Cognitive Appraisals and Lived Experiences During Injury Rehabilitation: A Narrative Account Within Personal and Situational Backdrop

1. Background

For any athlete, injury is a disruptive experience curtailing the mode of athletic expression within a milieu of uncertainty about return to play. This article provides an insight to the cognitive appraisals and progression through experiences during injury rehabilitation. The narrative describes the subjective experiences of an injured athlete within a personal and situational backdrop across the rehabilitation period. This narrative explores how an athlete constructs a sense of self, following an injury, providing meaningful events from the onset of injury towards ‘return to play’. Although physical factors like overtraining, equipment failure, environment, playing conditions are believed to be major contributing factors in injury, evidence suggests that psychological factors also play an important role in the incidence, injury prevention, and rehabilitation (1). The Integrated Sport Injury Model (2) highlights the dynamic nature of recovery processes by illustrating the influence of cognitive appraisals, emotional and behavioral response in injury rehabilitation with personal and situational factors serving as a background.

We have very often observed that injury results in a wide range of emotions such as frustration, anger, tension, and depression. To better understand and treat an injured athlete, it is important to study those personal and situational factors that can influence post injury reactions (3). Although ideal personal and situational factors such as excellent personal rapport, social support and enjoyable experiences can be contributory to positive cognitive appraisals during rehabilitation, in reality, the circumstances only offer this in some cases. Research studies have supported an association with cognitive appraisal and mood disturbance (4). For instance, when athletes are injured, negative moods are often manifested through maladaptive methods of coping such as disconnection and rejection, impaired autonomy, impaired limits, other directedness, and inhibitions (5). From the perspective of personal factors, a strong association between personal beliefs and rehabilitation adherence is documented (6).

Udry (7) has indicated the three stages that an injured athlete will pass through viz: information processing, emotional upheaval and the positive outlook phase. In the first phase, the athlete often tends to focus on the pain, how much training time would be lost, how and why the injury occurred and what could have been done to have prevented the injury. These are some of the initial cognitive appraisals. The cognitive appraisals combined with medical information about the injury and possible rehabilitation time; often result in an emotional upheaval in athletes. For instance, it is quite common to see athletes in denial about the injury or exhibiting different emotions (e.g. anger and frustration) besides experiencing isolation and dejection. In the positive outlook phase, the athlete has better acceptance of the injury state thus improving his emotions and mood. Additionally, the situational factors such as social support in the rehabilitation context and visible progress in the recovery would also contribute to the positive state of mind.

2. Objectives

Drawing on the basis of the above, the aim of the present study was to examine the cognitive appraisals and lived experiences within the backdrop of personal and situational factors from the narrative experiences of an injured athlete.

3. Patients and Methods

3.1. Participants

Fendy (Pseudonym) was an 18 years old national athlete for cycling. He trained for approximately 4 - 5 hours on a daily basis (2 sessions per day). The athlete presented with the complaint of right shoulder pain following a right shoulder dislocation one week prior. He was diagnosed as having anterior shoulder instability and further Magnetic Resonance Imaging (MRI) revealed a tear of the anterior band of inferior glenohumeral ligament with labral lesion. He was advised to go for surgery and in the interim to go for physiotherapy sessions and activity modifications.

3.2. Procedures

After seeking necessary research ethical approval, the participant was contacted who consented to narrate his experiences during injury rehabilitation. Narrative analysis was considered because it is designed to provide an opportunity for the participant to give a detailed account of a particular experience. A narrative offers a holistic and integrated account of the narrator and his world and throws light upon psychological and social realities. Meaning is usually not readily available within the transcript, but has to be derived through interpretation of narrative text. Understanding that the narrative account is shaped within a certain context and life story of an individual, the interviewer began with the question “Could you narrate your experiences during the onset of the injury through return to play? The narrative was structured around the core theme of injury rehabilitation. The session lasted for a total of 80 - 90 minutes (approximately with 20-30 minutes on three different contexts: on set, rehabilitation and return to play). The narrative was tape recorded and transcribed verbatim. The research team comprised of two medical doctors specialized in sports medicine and two experienced psychologists with doctoral degrees. To enhance the credibility of the themes, triangulation was performed and the text was then given to the participant for verification and confirmation (8).

3.3. Narrative Analysis

A six step narrative analysis (9) was adopted as a guideline to analyze the data. In step 1 we read and familiarized with the 22 single spaced transcripts to obtain a gist of emerging significant themes. In step 2 we identified the main concept and principal elements of personal narratives, such as narrative tone, imagery and themes (10). In step 3 we looked at the content and the manner in which the narrative was told. For example, whether the narrative tones of expressing his story were optimistic or pessimistic. In step 4 we identified imagery and themes, to examine if certain images are indicative of a particular theme. Narratives contain imagery which includes a set of images, and is personally meaningful to the narrator. We looked at the genesis of the images to identify if it was rooted in the family dynamics of the early days of an individual or located within the dominant discourses of the social context in which the individual lives. The theme helped us to understand the patterns about what is particularly important to the individual. In step 5 we constructed a working map of the narrative considering the tone, images and emerging theme. In step 6 we constructed an account of the narrative reflecting themes and personal meaning conveyed.

4. Results

The narrative explaining three different themes of personal and situational factors is described under the information processing phase, emotional upheaval phase, and a positive outlook phase. Theme 1: Injury and consequences in sporting life (Information processing phase). The narrative began in a pessimistic tone as the athlete described the history of the injury. The narrative structure initially focused on the impact of being injured and its consequences in his sports career. Fendy expressed concerns that injury followed by poor performance would result in his elimination from the national team, consequently depriving him of incentives and studentship in the university. Fendy’s appraisals about losing monetary benefits could be linked not only to the material gain but also to the social position he enjoyed as a national athlete. The narrative focused on Fendy’s experiences and appraisals of personal and situational factors.

“I need to prove my worth to secure a place in the national team. When I am injured I cannot train. If the recovery is slow, I would be replaced and have to go back. Sport is a means where I enjoy all the privileges and get financial incentives. If I win, I would even get a bonus to further my studies”. Theme 2: Childhood experiences, Emotions, Social support (Emotional upheaval phase). Throughout the narrative, Fendy emphasized his problems, which were not just injury pain and loss of training time but was psychologically rooted in his childhood days. Experiences within his broken family indicated a dominant theme of loss and rejection. His sequence of images and thoughts, expressed in language tone, appeared to have a link to the early experiences. Parental relationships and emotional support (11) can be a backdrop for early recovery and provide opportunity to compensate the vacuum created. Injury related experiences get intertwined with underlying pent up feelings and often results in athlete’s distress. Athletes become extremely vulnerable while injured, and sometimes develop a feeling of worthlessness. “My parents were divorced when I was 10 years old and my father remarried. I am angry with my father, he never asked about my education or appreciated my achievements; He never considered me as his own and never wished me on my birthday. I see my friends going out with their father, they interact, and they talk about sports.”

Friendships in sports are very often centered on athletic activities which get ruptured in the event of injury. Fendy expressed his discordant relations with his team mates and how he was taunted constantly. His feeling of dejection and loneliness was apparent in his narrative featuring a lack of enjoyment and emotional support. “My friends make fun of me and comment that my current timing was poor and I am not fit to be in the team. My mother had always encouraged me and told me to take all adversities as a challenge. If not for her support, I would have quit.” Theme 3: Trusting relationship, behavioural outcome and hopeful future (positive outlook phase).

We believe that trusting relation, is somewhat connected to the social support an athlete gets during rehabilitation. Rees and Hardy (12) generated four dimensions of social support viz: emotional, esteem, informational, and tangible support. During injury rehabilitation, the trust between the athlete and the therapist is vital in providing esteem support (11). Esteem support implies that an individual is given a positive feedback instilling a sense of belief that the person is able to cope with the stressful event. Fendy mentions that he frequently missed his rehabilitation session because he felt it was boring and monotonous. Athletes often question the adequacy of treatment and occasionally, they get absorbed in irrational thoughts due to lack of informational support (11). Informational support provides an individual with guidance concerning the possible solution to a problem. Self-motivated athletes that effectively used psychological skills, social support, reduce risk taking, and pursue appropriate rehabilitation recover better than those who do not engage in these (2). “I didn’t go for rehabilitation for about one month. I don’t know why, I’m fed up. I feel bored doing the same thing again and again. Most of the days I was training, resting, and training again; that’s all. I was not doing anything at all.”

Towards return to play, we observed that the initial pessimism had reduced considerably. The ongoing feelings of dejections were replaced by more positive language and images of self. Fendy had a future plan in place and adhered to rehabilitation program. He was also able to cope better with social pressure and deal with internal conflicts. We assume that this behavioural outcome is the result of his personal experiences of dealing with adversity and the trust he developed. “I plan to participate in the competition. Now I am less worried about the injury because when I am training it does not hurt or cause any problem. I also follow the doctor’s instruction of avoiding activities that can cause dislocation. I realize that I have to take care of myself.”

5. Discussion

The study explores the cognitive appraisals and progression through experiences within personal and situational backdrop across onset of injury, rehabilitation period and return to play. Of particular interest was how the narrative was constructed within personal and situational context intersecting with cognitive appraisals, emotional responses and behavioral outcome. Injuries are common in sport and athletes who sustain an injury are likely to experience different emotions such as stress, anger, depression, anxiety, tension, fear, and mood disturbances (13, 14).

The narratives centering on the onset of the injury reflected a series of challenges faced by Fendy. In the beginning, the narrative tone was pessimistic and Fendy’s cognitive appraisals reflected emotional disturbances and personal conflicts. This coincides with the findings by Daly et al. (4) where they found a correlation with cognitive appraisal and mood disturbance. Fendy’s cognitive appraisals in the initial stages are centrally linked with childhood experiences. The main force that impacted Fendy was situational factors such as interactions with team mates, family, and his own philosophy leading to appraisals such as sense of loss, and negative self-perception. Fendy believed that he would be out of the training program if he does not perform well, indicating self-doubt .This belief is typical among other athletes and research findings show a decline in self-confidence and self-efficacy about sport performance following injury (15). Fendy’s emotional responses were evident in his expression of grief resulting from shoulder injury. His emotional upheaval was portrayed in his own questioning of who would pay him the incentives if he was not performing well, which can be attributed to the personal stake in the sports market. The thought “why me?” by the injured athlete often leads to hopelessness (16). Thus, it was reasonable for Fendy to feel disappointed.

During the treatment period, Fendy’s initial thoughts were muddled with doubts and monotony about exercising and adhering to the treatment. The narratives reflected a few tragic features where a profound effect of feeling neglected was evident. For instance, the social support was dented, through the separation of his parents and hostility of friends and the associated negative appraisals would have hampered adherence to rehabilitation. In the absence of a clear understanding of the injury and rehabilitation, Fendy questioned the benefit of rehabilitation and felt it was a monotonous action. These experiences and associated cognitive appraisals explained Fendy’s behavior of refraining from rehabilitation program. It is possible that Fendy experienced events as inappropriate and lacking sensitivity.

In terms of narrative structure, Fendy’s story was stable with a classic beginning, middle and an end. In connecting the narratives with the context, Fendy links his feelings of dejection with his past experience and interpersonal context within the athletic career. The narrative however, had a reversal affect towards the end where the pessimistic narrative tone was replaced by an optimistic tone. Fendy began to see hope in future, and planned for preventive action. Better adherence to rehabilitation ushered in a more positive outlook which is evident in the ending of the narrative explained under positive outlook phase.

At a personal level, the narrative reflected different experiences across onset, treatment and return to play. Fendy’s broken family background rendered feelings of rejection and insecurity in his relationship with his team mates. The injury was perceived as a threat to his sporting life which was evident from his narrative. At an interpersonal level, Fendy details his experiences with team mates and with the rehabilitation staff connecting to the current situation. The cognitive appraisals were rooted in different experiences leading to different emotional responses such as frustration, disappointment, and anger. In the later part during rehabilitation, however, a shift from negative to positive outlook was evident. This is in line with the research findings which states that towards return to play, athletes have better acceptance of their injury and observe the progress (7).

The narrative captures the lived experiences of an injured athlete and takes us through the cognitive appraisals and, emotional upheaval to provide an understanding of how personal and situational factors affect the psychological responses of an injured athlete. Personal and situational factors have initial impact upon cognitive appraisal. In the applied setting we have observed that when cognitive appraisal represents negative content, an athlete perceives an imbalance between resource and coping, which results in stress response, putting an athlete at a risk of injury. From this narrative we can understand that lived experiences, life stress, and how significant others behave toward an injured athlete, can have tremendous impact upon the cognitive appraisals, feelings, and behavior following an injury.

While generalizing from the experiences of one athlete is limited, we used verbatim quotation to illustrate the participant through his own voice and to evoke authentic description of appraisals and experiences of an injured athlete. The study provides an insight into the complexities of the cognitive appraisals and experiences and suggests developing an integrative framework for a holistic approach in injury rehabilitation of athletes. The quotes from the narrative may well be salient and an eye opener to all the individuals involved in rehabilitation, aiming at ‘return to play’ in the shortest possible time.