Injury is part of playing sport. No-one wants to be injured, but it is an accepted risk. For some people, recovering from an injury is more complex. The pain persists and returning to play is a challenge. Here I look at how we can use this time to create the conditions for recovery from a persisting injury.
When a person comes to see me because they have not recovered as expected, the first question is why? What are the reasons for the on-going pain in this person? It is usually pain that is used as a yardstick to measure improvement. What are the unmet needs?
I have used the term ‘persistent injury’. However, more often it is not the injury that persists, but rather the pain and sensitivity. Sometimes the healing process is delayed or disrupted, but usually this moves along, orchestrated by the nervous and immune systems. However, for various reasons, the pain can persist despite healing. The first key step then, is to establish the relationship between pain and injury in the person. We can do this by listening to the player and examining how their story is embodied (the assessment).
Pain and injury are poorly related
Pain and injury are not the same and often poorly related. Pain is a perception. We experience pain as part of the way we protect ourselves. It is a need state, like hunger or thirst, motivating us to take action. Pain compels action. The problem people have is not knowing what to do when it persists. Feelings of despondency, frustration, anger and other normal emotions take hold. These are also part of the on-going protection, making us realise what is important. However, many need help to focus their energy on what to do to recover and resume play. This is where coaching comes in.
In the world of sport, and I am going to use professional football as an example, there are many pressures that compete with the biological healing process. An urgency to return to play, holding on to a place in the team and concerns about the longevity of one’s career all contribute to the context. Besides, an on-going problem impacts beyond the player, affecting the team dynamic, other players and people close by (friends, family, loved ones).
Person first, then player
As with any persistent pain, we consider the person first. Modern football managerial styles have progressed to think person first, then player. This is an important step forward because we are not working with a painful body part. We are guiding and encouraging a person who experiences pain and all the emotions that arise as a consequence of the injury and on-going challenges. There is an inner world of thoughts, feelings, hopes and dreams that both drives and destroys us.
The person feels pain, not the body part
Creating the time and space for the players to express themselves and speak freely about what it is like for them, is vital. The skills of deep listening and motivational interviewing both come into their own in these situations.
Now there is time
This unexpected hiatus in the season creates an opportunity. There is now time and space to create the right conditions for recovery from persistent pain and the recurring injuries. This includes helping players understand their pain, why it has persisted and then focus on the fullest possible recovery. Many of the day to day pressures have lifted, meaning that they can concentrate on the steps to take each day, at the right pace, incorporating all the important practices and rehabilitation, to move onwards.
Creating the conditions for return to play
Readers will have tuned into the positive approach described above. I have outlined a number of key components, but how can we build on this and guide the player back to playing the game?
Understanding pain is the first step. We all hold beliefs about pain, what it means and whether we feel we can do something about it or not. Most people have lived in a society dominated by the biomedical model that looks for a pathology or injury to explain the pain. However, for many years, studies of pain science and countless observations tell us something very different. Pain is a perception that is coloured by prior experiences, expectations, attentional biases, emotional state and context. Pain is poorly related to tissue state. Helping someone overcome a pain problem then, especially if it is on-going , requires much more than treatment upon the painful area.
There is no recipe, but there are a number of ingredients for recovery. These include the person first approach, listening to the player, being present, validating their experience, helping them understand the bigger picture (what is going on in their life?), creating a sense of safety, focused attention and a calm, encouraging environment. Building on this, we need movement, body sense training, strength and conditioning and sport specific preparation. But, the latter will only be effective if the former is in place.
Pain is related to the perception of threat. It need not be actual, just thinking about an undesirable outcome is enough to switch into a protect state. Will I get back to play? Is this the end of my career? These are very threatening thoughts, which have an impact on our state. In a protect state, healing is put on the back burner. As are digestion and the reproductive system.
With modern living and the constant demands, our protect systems are on more than is necessary, resulting in feelings of anxiety and excess body tension. In the short-term this is useful, but not on a regular basis. It is no surprise that the incidence of irritable bowel syndrome and infertility have increased when you consider this.
There are many strategies and practices that help. We need to be in flow states as much as possible, and especially when recovering and healing. This is why understanding pain is so important, as it reduces the threat. Consider the difference between a player who knows why their pain has persisted, has a programme to follow that he can now focus on because he feels safe, and has a clear picture of where he is going, versus a player who believes hat each time it hurts he has done more damage.
Getting into a flow state can be done in many ways. I describe this practice as shifting gears. Players often have their own method for getting into the zone. We can use this as a start point. Then we need self-awareness and insight: how am I? Knowing the current state allows me to acknowledge my needs right now and meet them, and change gears if necessary. As a simple starter, think about 3 things that give you positive energy. If you close you eyes and focus on one of these, what happens to your state? How do you feel?
We must create the best conditions for the player, and we must help the player create the best conditions themselves in their inner world. There are many ways we can do this and help them move onwards towards their picture of success.
Pain can and does change
We can be so much more hopeful with the modern understanding of pain. Pain can and does change. In fact, pain is always changing as are we. Nothing stays the same — life would not be possible if this were the case.
There are many practices, tools and exercises that help players move forward from being stuck. Often, their thinking has become stuck because of their beliefs — not their fault. This is the way we work as humans. But, we can unlock the door.
This way of thinking was what led to the concept of Pain Coaching: person first, focusing on their strengths, building on prior successes, using practical tools and tapping into our incredible potential. Taking what we know about pain, peak performance, encouragement, motivation and being human, we can create superb and comprehensive rehabilitation programmes. Pain Coaching focuses on individual humans at their very best.
Now is the time. Now is the time to create the conditions. It is time for recovery from a persisting injury.
To arrange an informal chat with Richmond about any players you are working with who are struggling to return to play, email us here.
Richmond works with people who suffer persistent and on-going pain, helping them focus on what they want to achieve and then creating practical programmes for them to follow, based on their strengths. In recent years he has worked with three professional football clubs, helping with understanding pain and players who are stuck.