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Unfortunately athletic injury is a common circumstance within elite sport performance. Sport injuries have been predicted to occur at a rate of 17 million per year, and 8 of 10 athletes become injured during high school and college (Robbins & Rosenfeld, 2001). Injury is often a traumatic event where emotional and psychological reactions are produced. Typically, these reactions are based on the individual's perceptions of loss (e.g., mobility, playing time, and career) (McDonald & Hardy, 1990; Smith, Scott, & Wiese, 1990). Although this loss is perceived differently by different individuals, injuries can often prevent athletes from pursuing a self-defining activity. Therefore, athletes may experience tension, loneliness, fear, shock/disbelief, and uncertainty of the future (Evan & Hardy, 2002b; Udry et al., 1997). It should be noted that athletes tend to look towards the head and assistant coaches, athletic trainers, teammates, family and friends for social support during an injury (Gould et al., 1997a; Robbins & Rosenfeld, 2001). The ability to understand the emotional reactions and adjust of athletes towards injury is vital in regard to the rehabilitation process. This has lead to the development of theoretical models such as:
Injury Response Model (Udry1997).
Model of stress and athletic injury (Andersen & Williams, 1988).
Adherence to the prescribed rehabilitation regimen is considered vital for achieving successful recovery from sport injury (Taylor & Taylor, 1997). Research has consistently shown links between rehabilitation adherence and the psychological well being of the athlete (Brewer, 1999). Therefore the utilization of conceptualized models aimed to develop an understanding of an athlete's emotional reactions towards injury, have been shown to merit direct application within individual cases. This paper will discuss researched applications of said models, the prevention of injury, emotional implication of injury, and the doping skills and strategies employed during injury rehabilitation.
There have been several studies which have focused of the prevention of injury through psychological methods. May and Brown (1989) employed several psychological strategies including; attention control, imagery, mental skills training, team building, communication, relationship orientations, and crisis interventions for individuals, pairs, and groups throughout the duration of the 1988 winter Olympic in Calgary when working with U.S. alpine skiers. The authors reported that their interventions led to reduced injuries, increased self-confidence, and enhanced self-control. However, May & Brown's (1989) intervention included several psychological strategies, therefore it is uncertain which strategy was the most successful. Other studies (Davis, 1991) have focused prevention treatment (stress management) using imagery with swimmers and football players to reduce injuries. As previous studies (Bramwell, Wagner & Holmes, 1975) have discovered, high levels of stress have been shown to increase the likeliness of injury when compared with low stress level. The programme employed by Davis (1991) involved progressive relaxation combined with imagined rehearsal of swimming and football skills and related content during the competitive season. Davis reported a 52% reduction in swimming injuries and a 33% reduction in football injuries. The use of stress management interventions to prevent injury has also received support from Kerr & Gross (1996).
It may also be an appropriate method of injury prevention to identify at-risk athletes (rather than all athletes on a team) and offer cognitive behaviour based intervention treatment. In order to identify athletes potentially at risk the use of several sport scientific questionnaire would be incorporated including; the Life Event Scale for Collegiate Athlete (LESCA; Petrie, 1992), the Sport Anxiety Scale (SAS; Smith, Smoll, & Schutz, 1990) and the Athletic Coping Skill Inventory (ACSI-28; Smith, Schutz, Smoll & Ptacek, 1995). Smith, Smoll, and Ptacek (1990) found that athletes who rated lower in psychosocial variables such as social support and coping resources, and had many life events, were the ones more likely to be injured. This method of injury prevention has been reported to dramatically lower the injury rates of at risk performers. If used in a systematic and planned structure, this intervention strategy posses the potential to prevent stress, and allows athletes to deal with stressful situations effectively. Kerr and Goss (1996), as well, highlighted the usefulness of early training in specific skills, such as relaxation, in order to prevent injury outcome.
Leddy, Lambert, & Ogles (1994) studied the emotional consequences of injury among male athletes and reported that a greater mood disturbance during the injury rehabilitation than after injury recovery. Moreover, the greatest disturbance in mood was reported during the initial phase of the injury, with anxiety, fear, anger, and confusion all cited emotions. These findings were supported by Udry (1997), who maintained that it is vital to work extensively with an athlete during the early phases of an injury as fluctuations in mood often occur from initial evaluation of the injury. Therefore, it is important that early post injury treatment is available as this is the time of greatest emotionality (Heil, 1993). Elevated concerns regarding the consequences of the injury including, loss of independence, losing place in team, and no longer having a strong "athletic identity" are also commonly present within athletes with a long term injury (Brewer, Van Raalte, & Linder, 1993; Howe, 2004). However, over time athletes accepted the situation, and reported perceiving the injury as a positive challenge.
Although the research has mainly focused of the negative aspects that suffering an injury has on an athlete's emotions, the affective responses to athletic injuries must also be understood and discussed. It is vital to the rehabilitation process that an athlete accepts the reality of the injury and is able to progress toward concentrating their energy on the recovery. The importance of internalizing, accepting, and taking personal control and responsibility over the injury and the recovery has been noted by several researchers (Brewer, Linder, & Phelps, 1995; Udry, 1997; Udry, Gould, Bridges, & Beck, 1997). Therefore, the emotional experience of the injured athlete may play a role in the rehabilitation process, especially in the early phases when emotional disturbances are reported to be at their greatest. Not only do individuals differ in post injury cognition, emotion, and behaviour as a function of their age, but the relationships among psychological and other rehabilitation variables may also vary by age. Just as maturation is a common consideration when evaluating the physical ramifications of sport injury, this should also be considered when evaluating the psychological ramifications of sport injury (Brewer, 2003).
However, it has been discovered (Mankad, Gordon, & Wallman, 2009) that athletes generally feel compelled to embrace group values of positivity and mental toughness which leads to the engagement of thought suppression. These suppressive coping strategies are often used by athlete in an attempted to hide negative emotions. According to Hochschild (1983), injured athletes also employed various strategies of emotional labour in which they suppressed the emotions they were feeling and displayed desirable emotions to give the impression of positivity and confidence. For these athletes, inhibition of genuine emotions and control of outward expression was a fundamental coping mechanism that was crucial in governing acceptable overt behaviour within the team environment. However, psychological stress, trauma, and thought suppression have long been associated with decrements in mental and physical health (Pennebaker. 1989; Petde, Booth, & Pennebaker, I99H; Smyth. 1998).
Coping Skills & Strategies:
Coping skills and strategies are employed by individuals in order to help protect them from being psychologically harmed by challenging experiences in their life (Pearlin & Schooler, 1978). Endler, Parker, and Summerfeldt (1993) suggest that four dimension of coping should be considered in response to health and injury stressors.
Instrumental Coping: Attempts to alleviate the sources of stress or discomfort through activities such as finding out more about health condition, listening to advice from health experts.
Negative Emotion Coping: Involves a preoccupation with the emotional consequences of injury stressors, such as feeling anxious and worrying that the injury may worsen.
Distraction Coping: Individuals attempt to cope with their stresses by thinking about other things and engaging in other activities.
Palliative Coping: Involves a variety of self-help activities and responses aimed to alleviate the unpleasantness of injury and to provide a soothing effect.
Traditionally research studies on coping skills and strategies has been focused outside the parameters of sport in such populations as cancer patients (Telch & Telch, 1985), and hearing-impaired adolescents (Kluwin, Blennerhassett, & Sweet, 1990). Recently however the coping skills adopted within the athletic population have been examined. The majority of which has explored the effect of coping skills on the vulnerability and emotional response of an athlete to injury (Smith & Smoll, 1991; Williams & Andersen, 1997). Strong links have been cited between the emotion consequences produced by an injured athlete's appraisal of their injury and the coping strategies that they employ (Udry, 1997). Udry's (1997) study utilized Lazarus and Folkman's (1984) cognitive appraisal model as a theoretical foundation in understanding the individual coping strategies employed by the athletes and the implications they had upon rehabilitation adherence.
Figure 1: Injury Response Model (Udry, 1997).
Udry's (1997) self proposed injury response model (Figure 1) consists of several steps, each of which aims to aid the understanding of an athlete psychological responses to injury. The first step of the model is the initial injury itself, however regardless of how the injury itself has occurred is secondary to how the athlete has appraised the injury (Step 2) (Brewer, 1994). Therefore, in theory the same injury could have a bigger psychological effect on one performer than another depending on how each appraise the injury. As previous discussed an athletic injury can result and a variety of emotional responses (Step 3), these responses can be influence by the cognitive appraisals of the athletes. Moreover, the emotional responses of the athlete are thought to influence the type of coping strategies employed (Step 4) to deal with the injury. The coping strategy employed is also thought to have a direct influence on the degree to which the athlete adheres to their injury rehabilitation program (Step 5). The role of social support towards injury rehabilitation has been cited to play an integral part of the injury stress and coping process (Thoits, 1986; Wiese-Bjornstal et al., 1995). However Udry (1997) found there to be no direct correlation between social support and commitment to injury rehabilitation. The final aspect of the model is its recursive nature. Both Brewer (1994) and Wiese-Bjornstal et al. (1995) have highlighted the importance of injury rehabilitation being seen as an ongoing process in which stressors may continue to occur in the form of re-injury and setback.
Udry's (1997) study indicated that instrumental coping was significantly related to rehabilitation adherence at nine weeks post-surgery. Specifically, individuals who exhibited more instrumental coping strategies (e.g., finding out information about their health condition) showed better adherence to their rehabilitation. Therefore, it appears that coping strategies help an athlete defend against negative life experiences, which can lead to increased resiliency against injury, and better adherence to rehabilitation should an injury occur. However, it must be considered that Udry's (1997) study was limited due to its small sample size prevented the exploration of age and gender effects and their pertain to coping and social support as well as preventing of an examination determining the sub groups within the sample (e.g., individuals low in both instrumental coping and social support). Therefore greatly reducing the statistical power of the study.
Andersen & William's (1988) conceptual model of stress and athletic injury has helped to clarify the role that psychological factors play in athletic injury. The model is originally derived from Smith's (1980) mediational model of stress. Similar models may be found in health (e.g., Allen, 1983; PeUetier, 1977) and in other areas of sport psychology (see Martens' 1975 model of the competition process). The model presented in this paper is simplified version of the model adapted by Weinberg & Gould (2007).
Figure 2: An Adapted Version of Andersen & William's (1988) Model of Stress and Athletic Injury (Weinberg & Gould, 2007)
The model demonstrates the clear relationship between athletic injury and psychological factors and that stress and how the athlete perceives a potentially stressful situation is a primary factor in such relationship. The model also identifies three major areas which influence the stress process and the probability of injury which are; personality factors, the history of stressors, and coping resources all of which have been identified (Rotella & Heyman, 1986; Wiese & Weiss, 1987) as psychological antecedents to athletic and physical activity injuries. A recent study has shown that up to 18% of time loss because of injury was explained by physiological factors (Smith, Ptacek, & Patterson, 2000). Although there is limited evidence based research identifying the relationship between personality and athletic injury, it has been discovered that factors such as optimism, self esteem, hardiness, and trait anxiety do play a role in athletic injury (Ford, Eklum, & Gordan, 2000; Smith et al., 2000). However, the role is extremely complex and requires more intensive academic research.
The history of an athlete's stressors (i.e., major life events, chronic daily problems, and previous injuries) can have an impact on stress response and injury risk. A thorough assessment of the stressors in an athlete's life may give the coach, trainer, or sport psychologist a good estimate of how much at risk of injury that athlete is. A lack of good coping behaviours may also lead to high levels of stress and risk of injury. Williams, Tonymon, and Wadsworth (1986) found that general coping resources measured by the Miller and Smith (1982) Vulnerability to Stress subscale of their Stress Audit Questionnaire were directly related to injury. Athletes who had low coping resources were more likely to be injured than those with better coping resources.
There have been several studies which have provided support for Andersen & Williams model. In an experimental manipulation (Williams & Anderson, 1998; Williams, Tonymon, & Anderson, 1990 & 1991), it was demonstrated that participants with high life stress experienced an increase in the likelihood and susceptibility to injury. Perna, Antoni, Schneiderman (1998) have also reported relatively greater attention disturbances, physical symptoms, and sleep difficulties among high life-stress athletes as compared with low life-stress athletes. Additionally, athletes with relatively high life stress, in comparison with low-stress athletes of similar ability, exhibited higher prolonged cortisol elevations with exhaustive exercise, indicative of relatively poorer exercise recovery (Perna & McDowell, 1995). Elevated levels of cortisol, the primary catabolic hormone after intense exercise, were also related to subsequent physical symptoms (eg, skeletal muscle pain). Together these studies support the proposition that stress-induced changes in attention, physiology, and behaviour may all mediate the stress-athletic injury relationship. However, there have been some recent contradictions to these findings. Davenport, Andrew, & Yuri (2005) found that the psychological state profiles of successful and injured performances demonstrated a close relationship with each other and interestingly, qualitative data indicated that most participants were playing well prior to injury. Davenport et al. (2005) suggest that increased risk taking, an increase in effort, and the over confidence of the athlete may play more of a decisive role within athletic injury. This notion is in contrast to existing practice that focuses mainly on stress-related issues accompanying athletic performance (Kolt and Kirby, 1994). Evidently, there is a need for further research to investigate emotional antecedents of injury.
This paper has discussed the psychological aspects of injury prevention and rehabilitation within sport. As sport is largely results orientated, it is essential that coaches and managers have their best players available consistently. Therefore, it is vital that a coach understand the implications that psychological dispositions have on injury. The evidence presented in this paper clearly illustrates the effect that psychological strategies such as stress management and relaxation methods can have on injury prevention. Consequently, the ability to identify at risk athletes and aid the prevention of injury through a series of psychological questionnaires discussed within this paper is vital. However, as injuries are a common circumstance of elite sport and understanding of the emotion responses that an athlete may experience is crucial. The correct social support and injury rehabilitation procedure can then be provided through structured injury response models. This paper utilizes two conceptual models; Udry's (1997) injury response model and Andersen & Williams (1988) model of stress and athletic injury. Both models aid the understanding of psychological response to injury. However, Udry's model has been shown to provide clear links the rehabilitation adherence, whereas Andersen and Williams' model is somewhat questionable. Although the model cites the antecedents of injury as stressful situations, recent research (Davenport et al., 2005) has shown that most injuries actually occur when an athlete is playing well and in good form.