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).




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.

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.


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.


Source of Support

Method of Delivering Support


Lack of confidence


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.


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.