Psychological Susceptibility to Injury

Sport and recreational-related injuries have become a  significant  public  health  concern  for  physically active persons. For example, in 2006 the Centers for Disease Control and Prevention estimated that participation  in  high  school  sports  will  result  in approximately  1.4  million  injuries  reported  to medical  staff  at  a  rate  of  2.4  injuries  per  1,000 athlete exposures (i.e., practices or competitions). As sport and other physical activities continue to be  promoted  as  part  of  maintaining  and  restoring health, there will continue to be an increase in sport-related  injuries.  These  trends  have  resulted in  multifactorial  perspectives  of  injury  prediction and prevention. Advances in safety of equipment, improvement  to  the  physical  environment,  and new  policies  to  protect  sport  participants  have been  implemented.  Of  relevance  to  this  resource, but not likely as well known, are those approaches that involve the monitoring and modifying of psychological factors associated with sport injury.

Psychological Stress and Sports-Related Injury

In the 1960s, Thomas Holmes and colleagues suggested that changes in social stress, as measured by assessing  accumulated  stressful  life  events,  were  a precursor  to  changes  in  overall  health.  Essentially, life  events  often  evoked  changes  in  psychological status that required increased efforts to cope. This response to stress, or stress reactivity, was the mechanism underpinning the relationship between stress and health, whereby as stress demands and coping efforts  increased,  health  would  be  compromised (e.g., onset of illness, progression of disease). In the1970s,  Holmes  and  later  S.  T.  Bramwell  and  colleagues were the first to explore this notion in sport. They surveyed American football players and found greater levels of stress were associated with increased likelihood of athletic injury. This prompted further exploration  of  the  relationship  between  stress  and sport  injury,  yet  much  of  what  followed  failed  to replicate Holmes and Bramwell’s findings. The literature lacked a unifying framework until 1988, when Mark B. Andersen and Jean M. Williams’s model of stress and athletic injury filled an important gap and provided direction for future efforts.

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Model of Stress and Injury

The stress-injury model posits that three categories of psychological risk factors (i.e., personality, history of stress, and coping resources) influence athletes’ response to stressful athletic situations that, in turn, influences the likelihood of athletic injury through  various  stress-response  mechanisms  (see Figure  1).  In  addition  to  proposing  psychological risk  factors,  their  model  offered  specific  avenues for psychological interventions and skills training to  buffer  adverse  stress-related  consequences  for athletes’  health  and  to  minimize,  or  ideally  prevent, athletic injury.

Stress Response Mechanisms

Cognitive Appraisal

Central  to  the  stress  and  injury  model  is  one’s cognitive  appraisal.  Based  upon  the  pioneering work  of  Richard  Lazarus  and  Susan  Folkman, the  cognitive  appraisal  involves  a  balance  (or imbalance)  between  two  perceptions.  The  primary  appraisal  reflects  perceived  demands  or threat  of  the  stressor  whereas  the  secondary appraisal  reflects  perceived  personal  and  situational resources to cope with those demands and/ or threat. When coping resources are perceived to be  adequate  to  manage  threat  or  demands,  stress reactivity  is  minimal.  In  contrast,  an  imbalance occurs  where  one’s  perception  of  stress  demands exceeds available coping resources, at which point stress reactivity is heightened.

Psychological Susceptibility to InjuryFigure 1 Stress and Injury Model

Physiological Considerations

Very  little  attention  has  been  given  to  physiological  considerations.  Within  the  model,  stress responses  that  were  initially  described  involved increase in muscle tension, which was thought to potentially  impair  motor  control  and  slow  reaction  time  (RT)  that,  in  turn,  may  heighten  injury vulnerability  when  engaged  in  sport  competition and/or training. Over time, three additional pathways  emerged  associating  psychological  stress  to physiological  response.  Perturbations  in  visual attention involving peripheral narrowing of visual field were described among highly stressed athletes and were hypothesized to heighten risk for injury (i.e., being blindsided). The other pathways linking stress to injury involved excess autonomic activity (e.g., increases in stress hormones) that were posited  to  increase  injury  risk  by  impairing  immune function and other cellular processes necessary for muscle  repair  following  strenuous  exercise  training, or by altering sleep and associated secretion of growth factors also required for muscle anabolism. To  date,  excess  elevation  in  psychological  stress-related  autonomic  activity  remains  as  the  leading mechanism associated with athletic injury, but the specific causal pathway(s) remains unknown.

Attentional Considerations

In  contrast  to  physiological  factors,  research studies  have  explored  stress-related  implications on  attentional  performance.  Measures  of  visual and  attentional  indices  have  included  peripheral narrowing  and  increased  distractibility.  In  1999, Mark  Andersen  and  Jean  Williams  first  demonstrated  that  peripheral  narrowing  mediated  the relationship  between  injury  outcomes  and  high stress  in  college  athletes,  and  this  was  later  replicated among high school athletes in 2005 by Traci Rogers  and  Dan  Landers.  While  stress-related effects  upon  attentional  and  visual  performance have been examined, there are other avenues (e.g., working  memory  capacity)  that  may  be  very  relevant yet remain unexplored in the psychological injury vulnerability literature.

Psychological Factors That Influence Stress Response

Athletes who have a history of stress, a personality that amplifies perceptions of stress demands and/ or  reactivity  to  stress,  and  few  available  or  effective coping resources are more likely to have cognitive appraisals of athletic situations that heighten their stress-reactivity. For those athletes, the consequences of heightened stress reactivity experienced within  a  sporting  environment  increase  their  risk of injury.


Research  examining  personality  has  measured patterns  of  behavior  likely  to  exaggerate  perceptions  of  stress  demands  and/or  responses.  In  the original  1988  model,  six  likely  personality  variables were proposed and those included hardiness, locus  of  control,  sense  of  coherence,  competitive trait  anxiety  (TA),  and  achievement  motivation. After  nearly  a  decade  of  research,  only  four  of those had received any attention and other characteristics had emerged that seemed appropriate that were  not  originally  included  (e.g.,  dispositional optimism). Today, well over 20 different personality factors have been explored as potentially associated  with  injury  vulnerability.  While  evidence for  an  injury-prone  athlete  personality  type  has not emerged from any of this literature, very few personality variables have been examined in more than  one  study.  Those  exceptions  that  have  been explored across multiple studies are anxiety, locus of control, mood states, and anger. Anxiety is the most  frequently  measured,  and  while  operational definitions vary considerably across studies, those studies  examining  competitive  TA  have  consistently  demonstrated  significant  associations  with injury.  In  contrast,  the  research  on  locus  of  control, mood states, and anger remains inconclusive.

Associated   with   personality,   other   characteristics  and  sport-related  patterns  of  behavior involving  behavioral  genetics  may  also  influence the athletes’ psychological stress and injury vulnerability.  Genome-wide  association  studies  (GWAS) have  found  particular  single  nucleotide  polymorphisms  (SNPs)  associated  with  sport-related  ligament injuries. GWAS has not been applied to the study  of  possible  mechanisms  linking  personality or  psychological  stress  factors  to  athletic  injury. However,  behavioral  genetic  findings  associated with   mood   regulation   and   conscientiousness identified in the general population may have relevance  to  athletes’  emotional  response  to  injury and  behavioral  adherence  to  recovery  protocols. As an emerging area of inquiry, further research is necessary.

History of Stress

Stress history was the initial and continues to be the  most  commonly  examined  psychological  risk factor  associated  with  injury.  Athletes’  history  of stress has been examined through measuring three different variables: major life events, daily hassles or minor life events, and prior injury history. Early studies  by  Holmes  and  Richard  S.  Rahe  and  colleagues measured accumulated life events (or total life  stress)  irrespective  of  the  specific  nature  or impact of those events. Over the years, a focus has shifted  away  from  measuring  only  accumulative life events and toward measures that examine the impact  and  valence  of  stressful  events,  as  well  as both life and sport-related stressful events typical of athletic populations. The evidence supporting a relationship between life events’ stress and athletic injury  is  by  far  the  clearest  and  most  consistent.

In  contrast  to  these  findings,  research  examining minor life events or daily hassles has been less clear. By  definition,  daily  hassles  occur  frequently  and therefore contribute to sustained stress activation. Unfortunately, daily hassles have not always been measured in a manner that captures its reoccurring nature; when it has, it has been significantly associated with injury. The third variable, prior injury history, influences athletes’ stress reactivity in a few important  ways.  Athletes  who  have  been  injured previously  may  be  physically  and/or  psychologically  vulnerable  to  re-injury  due  to  returning  to sport  prematurely  either  because  physical  and/or psychological recovery was not yet complete. For example, athletes may be physically recovered but may  still  have  considerable  self-doubt  and  anxiety.  Either  independently  or  conjointly,  cognitive and  physiological  symptoms  of  anxiety  further heighten  stress  reactivity  and  may  have  a  more pronounced  impact  upon  cognitive,  attentional, and/or physiological functioning. In recent reviews of  the  literature  done  by  Jean  Williams  as  well as  our  own  recent  work,  approximately  80%  to90% of studies have documented significant relationships  between  stress  history  and  sport  injury. Collectively,  the  evidence  supports  the  centrality of  athletes’  stress  reactivity  in  determining  stress-related vulnerability to sport injury.

Coping Resources

Compared to stress history and personality, less attention has been given to coping resources in the injury  vulnerability  literature.  Coping  resources involve both internal or personal factors as well as external or environmental factors, which collectively reflect  the  strengths  and  vulnerabilities  in  managing  demands  of  stress.  Internal  coping  resources examined have involved measuring athletes’ general coping behaviors or self-care (quality of nutritional intake, sleep, etc.) and psychological or sport coping skills  (regulation  of  one’s  thoughts,  energy,  attention,  emotion,  etc.).  Researchers  have  not  always been  able  to  demonstrate  a  significant  relationship between internal or personal coping resources and sport injury. When significant links have been reported,  they  have  almost  always  reflected  a protective  effect—greater  coping  was  directly  or indirectly associated with lower injury risk.

External  coping  resources  have  primarily  been evaluating  the  quality,  quantity,  and/or  effectiveness   of   athletes’   social   support   networks.   In contrast to personal coping resources, results from studies examining social support are quite contradictory. Some studies have reported stress-buffering effects of social support while others have demonstrated  increased  stress-reactivity  and  injury  risk with  greater  social  support.  These  contradictory findings are perhaps suggestive of different stress injury mechanisms across different sports.

Psychological Interventions for Health Promotion in Sport

The  most  exciting  avenue  of  research  is  the  efficacy  of  psychological  interventions  to  prevent athletic  injury.  Intervention  studies,  based  on Donald   Meichenbaum’s   cognitive   behavioral stress management (CBSM), involve the provision of  education  and  skills  training  to  athletes  aimed to  foster  adaptive  cognitions  (e.g.,  thought  stopping,  restructuring)  and/or  manage  physiological  and attentional functioning (e.g., relaxation, mental  rehearsal).  To  date,  intervention  studies  have yielded  medium  to  very  large  effects  (e.g.,  0.67–0.99), and the quality of this research has occurred at  the  highest  level  for  therapeutic  interventions (i.e.,  a  randomized  clinical  trial).  Findings  provide strong support for psychological services for athletes to mitigate negative health-related consequences of sport participation (e.g., reduced injury or illness, time loss due to injury).



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