Using sports psychology to treat lower back pain

How a young professional golfer used imagery to conquer his persistent lower back pain

Client background

John (pseudonym) is a 30-year-old Professional Tour golfer, who plays on the tour and is currently competing in the USA. John was referred to me from his physiotherapist because he was suffering from recurring lower-back pain, which was affecting his practice and performance in pro-tour events. The physiotherapist speculated that there could be additional issues contributing to John's back pain and advised him to make an appointment with me as the sport-psychology consultant at this particular London-based practice.

John has won numerous tour events in both the States and Europe and had a very successful 1997/98 season before he began to experience back pain later in 1998. He first started physiotherapy in November, 1998, when his anger and frustration at the debilitating effects of the pain reached their maximum stress level.

I first met John in February, 1999. He wanted to know if I could help him with his recent performance decline, and whether I could reduce the intensity of the back pain by specific sport-psychology intervention techniques. We agreed to work with each other for a revisable 12-week contract.

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Theoretical perspective

Research has shown that learning how to use imagery as a mental skill is an integral part of an injured athlete's rehabilitation programme. According to Gould and Weinberg (1995), the psychological skills which are part of an athlete's rehabilitation include:

1  : : : Positive self-talk
1  : : : Goal setting
1  : : : Imagery, visualisation
1  : : : Relaxation training

It is important in this case study to distinguish between two types of imagery (see also the recent special issue of PP on Mindpower). Athletes commonly use imagery from either an internal or external perspective, depending on the athlete and the situation.

Internal imagery: this refers to imagining the execution of a skill from your own vantage point. It is as if you had a camera on your head - you see and feel only what you would if you actually executed the particular skill. External imagery: this refers to seeing yourself from outside, as though watching yourself on videotape. The basics of imagery training, either internal or external, are that the athlete needs to be able to both create a vividness of the image and to control and manipulate the image so that it does what he/she wants it to. This is a skill and takes practice to become fully effective.

Research into the effects of imagery has revealed equivocal findings. For example, previous research by Pavio (1985) has shown that certain types of imagery might be more effective for some tasks than for others. Following this line of argument, which is important for our own case study, are the findings and proposals of White and Hardy (1995). They postulated that internal visual imagery would be superior for the acquisition and performance of open skills that rely on perception for their successful execution. On the other hand, external visual imagery would be more effective for the acquisition and performance of skills that rely on form for their successful execution. Of interest for our case study is the fact that Hardy (1997) and, earlier, Jeannerod (1994) reasoned that kinaesthetic imagery should enhance performance more than either visual imagery perspective alone because it should enable the performer to synchronise the timing and feel of the movements with the timing of the visual images used. Kinaesthetic imagery involves adding the feeling of movements to the visualisation. It can thus be very useful for enhancing golf technique and for injury rehabilitation.

Intervention

My first concern was to discover the possible underlying causes of the lower-back pain. To achieve this, we reduced the complete swing of John's drive to smaller, more accessible components. I introduced the concept and technique of imagery, and asked John, who was already familiar with imagery, to use an internal and kinaesthetic perspective to see and feel his swing on the driving range. In addition, I decided to use the Gestalt model of awareness and change (see later) - I chose this after noticing apparent alterations in John's tone of voice and behaviour when he mentioned or discussed his caddie at our early meetings.

During the first session, I asked for the drive to be broken down into smaller components. I then asked John to see himself going through the movement of the drive using an internal imagery perspective, and to identify at what point the pain would be most apparent. Through the use of imagery John identified that it was at the point of contact with the ball. The pain was caused because John, when driving, would tense up, locking his arms, so that he felt pain in his lower back. Thus we implemented an imagery programme which involved John seeing himself executing the shot freely, without tension or hitting the ball so hard, but allowing the movement to occur effortlessly. I encouraged John to feel the action and see himself executing the perfect, tension-free drive. I also encouraged the use of a visual marker in practice, both on the driving range and in the imagery process. This was used to increase John's precision in directing the ball. It also helped to distract him from the technical aspects of the drive and thus allow it to just happen automatically. I continued with the relaxation and imagery programme for a further six weeks.

I recommended that he use imagery combined with relaxation for 10 minutes per day. I gave him a self-assessment sheet to provide me with regular feedback each week on how the imagery training was progressing and to address any problems with the training programme. The aim of the relaxation techniques was to reduce the physiological and psychological processes linked to tension and anxiety. In week six, I gave John an audiocassette containing the imagery training we had covered for him to use at practice and in tour events.

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Unmasking the villain

During the following weeks of consultation, I introduced the Gestalt model of awareness. This created an environment in which John could discuss his golf more freely, allowing him to become aware that his caddie was indeed an issue and to realise how tense and anxious he became whenever he mentioned his caddie. This then led me to introduce the Gestalt cycle of experience, during which learned to understand that he had been creating blocks, which in turn were inhibiting his golf performance, both mentally and biomechanically. It turned out that his caddie would talk disparagingly to John just as he was about to execute his drive. This led to John finding it difficult to discuss with his caddie or even to mention the fact that this was upsetting his concentration and annoying him. Thus it became clear that the caddie was a major factor in causing John's tension and anxiety, which led to him locking his arms and upper body and creating a pain in his lower back. Two weeks later, after the fourteenth week of consultations, John fired his caddie.

Outcome

John continued the consultations for a further six weeks until he travelled to Europe to compete. I now coach him once a month and speak to him regularly on the telephone. He has a new caddie who he is happy with and his golf is returning to his best form. He finished eighth in an event in Spain and fifth in Portugal and has returned from the States after playing some 'awesome golf' (his words, not mine). Finally, although his back pain lessened and became non-existent before he left for Europe, he felt slight twinges in America. However, even those have now gone and pain is currently not an issue. John is in great form and enjoying being injury-free.

Amanda Owens

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References

Hardy, L. and Callow, N. (1999). 'Efficacy of external and internal visual imagery perspectives for the enhancement of performance of tasks in which form is important.' Journal of Sport and Exercise Psychology, 21, pp 95-112

Houston, G. (1995) 'The Now Book of Gestalt.' Gaie Houston, London.

Jeannerod, M. (1994). 'The representing brain: neural correlates of motor intention and imagery.' Behavioural and Brain Sciences, 17, pp 187-202

Pavio, A. (1985). 'Cognitive and motivational functions of imagery in human performance.' Canadian Journal of Sport Sciences, 10

White, A. and Hardy, L. (1995). 'Use of different imagery perspectives on the learning and performance of different motor skills.' British Journal of Psychology, 86, pp 191-216

Syer, J. and Connolly, C. (1998) 'Sporting Body, Sporting Mind. An athlete's guide to mental training.' Simon and Schuster, London.

Weinberg, R.S. and Gould, D. (1995). 'Foundations of sport and exercise psychology.' Human Kinetics.

 

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