2 April 2015

MIND OVER MATTER: THE PSYCHOLOGY OF REHABILITATION 

Daniel Gallan

Injury: the greatest fear for every athlete. Across any code, at any level, injury is a part of life for sportsmen and women. A torn hamstring, a broken arm, a severe concussion; all injuries require extensive physical therapy. But what about the mental battle that needs to be waged when injured? How does the psychological process measure up to the physiological one? Doctor Charlie Weingroff and Springbok captain Jean de Villiers reveal what an athlete goes through psychologically when undergoing physical rehabilitation.

 Springbok captain Jean de Villiers receives medical attention after sustaining a career threatening injury against Wales last year.  Image supplied by Jean de Villiers.  

Springbok captain Jean de Villiers receives medical attention after sustaining a career threatening injury against Wales last year. Image supplied by Jean de Villiers. 

On the 29th November 2014, at the Millennium Stadium in Cardiff, the South African rugby community held its collective breath when captain and 107 Test veteran Jean de Villiers fell to the floor clutching his left knee during a Test against Wales. His cries of agony could be heard over the live television feed with replays showing his leg bending at a sickening angle. A post-match prognosis indicated a broken knee cap, a torn hamstring and anterior cruciate knee ligament damage. What we had seen may well have been the abrupt end of one of the most illustrious and successful careers in the history of the sport.

“When it happened my first thought was definitely negative,” de Villiers says in an exclusive interview with CONQA Sport.  “I thought “that’s the end”. Because of my age and the stage of my career that I’m at, I immediately went to a negative place. I knew it was bad straight away.”

De Villiers is a positive person and those negative thoughts were vanquished within the first few minutes. The Springbok captain was being carried off the field on a stretcher when assistant coach Johan van Graan told him that he was still going to go to the World Cup in September. The road to recovery, and indeed the World Cup, started right there on his back.

According to de Villiers, the rehabilitation process is a mental battle from the very first day. Having a solid support base in the form of close friends and family is crucial as they are the ones that build the mind while the physiotherapists, surgeons and coaches rebuild the body.

Doctor Charlie Weingroff is someone who knows how to rebuild both. Weingroff, a certified Athletic Trainer and Strength and Conditioning Specialist, holds a doctorate degree in Physical Therapy. His work with elite athletes going through rehabilitation has brought him international renown and his time with the Philadelphia 76ers in the 2005/06 season saw the East Coast franchise ranked first in the NBA for the least amount of players missing games through injury.

For Weingroff, the mental side of rehabilitation is just as important as the physical process, but stresses that because everyone is different, there are no set rules when understanding the mental side of recovery. Unlike a ruptured hamstring or a broken arm, every mind is comprised of different experiences and emotions. Some players may need constant reassurance that their rehabilitation is on track; others may need as little social interaction as possible. According to Weingroff, some players are like “little mad scientists” and scrutinise over every scrap of data while others simply need to be told what to do. Some injured athletes blame coaches and trainers for their ailments and others push too hard in their pursuit of fitness. As a result of the variety of mental states, Weingroff instead chooses to solve the mental battle with a physical approach.

“The psychological side of rehabilitation is still scientifically observable,” explains Weingroff. “Spiked levels of dopamine and certain neurotransmissions can be monitored. Maintaining hormonal and neurotransmitter levels associated with positive mind-sets and positive rehabilitation is what we strive for.”

This is achieved in a number of ways. First, the mind needs to be tricked into thinking that the body is healthy. As de Villiers and Weingroff both point out, one of the major inhibitors for rehabilitation is the athlete’s frustration that high levels of performance are no longer possible while injured. Weingroff circumnavigates this negativity by focussing on another area of the body. If an athlete has injured his foot or knee, there is no reason why the upper body cannot be trained. If this happens, there is a reduced risk of central sensitisation, a condition of the nervous system that is associated with chronic pain. “The athlete does not dwell on the injured body part and the area does not occupy a larger space in the cognitive brain,” Weingroff says. “Pain is in the mind, not in the body.”

 Jean de Villiers in action against Australia side stepping Quade Cooper.  Image supplied by Jean de Villiers.

Jean de Villiers in action against Australia side stepping Quade Cooper. Image supplied by Jean de Villiers.

Focussing away from the injured area is also achieved through the use of external rather than internal cues. Weingroff explains that he will never say “lift your knee this way” or “push your shoulder in that direction” but will rather use phrases like “lift the dumbbell like this” or “push the floor away from you”. Through external cues the athlete has no direct association to the injured area. As a result, training successes, while injured, can be measured in terms of small victories achieved through small goals (working a different part of the body or focussing on the external cues.)

“It’s important for the individual to still feel like an athlete,” says Weingroff. “You need to continuously put the athlete in situations where he or she can succeed. It’s very acute, but the little spikes in dopamine have a positive effect psychologically.” Tackling a bag, running a certain distance, pushing a weight in a particular way; these small victories create a connection between physical exertion and success. The number one predictor of injury is a previous injury. The athlete needs to negate this fear by performing actions that are associated with positive cognitive functions. The task doesn't have to be difficult, in fact it shouldn't be. Successes, no matter how small, all add up to the overall positive mind-set. The athlete can now regain the athletic confidence that is required to replicate match situations during training.

De Villiers confirms that the fear factor for the returning athlete is very real. “We simulate a lot of what goes on during a game in training,” he says. “Each time you’re tackled or run a little further, that fear and doubt is reduced. It takes time but eventually you get there.” The cause of the injury needs to be simulated. If the athlete rolled his knee as a result of wet grass, those conditions need to be replicated in training. If the player was injured in a tackle or from mistiming a jump, the variables have to be repeated in training because a negative association with an in-game variable increases the risk of a repeat injury. Match situations will never be duplicated precisely in training but the cognitive loop that links the variable to injury needs to be broken.

At 34, de Villiers has experienced his fair share of lengthy layoffs. In 2002 he suffered his first serious injury five minutes into his debut against France and missed most of the successful 2007 World Cup with a bicep tear. “I think the fact that I had injuries in my career definitely helps because I’ve been through it and I’m mentally stronger,” he says. Both de Villiers and Weingroff agree that although older players have anxieties regarding career ending injuries (the financial implications being a major source of anxiety), they are able to draw on experience and maturity which are both vital to the rehabilitation process. Young players’ bodies generally heal a lot faster but the exuberance of youth can often be a detriment as frustration caused by an inability to see the bigger picture can create unrealistic expectations.

“I always tell injured players to expect the worst,” says de Villiers. “Anything better is a bonus but nothing is more damaging and more demoralising to the psychological side of rehabilitation than expecting to be fit before you really are. That can set you back a few months and then you have to start all over again. It’s harder for young players but the more you play the more you appreciate playing and that means you don’t take anything for granted.” That is one of the trade-offs with age. An injury is a loss, and like any loss, certain emotions need to be experienced before acceptance. Feelings like denial, anger, frustration, and blame are all part of the psychological rehabilitation process. Older players tend to get to the acceptance stage a lot quicker as time is against them. Only once a player has got to the acceptance stage can expectations can be managed.

Jean de Villiers faces the greatest battle of his rugby career. After regaining fitness after that lengthy lay -off he broke his jaw against Argentina last week. Getting fit for the World Cup in September would represent everything that de Villiers is about. This rugby legend is throwing all that he has got into getting his body fit and ready to regain the Webb Ellis Cup that all Springbok fans desperately crave. But getting his body fit is only half the battle. De Villiers will need every ounce of mental strength if he is to bring the curtain down on his career with a crescendo of noise and his arms aloft at Twickenham. 

Dr. Charlie Weingroff trains and rehabs golfers and athletes of all performance levels at Drive495 in Manhattan and Fit For Life in Marlboro, NJ. He is also currently the Lead for Physical Performance for the Canadian Men's National Basketball Team, managing the Senior National, Developmental, Junior, and Cadet teams with a regular staff of 6 and a team of consultants throughout the world.  He also holds a similar position with the Roddick-Lavalle School of Tennis.  He is also a member of the Nike Executive Performance Council and consultant to several organizations such as Equinox Fitness Clubs, Perform Better, and TPI.. Visit his website here

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