Dr Monna Arvinen-Barrow – Rehabilitation of the Biopsychosocial Athlete – Injury Rehab Network Event

The Injury Rehab Network went stateside for the September event of the Injury Rehab Network with BASRaT. Over 130 sports medicine and rehabilitation professionals joined the presentation from expert guest speaker Dr Monna Arvinen-Barrow (BPS Chartered Psychologist & Associate Professor University of Wisconsin-Milwaukee).

Dr Arvinen-Barrow’s presentation focused on the psychosocial processes of sports injury and rehabilitation. The presentation aimed to bridge the gap between theory and practice and make a case for a biopsychosocial approach to sports injury rehabilitation.

Click here to watch the recording

Dr Monna Arvinen-Barrow (BPS Chartered Psychologist)

Dr Monna Arvinen-Barrow is an Associate Professor in the Department of Rehabilitation Sciences and Technology at the University of Wisconsin-Milwaukee, USA, an online contributing faculty at the University of St Augustine for Health Sciences, the USA, and the Establishing Editor-in-Chief of the Journal for Advancing Sport Psychology in Research.

Monna is a Chartered Psychologist (CPsychol) and an Associate Fellow (AFBPsS) of the British Psychological Society, a Certified Mental Performance Consultant (CMPC®) and a Fellow (FAASP) of the Association for Applied Sport Psychology, a Finnish Psychological Association certified mental performance coach and exercise practitioner (UPV sert.), and an elected expert member of the Finnish Sport Psychology Association.

Dr Arvinen-Barrow has extensive research, teaching, and applied consultancy expertise in psychosocial aspects of sports injury occurrence, rehabilitation, recovery, and return to participation process. She is the lead editor of two textbooks; The Psychology of Sports Injury and Rehabilitation (2013) and The Psychology of Sport and Performance Injury: An Interprofessional Case-Based Approach (2019). She has authored and co-authored 50+ peer-reviewed research publications, 20+ book chapters, and 150+ workshops, seminars, symposia, and conference presentations, both in English and Finnish.

Rehabilitation of the biopsychosocial athlete

Dr Arvinen-Barrow’s presentation “Rehabilitation of the biopsychosocial athlete” discussed the psychosocial processes of sports injury, and how sports medicine professionals can facilitate (bio)psychosocial recovery with the goal to optimize athlete recovery.

Monna started her presentation with a light-hearted review of sport psychology and sports medicine memes. Monna’s reflection on the content available is that research and practice of a biopsychosocial approach are still relatively new and as such the internet is quite short on funny content about this subject matter. Furthermore, there is an opportunity to close some of the silos between sport psychology and sports medicine research, theory, and practice.

Dr Arvinen-Barrow discussed the purpose of the presentation, which aimed to present how a biopsychosocial approach to an injury can be of use to sports injury researchers and clinicians.

Disclaimers

Monna discussed her role as part of a team of professionals where she brings expertise as a psychologist but is not an athletic trainer or therapist. Monna does not claim to understand all that goes into being an MSK practitioner and described how she would not give advice on how sports rehabilitation professional should do their job.

Dr Arvinen-Barrow believes that as a psychologist, she does need to have an understanding of the professionals that she works alongside. For the purposes of the presentation, Monna used the term sports medicine professionals to refer to all professions that work with injured athletes.

How it all started

Dr Arvinen-Barrow referred back to two research papers from 1988, “A Model of Stress and Athletic Injury: Prediction and Prevention” by Mark Anderson and Jean Williams, and a review by the same researchers in 1998 “Psychosocial Antecedents of Sports Injury: Review and Critique of Stress Injury Model”.

Monna discussed empirical support for preinjury factors including a meta-analysis by Ivarsson et al in 2017 which showed that stress responses and history of injury have a strong association with injury rates. Stress response mediates the relationship between the history of stressors and injury rates.

Aim 1 – Adopting a biopsychosocial approach to sports injury rehabilitation: evidence

Dr Arvinen-Barrow discussed the theoretical and empirical evidence for a biopsychosocial approach to sports injury rehabilitation including the role of cognitive appraisals in sports injury where sports medicine professionals may be able to address psychosocial factors alongside physical aspects of injuries.

Monna used patellofemoral pain (PFP) as an example of evidence of how an individual’s responses to knee pain are also psychosocial.

• Cognitive responses – may include perceptions of pain, fear of pain and catastrophising.
• Emotional responses – anxiety, phobia, and depression.
• Behavioural responses – pain coping and changes in activities of daily living.

Dr Arvinen-Barrow described the biopsychosocial model of sports injury rehabilitation developed by Brewer et al in 2002. This model focuses on how a range of factors are interconnected and influence sports injury rehabilitation outcomes. In discussing this model, Monna stated that because of its complexity, the whole model is yet to be tested in its entirety, but support for each of its interrelationships has been found. She also discussed examples of empirical support for a pain-adherence relationship, social support (which can be positive or negative) and the importance of speed of surgical recovery.

Monna discussed some key points in support of a biopsychosocial approach including:

• Athletes are likely to be psychologically affected by their injuries.
• Sports injury rehabilitation is likely to be successful when an athlete is both physically and psychologically ready to return to activity.
• A key aspect of successful rehabilitation is to ensure an athlete copes well with their injury and the rehab process.

Dr Arvinen-Barrow discussed the views of sports medicine professionals about successful coping characteristics including:

1. Attitude
2. Mood
3. Rehabilitation behaviour

Monna pointed out how these successful coping characteristics, when placed back into the biopsychosocial model, provide support for the central role of psychological factors in injury rehabilitation.

Aim 2 – Professional practice models for sports injury rehabilitation

Monna discussed the historical context where sports injury prevention, diagnosis and treatment have historically been focused on the elimination of biological defects and little emphasis has been placed on biopsychosocial factors that may influence injury occurrence and rehabilitation.

Dr Arvinen-Barrow highlighted that a growing body of literature supports the significant role that psychosocial aspects can play in sports injury. There is a shift towards a more holistic, athlete-centred, biopsychosocial approach but little is known about how such approaches work in clinical practice.

Monna described how adopting a biopsychosocial approach to sports injury rehabilitation needs a shift from a lone practitioner approach to an interprofessional team approach. She outlined three such models currently proposed in sports injury literature: a multidisciplinary, interdisciplinary, and transdisciplinary team approach. While there is limited evidence to support each of these approaches in the literature, applied cases presented in the book titled “The Psychology of Sport and Performance Injury: An interprofessional, case-based approach,” highlights some key characteristics of a successful team approach to care:

• A primary treatment provider (athletic trainer or physio) typically coordinates care for the athlete.
• Typically, the role of sports medicine professionals is to focus on psychosocial interventions that promote understanding of injury (patient education) and rehabilitation adherence (goal-setting).
• Only appropriately trained professionals should be using psychosocial interventions that are designed to address clinical mental health conditions.
• The importance of other individuals and professionals (family and coaches) in successful rehabilitation.

Dr Arvinen-Barrow discussed how each injury case should be evaluated, diagnosed, and treated in a holistic/patient-centred manner.

Aim 3 – Role of sport medicine professionals in addressing psychosocial aspects of sport injury

Monna considered where psychology fits in sports injury rehabilitation and stated that it belongs to three key points in the injury and rehabilitation process:

1. Activities that patients did before they required sports rehabilitation, which may have contributed to or caused the need for therapy in the first place.
2. Activities that patients during the therapy/ rehabilitation treatment phase that affect the process and its outcomes.
3. Activities patients do after treatments that may have an impact on the overall quality of life and potential future need for therapy/ rehabilitation.

Monna described how practitioners can consider activities that patients may be doing or not doing (in sports, leisure, and home time).

From a psychological perspective, Monna discussed three phases of rehabilitation:

1. Reaction to injury
2. Reaction to rehabilitation
3. Reaction to returning to play

Dr Arvinen-Barrow discussed the work by Brewer et al (2002) and Kamphoff et al (2013) where evidence suggests that every new expected rehabilitation activity (behaviour) will elicit a range of thoughts and emotions that can positively or negatively affect the rehabilitation activity. The role of sports medicine professionals is therefore to:

• Understand how psychosocial factors affect the athlete at different phases of rehabilitation.
• Be aware of the potential effect of new rehabilitation activity and potential responses from the athlete.
• Address psychosocial responses within their competencies.
• Refer to an appropriate mental health professional when necessary.

Monna further discussed what sports medicine professionals can facilitate including:

• The need for autonomy and a patient’s need to be the initiator of their actions.
• The need for competence and a patient’s confidence in achieving desired outcomes.
• The need for relatedness and a patient’s experiences as part of a trusted relationship with their sports medicine professional.

When autonomy, competence and relatedness are facilitated, this can foster increased adherence, positive affect and perceived autonomy, as well as decrease perceived disability, resulting in enhance rehab outcomes, return to sports outcomes, and increased patient wellbeing.

Effective psychosocial strategies

Dr Arvinen-Barrow presented some of the most effective psychosocial strategies to facilitate an individual’s self-determination including:

• Autonomy Facilitating – Patient education, goal setting, variety of rehab exercises.
• Competence Facilitating – Patient education, goal setting, self-talk.
• Relatedness Facilitating – Social support, communication, keeping athletes connected with teammates.

Monna described how all interventions should be designed and implemented in a way that they have a specific outcome in mind and follow appropriate guidelines. Taking an evidence-based approach is paramount and all interventions should be implemented by appropriately trained professionals.

Summary

Dr Arvinen-Barrow shared some final thoughts to conclude her presentation and stated that everyone can play a role in the process.

• Sports medicine professional is part of the socio/cultural factors in rehabilitation, thus has the ability to affect the rehabilitation environment
• When a sports medicine professional provides patient education they affect the athlete’s biological and psychological factors
• Injury (e.g., knee) and person (e.g., age, gender) characteristics also influence how an athlete responds to the rehabilitation
• Within sports medicine, often the goal is to increase adherence to rehab activity (i.e., behaviour and therefore psychological factor) as we know this will improve motivation and rehabilitation outcomes.

Further reading and listening

Dr Arvinen-Barrow provided links to further reading and listening.

1. The Psychology of Sport Injury and Rehabilitation – Edited by Monna Arvinen-Barrow and Natalie Walker
2. Psychology of Sport Injury – Britton W Brewer and Charles J Redmond
3. The Psychology of Sport and Performance Injury – Edited by Monna Arvinen-Barrow and Damien Clement
4. Sport Injury Psychology, Cultural, Relational, Methodological, and Applied Considerations – Edited by Ross Wadey
5. Eighty Percent Mental Podcast – How can psychology help with injuries?
6. Eighty Percent Mental Podcast – “Put me back in, Coach!” – Psychological responses to sports injury

Q&A

Monna kindly answered questions put forward by the practitioners who attended the session.

Q1. Does the acceptance approach work with athletes?
A1. Yes, but most psychology of sports injury rehabilitation research has focused on CBT (Cognitive Behavioural Therapy) as opposed to the ACT approach (Acceptance and Commitment Therapy).

Q2. Is there a link between emotions and perceptions of pain?
A2. Yes, perception of pain is a type of cognitive appraisal and therefore results in both emotional and behavioural responses.

Q3. How would you advise managing conflict across a team, regarding timelines for an athlete to return to play?
A3. A true interprofessional team will have an athlete’s health first focus. It’s important for the team to work together to communicate the right timeline for return to play. Psychosocial readiness for return to play should be considered alongside physical readiness.

Q4. How can neuroscience be integrated into sport?
A4. This is not my (Monna) area of expertise, but yes, there is growing evidence in support of using biofeedback for example in injury rehabilitation. Since neuroscience is not my area of expertise, I cannot comment further.

Q5. Can anger trigger more pain?
A5. Anger may cause greater sensitivity to pain but can also trigger higher pain tolerance. Perceptions of pain, which is a type of cognitive appraisal does have a bidirectional relationship with emotions, including anger. These responses can be influenced by things like teams’ culture around pain and injury.

Q6. How should sports rehabilitators manage a young athlete with pushy parents?
A6. Setting clear expectations of rehabilitation from the onset with the parents and the athlete is important. It is important to ensure patient confidentiality and trust for the athlete but it is also important to work with parents and share relevant information within agreed parameters.

Q7. What would you recommend for athletes who aren’t open to talking?
A7. Ensure that athletes know that they can speak to you in confidence and that you provide a safe place to talk.

Q8. Can you recommend any strategies to help re-integrate athletes who may suffer from anxiety?
A8. One strategy that is within most sports medicine professionals’ competencies is to encourage using deep breathing or ratio breathing techniques. Breathing can be simple, yet effective in managing anxiety as it affects our fight or flight response.

Presentation recording

The recording of Monna’s presentation is available on YouTube here

Follow Dr Monna Arvinen-Barrow

• Email arvinenb@uwb.edu
• Twitter @MABSportPsych

The next event of the Injury Rehab Network

The next Injury Rehab Network is taking place on the 13th of October and features a presentation from clinical psychotherapist Gary Bloom. To reserve a place, sign up with BASRaT – click here to register.

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