Strategies to Improve Mental Health During ACL Rehab

Do you remember that scene in Big Daddy where Sunny gives Julian his invisible sunglasses? When Julian puts them on, no one can see him until he is ready to be seen.

Well, in college, I had my own version of invisible sunglasses. I usually put them on whenever I was struggling with major depression… which usually coincided with some sort of season-ending injury. I would walk around campus with my hood up, giving off the “don’t look at me” vibe. It would work to some extent, but there was always one person who could see right through my tricks. Whenever my hood was up, I could almost always count on a conversation and/or hug from my certified athletic trainer or sports medicine staff.

My hood was my “sign” or signal for help. Whether you are a clinician or athlete – or even just a human-being for that matter – it is important to know the signs and signals of someone struggling with mental illness. Recall from my last post the overwhelmingly high number of NCAA student-athletes dealing with anxiety or depression. Unfortunately, due to the stigma and shame that exists in today’s society surrounding mental health, many (if not most) choose not to come forward and seek care. While we continue the effort to prioritize mental health conversations, it is our duty to pick up on the subtle signs of someone quietly asking for help.

Some of these signs are more obvious than others. They include: withdrawal from social activities, irritability, self-criticism, low self-esteem, frequent aches and pains (somatic symptoms), tearfulness and crying, academic issues, social challenges, family conflict, substance use/abuse, self-injury, or thoughts of suicide. Unfortunately, these signs and signals can be so covert, that we often miss identifying them in those who need help most.

Although physical activity is often considered a protective factor in relation to mental health, it can also contribute to high levels of anxiety and depression in competitive athletes. Competitors often face stressors like: potential of being cut from the team, risk of injury, or performance challenges (i.e. fighting for that starting position, scholarships contingent on play, etc.). It is no mystery that as many as 31% of male and 48% of female student-athletes experience symptoms of anxiety or depression. A study by Neal et al. in 2015 stated that student-athletes have been identified as having higher levels of sleep disturbance, appetite loss, mood disturbance, irritability, and concentration difficulty compared to the general student population. The study also concluded that these athletes had decreased self-confidence and decreased interest in enjoyable things compared with regular students. The National Comorbidity Survey of Adolescents showed a lifetime prevalence of mental illness among U.S. adolescents aged 13-18 to be 49.5%. That means almost 1 in every 2 kids struggles with anxiety or depression. If you are a coach or rehabilitation clinician, this is a staggering statistic to consider when dealing with young athletes – especially those stuck on the sidelines.

Unfortunately, there is also a plethora of empirical evidence that shows a positive correlation between anxiety/depression and increased injury rate. Anxiety and depressive symptoms can lead to an increased vulnerability to injury because of decreased concentration and attention levels during practices and game. There is also a reduced or insufficient level of apprehension demonstrated by these athletes in the presence of threatening stimuli or situations. Research also shows that a high level of trait anxiety can be a great indicator of mental health in the pre-season. It might also be a key risk factor for in-season injury, but more research must be conducted in this domain.

So if you’re following along so far, injury can lead to anxiety and depression, which can lead to injury, which can lead to anxiety and depression, which can lead to injury… Talk about a vicious cycle.

So what can you do?

If you are a coach or concerned teammate, try to identify these individuals. Always, always, always demonstrate compassion. Stay calm during your interactions. Use a non-judgmental approach and attempt to validate their perspective while normalizing and de-stigmatizing the athlete’s experience. Remember, you don’t have to agree with them, and you certainly don’t have to solve the problem. Just lend an ear or shoulder, and, if you can, provide a few available resources.

If you are an injured athlete, remember: this too shall pass. There are plenty of people qualified to help you find your way out of the dark. There are also different strategies you can implement on your own to help calm those nerves and get you out of that funk. They include goal setting, positive self-talk, thought stopping, countering, and reframing.

Goal-setting can help you put a plan in place. In physical therapy, we develop a bunch of short and long-term goals to help direct our plan of care. Why are we doing what we are doing? These goals are there to remind us to stay on task with our treatment interventions. Try implementing the SMARTY principle. This means the goal must be Specific, Measurable, Adjustable, Realistic, Time-bound, and personally valued by You.

Self-Talk is incredibly important. Unfortunately, athletes recovering from injury frequently have negative self-talk – whether conscious of it or not. “I will never be as good as I was before” or “I’m not making enough progress fast enough.” These are common thoughts experienced during the rehabilitation process. However, they are not facts. Learning to challenge negative-self talk and refocus is essential for anyone struggling with anxiety or depression. In order to change negative self-talk, you must first be aware it is occurring. Then, try implementing some more of the following.

Thought stopping is where you consciously realize a negative though and then purposely put a stop to it. Try imagining a big red stop sign in your head and focus on the task at hand. This one is a hard one, but once you get it – it can change your life!

Countering. Create an internal dialogue that uses facts to refute the underlying beliefs and assumptions that lead to negative thinking. This is the ultimate basis of cognitive behavioral therapy, and can be tremendously helpful. Take a breath and remember, what are the facts?

Reframing is where you create alternative frames of reference or different ways of looking at the world. It’s where you turn negative to positive. Try pairing a negative thought with a positive thought to help redirect your attention and remind you of why you do what you do.

If you are a rehabilitation clinician, talk to your athletes. Spend time with them. Ask about the context of the injury. Did your athlete blow her knee out the week before the big college showcase? Did she tear her ACL during the last game of her senior season? Different contexts will elicit different emotions and responses from your athletes. Get to know these patients. Get to know all of your patients.

Self-Determination Theory states that our behaviors are regulated by the desire to satisfy three basic needs, including: autonomy, competence, and relatedness. Autonomy refers to having a sense of control over what you do. Competence refers to feeling ready and capable, or efficient, at a skill. Relatedness refers to feeling a meaningful connection to others. When one or all of these needs are challenged during injury, behavior can go awry and crisis can ensue. Let these needs guide your treatment sessions.

Autonomy. When an athlete is not given the chance to influence her recovery, she is more likely to burnout due to feeling a lack of control in her life. To help combat this, I usually start my treatment sessions with “what do you want to do today?” or “would you rather do exercise A or exercise B?” Giving options allows athletes and patients alike to choose and have some sense of control over their recovery.

Competence. Provide external feedback and help your athletes succeed with whatever they are doing, whether it be improving landing mechanics or preventing dynamic valgus during a single-leg squat. Teach the athlete the purpose of each exercise and then intermittently quiz them. “What are we looking for with this exercise?” “Why am I having you do this?” “What is the point here?” Keep them engaged. You might find this simple concept can also create a world of difference.

Relatedness. Last, but not least – Humans tend to behave out of an innate need to feel meaningful connections with other. It is not good to go alone. While not always possible, I often try to schedule similar level athletes going through similar injuries together or overlap their treatment sessions. Encouraging conversation and bolstering a sense of community can be huge for boosting morale and increasing adherence. I often create little circuits where both athletes can participate at the same time meeting both of their individual rehab goals. It creates a fun alternative to just going through the same mundane exercises individually. Give it a try and let me know what you think!

Clinicians should always aim to identify any immediate threats to patient safety. Are they thinking about hurting themselves or others? Is someone else harming the athlete? If yes, refer them to those who can best serve their psychological needs. While physical therapists and athletic trainers tend to be extremely skilled at managing orthopedic conditions, it is often the mental or emotional side of injury that can present the biggest challenge when treating these patients. Working as a collective sports medicine team and paying attention to the mental aspect of ACL injury will maximize physical recovery and help your athletes bounce back stronger than ever.

If you or anyone you know is struggling with thoughts of depression or suicide, call the NAMI helpline at 800-950-6264 or text ‘NAMI’ to 741741.

*Special thanks goes out to Kelsey Griffith, Dara Spital, and Emily Pluhar who eloquently presented on these topics and ideas during the 2018 Micheli Lecture: Psychology of Sports Injury and Rehabilitation at Boston Children’s Hospital in Boston, MA.*