0363-5465/100/2828-S10$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 28, No. 5 © 2000 American Orthopaedic Society for Sports Medicine

The Influence of Psychological Factors on Sports Injuries Review of the Literature Astrid Junge,* PhD

From the Schulthess Clinic, Zurich, Switzerland and appropriate training and competition conditions be considered, but psychological factors should also be considered, as these can be expected to be of importance.23, 57 The empirical studies published to date concerning the relationship between sports injuries and psychological factors have employed heterogeneous designs, various criteria, different evaluation strategies, and, at times, have also displayed considerable methodological flaws. This renders comparison between the studies somewhat difficult. Specific examples of these deficiencies include lack of differentiation between the type of sport54 or between the sexes,46 retrospective investigation of injuries,27, 49 investigation periods varying between 3 months6 and 1 year,58 and no detailed definition of the criteria used (frequency of injury, severity of injury, absence from the sport). These studies focused mainly on the influence of life events or personal characteristics on the risk of injury, although other psychological attributes (for example, control beliefs, self-concept, and type A behavior) were also investigated. The currently available reviews are either incomplete, out-of-date, or describe different investigation approaches without regard to an integrative theoretical model.2, 12, 21, 25, 26, 40, 64 Only Andersen and Williams1 have developed a model based on stress theory. According to this model, the reaction of the athlete to a potentially stressful athletic situation is decisive in determining whether injury will ensue. Further, the “stress response” of the athlete depends on a series of psychological factors, either directly or indirectly, and can be influenced by psychological interventions. The aim of the present review is to summarize the existing evidence regarding the relationship between psychological factors and sports injuries and to develop an integrative theoretical model based on stress theory (adapted from Andersen and Williams1).

ABSTRACT The influence of psychological factors on sports injuries has been demonstrated in numerous empirical studies. Almost all investigations have been based on stress theory or a personality-profile approach. Although the majority of studies have employed different methods, the results are in general agreement that “life events” can influence the risk of injury in athletes. In this context, social support appears to have a buffering effect. According to existing results, the influence of stress-coping strategies is somewhat questionable. From the numerous psychological attributes that have been investigated in relation to sports injuries, only competitive anxiety has been shown to be associated with injury occurrence. A personality profile typical of the “injury-prone” athlete does not exist. However, several studies have shown a certain readiness to take risks (lack of caution, adventurous spirit) on the part of injured athletes. In this review, the current knowledge regarding the relationship between psychological factors and sports injuries is presented and a stress theory model is developed.

Over the last 10 years, psychosomatic medicine has been concerned with examining the influence of psychosocial factors on the origin and course of psychological disturbances and physical illnesses. However, with regard to the relationship between sports injuries and psychological factors, there is only limited scientific knowledge. In view of the increasing frequency of injury, not only during leisuretime activities but also in professional sports, it is clear that analyses of risk factors for sports injury are urgently required as a prerequisite to the development of prevention programs. Not only should the level of physical fitness

LIFE EVENTS

* Address correspondence and reprint requests to Astrid Junge, PhD, Spine Unit, Schulthess Clinic, Lengghalde 2, CH-8008 Zurich, Switzerland. Neither the author nor the related institution have received any financial benefit from research in this study.

Since the mid-1960s, a field of research has developed that is concerned with the influence of life-changing events on S-10

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disease, based on the stress-theory approach. The term “life events” describes occurrences that result in major changes in the life of those affected, such as marriage, the death of a close friend, or the loss of a job. To quantify life events, Holmes and Rahe22 developed the Social Readjustment Rating Scale. This scale comprises a list of events, each of which is weighted with a life change unit. The Social Readjustment Rating Scale is thus far one of the most frequently employed methods used in the assessment of life events, and a new version was recently published.39 Bramwell et al.6 modified the Social Readjustment Rating Scale for the investigation of psychosocial factors influencing sports injuries. The Social and Athletic Readjustment Rating Scale contained additional sport-specific items, whereas some of the original items that were irrelevant for athletes were removed. Compared with uninjured players, injured players were significantly more burdened with life events. This result was corroborated by Cryan and Alles.13 Kerr and Minden27 employed a comparable method (Life Event Record9) and found a significant relationship between the sum of life change units and the frequency and severity of sports injuries. With a shortened version of this events list, Thompson and Morris59 showed that an increased risk of injury existed only when the life events had occurred in the last 12 months and— or possibly because—vigilant attention was correspondingly reduced. Lysens et al.30 developed the Social and Athletic Readjustment Rating Scale further by modifying the items and, more importantly, by making changes to the response scales. In the newly developed Life Event Questionnaire, instead of just indicating the applicable event, each event required further grading on a 10-point scale with regard to the extent of social readjustment that it demanded. The events that occurred were thus individually weighted, rather than being assessed with a standard life change unit. Using the sum of the individual event grades, significant differences were observed between groups displaying different frequencies of injury. Whereas Holmes and Rahe22 assumed that each major change, whether positive or negative, represented a stressor and could thus be detrimental to the health of the person, other authors postulated that only negative events had an influence. In their life-event scale developed for adolescents, Coddington and Troxell10 differentiated between four types of events. Significant differences were found between injured and uninjured players in relation to family events and personal loss (the death of a close friend, separation from girlfriend or wife). In answering the Life Experience Survey of Sarason et al.,48 each athlete characterizes the event that occurred as positive or negative and the impact of the event is assessed on a four-point scale. Passer and Seese42 modified the item choice of the Life Experience Survey to make it applicable to athletes (Athletic Life Experience Survey) and were able to show that positive life events had no effect on sports injuries. A relationship of negative events and personal loss with injury could be demonstrated in only one of two investigated teams. In assessing life events, Smith et al.54 employed a mod-

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ified version of the Adolescent Perceived Events Scale,11 in which events were classified as either negative or positive and then as minor or major. None of these variables had a significant correlation with subsequent sports injuries. However, athletes low in both coping skills and social support exhibited a significant stress-injury association. In a later investigation by the same authors,52 a significant positive relationship between major negative sportspecific life events and subsequent time-loss caused by injury existed only for athletes who scored low in sensation-seeking. These results indicate that the relationship between life events and sports injuries is moderated by several factors. Neither Williams et al.63 nor Rider and Hicks46 were able to show any relationship between life events and sporting injuries. In other studies, the extent of negative life events and total life changes were predictors of the frequency of sporting accidents.19, 20 The severity of an injury could not, however, be predicted. Personal loss (as defined by Passer and Seese42) had a significant effect only in a group of track and field athletes. Using discriminant analysis, Hanson et al.18 showed a relationship between negative life events and severity of injury, and between positive life events and frequency of injury. In the investigation of Petrie,45 no association existed between the Social and Athletic Readjustment Rating Scale and sporting injuries. However, using a questionnaire developed by the author (Life Event Survey for Collegiate Athletes),45 in which the positive or negative impact of an event was subjectively assessed, injured and uninjured players differed significantly in negative life events experienced. In a later study, Petrie43 used multiple regression analysis to demonstrate that the existence of positive life events could predict the number of days missing from either training or competition. Table 1 summarizes the results of various studies on life events and sports injury. Although, at first glance, the results may appear to be quite heterogeneous, they can be summarized to an extent as follows. In the most frequently investigated sport, American football, almost all studies have shown a relationship between life events and sports injuries.4, 6, 9, 13, 42– 44, 59 The only exception was one of the two teams investigated by Passer and Seese.42 Comparable results were also found for gymnasts,27, 45 track and field athletes,18 athletes in other noncontact sports,20 and physical education students.30 However, no relationship between life events and sports injuries could be demonstrated in either volleyball players63 or basketball players.46 Neither the methodology employed nor the description of the sample investigated in these studies was able to account for the findings. In the studies of Smith et al.,52, 54 it was not possible to demonstrate any general association between life events and sports injuries. In these investigations, however, very different types of sport (basketball, wrestling, gymnastics) were examined collectively, such that confounding effects of the type of sport on the frequency of accidents may have obscured any such associations.

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American Journal of Sports Medicine TABLE 1 Studies Concerning Life Events and Sports Injuries No. of subjects

Type of sport

Methoda

Resultb

Bramwell et al.6 Coddington and Troxell10 Cryan and Alles13 Passer and Seese42 May et al.34 Schafer and McKenna49 Lysens et al.30 Williams et al.63 Hardy and Riehl20 Kerr and Minden27

92 114 151 104 73 572 99 179 86 41

American football American football American football American football Skiing Running Physical education Volleyball 4 types Gymnastics

LCU: Injured ⬎ uninjured LCU: Injured ⬎ uninjured LCU: Injured ⬎ uninjured LCU: Injured ⬎ uninjured in one of two groups LCU: Correlation with health problems LCU: Correlation with frequency of injury LCU: Injured ⬎ uninjured No effect TLC, NLC: Effect on frequency of injury LCU: Injured ⬎ uninjured

Blackwell and McCullagh4 Smith et al.54 Hardy et al.19 Hanson et al.18

105 424 170 181

American football 3 types 7 types Track and field

SARRS LES-A SARRS ALES SARRS, LES-A Modified SRRS LEQ SARRS, ALES ALES Modified SARRS ALES APES ALES ALES

Petrie45

103

Gymnastics

SARRS, LESCA

Smith et al.52 Petrie43 Petrie44 Thompson and Morris59

425 158 98 120

3 types American football American football American football

Rider and Hicks46 van Mechelen et al.61

67 139

Basketball Not specified

APES LESCA LESCA Modified SARRS SARRS, ALES LES

Study

TLC, NLC, PLC: Difference in extreme groups No effect TLC: Effect on frequency of injury NLC: Effect on severity of injury PLC: Effect on frequency of injury No effect TLC: Injured ⬎ uninjured LCU: only for “low sensation seekers” PLC: Effect on days missed NLC: Effect on frequency of injury LCU: Increased risk of injury No effect Life events related to occurrence of injury

a

SARRS, Social Readjustment Rating Scale; LES-A, Life Event Scale for Adolescents; ALES, Athletic Life Experience Survey; LEQ, Life Event Questionnaire; APES, Adolescent Perceived Events Scale; LESCA, Life Event Survey for Collegiate Athletes. b LCU, life change units; TLC, total life change; NLC, negative life change; PLC, positive life change.

COPING RESOURCES The influence of coping skills and social support are both frequently discussed in connection with life events. It is to be assumed that adequate resources in these areas would act to reduce the effect of life events on the risk of injury, whereas a lack of resources would intensify the effects.1 Smith et al.53 published the Athletic Coping Skill Inventory, which was designed to examine special sportspecific attributes of coping (for example, mental preparation, ability to be coached, peaking under pressure). In their earlier investigation,54 no direct effect of coping skills or social support on the risk of injury could be demonstrated. However, a significant correlation between negative life events and absence from sports because of injury existed in the groups with minimal coping skills and social support. In a later study, the authors stated that differences in coping efficacy did not mediate the differences in injury vulnerability.52 Rider and Hicks46 also found no relationship between coping skills and sports injuries. In contrast to these results, Petrie,43 using multiple regression analysis, identified coping as a predictor of the number of days of absence from training or competition due to injury. In a study by Williams et al.,63 injured and uninjured players gave significantly different answers to the Coping Resource questionnaire of Miller and Smith,38 which contained, predominantly, questions about health behavior and social integration. Also, the results of Blackwell and McCullagh4 showed that injured players had fewer coping resources at their disposal than uninjured players. Han-

son et al.,18 who employed a modified version of this questionnaire in their investigation, used discriminant analysis to demonstrate an influence of these variables on the severity and frequency of sports injuries. Hardy et al.19 showed that social support had a buffering effect on the impact of negative life events on the frequency of injury. Petrie44, 45 was also able to demonstrate that social support had a modulating effect on the relationship between life events and sports injuries. Discriminant analysis showed that the degree of social support available contributed to the differentiation of groups with different severities of injury, although the case was not the same for frequency of injury.18 Only Rider and Hicks46 found no relationship between social support and sports injuries.

PERSONALITY TRAITS Personality traits are defined as situation-independent, psychological attributes with which a person can be characterized. Some authors maintain that, as a result of their personality traits, certain athletes have a particular predisposition toward being injured, in other words, that they are injury-prone.31, 56 To further identify the traits associated with being injury-prone, numerous investigators have compared the scores on personality questionnaires of injured and uninjured athletes (Table 2). The results can be interpreted as indicating that no characteristic personality profile exists for the injury-prone athlete. However, investigators in four studies alluded to the existence of a

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TABLE 2 Studies Examining the Relationship Between Personality Traits and Sports Injuries Personality trait of injured players compared with uninjured players

Study

No. of subjects

Type of sport

Methoda

Brown7 Jackson et al.24 Valliant60 Lysens et al.31 Hamilton et al.17 Taimela et al.58 Garcia and Aragues16

186 110 21 185 29 37 149

Football Football Running Physical education Ballet Football Football

CPI 16 PF 16 PF GPP, GPI, ABV API 16 PF 16 PF

No difference “Tough minded” (I) No significant difference Lack of caution, emotional lability “Enterprising” “Adventurous,” “forthright” (H,N) Very high and very low anxiety

a CPI, California Personality Inventory; 16 PF, Sixteen Personality Factor Questionnaire; GPP, Gordon Personal Profile; GPI, Gordon Personality Inventory; ABV, Amsterdamse Biografische Vragenlijst; API, Adult Personality Inventory.

certain “readiness to take risks” (lack of caution, adventurous spirit) in athletes who became injured. Control beliefs and anxiety have frequently been investigated in connection with sports injuries. The results regarding the influence of locus of control47 on sports injuries are contradictory. Although a relationship between these two variables has been demonstrated in two studies,14, 41 this has not been the case in the majority of investigations.18, 27, 35, 36, 42 With regard to investigations on anxiety, it is important to distinguish between anxiety as a personality trait and situational anxiety in relation to competition. General anxiety as measured by the StateTrait Anxiety Inventory (STAI), has no clear effect on sports injuries (Table 3).27, 31, 55

SITUATION-DEPENDENT EMOTIONAL STATES Although general anxiety, in the sense of a personality trait, appears to have no clear effect on sports injuries, competitive anxiety (Sport Competition Anxiety Test32, 33) is apparently of the utmost importance (Table 3). In all four studies undertaken to examine whether there is a direct relationship between competitive anxiety and sports injuries, the authors have indeed been able to demonstrate the existence of such an association.4, 18, 28, 43 Passer and Seese42 suggested that competitive anxiety may be a modulator of the effect of life events, but they were unable to demonstrate that it played such a role. In examining the impact of general well-being on sports injuries, Kolt and Kirkby28 showed that the frequency of injury was influenced not only by scores obtained on the cognitive anxiety scale of the competitive anxiety questionnaire (CSTAI-233), but also by the anxiety scale of the Profile of Mood States.29 Studies concerning the associa-

tion between general well-being and sports injuries have contradictory results.34, 37, 51, 62 In addition to the aforementioned characteristics, a series of other specific psychological attributes has been investigated in connection with sports injuries: type A behavior,8, 15 expression of anger,59 self-concept,27, 41, 65 self-esteem,51 attentional and interpersonal style,3, 5 vital exhaustion,61 fatigue,50 reaction time,58 and everyday problems.4, 18 The results of these studies are partly contradictory and do not allow for any meaningful interpretation.

CONCLUSIONS The influence of psychological factors on sports injuries has been examined in numerous empirical studies. It is difficult to directly compare the results because of differences in the methods used. Nonetheless, an overview of the literature shows that psychosocial stressors, coping resources, and situation-dependent emotional states seem to have an effect on an athlete’s risk of incurring a sports injury. The most frequently investigated and substantiated of these influential factors are life events. In association with this attribute, social support appears to have a buffering effect. A modulating influence from stress coping skills is, according to existing evidence, somewhat questionable. Personality traits seem to have no influence on the risk of injury and there is no typical personality profile for an injury-prone athlete. However, there is evidence from several studies that injured athletes demonstrate a more pronounced readiness to take risks (insufficient caution, adventurous spirit).17, 31, 58 From the several psychological attributes that have been investigated in the context of their relationship to the risk of

TABLE 3 Studies Performed in Relation to Anxiety and Sports Injuries

a

Study

No. of subjects

Type of sport

Methoda

Result

Passer and Seese42 Kerr and Minden27 Lysens et al.31 Blackwell and McCullagh4 Hanson et al.18 Petrie43 Kolt and Kirkby28

104 41 185 105 181 158 115

American football Gymnastics Physical education American football Track and field American football Gymnastics

STAI, SCAT STAI STAI SCAT SCAT SCAT CSTAI-2

No modulating effect No effect Curvilinear relationship Difference in group extremes Effect on severity of injury Effect on absence from the sport Effect on frequency of injury

STAI, State-Trait Anxiety Inventory; SCAT, Sport Competitive Anxiety Test; CSTAI-2, Competitive State Anxiety Inventory-2.

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Figure 1. Model of the influence of psychological factors on sports injury.

incurring sports injuries, only competitive anxiety consistently shows any association with injury. Few studies have employed multivariate evaluations, so there is still a lack of knowledge concerning the interaction of the different factors. Based on our literature review, a modification of the stress theory model of Andersen and Williams1 is proposed (Fig. 1). Whether an athletic situation leads to an injury is determined by the reaction of the athlete to the situation, which can be influenced by several psychological factors. The significant impact of psychosocial stressors (in particular, life events) on the risk of incurring a sports injury has been confirmed, but coping resources and situation-dependent emotional states can also be assumed to influence the reaction of athletes. These psychological factors surely are not independent from each other. In the literature, a number of theories are discussed to clarify how life events influence the risk of sports injury.61 It can be supposed that psychosocial stressors modify the emotional state, especially characteristics such as vigor, concentration, or attention. However, this particular area of research has previously been neglected, both theoretically and empirically. Especially conspicuous is the neglect to date of aspects such as susceptibility to anger and aggression, concentration, and reaction. Because situation-related emotional states and coping resources may represent important avenues for intervention, it is suggested that these factors be investigated with respect to injury prevention and improvements in performance. Although the role of psychological care and mental preparation for competition in top athletes has long been recognized, the importance of the influence of psychological factors on the risk of injury has, to date, been underestimated. In view of the increasing frequency of injuries in both leisure-time and professional sports, the resulting primary and secondary costs, and—not least—the personal suffering of those affected, preventive measures are

urgently required. In developing a suitable program, the influence of psychological factors on the risk of injury should be considered to be of utmost importance.

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