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.

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.

 

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.

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.