete questions how the injury happened and recognizes the negative consequences and inconveniences of being injured the second category emotional upheaval and reactive Behavior essentially encompasses the majority of emotions previously broken up into separate stages athletes may feel agitated emotionally depleted isolated and even disconnected they may experience shock disbelief denial or even self-pity and finally in the last category a positive outlook in coping the athlete accepts the injury and begins to deal with its consequences the athlete tends to be optimistic and is relieved to sense progress towards the injury healing while this model does allow for individual differences it is still somewhat stage like the wiseborn stall at all integrated model of response to sport injury in 1998 the integrated model of response to sport injury expands on Brewer's model by emphasizing that both pre-injury and post injury factors influence reactions rather than stage like this model emphasizes that cognitive emotional and behavioral responses to injury can and will change over time in a dynamic way illustrating the athletes evolving and complex response to injury the model encompasses pre-injury stress factors and the impact of The Athlete's perception on the injury as a stressor implying that the resulting emotional response depends on The Athlete's cognitive appraisal finally the interaction between the appraisal and the emotional response dictates the behavioral response to injury there is an additional model by Burr Anderson and Van rallite a biopsychosocial the progression of emotional response models led to the development of the biopsychosocial model to offer a broad perspective of sport injury Rehabilitation processes this model explores the numerous factors that include characteristics of the injury itself as well as the various biological psychological and social correlates understanding the influence of these variables on the emotional response and subsequent recovery is important for athletic trainers this model has seven components injury characteristics socio-demographic variables biological variables psychological variables social or contextual variables intermediate biopsychological responses and Rehabilitation outcomes viewing emotional responses from this multifaceted perspective allows athletic trainers to see injury processes more holistically as one involves physical cycle psychological and social components this model does help to integrate existing models and to highlight the connection of biological factors that had not been previously included to this extent and finally hedgepath and geek the progressive reaction of injured athletes is based on the severity of injury and length of Rehabilitation that came out in 2004 this model attempts to predict typical emotional reactions based upon the anticipated length of Rehabilitation following injury injuries that require shorter Rehabilitation less than four weeks those that require longer Rehabilitation more than four weeks chronic injuries and career ending injuries each have a different set of typical responses to injury to Rehabilitation and to return to activity for example athletes will likely experience shock and perhaps relief following injuries that require shorter Rehabilitation or less than four weeks and therefore athletes will likely approach Rehabilitation with optimism and likely impatience and will be eager and anticipate their return to sport athletes who experience chronic injury are generally angry and frustrated with the injury and may be apprehensive of The Rehabilitation process additionally they may either be confident or skeptical as they approach their return to activity following a career-ending injury athletes will likely react with grief or isolation and may experience a loss of athletic identity during the rehabilitation process but they should ultimately come through the experience with closure and a sense of renewal factors that influence emotional response and subsequent behaviors personal factors typically relate to the stable characteristics within an individual these include physical factors the aspects of injury individual differences and demographics situational factors tend to vary extensively over time they include both internal and external factors that may influence the reactions and may include sport factors social factors and environmental factors both internal and external factors May influence reactions these may include personality attributes and characteristics sport context injury history injury context and even other pressures it is common for athletes who experience injury to also experience a social loss because of perceived or real disenfranchisement with teammates and coaches following injury is a stressful and emotionally challenging period for many people to manage during this time athletes may use emotion focused or instrument coping techniques emotion focused coping involves using self-regulation to manage what is causing stress and it can either be proactive such as relaxation or meditation or potentially detrimental such as withdrawal or even self-blame the intention of emotion-focused coping strategies is to soothe the individual and to increase their overall quality of life instrumental cope or problem focused coping involves finding out specific information about the injury or the activity in cooperating strategies to alleviate the source of stress or discomfort such as listening and complying with advice from Health Care Providers participating in goal setting and participating in positive self-talk instrumental coping strategies focus on actively finding and implementing solutions to stressful problems athletic identity athletic identity is the degree to which an individual identifies with an athlete role individuals with a strong athletic identity are those whose self-worth is closely tied to their identity as an athlete this predominant perception seems to have a severely negative effect on psychological recovery from injury one athletic ability is taken away even temporarily individuals with strong athletic identity may be unable to adjust to being injured and as a result athletic Traders should pay special attention to helping these individuals to maintain their identity as perceived incompetence in this highly valued domain can profoundly affect their feelings of self-worth researchers have demonstrated correlations between individuals with High Athletic identity and psychosocial distress following injury and Sport career termination athletic identity is fairly stable across time however it does tend to decrease following severe injuries that threatens for participation this may be a self-protective mechanism athletes with a strong athletic identity can also learn how to transfer their athletic strategies to the rehabilitation setting primarily by using some of the same strategies that made them successful in their sport to make them successful during rehabilitation although athletic trainers should encourage athletes to stay involved in their sport as much as possible to adjust to time away from physical activity they should also be persuaded to focus on other areas of their sport or events athletes can be encouraged then to use this physical break as a chance to work on their mental game there are a couple red flags that we need to be aware of athletes with strong exclusive athletic identity may be added increased risk for negative mood disturbances and depression following injury the Ames is a seven item like art scale that can be used to evaluate athletic identity in injured athletes individuals rate the extent to which they agree with seven statements regarding identification with the athletic role this measure encompasses both strength and exclusivity of athletic identity and researchers have found it to be a valid representation of the social cognitive and effective aspects of athletic identity the athletic trainer could have athletes complete this survey to gain an understanding of their athletic identity and to take steps to ensure that they maintain this important identity throughout the injury recovery process secondary gain and malingering secondary gain is a complex phenomena in which an athlete who is motivated by return to participation May prolong the recovery process because of subconscious benefits of remaining injured these typically include a need for attention that they're not receiving from other areas or from a fear of returning to sport or both malingering is a conscious attempt to act injured because of perceived external incentives for being or remaining injured these may include fear of returning to activity the need for attention or both the malingering athlete presents a special challenge for an athletic trainer there is no definitive test for malingering and it is impossible to know for certain whether the athlete is truly malingering or exhibiting legitimate physical symptoms that are not textbook characteristics of the injury this can sometimes be frustrating not only for the athletic trainer and the sports medicine team but also for coaches parents and even teammates although determining malingering Behavior can be difficult observing behavioral patterns May indicate obvious red flags for example because malingering is a conscious effort to gain some external incentive injuries tend to occur only at times that are super convenient for the athletes the malingering athlete will also feel no guilt for letting a team down by being injured and has no real motivation to return to sport participation one area that we need to delve into specifically is emotional disturbances following concussion special considerations often need to be made when dealing with concussive injuries because they are complex and involve unique problems with respect to the physical and psychological response and recovery process it is important to understand that concussions not only have a physical impact on athletes but an emotional one as well following concussion it may be difficult for athletes to attend class focus on schoolwork or even take tests cognitive rest may include a temporary leave of absence from school reductions in overall workload an allowance for additional time to complete assignments and take tests athletic trainers must communicate with administrators and faculty to be sure that they understand that these accommodations are legitimate and necessary to ensure full recovery following concussions a unique issue is the overlap of post-concussive symptoms with commonly reported psychological responses to injury as noted earlier it can be difficult to determine what typical emotional responses are and how long they may last when it can be so individualistic and based on so many personal and situational factors because post-concussion symptoms continue for a prolonged time it can be difficult for athletic trainers to differentiate symptoms of the normal healing process from A post-concussive syndrome for most people post-concussive syndrome generally occurs within the first seven to ten days and will go away within two to three months however these symptoms May persist for a year or more catastrophic and career-ending injuries the end of an athletic career can be an emotional experience under any circumstance however there is an unquestionable difference in emotional response following a planned retirement as opposed to an unexpected termination caused by injury referrals to mental health professionals may be necessary when athletes feel they have no sense of control when injuries result in catastrophic or career-ending injuries isolation can occur as an individual isolation can occur as the individual Grieves the loss of this important aspect of themselves they may also experience negative emotions related to the loss of their career identity place in society or even social groups such as their teammates and they may deal with permanent loss of physical function we can try to help engage our athletes by facilitating positive emotions and behaviors the life development model suggests that people are continually growing and developing yet this growth is not necessarily sequential change is inevitable in life an essential tenet of the life development model is to embrace this change and look for ways to foster personal growth from it the life development intervention goal setting is a way to empower athletes to gain a sense of control over their situation goal setting can serve many purposes and athletic trainers are well aware of its use in sport performance having injured athletes focus on goals while healing from their injuries can serve to motivate them to action and to gain control over their lives which can enhance the feelings of self-efficacy post-traumatic growth is a term that is used to describe the concept of growth occurring through trauma this can also be applied to Injured athletes post-traumatic growth is not something that automatically happens a number of factors such as personal characteristics environmental characteristics characteristics of the negative event and the various coping resources available lead to the potential for experiencing post-traumatic growth there are five domains where studies demonstrate that subjects consistently experience growth and these include social cognitive emotional personal and spiritual or philosophical growth areas when to refer the red flag warning signs of poor adjustment to athletic injury it can be difficult to determine whether athletes are experiencing a typical negative post-injury response or whether they may benefit from psychosocial interventions pepitas and danish in 1995 identified the following red flags as warning signs for poor adjustment to athletic injuries and these include feelings of anger and confusion denial or minimizing the extent of injury the individual becomes obsessed with when they can return to play repeatedly coming back from injury too soon exaggerated bragging about past accomplishments dwelling on minor physical complaints feelings of guilt or letting teammates down withdraw from significant others rapid mood swings and consistent statements expressing doubt that they will ever recover athletic trainers should be aware of these warning signs and have a referral protocol in place to Aid injured athletes in recovering psychologically from their injury as well as a physiological healing process