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Sport, exercise & performance psychology
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  • Writer's pictureElliot Smith

Part 1: The role of sport psychology in injury rehabilitation and returning to sport

Updated: Jul 28

Note to reader: The content of this blog was inspired by a workshop I attended, which was organised and delivered by Helen Pickford. Helen is currently conducting a PhD which involves studying the impact of educational workshops on the practice of sport psychologists. In particular, the workshop that I attended revolved around supporting long-term injured athletes using Acceptance Commitment Therapy. The workshop was informative, applicable and inspirational for my own work as a sport psych. So I owe a big thank you to Helen, and if you're interested in this subject and the content of this blog please don't hesitate to check out Helen on social media and stay up to date with her research.

Find Helen Pickford on LinkedIn

In this blog (Part 1) I will talk about the first aspect of injury rehabilitation, pain and stress. Before talking about the processes of rehabilitation and the kind of psychological support athletes might benefit from one first has to understand what it means exactly to experience pain and feel stress. By recognising the biology and psychology of pain one can begin to see how sports psychology in particular as well as therapy can be really beneficial for athletes going through injury and rehab. So in Part 1 the focus will largely be on what athletes experience when they're injured, why they are experiencing it in the first place and also to shed light on what kind of factors are going to be important in designing a successful and effective rehabilitation programme. And it is important to note that this blog comes from a purely psychological perspective and it would be remiss to not highlight the importance of physiotherapy, strength and conditioning, nutrition, and the role of the coach as crucial support mechanisms with respect to the athlete’s recovery.


Injuries in sports are relatively common, as the physical nature of many sports activities can increase the risk of accidents and injuries. The frequency and severity of injuries can vary depending on the sport, level of competition, age group, and various other factors. Here are some general points regarding the commonality of sports injuries:

  1. Contact sports: Sports such as football, rugby, ice hockey, and martial arts have a higher incidence of injuries due to the physical contact involved.

  2. Overuse injuries: These occur when repetitive motions or excessive training strain certain body parts. They are more common in sports like long-distance running, tennis, swimming, and baseball.

  3. Collision injuries: Sports that involve collisions, such as football, can lead to traumatic injuries like fractures, concussions, sprains, and dislocations.

  4. Non-contact injuries: Some sports involve sudden movements or changes in direction, which can result in injuries like muscle strains, ligament tears (e.g., ACL tears in soccer or basketball), and tendonitis.

  5. High-intensity sports: Sports that require explosive movements, like gymnastics, skiing, and basketball, can lead to injuries such as fractures, sprains, and strains.

  6. Competitive level: Injuries tend to be more common in highly competitive sports, where athletes often push themselves to their limits and may take more risks.

  7. Age and skill level: Younger athletes and those who are less experienced or less conditioned may be more prone to injuries due to physical immaturity or lack of proper technique.

It's important to note that while injuries are relatively common in sports, they can often be prevented or mitigated through proper training, warm-up exercises, protective equipment, rule enforcement, and adequate rest and recovery. Sports organizations and governing bodies continually work to improve safety measures and implement guidelines to reduce the risk of injuries in sport.

Sport psychology is important for injury rehabilitation because it addresses the psychological and emotional aspects of the recovery process. Recovering from an injury can be a challenging and stressful experience for athletes, as it often involves physical pain, limitations, and disruptions to their training and competitive routines. Here are several reasons why sport psychology is crucial in injury rehabilitation:

  1. Emotional well-being: Sports injuries can have a significant impact on an athlete's emotional state, leading to frustration, anger, sadness, or anxiety. Sport psychologists can help athletes cope with these emotions, providing strategies to manage stress, maintain motivation, and develop a positive mindset throughout the recovery process.

  2. Mental resilience: Rehabilitation from an injury requires resilience and mental toughness. Sport psychologists work with athletes to develop psychological skills such as goal-setting, positive self-talk, visualization, and relaxation techniques. These skills can help athletes stay focused, maintain confidence, and persist through challenges during their recovery journey.

  3. Adherence to rehabilitation protocols: Following a rehabilitation plan consistently is crucial for successful recovery. However, it can be difficult for athletes to stay motivated and adhere to the prescribed treatments, exercises, and rest periods. Sport psychologists can help athletes set and maintain short-term and long-term goals, establish routines, and develop strategies to overcome barriers and maintain adherence to their rehabilitation program.

  4. Return-to-sport readiness: When an athlete is physically healed, they may still have lingering doubts, fear of re-injury, or lack of confidence before returning to their sport. Sport psychologists can work with athletes to build their self-belief, manage performance anxiety, and develop strategies to gradually reintegrate into training and competition. This psychological preparation is essential for a successful return and helps minimize the risk of reinjury.

  5. Transition and adjustment: For athletes who have been out of their sport due to an injury, there may be challenges in readjusting to the competitive environment and regaining their previous level of performance. Sport psychologists can assist athletes in navigating this transition, managing expectations, and developing strategies to rebuild confidence and performance.

Overall, sport psychology plays a vital role in injury rehabilitation by addressing the mental and emotional aspects of recovery. It helps athletes develop the necessary psychological skills, resilience, and mindset to cope with the challenges, maintain motivation, and ultimately return to sport successfully.

Talking about pain and stress

Feeling pain is a complex and subjective experience that is typically associated with physical or emotional discomfort. It is a fundamental aspect of human and animal existence, serving as a protective mechanism that alerts us to potential or actual harm. Physical pain often arises from tissue damage, injury, or illness. Nociceptors, specialized sensory nerve endings, detect harmful stimuli such as heat, pressure, or chemical signals, and send signals to the brain. These signals are then processed and interpreted by the brain, resulting in the experience of pain. Physical pain can vary in intensity, duration, and location, and it can be acute (short-term) or chronic (long-lasting).

Emotional pain, on the other hand, is related to psychological and social factors. It encompasses feelings such as sadness, grief, heartbreak, or distress. Emotional pain can be triggered by various life events, such as the loss of a loved one, the end of a relationship, or feelings of rejection. It is often a response to a perceived threat or loss and can be just as real and distressing as physical pain.

It is important to note that pain is a subjective experience and can vary greatly from person to person. Factors such as individual pain thresholds, personal experiences, cultural influences, and psychological factors can all influence how pain is perceived and expressed. Furthermore, chronic pain conditions can be influenced by complex interactions between physical and psychological factors.

Overall, feeling pain serves as an important mechanism that helps protect our bodies and minds by alerting us to potential harm, promoting healing and recovery, and encouraging us to seek appropriate medical or emotional support.

When an injury occurs, it can have an impact on stress levels and cortisol production in several ways. Here are a few key points to consider:

  1. Acute Stress Response: Initially, an injury can trigger an acute stress response in the body. The body perceives the injury as a threat, leading to the activation of the "fight-or-flight" response. This results in the release of stress hormones, including cortisol, to prepare the body for action and promote healing.

  2. Cortisol Release: Cortisol, often referred to as the primary stress hormone, plays a crucial role in the body's response to stress and injury. In the case of an injury, cortisol levels typically rise in order to mobilize energy resources, increase blood sugar levels, and suppress inflammation to aid in the healing process.

  3. Inflammation and Pain: Injuries often lead to inflammation at the site of the injury. While inflammation is a natural part of the healing process, it can also contribute to increased stress and cortisol levels. Pain associated with the injury can also trigger stress responses and elevate cortisol levels.

  4. Psychological Impact: In addition to the physiological effects, an injury can have a psychological impact, leading to increased stress levels. Dealing with pain, reduced mobility, and the potential disruption of daily activities can cause emotional distress and anxiety, which can contribute to elevated cortisol levels.

  5. Chronic Stress: If the injury becomes chronic or the recovery process is prolonged, it can result in chronic stress. The ongoing stress associated with a persistent injury can lead to sustained elevation of cortisol levels, which may have negative effects on physical and mental health.

It is important to note that the relationship between injury, stress, and cortisol levels can vary from person to person. Factors such as individual resilience, coping mechanisms, social support, and pre-existing stress levels can influence how an injury affects stress and cortisol responses.

How do we respond to stress?

The autonomic nervous system (ANS) is a division of the peripheral nervous system that controls involuntary functions in the body, such as heart rate, digestion, breathing, and glandular secretion. It works in the background, regulating these processes without conscious effort or awareness.

The ANS is further divided into two branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). These two branches often have opposing effects on bodily functions, maintaining a delicate balance and ensuring appropriate responses to different situations.

  1. Sympathetic Nervous System (SNS): The SNS is responsible for the body's response to stressful or threatening situations, often referred to as the "fight-or-flight" response. When activated, it prepares the body for action by increasing heart rate, dilating the airways, releasing stress hormones (like adrenaline), and redirecting blood flow to the muscles. These physiological changes enable the body to respond to perceived threats effectively.

  2. Parasympathetic Nervous System (PNS): The PNS acts as a counterpart to the SNS, promoting rest, relaxation, and restoration. It is often referred to as the "rest-and-digest" response. When the body is in a safe and non-threatening environment, the PNS slows heart rate, stimulates digestion, promotes relaxation, and conserves energy.

The SNS and PNS work in a dynamic interplay to maintain homeostasis—balancing bodily functions to meet the body's needs based on internal and external stimuli. This balance is crucial for optimal functioning and adapting to various situations. The autonomic nervous system operates largely autonomously, meaning it functions involuntarily without conscious control. However, it is also influenced by higher brain centres, such as the hypothalamus, which receives input from the senses and initiates appropriate responses through the ANS.

It's worth noting that while the sympathetic and parasympathetic systems are often discussed as opposing forces, they actually work together to regulate bodily functions. They act in a coordinated manner, adjusting their activities to maintain equilibrium and respond to changing demands and environmental conditions.

The Polyvagal Theory, developed by Dr. Stephen Porges, is a neurobiological theory that helps us understand how the autonomic nervous system (ANS) influences our physiological and psychological responses in various social and environmental contexts. It provides insights into the interconnectedness of the nervous system, emotions, social behaviour, and overall well-being.

The theory is based on the idea that the ANS consists of not just two branches (sympathetic and parasympathetic) but three distinct components, each associated with different adaptive responses. These components are:

  1. Ventral Vagal Complex (VVC): The ventral vagal complex represents the highest level of regulatory capacity in the ANS. It includes the ventral branch of the vagus nerve, which is associated with the parasympathetic nervous system. When the VVC is active, it promotes social engagement, feelings of safety, and relaxation. It enables positive social interactions, emotional regulation, and cognitive flexibility. The VVC is associated with the ventral vagal response, characterized by connection, engagement, and well-being.

  2. Sympathetic Nervous System (SNS): The sympathetic nervous system is traditionally associated with the fight-or-flight response, mobilizing the body for action in response to perceived threats or stressors. It prepares the body for self-defence or escape by increasing heart rate, dilating blood vessels, and redirecting blood flow to the muscles. However, the Polyvagal Theory also recognizes that the SNS can work in coordination with the VVC to support adaptive responses.

  3. Dorsal Vagal Complex (DVC): The dorsal vagal complex includes the dorsal branch of the vagus nerve and is associated with the older evolutionary mechanisms of immobilization, disconnection, and shut down. Activation of the DVC can occur when a perceived threat is overwhelming or when there is a perception of helplessness. It is associated with the freeze or immobilization response, where the body's metabolic activity decreases, heart rate slows, and there is a withdrawal or dissociation from the environment.

The Polyvagal Theory emphasizes the hierarchical organization of these components and how they influence our responses to social interactions and environmental cues. The theory suggests that the VVC is the foundation for healthy social engagement, emotional regulation, and overall well-being. However, disruptions or dysregulation in the VVC can lead to activation of the SNS or DVC, resulting in maladaptive responses and difficulties in social interactions and emotional well-being.

Understanding the Polyvagal Theory can help us recognize the importance of creating safe and supportive environments that foster social engagement and help regulate stress responses. It highlights the significance of positive social connections, emotional safety, and self-care practices in promoting overall health and resilience. The theory has been influential in various fields, including psychology, psychiatry, trauma treatment, and interpersonal relationships.

Dorsal vagal response

At the bottom, our lowest level of functioning, is the dorsal vagal response which most likely formed about 500 million years ago. The dorsal vagal response, also known as the freeze or immobilization response, is a component of the autonomic nervous system (ANS) that is associated with a specific pattern of physiological and behavioural responses during periods of intense or overwhelming stress. It is a protective mechanism that can occur when an individual perceives a threat or feels helpless. The response is mediated by the dorsal vagus nerve, which is a branch of the vagus nerve—the main nerve of the parasympathetic nervous system. The dorsal vagal response is often considered the "shutdown" response, as it involves a temporary inhibition or reduction of certain physiological functions.

During the dorsal vagal response, the body enters a state of conservation and immobility. Some key characteristics of this response include:

  1. Parasympathetic dominance: The parasympathetic nervous system, primarily through the dorsal vagus nerve, becomes dominant during the dorsal vagal response. This leads to a decrease in heart rate, blood pressure, and metabolic activity.

  2. Immobility and disengagement: The individual may experience a sense of immobilization or feeling "stuck." There can be a decrease in movement, reduced responsiveness to the environment, and a tendency to withdraw or dissociate from the present situation.

  3. Hypoarousal: The individual may exhibit reduced arousal levels, decreased sensory perception, and a dampened emotional response. This can manifest as emotional numbing, a sense of detachment, or a feeling of being emotionally disconnected from the surrounding stimuli.

  4. Potential physiological changes: The dorsal vagal response can also involve physical symptoms such as decreased muscle tone, shallow breathing, lowered body temperature, and decreased digestive activity.

The dorsal vagal response is believed to be an evolutionary adaptation to extreme stress or life-threatening situations. It can serve as a protective mechanism when other options, such as fight or flight, are not feasible or effective.

It's important to note that while the dorsal vagal response can be adaptive in certain situations, prolonged or frequent activation of this response can have negative effects on well-being. Chronic immobilization and disengagement can contribute to feelings of depression, helplessness, and social withdrawal. Understanding and addressing the underlying causes of stress and seeking appropriate support can be important in managing and recovering from the dorsal vagal response.

Sympathetic response

At the next level of functioning, the sympathetic response resembles perhaps the most renowned form of the autonomic nervous system. This is our ‘fight or flight’ response, in the face of danger the sympathetic response provides energy to take action, to either escape or confront our fear. Developed almost 400 million years ago, this level of functioning is particularly relevant in sport, wherein athletes are often faced with ‘make or break’ situations. The fight-or-flight response is a physiological and psychological reaction triggered by a perceived threat or stressor. It is a fundamental survival mechanism that prepares the body to either confront the threat (fight) or escape from it (flight). The response is primarily mediated by the sympathetic nervous system (SNS), which is a division of the autonomic nervous system (ANS).

When the fight-or-flight response is activated, several physiological changes occur in the body to help prepare it for action. These changes include:

  1. Increased Heart Rate and Blood Pressure: The heart rate and blood pressure rise to deliver oxygen and nutrients to the muscles and vital organs, ensuring they have the necessary resources to respond effectively.

  2. Dilated Pupils: The pupils of the eyes dilate, allowing for improved vision and heightened awareness of the surroundings.

  3. Increased Respiration: Breathing becomes rapid and shallow, supplying the body with an increased amount of oxygen to meet the heightened demands.

  4. Enhanced Blood Flow: Blood is redirected from non-essential functions, such as digestion and immune response, to the muscles and limbs, which are needed for immediate action.

  5. Release of Stress Hormones: The adrenal glands release stress hormones, primarily adrenaline (epinephrine) and noradrenaline (norepinephrine), into the bloodstream. These hormones increase energy production and mobilize resources for the body's response, promoting alertness and readiness.

  6. Increased Blood Sugar Levels: The liver releases stored glucose, increasing blood sugar levels, which provides additional energy for the body's immediate needs.

  7. Heightened Mental Alertness: Cognitive functions, such as attention, focus, and decision-making, are enhanced to assess the threat and make rapid judgments.

The fight-or-flight response is adaptive in situations where immediate action is required to deal with a perceived threat or danger. It can help individuals respond quickly and effectively to emergencies or stressors. However, prolonged activation of the fight-or-flight response, especially in non-life-threatening situations, can have negative effects on physical and mental well-being.

Ventral vagal response

Finally, at the top of the hierarchy, evolved 200 million years ago, the ventral vagal response is our highest level of autonomous functioning. The ventral vagal response, also known as the social engagement system, is a component of the autonomic nervous system (ANS) that is associated with social engagement, connection, and feelings of safety. It is mediated by the ventral branch of the vagus nerve, which is part of the parasympathetic nervous system.

The ventral vagal response is characterized by a state of calm, connection, and engagement with others. It promotes social interaction, relaxation, and overall well-being. Some key features of the ventral vagal response include:

  1. Social Engagement: The ventral vagal response supports positive social interactions and the ability to connect with others. It is involved in facial expressions, vocalization, and non-verbal communication, facilitating empathy, bonding, and mutual understanding.

  2. Relaxation and Regulation: Activation of the ventral vagus nerve helps regulate physiological functions, promoting relaxation and restoration. It influences heart rate variability, digestion, and other processes involved in maintaining bodily homeostasis.

  3. Emotional Regulation: The ventral vagal response contributes to emotional regulation by dampening excessive stress responses and promoting a sense of safety and calm. It helps individuals to better manage and regulate their emotions, leading to improved emotional well-being.

  4. Playfulness and Creativity: When the ventral vagal response is active, individuals may experience a sense of playfulness, curiosity, and creativity. It supports exploration, flexible thinking, and the ability to engage in joyful and creative activities.

The ventral vagal response is considered an adaptive state that fosters positive social connections, resilience, and overall well-being. It helps individuals feel safe and secure in their environments, allowing them to engage with others in healthy and meaningful ways.

However, it's important to note that disruptions or dysregulation in the ventral vagal response can occur, leading to difficulties in social engagement and emotional regulation. Traumatic experiences or chronic stress can impact the functioning of the ventral vagus nerve and contribute to challenges in social interactions and emotional well-being.

Understanding the ventral vagal response and nurturing positive social connections through supportive relationships, healthy communication, and self-care practices can help promote the activation of this response and enhance overall social and emotional well-being.

When working with injured athletes, it is the aim of the sport psychologist to encourage the athlete to operate at the highest level of functioning, to induce the ventral vagal response. So that, when met with signals of ‘pain’ the athlete can decode what exactly is going on and what the most appropriate response is. Importantly, the ventral vagal response does not catalyse an athlete’s reactions to stress to the same extent as the sympathetic and dorsal vagal response. It is important to be aware of these different autonomic responses as each of them may present themselves uniquely in different athletes at different stages of the rehabilitation journey. Some athletes in the face of a serious injury the likes of which could be career threatening will respond by being very proactive and hard working and their motivation maybe persistent, in which case that response would be characterised by choosing to fight. However some athletes placed in the same situation may choose to fly away from the problem so to speak and they may show very little motivation to engage in the rehabilitation process and they may have little or no aspirations of returning to sport. Equally when faced with the relentlessness of rehabilitation and the very slow progress that is often made athletes might choose to shut down and remove themselves from the environment becoming antisocial and unengaged. And any of these reactions can take place at any one of the different stages of injury rehabilitation, and I suppose the purpose of part one is to illuminate the reasons why athletes might feel the way they feel. But none of these reactions are typically permanent and athletes can often switch and change between different responses or they may exhibit a combination of reactions to stress and pain. Hence the role of the sports psychologist is so important because they can enable the athlete to navigate these feelings and thoughts and allow them to best understand what exactly they are going through.

In Part 2 I will go into more detail as how to facilitate the ventral vagal response, from a perspective of using acceptance commitment therapy. If you haven't notice already a fundamental feature of a successful rehabilitation programme is having positive social support and being able to regulate thoughts and emotions in a healthy way. These features are a core component of acceptance commitment therapy hence why its application is appropriate and suited towards supporting the athlete during their journey through rehabilitation. And in Part 2 I will explain how features of acceptance commitment therapy can be applied to different stages of rehabilitation where there are unique challenges that are specific to each stage.

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