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Is there a solution in preventing injury by managing stress?

The ability to regulate one’s own level of emotional response often influences an athlete’s performance in a positive or a negative way (Gould & Udry, 1994) which can increase risk of injury in sports events and competitions at any level (Pensgaard & Ursin, 1998). The existence of stress is not the concern rather it is the manner in which the athletes manage the stress to prevent the occurrence of injury is what matters most. Approximately 50% of reported stress experiences occur before competition, therefore this indicates that athletes need to be adequately prepared to face this period with suitable strategies to prevent injury (Pensgaard & Ursin, 1998). Many researchers claim that psychological interventions could prevent or reduce injuries in sport (Andersen & Williams, 1988; Pensgaard & Ursin, 1998; Gould & Udry, 1994). But in terms of long-term benefits these interventions are primarily dependent on whether the athletes and coaches implement and adhere to the injury prevention behaviours (Chan & Hagger, 2012).

Andersen and Williams (1988) proposed model of stress and athletic injury suggests that it is influenced by psychological interventions such as cognitive restructuring, relaxation skills, autogenic training and imagery/mental rehearsal. These interventions have been shown to work reasonably well in managing stress in clinical settings but do they prevent injury from occurring during competition or at all??

Cognitive restructuring focuses on replacing negative self-statements and images with positive self-affirmations and images of performance that is desired (Gould & Udry, 1994). This intervention has been associated with superior performance in elite athletes but definite conclusions are not evident (Gould & Udry, 1994; Naylor, 2009). Studies have reported the effectiveness of lowering arousal states but have not examined injury prevention as a dependent variable.

Progressive muscle relaxation is a type of relaxation training that focuses on continuously tensing and relaxing the individual muscle groups in the body (Hanafi, Hashim & Ghosh, 2011). Engaging in this exercise helps individuals develop body awareness and educates them how to release muscle tension (Hashim & Yusof, 2011).Although it is apparent that relaxation training promotes enhanced performance in athletes by reducing stress levels, research only indicated that it reduced injury rates, it did not prevent injury from occurring.

Autogenic training is based on passive concentration of bodily perceptions that are facilitated by exercises to control one’s own body and distress signs. It consists of self-suggestion of heaviness and warmth of arms, legs, and abdomen, rhythm of breath and heartbeat (Farne & Jimenez-Munoz, 2000). In many sports, athletes are subjected to autogenic training as a relaxation technique included in their mental training (Takai, Saijo & Kusumoto, 2009). Although advantageous are obvious by the results shown in the Table 1, there is no evidence in current literature to suggest that this intervention actually prevents or even reduces injuries in athletes.

Imagery rehearsal, also known as mental skills training is defined as consistent rehearsal of a physical task in the mind in the absence of any gross muscular movement to achieve a desired result (Kendall, Hrycaiko, Martin & Kendall, 1990). An example includes mentally practicing a tennis stroke. Literature suggests that practice of imagery enhances performance more than not practicing at all (Warner & McNeill, 1988). Imagery rehearsal combined with progressive relaxation seemed to reduce swimming injuries by 55% and football injuries by 33% (Davis, 1991). Although enhanced performance is evident, studies in this area contain too many practical tasks and individual differences to draw definitive conclusions on its effects of preventing injury. No literature into the effects during game situations or competition performances was identified, only clinical trials.

Limitations of past research are evident when examining the stress-injury relationship. Firstly, most research only investigates a single cause of injury, preventing the complexity of potential responses and secondly, there has been a lack of reports indicating severity of the injury. Individual differences also need to be taken into consideration. In theory, reducing injury rates and enhancing performance is possible via these interventions but only limited studies provide evidence that do not produce strong conclusions. Future research must investigate further into the effectiveness of psychological prevention programs with a specific focus on prevention of athletic injury to enhance sporting performance.

 Table 1: Shows the advantages and disadvantages of the interventions mentioned within the stress-injury model created by Andersen & Williams (1988).

Intervention

Advantages

Disadvantages

Cognitive Restructuring-Stress Management Training (Gould & Udry, 1994; Johnson, 2006; Johnson, Ekengren & Andersen, 2005; Warner & McNeill, 1988) ↑Concentration, ↑Brain Activity, ↑Awareness, ↓Negative thoughts, ↓Thought disruption, ↓Injury rates, Easily taught, No special equipment required -decreases in number of injuries only prevalent during intervention period-only works for some individuals in some situations
Relaxation Training-Progressive Muscle Relaxation (Walsh, 2011; Gould & Udry, 1994; Warner & McNeill, 1988) ↓Heart Rate, ↓Breathing Rate, ↓Blood Pressure, ↓Muscle Tension, ↓Stress related hormones, ↑Self Efficacy, ↑Attention Span, ↑Positive Mood, ↓Depression, ↓Injury rates, Easily taught, No special equipment required -↓ injury risk but does not prevent injury in sport.-Only short term effects observed in research, not enough research on long-term effects-Inconsistent evidence on the number of sessions required before mastery of technique is achieved.
Autogenic Training (Farne & Jimenez-Munoz, 2000; Warner & McNeill, 1988) ↑Self efficacy, ↑ Self esteem, ↑Skin temperature, ↑Nerve activity, ↑Positive Mood, ↓Emotional tension, ↓Respiratory rate, ↓Depression, ↓Stress levels, Regulates blood circulation, Easily taught, No special equipment required -Must be combined with other therapies to be effective-Takes one to two months to become sensitive to the warmth and weight of one’s body.-Motivation therefore needs to be acquired by athlete to gain results.
Imagery/Mental Rehearsal/Meditation (Kendall, Hrycaiko, Martin & Kendall, 1990; Johnson, 2006; Hecker & Kaszor, 1988; Warner & McNeill, 1988)  ↑Self-confidence, ↑Self-control, ↑Focus, ↓Blood Pressure, ↑Brain activity, ↓Stress levels, ↓Thought disruption, ↓Injury rates when combined with progressive muscle relaxation training, Easily taught, No special equipment required -Works better in experienced performers than novice-Imagery combined with relaxation is more effective than imagery alone.-Evidence of slow process to achieve results therefore less motivation by athletes can be seen.-Coaches cannot see how the patient is practicing and thus there is little opportunity for correction.

By Vanessa Gaynor

Reference List

  • Andersen, M. B., & Williams, J. M. (2007). A model of stress and athletic injury: Prediction and prevention. D. M, Smith, Bar-Eli, Essential readings in sport and exercise psychology. Champaign, IL: Human Kinetics, 325-330.
  • Chan, D. K. C., & Hagger, M. S. (2012). Transcontextual Development of Motivation in Sport Injury Prevention Among Elite Athletes. Journal of Sport and Exercise Psychology34(5), 661.
  • Davis, J. O. (1991). Sports injuries and stress management: An opportunity for research. The Sport Psychologist.
  • Farne, M. A., & Jimenez-Munoz, N. (2000). Personality changes induced by autogenic training practice. Stress and Health16(4), 263-268.
  • Hanafi, H., Hashim, H., & Ghosh, A. (2011). Comparison of Long-term Effects of Two Types of Relaxation Techniques on Choice Reaction Time and Selected Psychophysiological Variables Following Repeated Sub-maximal Iintensity Exercises in School Level Athletes. International Journal Of Applied Sports Sciences23(1), 183-197.
  • Hashim, H., & Yusof, H. (2011). The Effects of Progressive Muscle Relaxation and Autogenic Relaxation on Young Soccer Players’ Mood States. Asian Journal of Sports Medicine2(2).
  • Hecker, J. E., & Kaczor, L. M. (1988). Application of imagery theory to sport psychology: Some preliminary findings. Journal of Sport & Exercise Psychology10(4), 363.
  • Johnson, U., Ekengren, J., & Andersen, M. B. (2005). Injury prevention in Sweden: Helping soccer players at risk (Doctoral dissertation, Human Kinetics Publishers).
  • Johnson, U. (2006). Sport injury, psychology and intervention: an overview of empirical findings. Int J Sport Exercise Psychol57, 1-10.
  • Kendall, G., Hrycaiko, D., Martin, G. L., & Kendall, T. (1990). The effects of an imagery rehearsal, relaxation, and self-talk package on basketball game performance. Journal of sport & exercise psychology.
  • Naylor, A. H. (2009).The Role of Mental Training in Injury Prevention. Athletic Therapy Today, 14(2), 27-29
  • Pensgaard, A. M., & Ursin, H. (1998). Stress, control, and coping in elite athletes. Scandinavian journal of medicine & science in sports8(3), 183-189.
  • Takai, H., Saijo, O., & Kusumoto, Y. (2009). A Comparison of Psychological and Physiological Responses to Autogenic Training and Autogenic Feedback Training: The Response of Athletes New to Autogenic Training. International Journal Of Sport & Health Science7(2009), 50-58.
  • Walsh, A. E. (2011). The Relaxation Response: A Strategy to Address Stress. International Journal Of Athletic Therapy & Training. 16(2). 20-23.
  • Warner, L., & McNeill, M. E. (1988). Mental imagery and its potential for physical therapy. Physical Therapy68(4), 516-521.
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How Can We Decrease The Increasing Injury Risk which Accompanies Stressors?

Competitive sport demands athletes to display not only a large amount of physical but also psychological skills to handle the stressful situations they face[1]. So how can we decrease an athlete’s risk of injury and ensure they are psychologically prepared for stressful situations?

Until recent years research on improving our skills to predict sports injury has mainly focused on physiological and training factors[2], however in recent years more studies have focused on studying the psychological factors that impact injury susceptibility[3].

Injury to an athlete can occur when stressors not related to the task at hand interrupt their focus, this is due to the athlete missing important play cues or not being aware of what’s happening in their peripheral[4]. Disruption to focus can also be joined by increased muscle tension, which can interfere with normal coordination, increasing the risk for injury[5].

Williams and Andersen’s (1998) “stress injury model” is the most widely referenced stress injury model and it states that injury risk may be increased by various psychosocial factors that may cross over. Their model suggests that these factors may potentially influence the athlete’s ability to manage a stressful situation such as a game or competition and they have divided them into three categories;

  • Personality factors
  • History of stressors
  • Coping resources[6]

They argue that an athlete that is/has experiencing/experienced a greater amount of life stressors will hold personality traits that increase susceptibility to stress and manifest for example as anxiety. Also suggested is that an athlete with poorly developed coping resources will view more situations as threatening which in turn will increase muscle tension, impair peripheral view and hence increase risk of injury.

Encouraging players to take part in ‘lifestyle interventions’ such as Mindfulness based stress reduction (MSBR) could be an extremely useful tool for coaches to implement[7]. MSBR is a highly structured 8-week program, which involves 1 class per week and daily 45 minutes personal meditation. At the end of the sixth week there is also a full retreat day of silent meditation. MSBR has been used with elite athletes to improve concentration, performance and recovery, which could decrease an athlete’s injury risk[8]. Athletes could undertake this program during the off-season or directly after a seasons end to aid in psychological health and self-knowledge.

This type of lifestyle intervention could provide education for athletes as to how to ‘tweak’ their psychological state and in turn reduce injury risk, however, ensuring athletes complete each task of the full 8 week program could be hard to manage and motivating professional footballers to get in touch with their inner vulnerabilities could be a hard task.

Coaches and sporting organisations could also put in place offers of support to players in the way of team psychologists to assist with educating the players on coping strategies to combat the ill effects of stressful situations that may arise in their life.[9] Having a sports psychologist on hand for players to discuss their issues, although an extremely expensive addition to coaching staff, could really help players to attack an issue before it becomes an injury risk, however players may be faced with stressful life situations (divorces, issues with teammates, drug abuse, reoccurring pain of previous injury) that they may not want to bring to the attention of coaching staff and may shy away from this option in fear of losing their place on the team or the comradery of teammates.

Developing individual training programs for players based on regular meetings with coaching and medical staff in which they asses the players psychological state, would be a very efficient way to ensure players injury risk due to psychological factors is low. Completion of questionnaires such as;

  • Scales of personality[10]
  • Daily hassles scale[11] and
  • Brief cope[12]

Could be implemented in these interviews and programs created with the results of these in mind. Although this strategy to plan and decrease of injury would be greatly individualised and in turn beneficial to the players and team, it is unlikely that coaches and medical staff possess the time or resources to focus on the implementation of this. It would be extremely time consuming and individualised programs would split team trainings and may in turn have a detrimental effect on team morale – e.g. why is Tony doing one on ones daily and we are all training together?

Team psychologists are vastly becoming a vital part sporting organisations. Although the cost is a factor to lower earning clubs, Including a team psychologist could help implement questionnaires or possible MSBR at appropriate times of the season, leading to coaches having a greater understanding of how athletes are coping, what changes may need to be made to training programs, as well as decrease the costs created by the loss/treatment of injured players.

By Annie Gallacher


[1] Maddison, R. and Prapavessis, H. (2007) Preventing sport injuries: A case for psychology intervention. In: Psychological bases of sport injuries. Ed: Pargman, D. Morgantown, WV: Fitness Information Technology, 25-38.

[2]Bahr, R., & Krosshaug, T. (2005). Understanding injury mechanisms: a key component of preventing injuries in sport. British Journal of Sports Medicine, 39(6), 324-329.

[3] Wiese-Bjornstal, D.M. (2010). “Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement”.

[4] Williams, J.M., et al. 1991. The effects of stressors and coping resources on anxiety and peripheral narrowing. In R.S. Weinberg & D. Gould, Foundations of Sport and Exercise Psychology (3rd ed., p. 405). Champaign, IL: Human Kinetics.

[5] Nideffer, R.M. 1983. The injured athlete: Psychological factors in treatment. In R.S. Weinberg & D. Gould, Foundations of Sport and Exercise Psychology (3rd ed., p. 401). Champaign, IL: Human Kinetics.

[6] Williams, J.M., & Andersen, M.B. 1998. Psychosocial antecedents of sports injury: Review and critique of the stress and injury model. Journal of Sport and Exercise Psychology, 10, 5-25.

[7] Johnson, U., & Ivarsson, A. (2011). Psychological predictors of sport injuries among junior soccer players. Scandinavian journal of medicine & science in sports, 21(1), 129-136.

[8] Goldin, P. R., & Gross, J. J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion, 10(1), 83.

[9] Johnson, U. (2007) Psychosocial antecedents of sport injury, prevention, and intervention: An overview of theoretical approaches and empirical findings. International Journal of Sport and Exercise Psychology 55, 352-369.

[10] Gustavsson, J. P., Bergman, H., Edman, G., Ekselius, L., Von Knorring, L., & Linder, J. (2000). Swedish universities Scales of Personality (SSP): construction, internal consistency and normative data. Acta Psychiatrica Scandinavica, 102(3), 217-225.

[11] DeLongis, A., Coyne, J. C., Dakof, G., Folkman, S., & Lazarus, R. S. (1982). Relationship of daily hassles, uplifts, and major life events to health status. Health psychology, 1(2), 119.

[12] Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the brief cope. International journal of behavioural medicine, 4(1), 92-100.

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Alternative to the Self-Determination Theory?

In the self-determination theory (SDT), it’s assumed that all athletes possess an essential tendency for self-actualisation as well as psychological well-being. Is it fair to assume the athlete will be in a strong psychological state after returning from injury? The environment also needs to nourish and support three basic psychological needs, particularly competence, autonomy and relatedness (Podlog, L., & Eklund, R. C., 2010).

It has been highlighted through results from studies in the field and laboratory, that if an athlete’s needs and confidence, etc. has been deflated, (Podlog & Eklund, 2006, 2007) they are more likely to experience ill-being and non-optimal functioning. This theory generalises and mainly accounts for those who have the mentality and well-being to overcome injury and return to play.

Failure to return to competition, diminished post-injury performance and decrease in confidence can lead from anxiety and pressure of returning to sport from an injury (Podlog, L., & Eklund, R. C, 2010).

There needs to be a more specific theory that can be shaped and used according to the specific problems the athlete is dealing with when returning to sport from injury. The majority of coaches acknowledged that athletes had to overcome psychosocial barriers such as a loss in confidence, re-injury concerns, feeling isolated from the team and pressure to return to sport following injury (Podlog, L., & Eklund, R. C, 2007). To develop a construct that athletes can use, and determine what action to take when they are feeling a particular way, is an alternative to the

A new construct that can support all kinds of athletes needs to be developed. An athlete doesn’t need to have the mentality and well-being to overcome injury to be able to effectively use this theory, as opposed to the athlete needing these aspects to be able to use the self-determination theory (Deci, E. L., & Ryan, R. M., 1985). This new construct, as designed below, can be moulded to fit any athlete experiencing difficulty returning to sport post-injury.

Characteristic

Source of Support

Method of Delivering Support

Example

Lack of confidence

Coach

Through training exercises

Start with simple exercise, and increase intensity, volume and difficulty

Figure 1: Basic Layout of New Construct for Athlete’s Returning from Injury, an Example used with Lack of Confidence

An example of a characteristic that an athlete may have once they have returned to sport following an injury would be lack of confidence. An example of the support they would get would be from coaches, and mechanisms, perhaps even training sessions developed to provide the confidence the athlete needs to return to sport. This could be done through the coaches starting with basic sessions that the athlete is comfortable with, and gradually increase with intensity and volume to gain the confidence of the individual. Another example may be that the individual is suffering from anxiety, and having the support of the psychologist that has developed relaxation exercises for the athlete to carry out a particular number of times a week, to reduce their anxiety and assist them in becoming calm and capable of playing sport at a level at which they had pre-injury.

This solution to the problem of the previous, broad and generalised theory may be difficult to replicate or perhaps have effective results on the kind of individual who are facing adversity when they have returned to sport. An idea or construct such as this basic one that has been developed will need to be validated and reliable, showing that it can work for athletes returning to sport post-injury. For this to occur, it needs to be used on a wide range of athletes from different sports and different types of injuries to show its flexibility and efficiency. Those responsible for this development are those who will conduct studies and research with participants returning to sport from injury, as well as the athletes themselves, their coaches as well as their support network. The more research and evidence produced will show the effectiveness of this new construct and highlight the importance of having such a flexible and useful tool to assist those returning to sport from an injury, and how to deal with the difficulties they face.

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A CONCEPT OF HOW TO DEAL WITH PRESSURE CAUSED BY SOCIAL MEDIA ON ATHLETES IN DECIDING WHETHER TO PLAY WITH INJURY

In my first blog entry I discussed the current dilemma athletes face while trying to decide whether they should compete in their chosen field while sick or injured.  In the blog I investigated the role the media can play in the decision making process of the injured individual and how the pressure (both real and perceived) can cause an adverse effect on the performance of the athlete. The following blog then looked into the strategies currently utilised by a variety of sporting teams and sports psychologists that attempt to reduce the impact the media can have on the athlete.

 

An athlete’s self-identity may have a major influence on the decision to play with an injury or not.  An individual who has engaged in a specific sport over a long period of time with high levels of success will often depict their successes as personal attributes, so instead of being a person who plays football or netball, they instead see themselves as a footballer or a netballer (Brewer, et al. 1993).  The result of this is that the athlete is more likely to continue to play the game while they are injured as the game has become an ingrained personality trait.

 

A study by Howe (2001) found that these high level athletes who decide to play with pain and injury become accustom to the pain, and in the minds of the athlete, playing through the injury becomes the normal expected standard of commitment and dedication. Added expectations to the athletes to play with injury were also shown by (Déroche, et al. 2011; Loland, et al. 2006). Their studies revealed the media attention and money associated with winning at the highest levels of sport, the pressures to compete through pain have grown significantly within the last fifteen years.  It has also been shown that an athlete who is willing to play though the pain of an injury is more likely to gain the respect of coaches, teammates and the media (Nixon. 1994).

As mentioned in the second blog entry the current method of trying to increase the athletes mental toughness is flawed, as the attributes given to mental toughness such as, focus and ability to control their feelings, are learned though life experiences (Jones, et al. 2007; Bull, et al. 2005).  This is important because if the athlete’s ability to perform under the pressure of the media is dictated by the mental toughness of the individual, and it can’t be taught, coaches will have to find a new strategy to help their athletes deal with the added pressures placed upon them (Jones et al. 2002).

 

In theory, the combination of an athlete with strong mental toughness and a high athletic identity will be more likely to want to play with an injury while having the ability to deal with any extra media pressure placed on them to perform. This however is not the case.  The positives that are associated with having a high athletic identity are far fewer than the positives that will occur with those of an athlete with a more balanced self-worth.

 

The development of a strong self-worth within the athlete can create the positive adaptions wanted in the athlete to help move past any bad performances.  If the athlete who had a high athletic identity is able to differentiate between underperforming in the game and their value as a person, the likelihood of them carrying the bad form from the previous game is reduced.  The athletes confidence may also so an increase in response with a better feeling of self-worth, resulting in greater performances in their chosen field.

 

The positive adaptions that can be created with a more balanced self imagine may give the athletes the ability to handle the pressure created on them by the media and help them make the appropriate decisions in their career regarding whether or not to play with an injury.

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current strategies in dealing to deal with pressure on athletes in deciding whether to play with injury

In my first blog entry I discussed the issue of social media affecting the decision of athletes to play with an injury and the resulting effects on their mental health.  This part of my blog I will investigate if there are currently any strategies in place to help the athletes deal with the pressures to compete when injured that are placed upon them from these outside stimuli, and will try to make a determination of their effectiveness.

 

The current perception that social media is having a negative influence on professional athletes performances has resulted in articles that attempt to determine whether any correlation exists.  One such article “Does the media impact on athletic performance?” discusses how use of media can cause either a positive or negative out comes on an athletes` performance (Ott 2006).   This article cites the case of David Swerdlick’s editorial “Ricky Williams”.  Ricky Williams was a professional football player who left the game as result of not being able to handle the pressure being placed upon him by the media. Ricky was a camera shy superstar of the game who lost millions of dollars when he walked out on his team after the scrutiny that he was receiving became too much for him to handle (Swerdlick 2005).  This example is compared to other cases where the athlete was able to use the media to their advantage.  The conclusion was made that mental toughness of the athlete was the key factor in determining what affects the stress has on the athlete, and how they respond to these stresses (Ott 2006).

 

The current excepted coping strategy for helping someone overcome external pressure placed on them to preform, is to increase the attributes that develop mental toughness.  This term is so broad however it can be used to cover all aspects of phycology in the athletic field.  The current frame work looks at factors such as, self-belief (confidence), focus, ability to handle pressure and the ability to control their feelings (Jones et al. 2007).  These qualities are usually learned through the persons experiences in life (Bull et al. 2005), thus coaches generally find that mental toughness can`t be taught (Jones et al. 2002).  As a result, when an athlete tries to return from an injury, skills are instead used to re-instil confidence in the athletes` abilities.  These skills include meditation, relaxation imagery, breathing exercises and imagery of the task (Cohn 2013) (Hamson 2006).

 

The problem with the research to determine the best way for athletes to deal with the external pressures placed upon them is that there seems to be an assumption that the athlete is healthy.  The coping mechanisms  put in place to help  the stresses placed on an athlete, for example meditation (Hamson 2006), can provide potential strategies that can be implemented in the hopes to reduce the impact of future confidence issues involving injury. The other articles that injury was the focus also targeted the stress placed on athletes returning from an injury.  Again these athletes although were injured are now healthy.  Although these articles do focus on the more of the mental state of the athlete, the focus is on the stress relation to re-injury and not any impact that the media is placing upon them.

 

There appears to be a severe lack of literature written on this subject with almost no studies done on the impact social media is having on these athletes playing with injury.  The only time it is addressed is by the athletes themselves, normally during press conferences.  Because of this in my next blog I will investigate the most effective way in which this problem can be properly studied and try to come up with a solution to this problem.

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Pre Injury Education the key to a Smoother Rehabilitation?

Participating in sport has been shown to decrease depression, alleviate anxiety and can be used as a tool to cope with stress [1], on a professional level athletes have been shown to base a large amount of self-efficacy around their sporting achievements [2]. If an injury is to occur it is understandable that these self-efficacies will suffer and have a psychological impact on the athlete, causing interruptions to rehabilitation.

Athletes have reported a sense of disbelief and shock that the injury actually occurred and a sense of fear of the unknown as to what lies ahead in the rehabilitation process [3]. I question that if athletes were educated in the psychological process of an injury BEFORE the injury occurs, would they be better equipped to deal with the psychological aftermath of an injury?  And would a clear understanding of these processes result in a more effective rehabilitation and return to play process? In saying this, we would need to accurately determine an appropriate model of the psychological impact through injury; and this is where the problem lies. With psychological research largely based on interviews and questionnaires for data collection there is no one answer – so how can we determine the best way to educate these athletes yet keep it to a general enough theory that will hopefully encapsulate athletes on a large scale?

It is widely accepted within the sport psychology spectrum that the conceptual background of an athlete’s reaction to an injury is based loosely on the works of Kubler-Ross on death and dying[4]. After working with her terminally ill patients Kubler -Ross presented the idea that we as humans go through five stages of grief – denial, anger, bargaining, depression and acceptance/re organisation. Kubler-Ross’ grief stage theory has been applied to athletic injury, however research has failed to prove that injured athletes move in a regimented fashion through a series of stages while rehabilitating[5]. Evans and Hardy (1995)[6] suggest that in relation to sports injury grief should be viewed as “an emotional response to perceived loss, and as a process characterised by behavioural and psychological manifestations” (Evans and hardy 1995 p242).

Heil (1993)[7] has proposed a model of the affective cycle of injury that builds on Kubler-Ross’ theory and relates to sport.

The affective cycle of injury model builds on the belief that the rehabilitation process is not a one way linear process but a cycle that may repeat. This cycle consists of three key elements, distress, denial, and determined coping;

 

  1. Distress includes anger, bargaining with oneself (eg if I recover I promise I will be more diligent with my warm up), anxiety, depression, guilt & helplessness. Athletes regularly circle back to feelings of distress, possibly after an unsuccessful rehabilitation session or when goals are not reached in the desired timeframe.
  2. Denial is encapsulated in feelings of disbelief or in failure to accept the severity of ones’ injury – “I’ll be right to play in two weeks coach”.
  3.  Determined coping is reached when the athlete has accepted the injury and utilized their resources to plan an appropriate rehabilitation timeframe and strategy[8].

The problem of the aftermath of an injury being so extreme affects not only the athlete themselves but all those around them; teammates need to be socially aware of a necessary shift in treatment of the athlete, team doctors need to pay close attention to physical and psychological rehabilitation strategies, coaches need to decide the capacity of the athletes involvement – will they still be at training? Do they have the confidence the athlete will return to full form?  Family members will be those with the most contact and will witness the cycle of denial and distress, as well as taking on any family responsibilities the athlete is no longer able to manage either emotionally or financially.

Coaches and medical/psychological staff need to be working together to implement a model that ensures the athletes know what is psychologically possible if an injury occurs.

Athlete education in the psychological process involved in injury may not eradicate the issue of psychological distress post injury; however it may positively effect the level of distress and denial affecting athletes post injury (self-esteem, monetary, psychosocial, career ending, motivation and fear of re – injury[9]).

A possible approach in educating athletes is through exposure to mentor like figures from the sporting community. These respected members of the sporting community are able to shed light their experiences with injury as well as offering advice on managing injurys both physically and mentally. Older, respected members of the sporting community are able to anecdotally describe what they would have liked to known before they were injured in order to possibly avoid the extent of denial and distress they experienced. Taylor and Taylor’s psychological distress checklist is a tool to indicate athletes post injury mental health and could be a model utilised to develop a pre injury model of educating athletes or indicating possible emotional and mental factors if an injury was to occur[10].

By Annie Gallacher


[1] Deutsch, R. E. (1985). The psychological implications of sports related injuries. International Journal of Sport Psychology, 16(3), 232-237.

[2] Feltz, D. L., & Lirgg, C. D. (2001). Self-efficacy beliefs of athletes, teams, and coaches. Handbook of sport psychology, 2, 340-361.

[3] Tracey, J. (2003). The emotional response to the injury and rehabilitation process. Journal of Applied Sport Psychology, 15(4), 279-293.

[4] Walker, N., Thatcher, J., & Lavallee, D. (2007). Review: Psychological responses to injury in competitive sport: a critical review. The Journal of the Royal Society for the Promotion of Health, 127(4), 174-180.

 

[5] Brewer, B. W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of applied sport psychology, 6(1), 87-100.

[6] Evans, L., & Hardy, L. (1995). Sport injury and grief responses: A review. Journal of Sport & Exercise Psychology.

[7] Heil, J. (1993). Psychology of sport injury. Human Kinetics Publishers.

 

[8] Heil, J. (1993). Psychology of sport injury. Human Kinetics Publishers.

 

[9] Brewer, B. W. (1993). Self‐identity and specific vulnerability to depressed mood. Journal of personality, 61(3), 343-364.

 

[10] Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Wolters Kluwer Health.

 

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Returning to Sport Post-Injury with Focus on a Key Issue

A team full of the likes of Sonny-Bill would be a pretty impressive team wouldn’t it? Close to perfect, right. (Yes, I’m an avid Roosters fan – 2013 premiers). However, not one team or one athlete are the same, training programs aren’t “one program fits all”. So why is there one generalised theory that is designed to assist players who have recovered from injury to return to sport? In the self-determination theory (SDT), it’s assumed that all athletes possess an essential tendency for self-actualisation as well as psychological well-being. Is it fair to assume the athlete will be in a strong psychological state after returning from injury? The environment also needs to nourish and support three basic psychological needs, particularly competence, autonomy and relatedness (Podlog, L., & Eklund, R. C. (2010).

SDT is a macro-theory of human motivation, emotion and personality, and is something that has not been fully developed for 40 years, following the ground breaking work by Deci and Ryan (Vansteenkiste, M., Niemiec, P. C., Soenens, B., 2010). The problem is that there is only the one main theory trying to accommodate for most athletes returning to sport post-injury. However, there are five mini-theories underneath SDT that was developed to explain abnormal data that was collected from laboratory and field research, with each theory addressing a different aspect of motivation or how the particular athlete’s personality functions (Podlog, L., & Eklund, R. C. (2007).

The five mini-theories include cognitive evaluation theory concerning intrinsic motivation, organismic integration theory which includes extrinsic motivation, causality orientations theory involving individual’s tendencies to gravitate to particular environments and how they decide to regulate their behaviour, basic needs theory which refers to their psychological health and well-being, as well as goal content theory which determines the difference and need for extrinsic and intrinsic goals that the individual should be making when considering returning to sport (Vansteenkiste, M., Niemiec, P. C., Soenens, B., 2010). But what if an athlete doesn’t “fit” these theories?

It is important for the athlete to have a support network and a healthy and positive outlook on their well-being, as the environment needs to support the fundamental aspects of the theory for it to be effective, particularly with the psychological needs that are competence, autonomy and relatedness (Podlog, L & Dionigi, R, (2010). Without this supportive environment, the individual can re-injure themselves, as it has been proposed that anxiety related to the athlete reinjuring themselves has a number of consequences (Bianco, 2001; Kvist, Ek, Sporrstedt, & Good, 2005).  Failure to return to competition, diminished post-injury performance and decrease in confidence can lead from anxiety and pressure of returning to sport from an injury (Podlog, L., & Eklund, R. C. (2010).

The problem affects athletes, coaches and parents. There was a study that looked at coaches’ roles at deciding to return athletes to training and competition, their perspective on return-to-sport transition, and their role in assisting athletes with this transition (Podlog, L. & Eklund, R, C. (2007). The coaches possessed a good understanding of the stressors of returning to sport and recognised the importance of assisting athletes with this transition.

Imagine, two athletes both recovering from an ACL reconstruction. Both athletes are successful with their rehabilitation; however one of the athletes is struggling in regards to anxiety and fear of re-injury, decreased confidence levels and as a result, has failed to return to competition. How do you use the self-determination theory for both athletes, as they have reacted differently to their return from injury? It has been highlighted through results from studies in the field and laboratory, that if an athlete’s needs and confidence, etc. has been deflated, (Podlog & Eklund, 2006, 2007) they are more likely to experience ill-being and non-optimal functioning. This theory generalises and mainly accounts for those who have the mentality and well-being to overcome injury and return to play.

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Key Issues in Regards to the Stress Response and Injury Prevention

“The clock is ticking. Your team has to score one goal in the next minute in order to win the grand final. Everyone on the team is feeling the tension. Your heart is racing, your vision is blurring and adrenaline is rushing through your body causing you to feel nauseous. The coach is pacing the sideline, shouting at you and your team mates on the court; the crowd is going wild. You manage to position yourself in line with the goal. You receive the ball, take the shot and miss just as the buzzer declares game over.”

Highly stressful situations are an integral part of the sporting experience and this scenario is very common in sporting competitions, especially team sports. Competitive stress can be defined as “an ongoing transaction between an individual and the environmental demands associated directly with competitive performance” (Mellalieu & Hanton, 2009). It can also be identified as positive stress (eustress) which is desired as it demonstrates appropriate responses to physical and psychological overloads compared to negative stress (distress) as it occurs due to the existence of imbalances between imposed training demands and coping capacities (Larson, 1989; Silva III, 1990).

Competitive stress affects athletes and teams at any age, skill level or career stage, therefore for optimal performance it is critical that an individual has the ability to regulate one’s own emotions throughout stressful situations during competition (Gould & Maynard, 2009).

The stress response can affect the athlete’s emotional reactions with positive or negative outcomes on their performance, daily functioning and injury rehabilitation and is influenced by personal, situational and environmental factors (Larson, 1998; Gould & Maynard, 2009; Walsh, 2011). Many studies (Andersen & Williams, 1988; Davis, 1991; Pensgaard & Ursin, 1998; Gould & Maynard, 2009) have discovered factors that initiate a stress response, how the athlete copes and prevention interventions, but there are no studies reporting any attempts to put a stop to stress in the first place via stress management or other psychological means to prevent injury which is a key issue in this area.

Earlier in this blog I discussed the stress-injury model created by Andersen & Williams (1988). This model was created to predict the occurrence of sport injury by considering certain factors such as personality characteristics, history of stressors and coping resources that an individual might have compared to others (Andersen & Williams, 1988). It also suggests interventions to prevent stress from causing injury but it does not consider strategies to manage stress during a competition or game.

According to the model, athletes that demonstrate certain personality characteristics such as hardiness and internal locus control have fewer injuries than those who are less hardy or have an external locus control (Larson, 1998).  High competitive trait anxiety is significantly related to rate and severity of injury and fear of re-injury also leads to high stress responses and increases the probability of re-injury (Andersen & Williams, 1988; Lavallee & Flint, 1996). Individuals with a low social support system, high in avoidance-focused coping were most likely to miss more time on the field due to injury and sustain more injuries than individuals with the opposite profile (Maddison & Prapavessis, 2005).

As you can see this model only just begin to open our eyes to the problem we are actually facing; managing the negative effects of stress to prevent injury. Further research needs to focus on providing guidelines for coaches specifically outlining ways to prevent the negative effects and the onset of the stress response during situations under intense pressure. These need to be practiced throughout training sessions and implemented before, during and after the game for maximum performance to be established.

Both the athlete and the coach need to be involved in generating a solution together to prevent the stress response from causing injury. Rather than only dealing with stress that’s already occurred, coaches need to search for stress management techniques that avoid stress in the first place. In a review by Gould & Maynard (2009) they could not identify a specific coping strategy but instead they discovered that athletes were using several different coping strategies often used in combination of one another that were suitable to their individual needs at the time. Although it may be difficult and complicated, it is a problem that can be solved. No one strategy is likely to be successful in all circumstances (Pensgaard & Ursin, 1998), therefore athletes and coaches need to work together to develop a variety of coping strategies that will be available to them.

By Vanessa Gaynor

References

  • Andersen, M.B., & Williams, J.M (1988). A Model of Stress and Athletic Injury: Prediction and Prevention. Journal Of Sport & Exercise Psychology, 10(3), 294-306.
  • Davis, J. O. (1991). Sports Injuries and Stress Management: An Opportunity for Research. Sport Psychologist, 5(2), 175-182.
  • Gould, D., & Maynard, I. (2009). Psychological preparation for the Olympic games. Journal Of Sports Sciences, 27(13), 1393-1408. doi:10.1080/02640410903081845
  • Larson, G. A. (1998). Psychosocial Variables: Predicting and Preventing Athletic Injury. Athletic Therapy Today, 3(1), 7-11.
  • Lavallee, L. L., & Flint, F. F. (1996). The relationship of stress, competitive anxiety, mood state, and social support to athletic injury. Journal Of Athletic Training, 31(4), 296-299.
  • Maddison, R., & Prapavessis, H. (2005). A Psychological Approach to the Prediction and Prevention of Athletic Injury. Journal Of Sport & Exercise Psychology, 27(3), 289.
  • Mellalieu, S. D., & Hanton, S. (2009). Advances in applied sport psychology: A review. (p. 126). USA & Canada: Routledge.
  • Pensgaard, A. M, & Ursin, H. H. (1998). Stress, control, and coping in elite athletes. Scandinavian Journal Of Medicine & Science In Sports, 8(3), 183.
  • Silva III, J. M. (1990). An analysis of the training stress syndrome in competitive athletics. Journal of Applied Sport Psychology2(1), 5-20.
  • Walsh, A.E. (2011). The Relaxation Response. A Strategy to Address Stress. International Journal Of Athletic Therapy & Training, 16(2), 20-23.
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Rehabilitation of Injury and Return to Sport

Returning to a sport following an injury can be difficult. The individual can feel pressure from themselves or those surrounding them, to return and compete at pre-injury level (Podlog & Dimmock, 2011, 12(1), p. 36-42). The athlete will need to overcome any doubt they have and work on their mental toughness. Ultimately, the idea of returning to sport following an injury is the aim for most athletes.

 

Research has provided information in regards to what the athlete should primarily focus on when returning from injury. A study conducted by Podlog & Eklund (2005, 14(1) p. 20-34) revealed that intrinsic motivations for returning to competition were associated with a positive renewed perspective on sport participation. Setting achievable goals, and obtaining motivation and determination when the individual has returned to sport has them concentrating on taking necessary steps in returning and playing at an optimum level. Intrinsic motivation refers to engaging in an activity for itself and for the pleasure and satisfaction derived from participation (Vallerand, R J., 2004, p. 427-430). In 1992, Vallerand and colleagues proposed and showed that there are at least three types of motivation. These included intrinsic motivation to know, towards accomplishments and to experience stimulation (Vallerand, R J., 2004, p. 427-430). All three of these aspects allows the individual to feel the pleasure of learning, as well as trying to exceed themselves and for the aesthetic and sensory pleasure of playing, and as a result, allow athletes to begin feeling comfortable playing post-injury.

 

Recent literature has highlighted the adversity injured athletes are faced with when returning from sport, with a range of psychosocial concerns. The results suggest that athletes returning to sport from injury may experience concerns related to their sense of competence, autonomy and relatedness (Podlog L, Dimmock, J & Miller, J., 2011, 12(1) p. 36-42). This is concerned as poor self-confidence; creating anxiety can lead to much bigger problems such as depression and even substance abuse.

 

Self-efficacy is something the individual athlete needs to develop to overcome their sense of poor confidence and autonomy. The self-determination theory (SDT) is a theory of motivation, where the athlete needs to have self-belief and drive if they are to have any success when they return to sport. This theory can assist in overcoming the self-doubt some may have, which can therefore overcome any negativity related to returning to sport from injury. For self-determination to improve, Ryan & Deci (2000) concluded that the environment must satisfy three basic psychological needs, namely competence, autonomy and relatedness (Podlog. L, Eklund. R. C., 2010, 28(8), p. 819-831). Three distinct types of primary appraisals have been identified that assist in self-determination (Gagne, et al., 2003), which are goal relevance, motivational congruence and ego-involvement. These factors also support previous research that flexible goals focusing on skill development are likely to foster a sense of competence (Podlog, L. & Dionigi, R. 2010, 28(11), p. 1197-1208), which tends to be absent when an athlete returns from an injury.

 

Taylor and Taylor (1997) produced a stage model on the return to sport of an athlete. This model was composed of five physical and psychological stages. They also suggested that adaptation was likely to occur as the athlete came to accept the injury, recognises the inevitability of what the future may hold, and receives social support to alleviate negative emotions (Podlog, L. & Eklund, R C., 2007, 8(4), p. 535-566). These support the base of the self-determination theory, and highlight the importance of the theory’s constructs.

 

There are necessary developments for future research when athletes are returning from sport post-injury, as there is little agreement that exists in regards to the meaning of a ‘successful’ return. Competitors are increasingly pressured to return to sport as soon as they can, which can lead to them returning before they are ready, not just physically, but also psychologically, increasing the chance of a re-injury (Bauman, J., 2005, 15(6), p. 432-435). The SDT has potential for understanding findings in this area and for guiding future research (Podlog, L. & Eklund, R C., 2009, 10(5), p. 535-544) ensuring athlete’s needs are being met, which may produce positive return-to-sport outcomes.

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the psychological and physical risks of playing through an injury

In my blog I will talk about the pressures of playing through injury and illness in professional sport and the mental and psychological effect on the athletes` ability to perform.

It is a reality that most athletes will experience an injury (or illness) at some point in their career. Depending on the type of injury, severity, and the time at which it (injury) occurs in the athletes career, the individual`s mindset and emotional health has the potential to be impacted negatively, resulting mental health issues Nixon HL, ll (1996).   There are many factors that can contribute to the deterioration of the mental health of the athlete, one being, psychological pressure placed upon the athlete to compete and excel regardless of their illness or injury (Kyle et al., 2006).  These expectations are often unrealistic and may result in harsh criticism for those injured athletes who are not able to fight through the pain of the injury and continue to play, or be willing to risk further injury to themselves.

Culturally, there is a belief in sport that if you are physically able to play, you must and that anything less is not acceptable.  The reaction to an athlete that overcomes an injury or illness to have a positive result on the game has gone from being one of adulation to now being that of expectation (Greenleaf et al., 2001).. This change in expectation places a whole new type of pressure on the modern day athlete that has never existed in the past.

In the 1990`s, when televised sports were really becoming increasingly accessible and popular in society, the community perception was that of pure amazement while watching the likes of Michel Jordan scoring 38 points while suffering with the flu in a vital playoff game, ignoring the risk of damaging his heart.  At that point in time, playing while ill or injured was not normal accepted behaviour. However, with the creation of social media and its use in the sporting arena, there is a new and unfounded criticism of those who are either not able to replicate the feats of those from the past, or those who are not willing to further damage their bodies in the pursuit of those accomplishments.

The added pressure that athletes now have with the constant criticisms coming from social media compounded with already existing stresses that comes with carrying an injury may start to have hugely negative effects on both the athletes` mental health and also their performance in their given field (Kyle et al., 2006). The anxiety that can be associated with playing with an injury can also be compounded with the stresses that come from constant criticism by the media.  After a bad performance by an athlete with a known injury, media will often question the athlete on the injury and their ability to perform. This has the potential to increase the level of anxiety over the injury, decreasing arousal, resulting in poorer performances O`Connell (2012). Further, if the injury is ongoing, prolonged anxiety and stress to perform over a long period can affect the immune system, leading to other illnesses.

It is not hard to find examples of the anxiety and stress athletes face when deciding whether or not to play with an injury and the resulting effects being easily viewable. Examples are outlined in Table 1.

Table 1. List of injured players, their decisions to play and the out comes

Player Injury Play/sit out Effectiveness Criticism/adulation
Rajon Rondo Dislocated elbow Played Played well/team lost Rondo received little adulation and received limited criticism
Dwight Howard Herniated disk in back/ torn labarum Sat out Team was losing Received harsh criticism for choosing not to play through pain
Dwight Howard Played Under preformed for him (still well)/ team was losing Criticism for not dominating position
Derrick Rose Torn acl Sat out Team was winning but needed him in finals Much debate if should return at under 100%  heavy criticism form fan base
Tony Parker Strained hamstring Played limited minuets Team performed well but lost Criticised for lack of value/reduce by other circumstances
Kerri Strug Sprained ankle Competed Won Adulation
Patrice Bergeron Separated shoulder, broken ribs, torn cartilage and muscles Competed Lost Adulation/ injuries because life threatening
Michael Jordan Flu Competed Won Adulation
Stephen Curry Ankle injury Competed Team remained competitive Neither/further damaged ankle

Taking two of the examples from the table above the risks to the athlete, physically and psychologically, can be examined easily.

During the 2013 Stanley Cup playoffs, Bruins centre Patrice Bergeron played the final game of the series having suffered a broken rib, torn cartilage in his ribs and separated shoulder the game before.  For Bergeron to enter the final game with these injuries, suggests substantial pressure, both internal and external, not to let his team down. The result was Bergeron was praised for his actions; however Bergeron suffered a punctured lung during the game, a potential life threatening condition Mcdonald (2013).

However, not every athlete will choose to take that route.  During the 2012-13 NBA season the Los Angeles Lakers centre Dwight Howard decided to sit out the start of the season.  Howard was suffering with a surgically repaired back and torn labrum.  He had the ability to play but would have been in extreme pain.  As a result of his decision, he was ridiculed by the media, past greats of the game and his then team mates until he gave into the pressures of playing.  Upon his return he was still the best centre in the league but as his team was losing, criticism continued.  After the season most journalists admitted they were probably too hard on him but justified it with “comes with the territory of playing under pressure for such a storied franchise like the Los Angeles Lakers” Vitti (2013).

The added pressure and stress that is being placed on athletes to play while injured could be having a huge detrimental effect on these athletes` health and wellbeing, both physically and mentally.  In the next part of my blog I may discuss potential strategies for the athlete to overcome these anxieties and stresses.