Injury Prevention in Sport and Performance Psychology
Summary and Keywords
This article aims to provide a narrative overview on injury prevention in sport and performance psychology. Research and applied interest in psychological injury prevention in sport and performance psychology has risen in popularity over the past few decades. To date, existing theoretical models, pure and applied research, and practice-based evidence has focused on conceptualizing and examining psychological injury occurrence and prevention through stress-injury mechanisms, and predominantly in sport injury settings. However, given the inherited similarities across the different performance domains however, it is the authors’ belief that existing injury prevention knowledge can be transferable beyond sport but should be done with caution. A range of cognitive-affective-behavioral strategies such as goal setting, imagery, relaxation strategies, self-talk, and social support have been found beneficial in reducing injuries, particularly when used systematically (a) prior to injury occurrence as part of performance enhancement program and/or as a specific injury prevention measure, (b) during injury rehabilitation, and (c) as part of a return-to-activity process to minimize the risk of secondary injuries and reinjuries. Existing theoretical and empirical evidence also indicates that using cognitive-affective-behavioral strategies for injury prevention are effective when used as part of a wider, multi-modal intervention. Equally, such interventions may also need to address possible behavioral modifications required in sleep, rest, and recovery. Considering the existing empirical and anecdotal evidence to date, this paper argues that injury prevention efforts in sport and performance psychology should be cyclical, biopsychosocial, and person-centered in nature. In short, injury prevention should be underpinned by recognition of the interplay between personal (both physical and psychological), environmental, and contextual characteristics, and how they affect the persons’ cognitive-affective-behavioral processes before, during, and after injury occurrence, at different phases of rehabilitation, and during the return to activity or retirement from activity process. Moreover, these holistic injury prevention efforts should be underpinned by a philosophy that injury prevention is inherently intertwined with performance enhancement, with the focus being on the individual and their overall well-being.
Injuries, characterized by any unintentional or intentional “trauma to the body or its parts that result in at least temporary, but sometimes permanent physical disability and inhibition of motor function” (Berger, Pargman, & Weinberg, 2007, p. 186) are frequently experienced by individuals who participate in sport and other performance domains (e.g., circus performers, dancers, firefighters, and musicians, to name a few). These injuries often have significant physical (e.g., movement restrictions); psychological (e.g., changes in mood); social (e.g., time away from sport or work or both); and a range of range of tertiary (e.g., loss of income) consequences (Arvinen-Barrow & Walker, 2013; Brewer & Redmond, 2016; Taylor, Stone, Mullin, Ellenbecker, & Walgenbach, 2003). It is therefore no surprise that sport and a range of other performance domains have spent considerable amount of time, money, and other resources in developing and implementing injury prevention programs. Commonly, such programs have predominantly focused on the physical and biomechanical aspects of movement with the aim to teach, correct, and strengthen a range of movement patterns—such as safe landing, starting, stopping, and skills required to successfully execute performance demands (e.g., John Muir Health, 2017; Kerkhoffs et al., 2012; Sutter Health, 2015; Vanderbilt University Medical Center, 2017). Injury prevention programs have also aimed to facilitate the development and adoption of a range of other preventative and regulatory behaviors such as use of protective equipment, appropriate stretching, and ensuring adequate nutrition, rest, recovery, and sleep. More recently, injury prevention programs have also incorporated cognitive, affective, and behavioral strategies aimed to address a range of psychosocial factors found to be potential risks for injury occurrence (e.g., Maddison & Prapavessis, 2005).
This article aims to provide a narrative overview on injury prevention in sport and performance psychology. For the purposes of this article, performance will be defined as an “act of doing something,” and “any activity or gathering of reactions which leads to an outcome or has an impact on the surroundings” (Nugent, 2013). It is the authors’ opinion that this definition thoroughly encompasses many performance domains, including sport. Henceforth, the article will not make a distinction between sport and performance, but rather use the term “performance” as an overarching term to cover domains such as dance, music, sport, and a range of occupational athletes such as circus, firefighting, military, where injuries typically occur. It is also noted that theoretical, empirical, and practice-based evidence in injury prevention literature across the different performance domains is currently limited. Much of the knowledge is acquired from (competitive) sport settings, and it is therefore this literature that will dominate. Given the inherited similarities across the different performance domains however, it is the authors’ belief that existing injury prevention knowledge can be transferable beyond sport but should be done with caution.
The article is divided into three parts. First, it will provide a brief synopsis of the existing theoretical models relevant to psychology of injury prevention. Second, it will introduce a range of cognitive-affective-behavioral strategies pertinent to injury prevention. Drawing from the information presented in the earlier parts of the article and based on the premise that injury prevention should be at the root of any pre-injury performance enhancement programs, and as part of the rehabilitation and return-to-sport process, the article will then propose an integrated and holistic framework to help researchers and practitioners better conceptualize injury prevention in sport and performance psychology.
Theoretical Models of Psychology of Injury
Interest in the psychology of injury dates back to the mid-1960s when the seminal work emerged predominantly from anecdotal clinical and sport coaching experiences (e.g., Ogilvie, 1966). This was followed by a decade of controlled empirical investigations into a potential personality trait-injury occurrence relationship. The results of such investigations were contradictory and were later surpassed by research exploring stress-injury relationship as a potential framework for psychology of injury occurrence (Andersen & Williams, 1988).
The first theoretical model developed to explain the stress-injury relationship was a sport-specific variant of the stress-injury model by Holmes and Rahe (1967). The model of stress and athletic injury (Andersen & Williams, 1988; Williams & Andersen, 1998) is founded in the premise that when placed in a physically and psychologically stressful situation, an individual will make both primary and secondary cognitive appraisals about the demands, resources, and consequences of the situation (Heil, 1993; Williams & Andersen, 1998). These appraisals are bidirectionally connected to physiological and attentional changes in the individual, commonly known as the stress response. Depending on the outcome of the stress response, an individual may either increase or decrease the likelihood of encountering an injury in the said situation. The stress response is also suggested to be influenced by a bidirectional interaction between three main psychosocial antecedents: range of personality variables, history or stressors, and coping resources (Williams & Andersen, 1998). The model also proposes that range of cognitive-behavioral interventions—such as cognitive restructuring, relaxation strategies, and imagery—can be helpful in managing, controlling, and alleviating the stress response, subsequently potentially reducing the risk of encountering an injury.
Research support for the different components of the model is equivocal as only 48 studies have been published to date (for more details, please see a meta-analysis by Ivarsson et al., 2017). What is known, is that number of antecedents are associated with higher injury incident rates. For example, personality variables such as trait anxiety (e.g., Ivarsson, Johnson, & Podlog, 2013), locus of control (e.g., Kolt & Kirkby, 1996) and mood states (e.g., Dvorak et al., 2000) have been found to influence injury occurrence. Higher number of daily hassles (e.g., Ivarsson & Johnson, 2010; Luo, 1994), negative life events (e.g., Ivarsson et al., 2013), and previous injury history (e.g., van Mechelen et al., 1996) have also been associated with increased injury incidence rates. Moreover, having good coping resources (e.g., Luo, 1994) and a supportive social network (Appaneal & Habif, 2013) have been associated with reduced risk of injury. Only a handful of studies have exclusively investigated the stress response–injury occurrence link (Appaneal & Habif, 2013). Regardless, a recent meta-analysis did support the Williams and Andersen (1998) stress and athletic injury model, by concluding that the stress response does mediate between history of stressors and actual injury occurrences (Ivarsson et al., 2017) and that the stress-response and history of stressors had the strongest associations with injury incidences. In addition, existing injury prevention studies (n = 7) employing a range of cognitive-affective-behavioral interventions targeted to reduce stress responses, showed decreases in injury occurrences (Ivarsson et al., 2017). To date, the core of the Williams and Andersen (1998) stress and athletic injury model remains largely uncontested, and it is often referred to as foundation for all psychology of injury research (Appaneal & Habif, 2013).
Other pre-injury models have since been developed to further elaborate on specific elements of the original stress and athletic injury model (Andersen & Williams, 1988; Williams & Andersen, 1998). The psychophysiological model of injury risk (Heil, 1993) expands the stress and athletic injury model by explaining injury occurrence specifically in high threat environments where fear of injury (or reinjury) is a factor affecting performance. The psychophysiological model proposes that individual’s perceptions (i.e., a cognitive appraisal) of stress leads to an emotional response of fear, which will diminish performance and increase injury risk via changes in individual’s behavior. These include behaviors such as undesired changes in attentional focus, improper use of physiological resources, and faulty movement biomechanics.
A more recently developed biopsychosocial model of stress athletic injury and health (Appaneal & Perna, 2014) also adds to the original Andersen and Williams model. Similar to the aforementioned models, the biopsychosocial model is also founded in the stress-injury relationship. The model aims to explain how negative life stress and associated emotional distress (psychological factors) can influence injury occurrence though the activation of the autonomic nervous system (ANS) response pathways, particularly in relation to increasing the adverse effects of prolonged high-intensity and high-volume exercise (Appaneal & Perna, 2014).
What is common between all of the three models described above is that they all consider individuals’ stress appraisal to a potentially stressful situation (e.g., competition, team tryouts, and other performances) as a catalyst for injury occurrence. Such appraisal will then elicit a combination of physiological, emotional, and/or behavioral changes, which in turn can lead to an increased or decreased risk of injury. In the context of psychology of injury prevention, based on these conceptualizations and empirical evidence, it would make sense to target planned cognitive-affective-behavioral strategies in a way that they teach the individual how to: (a) best prepare for a stressful situation before faced with one, and (b) self-regulate and manage cognitive-affective-behavioral and physiological responses when in a stressful situation.
In addition to acting as a catalyst for much of psychology of injury occurrence and prevention research, the Andersen and Williams (1988) model has also provided a framework for psychological post-injury research and applied work. Building on the original work by Andersen and Williams, early research and theoretical conceptualizations of post-injury psychological reactions recognized that injuries have cognitive-affective-behavioral antecedents, subsequently focusing heavily on affective stage- and cycle-based models (Evans & Hardy, 1995; Heil, 1993; McDonald & Hardy, 1990), and simple cognitive appraisal models (Brewer, 1994). In short, the early post-injury models were developed based on the premise that if injuries are a consequence of psychophysiological stress response to a stressful situation, influenced by a range of psychological antecedents, then it is likely that injuries themselves will become a stressor, and that the pre-injury cognitive-affective-behavioral responses can also influence injury rehabilitation.
In 1998, somewhat concurrently with the publication of the revised stress and athletic injury model (Williams & Andersen, 1998), a first comprehensive stress-based cognitive appraisal model to truly integrate the early work by Andersen and Williams (1988) with post-injury responses was the integrated model of psychological response to the sport injury and rehabilitation process (from now on, referred to as the integrated model, Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998). The model is grounded in the notion that upon encountering an injury, a potential consequence of a negative stress response to a stressful situation (see Williams & Andersen, 1998), the injury itself becomes a stressor. The model also posits that following injury occurrence, an individual will make a cognitive appraisal of their situation, which then elicits a number of subsequent cognitive appraisals and emotional and behavioral responses (see Brewer, 1994). Known as the dynamic core, these thoughts, emotions, and behaviors interact in a cyclical, bidirectional manner, ultimately affecting the overall psychosocial and physical rehabilitation and return-to-activity outcomes. The dynamic core is also influenced by pre-injury factors that may have contributed to the injury occurrence, as well as a number of other personal and situational factors, including characteristics of injury, and range of psychological, physical, social, environmental, and activity-specific factors.
The integrated model is regarded as the most comprehensive theoretical model explaining the psychological process of injury occurrence, rehabilitation, and to return-to-activity (Walker & Heaney, 2013a). It has been used extensively by researchers and applied practitioners, and more recently also modified to conceptualize the similar, yet somewhat unique psychological process of concussion injuries (Wiese-Bjornstal, White, Russell, & Smith, 2015). Despite its ever-growing popularity, the integrated model has been criticized for its lack of inclusion of biological factors affecting injury occurrence, rehabilitation, and the return to participation process (Walker & Heaney, 2013a; Walker, Thatcher, & Lavallee, 2007).
To address the above critique, the biopsychosocial model of injury rehabilitation (Brewer, Andersen, & van Raalte, 2002) aimed to bridge the gap between medical and psychological models. It proposes that biological, psychological, and social/contextual factors have a reciprocal relationship with each other, all of which are proposed to influence both the intermediate and overall rehabilitation outcomes. The biopsychosocial model also highlights the bidirectional relationship between intermediate rehabilitation outcomes and psychological factors, a relationship that has not been explicitly recognized in previous theoretical conceptualizations. Although initially appealing, particularly in applied intervention settings, the biopsychosocial model has its share of critique. The model fails to explain the details of the cyclical interaction between thoughts, emotions, and behaviors to the extent that the integrated model (Wiese-Bjornstal et al., 1998) does, and how the different biopsychosocial factors interact to produce the different return-to-activity outcomes (Heil & Podlog, 2012).
Thus far, only one theoretical conceptualization distinctly aimed at explaining the psychological return-to-activity process has been proposed in the literature. This stage-based return-to-activity model (Taylor & Taylor, 1997) depicts that when returning back to activity, an individual will progress through five successive physical and psychological stages during which the person will encounter a number of mind-body challenges. It is proposed that through these stages, an individual will have to confirm their physical and psychological readiness to return, including confirmation on the readiness to pursue performance related activities without an increased risk of reinjury, or indeed, any other new injury.
In the context of injury prevention, all of the above psychological models are worthy of noting. Despite their differences, a common theme across all is evident: psychological and physical rehabilitation and return-to-activity processes are influenced by individuals’ cognitive appraisals and emotional and behavioral responses that will affect the recovery outcomes. This process is cyclical in nature; individuals with a tendency for negative appraisals prior to injury occurrence are more likely to display similar responses across the rehabilitation and return-to-activity process. At the core of the injury occurrence, rehabilitation, and return-to-activity process appears to be stress response, which, if not addressed appropriately, can continue to amplify individuals’ subsequent injury risk.
Cognitive-Affective-Behavioral Strategies in Injury Prevention
In the absence of any psychological models aiming to explain injury occurrence, early work on using a cognitive-affective-behavioral strategies for injury prevention was predominantly anecdotal and case report based (Brewer & Redmond, 2016). Indeed, such interventions in the 1980s and 1990s were predominantly focused on performance enhancement (e.g., Davis, 1991; DeWitt, 1980; Murphy, 1988) rather than injury prevention per se. The development of the stress-injury model (Andersen & Williams, 1988) and the dominance of the stress-injury relationship as the key mechanism underlying injury occurrence have caused investigators to refine their focus to injury occurrence and prevention. It is however the authors’ opinion that the early relationship between injury prevention and performance enhancement should not be forgotten or ignored. To date, much of the psychological injury prevention efforts have been focused on strategies aimed to (a) affect individual’s cognitive appraisals and/or somatic responses to stress, as well as (b) any of the potential antecedents influencing the stress response (e.g., personality traits and states, history of stressors, and range of coping strategies) as outlined in the Williams and Andersen (1998) model. It appears only a limited number of intervention studies to this effect have been conducted in sport (for reviews, see Appaneal & Habif, 2013; Brewer & Redmond, 2016; Ivarsson et al., 2017; Tranaeus, Ivarsson, & Johnson, 2015) and even less so in other performance domains. The next section of this article will introduce a range of cognitive-affective-behavioral strategies that have been most commonly used and found to be beneficial in injury prevention efforts within sport and performance psychology.
Goal setting is a cognitive-affective-behavioral strategy whereby an individual identifies something they want to achieve or accomplish, and subsequently establish measurable tasks and timelines needed to successfully reach their goal (Locke & Latham, 1985). Setting specific, measurable, attainable, realistic, and time-specific yet flexible (in case of injury) goals can help alleviate cognitive appraisals related to a potentially stressful situation (Arvinen-Barrow & Hemmings, 2013). Such goals can (a) increase individual’s self-confidence/efficacy related to their perceived ability to successful meet the demands, (b) help in setting realistic expectations for themselves within their own resources available, and (c) reduce potential anxiety and worry related to potential consequences of their performance. In addition to goal setting being useful for performance enhancement (for more details, see Weinberg & Gould, 2015), injury rehabilitation, and/or return-to-activity process(for more details, see Arvinen-Barrow & Walker, 2013), empirical evidence has also identified goal setting as beneficial injury prevention when it is used as part of a wider psychosocial, typically stress-inoculation-therapy–based intervention (e.g., Ivarsson et al., 2017; Johnson, Ekengren, & Andersen, 2005; Olmedilla-Zafra, Rubio, Ortega, & García-Mas, 2017; Perna, Antoni, Baum, Gordon, & Schneiderman, 2003; Tranaeus, Ivarsson, et al., 2015; Tranaeus, Johnson, Engström, Skillgate, & Werner, 2015; Tranaeus, Johnson, Ivarsson, et al., 2015).
Commonly defined as an “activity which involves creating a clear mental picture of the situations” (Arvinen-Barrow, Clement, & Hemmings, 2013, p. 72), imagery is a cognitive-affective-behavioral strategy found to be beneficial for performance enhancement (e.g., Feltz & Landers, 1983; Thelwell, Greenlees, & Weston, 2010) and the injury rehabilitation and return-to-sport process (Arvinen-Barrow & Hemmings, 2013; Beneka et al., 2007). In the context of injury prevention, imagery can be used for both cognitive (e.g., skill and routine rehearsal) and a range of motivational purposes (Hall, Mack, Paivio, & Hausenblas, 1998) in the hope of reducing injury risk. Imagery can be effective in (a) modifying and reinforcing cognitive appraisals (e.g., self-confidence, self-efficacy, motivational orientation), (b) positively influencing and controlling range of affective states (e.g., anger, anxiety, arousal, overall mood, worry), and (c) providing both visual and kinesthetic mental experiences of successful skill and routine rehearsal. Use of imagery is typically most effective for injury prevention or reduction or both when used in conjunction with relaxation strategies, and as part of a wider cognitive-affective-behavioral stress management intervention (e.g., Davis, 1991; Kerr & Goss, 1996; Maddison & Prapavessis, 2005; Noh, Morris, & Andersen, 2007).
Relaxation strategies refer to a range of cognitive-affective-behavioral techniques that are used to reduce stress response in the body and to facilitate physical and mental well-being (Walker & Heaney, 2013b). Typically divided into physical and mental relaxation strategies (Flint, 1998), these strategies can be effective in injury prevention by (a) shifting focus away from negative cognitive appraisals and increasing attentional control, (b) reducing negative affective states (e.g., anger, anxiety, mental tension, worry), and (3) directly influencing the physical stress responses (e.g., reducing muscle tension, heart rate variability). According to Walker and Heaney (2013b), the most commonly known and used physical rehabilitation strategies include biofeedback (e.g., Crews, 1993); progressive muscular relaxation (Jacobson, 1938); and a range of breath control techniques such as centering (e.g., Harwood, 1998), diaphragmatic breathing (e.g., McConnell, 2011), and ratio breathing (e.g., Dosil, 2006). Common mental relaxation strategies include autogenic training (Schultz & Luthe, 1969), transcendental meditation (Benson & Proctor, 1984), and more recently, mindfulness (Ivarsson, Johnson, Andersen, Fallby, & Altem, 2015; Kabat-Zinn, 1994). To date a majority of injury prevention studies have incorporated relaxation strategies into stress management interventions in a range of ways: (a) as part of a wider goal-setting program in the hope of reaching the desired goal, (b) as a prerequisite foundation for successful implementation of other cognitive-affective-behavioral interventions such as imagery, and (c) by pairing relaxation techniques with other strategies (e.g., self-talk and cue words) to facilitate changes in anxiety and arousal (Ivarsson et al., 2017). Anecdotal and empirical evidence have highlighted the prominent place of relaxation strategies for performance enhancement (DeWitt, 1980; Parnabas, Yahaya Mahamood, Parnabas, & Abdullah, 2014), injury prevention/reduction (Edvarsson, Ivarsson, & Johnson, 2012; Ivarsson et al., 2017; Kerr & Goss, 1996; Murphy, 1988; Perna et al., 2003; Tranaeus, Johnson, Engström, et al., 2015; Tranaeus, Johnson, Ivarsson, et al., 2015), injury rehabilitation, and return-to-activity process (Christakou & Zervas, 2007; Naoi & Ostrow, 2008).
Self-talk, commonly defined as “what people say to themselves either out loud or as a small voice inside their head” (Theodorakis, Weinberg, Natsis, Douma, & Kazakas, 2000, p. 254) is a cognitive-affective-behavioral strategy often used by individuals in a range of performance domains. Typically used to modify negative cognitive appraisals or to shift attentional focus to relevant tasks at hand (Walker & Hudson, 2013), self-talk strategies have been found to be beneficial for performance enhancement (Tod, Hardy, & Oliver, 2011) and during the injury rehabilitation and return-to-activity process (Walker & Hudson, 2013). Common self-talk strategies include use of cue words, thought-stopping, and reframing aimed to (a) elicit greater awareness and ability to control/change cognitive appraisals such as self-confidence, self-efficacy, motivational orientation, (b) positively influence and control range of affective states such as anger, anxiety, arousal, overall mood, worry, and (c) provide instructional behavioral reminders such as focus on breathing, attentional focus, knees over toes. Different self-talk strategies have also been found to be useful as part of a multimodal stress-management injury prevention intervention (DeWitt, 1980; Ivarsson et al., 2017; Johnson et al., 2005; Kerr & Goss, 1996; Noh et al., 2007; Perna et al., 2003; Tranaeus, Ivarsson, et al., 2015; Tranaeus, Johnson, Engström, et al., 2015; Tranaeus, Johnson, Ivarsson, et al., 2015) as well as part of an injury prevention program founded on neuromuscular training (Benjaminse, Gokeler, et al., 2015; Benjaminse, Welling, Otten, & Gokeler, 2015). In addition to performer-driven self-talk strategies, instructor/coach driven instructional strategies have also been found to be beneficial in injury prevention programs. A recent systematic review (Benjaminse, Welling, et al., 2015) found when using externally focused instructions (e.g., concentrate on the rungs of the Vertec) instead of internally focused instructions (e.g., concentrate on the tips of your fingers), significantly better motor performance and movement technique were achieved.
Social support, typically defined as “knowing that one is loved and that others will do all they can when a problem arises” (Sarason, Sarason, & Pierce, 1990, p. 119) is a multifaceted cognitive-affective-behavioral process that can help an individual deal with existing stressors more effectively. More specifically, social support is theorized as being helpful in either (a) directly influencing an individuals’ stress response or, (b) buffering the individual from any potential harmful effects of stressors (Rees, 2007). Much like the other cognitive-affective-behavioral strategies, social support has been found to be beneficial for performance enhancement (e.g., Rees, Hardy, & Freeman, 2007) and during injury rehabilitation/return-to-activity process (Arvinen-Barrow & Pack, 2013). Existing research has also identified that individuals who lack social support are more likely to encounter injuries (e.g., Hardy, Richman, & Rosenfeld, 1991; Luo, 1994; Smith, Smoll, & Ptacek, 1990). Moreover, injury prevention programs that have incorporated broad-based coping skills strategies that include social support have also found to be successful in reducing injury incidences (Tranaeus, Ivarsson, et al., 2015).
Behavioral Changes in Sleep, Rest, and Recovery
An area not rigorously explored but worthy of mentioning as a potential behavioral strategy for injury prevention is the role of sleep, rest, and recovery. Thus far, sleepiness has been found to be related to accidents (Dinges, 1995) and sleeping problems/disturbances/quality have been found to have a relationship with injury occurrence in dancers (Adam, Brassington, Steiner, & Matheson, 2004); soccer players (Laux, Krumm, Diers, & Flor, 2015); and military (acute, traumatic event–related injuries only and not overuse injuries; Gregg, Banderet, Reynolds, Creedon, & Rice, 2002). In contrast, a study with Australian footballers examined the potential relationship between sleep duration and efficiency and injury occurrence found no significant relationship (Dennis, Dawson, Heasman, Rogalski, & Robeya, 2016). There is also some limited evidence that decreased perceived recovery (i.e., a cognitive appraisal) from physical training (van der Does, Brink, Otter, Visscher, & Lemmink, 2016) and fatigue (Laux et al., 2015) may lead to increased risk of encountering an injury. As such, when considering injury prevention in sport and performance psychology, multimodal cognitive-affective-behavioral interventions such as goal setting may also need to address possible behavioral modifications required in sleep, rest, and recovery.
In the context of injury prevention, based on the theoretical and empirical evidence discussed in the previous sections, it appears that no one cognitive-affective-behavioral strategy when used in isolation is effective in injury prevention. Instead, any interventions should be designed in a way that consist of appropriately selected strategies that complement each other and are tailored to the individual’s needs. In essence, it would be imperative to teach individuals how to recognize, manage, and alleviate the psychophysiological stress response before an injury occurs (i.e., as part of regular practice and competition performance enhancement). It would be equally important that appropriately qualified health care professionals are part of the injury rehabilitation team, to help the injured individuals address and manage stressors during injury rehabilitation and return-to-activity process.
Psychosocial Injury Prevention as a Cyclical Biopsychosocial and Person-Centered Process
Considering the existing evidence, the following conceptualization (see Fig. 1) is offered to provide researchers and practitioners a holistic framework to help theorize the psychological injury prevention process. In addition to drawing from existing psychological theoretical and empirical evidence, the proposed conceptualization is underpinned by a philosophy that injury and high performance should be viewed on a continuum. Doing so will allow natural fluctuations in performance as the individual balances stress and recovery in response to periodized physical training. While doing so, the individual will also make required changes to their nutrition and sleep, and when necessary, modify their use of protective equipment and other preventative and recovery behaviors such as stretching and use of ice baths. In addition, as part of the injury-performance continuum, the individual will also use number of cognitive-affective-behavioral strategies such as goal setting, imagery, self-talk, relaxation strategies, and social support in the hope of reaching optimal high performance. Given that injuries are activities that performers are typically trying to avoid (Pargman, 2007), it is proposed that performance enhancement should be viewed as inherently intertwined with injury prevention; successful injury prevention efforts should facilitate more “injury-free” training days and thus better performances, and successful performance enhancement efforts should limit the occurrence of injury.
Building on the knowledge gained from the three phases of the rehabilitation approach to injury management (Kamphoff, Thomae, & Hamson-Utley, 2013; Taylor et al., 2003) and evidence in support of this approach (Clement, Arvinen-Barrow, & Fetty, 2015; Ruddock-Hudson, O’Halloran, & Murphy, 2014), the model also proposes that the process of injury prevention in sport and performance psychology should be a cyclical, continuous process. In the unfortunate event of injury occurrence, any rehabilitation efforts should also be intertwined with preventative efforts to address any potential pre- and post-injury factors which could act as antecedents to further injury. Moreover, similar preventative efforts should also be applied to the return-to-activity phase, or in case of career-ending injuries, to the retirement process with the aim to minimize the psychosocial risk of re-injury and/or any subsequent secondary injury to a different area of the body.
At the center of the injury prevention cycle and surrounded by the environment, is the individual, whose thoughts, emotions, and behaviors interact in a bidirectional cyclical manner throughout the process as highlighted in the integrated model (Wiese-Bjonrnstal et al., 1998). These cognitions, affects, and behaviors are influenced by a range of personal, environmental, and/or contextual factors, including other social agents interacting with the individual (for more details, see Brewer et al., 2002; Meyer, Merkur, Ebersole, & Massey, 2014; Wiese-Bjornstal et al., 1998). The success of such intra- and interpersonal interactions will have an impact on the outcome of the preventative and rehabilitative efforts after injury, and will play a role in subsequent post-injury placement of the individual on the injury–high performance continuum.
In conclusion, much of the injury prevention efforts are founded in the stress-injury relationship in that injury occurrence is often a consequence of a maladaptive physical and psychological responses to stress. To best understand injury prevention in sport and performance psychology, it is imperative to understand its inherent relationship with performance enhancement, post-injury rehabilitation, return to activity, and/or retirement from activity. For successful injury prevention interventions to work, it is also important to recognize the individual differences in the injured persons’ cognitive-affective-behavioral responses to a stressful situation. Thus far research in this field has be limited and mostly conducted in a (competitive) sport setting. It is therefore encouraged that future empirical research and applied interventions should include participants from other performance domains, such as occupational athletes and performing artists. To ensure rigor and moving the knowledge of the field forward, these research and applied intervention efforts should be theoretically grounded in and utilizing sound qualitative and quantitative methodological approaches.
Adam, M. U., Brassington, G. S., Steiner, H., & Matheson, G. O. (2004). Psychological factors associated with performance-limiting injuries in professional ballet dancers. Journal of Dance Medicine & Science, 8(2), 43–46.Find this resource:
Andersen, M. B., & Williams, J. M. (1988). A model of stress and athletic injury: Prediction and prevention. Journal of Sport & Exercise Psychology, 10, 294–306.Find this resource:
Appaneal, R. N., & Habif, S. (2013). Psychological antecedents to sport injury. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 6–22). Abingdon, U.K.: Routledge.Find this resource:
Appaneal, R. N., & Perna, F. M. (2014). Biopsychosocial model of injury. In R. C. Eklund & G. Tenenbaum (Eds.), Encyclopedia of Sport and Exercise Psychology (pp. 74–77). Thousand Oaks, CA: SAGE.Find this resource:
Arvinen-Barrow, M., Clement, D., & Hemmings, B. (2013). Imagery in sport injury rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 71–85). Abingdon, U.K.: Routledge.Find this resource:
Arvinen-Barrow, M., & Hemmings, B. (2013). Goal setting in sport injury rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 56–70). Abingdon, U.K.: Routledge.Find this resource:
Arvinen-Barrow, M., & Pack, S. M. (2013). Social support in sport injury rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 117–132). Abingdon, U.K.: Routledge.Find this resource:
Arvinen-Barrow, M., & Walker, N. (Eds.). (2013). Psychology of sport injury and rehabilitation. Abington, U.K.: Routledge.Find this resource:
Beneka, A., Malliou, P., Bebetsos, E., Gioftsidou, A., Pafis, G., & Godolias, G. (2007). Appropriate counselling techniques for specific components of the rehabilitation plan: A review of the literature. In Physical Training: Fitness for Combatives. Retrieved from http://ejmas.com/pt/2007pt/ptart_beneka_0707.html.Find this resource:
Benjaminse, A., Gokeler, A., Dowling, A. V., Faigenbaum, A., Ford, K. R., Hewett, T. E., et al. (2015). Optimization of the anterior cruciate ligament injury prevention paradigm: Novel feedback techniques to enhance motor learning and reduce injury risk. Journal of Orthopaedic & Sports Physical Therapy, 45(3), 170–182.Find this resource:
Benjaminse, A., Welling, W., Otten, B., & Gokeler, A. (2015). Novel methods of instruction in ACL injury prevention programs: A systematic review. Physical Therapy in Sport, 16(2), 176–186.Find this resource:
Benson, H., & Proctor, W. (1984). Beyond the relaxation response. New York: Berkeley.Find this resource:
Berger, B. G., Pargman, D., & Weinberg, R. S. (2007). Foundations of exercise psychology (2d ed.). Morgantown, WV: Fitness Information Technology.Find this resource:
Brewer, B. W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of Applied Sport Psychology, 6, 87–100.Find this resource:
Brewer, B. W., Andersen, M. B., & Van Raalte, J. L. (2002). Psychological aspects of sport injury rehabilitation: Toward a biopsychological approach. In D. I. Mostofsky & L. D. Zaichkowsky (Eds.), Medical aspects of sport and exercise (pp. 41–54). Morgantown, WV: Fitness Information Technology.Find this resource:
Brewer, B. W., & Redmond, C. (2016). Psychology of sport injury. Champaign, IL: Human Kinetics.Find this resource:
Christakou, A., & Zervas, Y. (2007). The effectiveness of imagery on pain, edema, and range of motion in athletes with grade II ankle sprain. Physical Therapy in Sport, 8(3), 130–141.Find this resource:
Clement, D., Arvinen-Barrow, M., & Fetty, T. (2015). Psychosocial responses during different phases of sport injury rehabilitation: A qualitative study. Journal of Athletic Training, 50(1), 95–104.Find this resource:
Crews, D. J. (1993). Self-regulation strategies in sport and exercise. In R. N. Singer, M. Murphy, & L. K. Tennant (Eds.), Handbook of research on sport psychology (pp. 557–568). New York: MacMillan.Find this resource:
Davis, J. O. (1991). Sport injuries and stress management: An opportunity for research. The Sport Psychologist, 5(2), 175–182.Find this resource:
Dennis, J., Dawson, B., Heasman, J., Rogalski, B., & Robeya, E. (2016). Sleep patterns and injury occurrence in elite Australian footballers. Journal of Science and Medicine in Sport, 19(2) 113–116.Find this resource:
DeWitt, D. J. (1980). Cognitive and biofeedback training for stress reduction with university athletes. Journal of Sport Psychology, 2(4), 288–294.Find this resource:
Dinges, D. (1995). An overview of sleepiness and accidents. Journal of Sleep Research, 4(2), 4–14.Find this resource:
Dosil, J. (2006). The sport psychologist’s handbook: A guide for sport-specific performance enhancement. Chichester, U.K.: Wiley & Sons.Find this resource:
Dvorak, J., Junge, A., Chomiak, J., Graf-Baumann, T., Peterson, L., Rosch, D., & Hodgson, R. (2000). Risk factor analysis for injuries in football players: Possibilities for a prevention program American Journal of Sports Medicine, 28(90005), 69S–74S.Find this resource:
Edvarsson, A., Ivarsson, A., & Johnson, U. (2012). Is a cognitive-behavioural biofeedback intervention useful to reduce injury risk in junior football players? Journal of Sports Medicine, 11(2), 331–338.Find this resource:
Evans, L., & Hardy, L. (1995). Sport injury and grief response: A review. Journal of Sport & Exercise Psychology, 17, 227–245.Find this resource:
Feltz, D. L., & Landers, D. M. (1983). The effects of mental practice on motor skills, learning, and performance: A meta-analysis. Journal of Sport Psychology, 5(1), 25–57.Find this resource:
Flint, F. A. (1998). Specialized psychological interventions In F. A. Flint (Ed.), Psychology of sport injury (pp. 29–50). Leeds, U.K.: Human Kinetics.Find this resource:
Gregg, R. L., Banderet, L. E., Reynolds, K. L., Creedon, J. F., & Rice, V. J. (2002). Psychological factors that influence traumatic injury occurrence and physical performance. Work, 18(2), 133–139.Find this resource:
Hall, C. R., Mack, D. E., Paivio, A., & Hausenblas, H. A. (1998). Imagery use by athletes: Development of the sport imagery questionnaire. International Journal of Sport Psychology, 29(1), 73–89.Find this resource:
Hardy, C. J., Richman, J. M., & Rosenfeld, L. B. (1991). The role of social support in the life stress/injury relationship. The Sport Psychologist, 5(2), 128–139.Find this resource:
Harwood, C. (1998). Handling Pressure. Leeds, U.K.: The National Coaching Foundation.Find this resource:
Heil, J. (1993). Psychology of sport injury. Champaign, IL: Human Kinetics.Find this resource:
Heil, J., & Podlog, L. (2012). Injury and performance. In S. M. Murphy (Ed.), The Oxford handbook of sport and performance psychology (pp. 593–617). Oxford: Oxford University Press.Find this resource:
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment scale. Journal of Psychosomatic Research, 11(2), 213–218.Find this resource:
Ivarsson, A., & Johnson, U. (2010). Psychological factors as predictors of injuries among senior soccer players: A prospective study. Journal of Sports Science and Medicine, 9, 347–352.Find this resource:
Ivarsson, A., Johnson, U., Andersen, M. B., Fallby, J., & Altem, M. (2015). It pays to pay attention: A mindfulness-based program for injury prevention with soccer players. Journal of Applied Sport Psychology, 27(3), 319–334.Find this resource:
Ivarsson, A., Johnson, U., Andersen, M. B., Tranaeus, U., Stenling, A., & Lindwall, M. (2017). Psychosocial factors and sport injuries: Meta-analyses for prediction and prevention. Sports Medicine, Training and Rehabilitation, 47(2), 353–365.Find this resource:
Ivarsson, A., Johnson, U., & Podlog, L. (2013). Psychological predictors of injury occurrence: A prospective investigation of professional Swedish soccer players. Journal of Sport Rehabilitation, 22(1), 19–26.Find this resource:
Jacobson, E. (1938). Progressive relaxation. Chicago: University of Chicago Press.Find this resource:
John Muir Health. (2017). Sports injury prevention program: A program designed to teach healthy young athletes how to prevent injuries. In John Muir Health. Retrieved from https://www.johnmuirhealth.com/services/physical-rehabilitation/outpatient-physical-rehabilitation/sports-injury-prevention.html.Find this resource:
Johnson, U., Ekengren, J., & Andersen, M. B. (2005). Injury prevention in Sweden: Helping soccer players at risk. Journal of Sport & Exercise Psychology, 27(1), 32–38.Find this resource:
Kabat-Zinn, J. (1994). Wherever you go, there are you: Mindfulness meditation in everyday life. New York: Hyperion.Find this resource:
Kamphoff, C., Thomae, J., & Hamson-Utley, J. J. (2013). Integrating the psychological and physiological aspects of sport injury rehabilitation: Rehabilitation profiling and phases of rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 134–155). Abingdon, U.K.: Routledge.Find this resource:
Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A., van Beek, P. A., Hullegie, W. A., Bloemers, G. M., et al. (2012). Diagnosis, treatment and prevention of ankle sprains: An evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854–860.Find this resource:
Kerr, G. A., & Goss, J. (1996). The effects of a stress management program on injuries and stress levels. Journal of Applied Sport Psychology, 8(1), 109–117.Find this resource:
Kolt, G. S., & Kirkby, R. (1996). Injury in Australian female competitive gymnasts: A psychological perspective. Australian Journal of Physiotherapy, 42(2), 121–126.Find this resource:
Laux, P., Krumm, B., Diers, M., & Flor, H. (2015). Recovery-stress balance and injury risk in professional football players: A prospective study. Journal of Sports Sciences, 33(20), 2140–2149.Find this resource:
Locke, E. A., & Latham, G. P. (1985). The application of goal setting to sports. Journal of Sport Psychology, 7(3), 205–222.Find this resource:
Luo, Y. (1994). The relationship of daily hassles, major life events and social support to athletic injury in football (PhD Doctoral Thesis). University of Minnesota, MN, ProQuest Dissertations and Theses; 1994; ProQuest Dissertations & Theses (PQDT).Find this resource:
Maddison, R., & Prapavessis, H. (2005). A psychological approach to the prediction and prevention of athletic injury. Journal of Sport & Exercise Psychology, 27(3), 289–310.Find this resource:
McConnell, A. (2011). Breathe strong perform better. Champaign, IL: Human Kinetics.Find this resource:
McDonald, S. A., & Hardy, C. J. (1990). Affective response patterns of the injured athlete: An exploratory analysis. The Sport Psychologist, 4(3), 261–274.Find this resource:
Meyer, B. B., Merkur, A., Ebersole, K. T., & Massey, W. V. (2014). The realities of working in elite sport. What they didn’t teach you in graduate school. In A. M. Lane, R. J. Godfrey, M. Loosemore, & G. P. Whyte (Eds.), Applied sport science and medicine: Case studies from practice (pp. 137–142): CreateSpace: Self-published.Find this resource:
Murphy, S. M. (1988). The on-site provision of sport psychology service at the U.S. Olympic Festival. The Sport Psychologist, 2(4), 337–350.Find this resource:
Naoi, A., & Ostrow, A. (2008). The effects of cognitive and relaxation interventions on injured athletes mood and pain during rehabilitation. Athletic Insight, 10(1).Find this resource:
Noh, Y.-E., Morris, T., & Andersen, M. B. (2007). Psychological intervention programs for reduction of injury in ballet dancers. Research in Sports Medicine, 15(1), 13–32.Find this resource:
Nugent, P. (2013). Performance. Psychology Dictionary: World’s Most Comprehensive Online Psychology Dictionary. Available from https://psychologydictionary.org/performance/.
Ogilvie, B. C. (1966). Problem athletes and how to handle them. London: Pelham.Find this resource:
Olmedilla-Zafra, A., Rubio, V. J., Ortega, E., & García-Mas, A. (2017). Effectiveness of a stress management pilot program aimed at reducing the incidence of sports injuries in young football (soccer) players. Physical Therapy in Sport, 24(2), 53–59.Find this resource:
Pargman, D. (Ed.). (2007). Psychological bases of sport injuries (3d ed.). Morgantown, WV: Fitness Information Technology.Find this resource:
Parnabas, V. A., Yahaya Mahamood, Y., Parnabas, J., & Abdullah, N. M. (2014). The relationship between relaxation techniques and sport performance.Universal Journal of Psychology, 2(3), 108–112.Find this resource:
Perna, F. M., Antoni, M. H., Baum, A., Gordon, P., & Schneiderman, N. (2003). Cognitive behavioral stress management effects on injury and illness among competitive athletes: a randomized clinical trial. Annals of Behavioral Medicine, 25(1), 66–73.Find this resource:
Rees, T. (2007). Influence of social support on athletes. In S. Jowett & D. Lavallee (Eds.), Social psychology in sport (pp. 223–232). Champaign, IL: Human Kinetics.Find this resource:
Rees, T., Hardy, L., & Freeman, P. (2007). Stressors, social support, and effects upon performance in golf. Journal of Sports Sciences, 25(1), 33–42.Find this resource:
Ruddock-Hudson, M., O’Halloran, P., & Murphy, G. (2014). The psychological impact of long-term injury on Australian football league players. Journal of Applied Sport Psychology, 26(4), 377–394.Find this resource:
Sarason, B. R., Sarason, I. G., & Pierce, G. R. (1990). Social support, personality, and performance. Journal of Applied Sport Psychology, 2(2), 117–127.Find this resource:
Schultz, J., & Luthe, W. (1969). Autogenic methods (Vol. 1). New York: Grune & Stratton.Find this resource:
Smith, R. E., Smoll, F. L., & Ptacek, J. T. (1990). Conjunctive moderator variables in vulnerability and resiliency research: Life stress, social support and coping skills, and adolescent sport injuries. Journal of Personality and Social Psychology, 58(2), 360–370.Find this resource:
Sutter Health. (2015). Sports injury prevention program: Sutter Davis Hospital. Retrieved from http://www.sutterdavis.org/services/sports-injuries.html.
Taylor, J., Stone, K. R., Mullin, M., J, Ellenbecker, T., & Walgenbach, A. (2003). Comprehensive sports injury management: From examination of injury to return to sport (2d ed.). Austin, TX: Pro-Ed.Find this resource:
Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Gaithersburg, MD: Aspen.Find this resource:
Thelwell, R., Greenlees, I. A., & Weston, N. J. V. (2010). Examining the use of psycholigical skills througout soccer performance. Journal of Sport Behavior, 33(1), 109–127.Find this resource:
Theodorakis, Y., Weinberg, R., Natsis, P., Douma, I., & Kazakas, P. (2000). The effects of motivational versus instructional self-talk on improving motor performance. The Sport Psychologist, 14, 253–271.Find this resource:
Tod, D., Hardy, J., & Oliver, E. (2011). Effects of self-talk: A systematic literature review. Journal of Sport and Exercise Psychology, 33(5), 666–687.Find this resource:
Tranaeus, U., Ivarsson, A., & Johnson, U. (2015). Evaluation of the effects of psychological prevention interventions on sport injuries: A meta-analysis. Science & Sports, 30, 305–313.Find this resource:
Tranaeus, U., Johnson, U., Engström, B., Skillgate, E., & Werner, S. (2015). A psychological injury prevention group intervention in Swedish floorball. Knee Surgery Sports Traumatology Arthroscopy, 23(11), 3414–3420.Find this resource:
Tranaeus, U., Johnson, U., Ivarsson, A., Engström, B., Skillgate, E., & Werner, S. (2015). Sports injury prevention in Swedish elite floorball players: Evaluation of two consecutive floorball seasons. Knee Surgery Sports Traumatology Arthroscopy, 23(3), 899–905.Find this resource:
van der Does, H. T., Brink, M. S., Otter, R. T., Visscher, C., & Lemmink, K. A. (2016). Injury risk is increased by changes in perceived recovery of team sport players. Clinical Journal of Sport Medicine, 27(1), 1–6.Find this resource:
van Mechelen, W., Twisk, J., Molendijk, A., Blom, B., Snel, J., & Kemper, H. C. (1996). Subject-related risk factors for sports injuries: A 1-yr prospective study in young adults. Medicine and Science in Sports and Exercise, 28(9), 1171–1179.Find this resource:
Vanderbilt University Medical Center. (2017). Program for injury prevention in youth sports. Retrieved from http://www.childrenshospital.vanderbilt.org/sportssafety.
Walker, N., & Heaney, C. (2013a). Psychological response to injury: A review and critique of existing models. In M. Arvinen-Barrow & N. Walker (Eds.), The Psychology of Sport Injury and Rehabilitation (pp. 23–39). Abingdon, U.K.: Routledge.Find this resource:
Walker, N., & Heaney, C. (2013b). Relaxation techniques in sport injury rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 86–102). Abingdon, U.K.: Routledge.Find this resource:
Walker, N., & Hudson, J. (2013). Self-talk in sport injury rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds.), Psychology of sport injury and rehabilitation (pp. 103–116). Abingdon: Routledge.Find this resource:
Walker, N., Thatcher, J., & Lavallee, D. (2007). 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.Find this resource:
Weinberg, R. S., & Gould, D. (2015). Foundations of Sport and Exercise Psychology (6th ed.). Champaign, IL: Human Kinetics.Find this resource:
Wiese-Bjornstal, D. M., Smith, A. M., Shaffer, S. M., & Morrey, M. A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10(1), 46–69.Find this resource:
Wiese-Bjornstal, D. M., White, A. C., Russell, H. C., & Smith, A. M. (2015). Psychology of sport concussions. Kinesiology Review, 5, 169–189.Find this resource:
Williams, J. M., & Andersen, M. B. (1998). Psychosocial antecedents of sport injury: Review and critique of the stress and injury model. Journal of Applied Sport Psychology, 10(1), 5–25.Find this resource: