Psychology Of Sport Injury PDF

14 Psychology of Sport Injury also alter their standards in situations where sport performance outcomes are on the line. Sport Health Care Professional Health care personnel who work with athletes face a variant of the risk–pain–injury paradox (Nixon, 1994a) that is even more acute than the bind e...

14 Psychology of Sport Injury also alter their standards in situations where sport performance outcomes are on the line. Sport Health Care Professional Health care personnel who work with athletes face a variant of the risk–pain–injury paradox (Nixon, 1994a) that is even more acute than the bind experienced by coaches. Charged with ensuring athletes’ health, sport health care professionals are encouraged not only to restore health in injured athletes but also to return them as quickly as possible to the arena in which they were injured. This apparent paradox has been documented through qualitative research involving a variety of sport health care professionals. Specifically, interviews with sports medicine physicians, physiotherapists (Safai, 2003; Waddington, 2006), and student athletic trainers (Walk, 1997) suggest that acceptance and tolerance of risk, pain, and injury in sport are ubiquitous among sport health care professionals. Thus, the culture of risk is considered “part of the game” for this segment of sportsnets, too. Some sport health care professionals have described experiencing pressure from coaches to expedite an athlete’s return to sport competition faster than might be medically advisable, and in some cases they report making medical compromises with which they were not entirely comfortable (Waddington, 2006). Despite such pressure, which may also be exerted by athletes themselves, sport health care professionals have also reported that they are able to maintain focus on providing services in the best medical interests of athletes (Safai, 2003; Walk, 1997). Experimental backing for these claims of clinical objectivity was obtained by Flint and Weiss (1992), who administered the same procedures described earlier for research with coaches to athletic trainers working with high school and college basketball teams. Unlike the coaches’ decisions, however, the athletic trainers’ decisions about a hypothetical basketball player’s return to play after an injury were not influenced by either the player’s status or the game situation. In addition, Safai (2004) concluded that physicians and physiotherapists in sports medicine are not only influenced by the prevailing social climate in sportsnets but also are able to influence that social climate through their behavior. Indeed, Safai (2004) proposed that sport health care professionals could counteract the culture of risk by establishing a “culture of precaution” that resists the culture of risk and promotes an environment in which “sensible risks” are taken after careful consideration. In fact, a culture of precaution is already somewhat evident in the case of head and brain injuries, regarding which a zerotolerance approach is often taken to playing hurt (Safai, 2003). For more on sociocultural aspects of sport injury, see this chapter’s Focus on Research box. Athlete As noted by Nixon (1992) in his initial description of sportsnets and their role in the culture of risk, athletes learn that they must “be able to play hurt and come back from serious injuries . . . and accept or ignore the risks of pain and injuries” (p. 128). This assertion has been consistently supported by research examining the behaviors and beliefs of elite and nonelite athletes in Canada, the United Kingdom, and the United States in regard to risk, pain, and injury in sport (Liston et al., 2006; Nixon, 1994b; Safai, 2003; K. Young et al., 1994). The idea that pain and injury are normal parts of sport participation appears to be widely accepted among athletes. Nixon (1992) also proposed that athletes receive a “biased” set of messages reaffirming the values and beliefs associated with the culture of risk from other members of the sportsnet, who collectively constitute a “collusive, closed system that attempts to isolate them from external social contact” (p. 130) and conspires to have them play in pain. Evidence supporting the first part of this claim—regarding messages that athletes receive about risk, pain, and injury—was obtained in a survey of 156 collegiate athletes (Nixon, 1994b). Nearly half of the athletes (49 percent) reported feeling pressured by coaches to play hurt; in addition, 41 percent reported feeling such pressure from teammates and 17 percent from athletic trainers. The second (and more controversial) portion of the claim made by Nixon (1992)— regarding collusion by sportsnet members to isolate athletes from outside influences— remains without empirical support. In fact, B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. From the mid-1980s through the mid-1990s, the sociocultural aspects of pain and injury were hot topics in the sociology of sport. During that fertile period, articles on the subject appeared regularly in professional journals. In particular, a trio of prolific scholars published multiple papers examining various sociological issues associated with pain and injury in sport, thereby laying a theoretical and empirical foundation on which subsequent investigators could build. Timothy Jon Curry (1986, 1993; Curry & Strauss, 1994; Strauss & Curry, 1983) got the ball rolling with a series of studies examining social factors, pain, and injury among competitive wrestlers. Kevin Young (1991, 1993; K. Young & White, 1995; K. Young et al., 1994) followed Curry’s lead and brought gender roles into the discussion of risk and injury in sport. In addition, Howard L. Nixon II (1992, 1993a, 1993b, 1994a, 1994b, 1996a, 1996b) published a flurry of seven articles on pain and injury in sport from a sociological perspective over a five-year period. Best known for explicating the “culture of risk” that permeates sport, Nixon enjoyed an incredible run of scholarly productivity. Subsequent research (e.g., Liston, Reacher, Smith, & Waddington, 2006; Safai, 2003; Walk, 1997) validated Nixon’s ideas regarding the extent to which athletes and other members of their sport-related social networks (or “sportsnets”) endorse the values and beliefs associated with the culture of risk. These endorsements emphasize the idea that risk, pain, and injury should be accepted, tolerated, and played through (Nixon, 1992). Some of Nixon’s original assumptions about how sportsnets operate and impart the culture of risk to athletes have been questioned (e.g., Roderick, 1998) and challenged empirically, prompting him (Nixon, 1998) to note that “Walk’s (1997) research concerning student athletic trainers casts some doubt on the idea of insulated, culturally homogenous, and conspiratorial sportsnets of athletes and student trainers” (p. 82). In the ensuing dozen years or so, the sociocultural dimension of pain and injury in sport has remained a staple in the sociology of sport, as evidenced by the publication of a single-author book (Howe, 2004) and two edited volumes (Loland, Skirstad, & Waddington, 2006; K. Young, 2004) on the subject. Indeed, though the rate of scholarly productivity may have slowed since the mid-1990s, the topic is now being explored by a more diverse group of researchers. For example, the latter of the two edited volumes (Loland et al., 2006) featured scholars from seven nations, thus reflecting widespread interest in the topic. Most recently, attention to sociocultural issues has accompanied the explosion of scientific research on—and public awareness of—sport-related concussion, as multiple investigations have examined factors associated with athletes’ level of willingness to disclose concussion symptoms (e.g., Davies & Bird, 2015; Z.Y. Kerr, Register-Mihalik, Kroshus, Baugh, & Marshall, 2016). Although investigators have long recognized the psychological implications of sociocultural phenomena in sport injury (e.g., Flint & Weiss, 1992; WieseBjornstal, Smith, Shaffer, & Morrey, 1998), few studies have examined the subject from a psychological perspective, and many important questions remain unanswered. Here are a few examples: By what developmental process do athletes internalize the culture of risk? How do athletes learn to balance the requirements of their sport with measures that help ensure their health and well-being? What cognitive processes underlie athletes’ decisions to play hurt, as well as coaches’ and sport administrators’ decisions to allow athletes to do so? Can the culture of risk be modified without fundamentally altering the nature of sport? Answers to these and other key questions ramify in the realm of professional practice and therefore warrant attention from sport scientists. Walk (1997) presented evidence that athletes sometimes seek medical attention outside of their sportsnet and that although athletes may experience pressure from coaches to play hurt, such pressure is not implemented in a coordinated, consistent way across the sportsnet. Examining the relevant data, Roderick (1998) likewise rejected the notion that sportsnets conspired and colluded against athletes stating that “the risks of pain and debilitating injury . . . cannot be explained simply in terms of the planned intentions of coaches, management, owners, and other ‘powerful’ individuals” (p. 77). B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Focus on Research Documenting the Culture of Risk 15 16 Psychology of Sport Injury On the whole, although athletes are firmly entrenched in the culture of risk and subject to its influences, they are also capable of acting autonomously in the face of risk, pain, and injury. Walk (1997) stated that “we should not view athletes as ‘dupes’ in minimizing the roles and responsibilities they may play in exercising sovereignty over the treatment of their own bodies” (p. 54). Toward this end, Walk showed that by willfully disregarding medical recommendations and hiding injuries from coaches and sport health care professionals, athletes testified “to their relative freedom to use athletic training services at their own discretion” (p. 51). Similarly, athletes interviewed by Safai (2003) reported engaging in “intrapersonal negotiation” (i.e., internal discussions) about when and under which circumstances to seek treatment for conditions that are painful but not severe enough to preclude sport participation. Social Support Of course, not all of an athlete's social interactions pertain to the culture of risk; in fact, most of an athlete’s contact with other people involves matters other than risk, pain, and injury. Moreover, a portion of an athlete’s relationships can generally be labeled as social support. This type of relationship has been evaluated in many ways, including the number of one’s social relationships; the assistance one perceives as being available from others; the assistance one actually receives (House & Kahn, 1985); the exchange of resources between two or more people resulting in enhanced wellbeing for the recipient (Richman, Rosenfeld, & Hardy, 1993; Shumaker & Brownell, 1984); and companionship that provides emotional comfort, material help, or informational feedback (Straub, 2012). Despite the variability in how social support is defined, it is generally agreed that social support can involve multiple dimensions, providers, and functions. Dimensions of Social Support Various schemes have been proposed to describe the ways in which people provide sup- port to one another. Common elements in these schemes include three kinds of support: emotional, informational, and tangible (Hardy, Burke, & Crace, 1999). Emotional support involves caring for, comforting, instilling a sense of belonging in, listening to, reassuring, and showing concern and empathy for another person. Informational support provides advice, guidance, and, of course, information; tangible support, in contrast, provides material goods, monetary assistance, and personal services. Athletes receive these forms of social support from a variety of providers. Providers of Social Support Providers of social support for athletes include both the members of their sportsnets (i.e., coaches, sport administrators, sport health care professionals, and other athletes) and people outside of their sportsnets (in particular, partners and significant others, friends, and family members). Different providers may give athletes different kinds of support (Rosenfeld, Richman, & Hardy, 1989). For example, a collegiate softball player might receive emotional support from her partner or significant other and her friends, informational support from her coach and athletic trainer, and tangible support from her parents and other family members. Functions of Social Support Social support is widely recognized as benefitting both physical and psychological wellbeing (Hardy et al., 1999). These benefits are thought to occur both directly, through health-enhancing effects (Wills, 1985), and indirectly, through stress-buffering effects (Cohen & Wills, 1985). More specifically, and consistent with a biopsychosocial perspective, social support is positively associated with health-enhancing behavior and with cardiovascular, immune, and neuroendocrine functioning (Uchino, Cacioppo, & Kiecolt-Glaser, 1996; Uchino, Uno, & Holt-Lunstad, 1999)—all of which may contribute to improved health and well-being. Social support also reduces the effects of stressors on physical and mental health, both by making stressors themselves less potent (e.g., by providing financial assis- B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Biopsychosocial Foundations of Sport Injury   17 tance to relieve debt) and by empowering individuals to better handle stressful situations (e.g., by demonstrating how to view a problem in a new and constructive way). As shown in the chapters ahead, the relationship between social support and well-being carries important implications for sport injury occurrence, response, and recovery. Biopsychosocial Analysis Let us now review this chapter’s key concepts by returning to the case of Lisa, which opened the chapter, and examining it from a biopsychosocial perspective. Lisa experienced an injury in her ankle due to macrotrauma from forces generated when she under-rotated her vault landing. Fueled by her strong motivation to participate in the conference championships, Lisa then repeatedly traumatized the injured area by continuing to participate actively in gymnastics. The ongoing stress in her ankle prevented her from getting past the inflammatory-response phase, to which she responded with repeated icing and copious amounts of ibuprofen. Healing could not begin in earnest for Lisa until she stopped abusing her ankle and sought treatment for her injury from a qualified practitioner. Given Lisa’s academic background, she understood the painful signals she was receiving from her ankle; however, she willfully chose to ignore the symptoms and conceal them from her coaches, teammates, and sport health care professionals. In attempting to play through her painful injury, Lisa seems to have internalized the sport ethic and decided that competing in sport at a high level was worth the potential long-term risks to her musculoskeletal health. Outside of the tangible assistance she received from her roommate, Lisa eschewed social support due to fear that her secret would be discovered and her progress toward her goal would be thwarted. Thus biological, psychological, and social factors converged in influencing the situation in which Lisa found herself and her responses to it. Summary In order to best prevent and treat sport injury, we must look beyond the physical perspective and consider psychological and social factors as well. The biomedical model, which holds that the mind and the body are separate entities and that health is affected only by physical factors, has persisted for some time; however, appreciation has also emerged of the mind’s role in contributing to health. With origins in ancient medical systems, a biopsychosocial approach encourages us, as its name indicates, to examine biological, psychological, and social factors when considering health issues. This approach carries important implications for understanding how sport injuries occur, how athletes respond psychologically and socially to sport injury, and how athletes recover physically from sport injury. Sport injuries can be classified along multiple biological dimensions, including mechanism (e.g., macrotrauma, microtrauma, overuse), type (e.g., sprain, strain), location (e.g., upper or lower extremity), and severity. Healing of a sport injury typically includes three stages: inflammation, fibroblastic repair (scarring), and tissue remodeling. Rehabilitation of a sport injury generally involves limiting tissue damage while decreasing pain and swelling, restoring normal function of the tissue and structures involved (e.g., range of motion, strength, balance), and returning to sport functioning. In the holistic approach that characterizes this text, we must understand the role of both physical and psychosocial factors in supporting an athlete’s healing and safe return to full sport participation. In particular, we must attend to biological systems (e.g., musculoskeletal, cardiovascular, nervous), psychological aspects (e.g., cognition, motivation, perception), and social influences (e.g., social support). We must also account for interactions between the biopsychosocial factors, which include reciprocal influences on each other. Although social influences exist outside of athletes, their role should not be underestimated in the occurrence of sport injury or in athletes’ short- and long-term responses B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 18 Psychology of Sport Injury to injury. Social support can take the form of emotional support (e.g., listening to, comforting), informational support (e.g., providing advice and guidance), or tangible support (e.g., providing monetary assistance and personal services). Common providers of social support to athletes include teammates, coaches, sport health care professionals, sport administrators, friends, partners, a nd family members. Research suggests that both male and female athletes are socialized into a culture of risk that encourages them to minimize pain, conceal injury, and play hurt; in fact, these actions are treated as regular elements of sport participation and are considered to be acceptable behaviors. The process by which athletes adopt the sport ethic (which involves making sacrifices, striving for distinction, accepting risks, playing through pain, and refusing to accept limits) and the factors (e.g., coaches, teammates, parents, administrators, sport health care professionals, media) that can influence an athlete’s adherence to the culture of risk are not fully understood and, therefore, warrant further investigation. Discussion Questions 1. How does a biopsychosocial approach to sport injury differ from that of the biomedical model? 2. Why is it sometimes difficult to determine the severity of a sport injury? 3. How do perceptions of sport injury differ from cognitions about sport? 4. What is the “sport ethic”? 5. What roles do sport administrators, coaches, sport health care professionals, and athletes play in the “culture of risk”? B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 20 Psychology of Sport Injury As Alex was unfortunate enough to learn, injury is a common by-product of sport participation; as a result, sport health care professionals have long sought strategies for preventing (or at least minimizing) the occurrence of injury among athletes. In order to develop such interventions, professionals must thoroughly understand the processes by which athletes become injured (W. van Mechelen, Hlobil, & Kemper, 1992). Knowing the etiology of sport injury helps professionals determine when, where, and how to intervene in order to achieve maximal prevention. To that end, this chapter addresses models of sport injury occurrence, psychosocial predictors of sport injury, and mechanisms of psychosocial influence on sport injury occurrence. Models of Sport Injury Occurrence At first glance, explaining Alex’s injury would seem to be a simple task. He collided with another player, fell to the ground, and dislocated his shoulder as a result of the impacts he sustained. End of story, right? Not necessarily. Contemporary models of sport injury occurrence suggest that although the physical forces Alex absorbed may have delivered the final blows, other culprits may have contributed to his injury. More specifically, models of sport injury occurrence have been proposed by two schools of thought—the multifactorial model of sport injury etiology, which is based primarily in sports medicine and epidemiology, and the stress–injury model, which is based predominantly in sport psychology. Despite a shared recognition that multiple biological, psychological, and social factors may contribute to sport injury occurrence, these two models have evolved in large part independently of each other. Both models have made important contributions to contemporary understandings of the etiology of sport injury and therefore warrant further exploration. Multifactorial Model of Sport Injury Etiology Developed over the past four decades, the multifactorial model is less a single, unified con- ceptualization of the causes of sport injury than a series of related representations of the processes by which sport injury is thought to occur. As described by W. van Mechelen et al. (1992), the earliest versions of the model focused on identifying both internal (i.e., intrinsic or personal) factors and external (i.e., extrinsic or environmental) factors that contribute to the occurrence of sport injury. These early versions of the model posited that internal factors determined an athlete’s capacity to deal with the stress produced by environmental factors and that injury was most likely to occur when stress exceeded the individual’s capacity. Among the internal factors thought to affect this capacity were biological variables (e.g., previous injury, physical defect, height, weight, joint stability, body fat, age, sex), psychological variables (e.g., self-concept, locus of control, risk acceptance, personality), and physical fitness variables reflecting the interaction between psychological states (e.g., motivation, behavior) and physiological parameters (e.g., aerobic endurance, strength, speed, sport skill, coordination, flexibility). External factors thought to confer stress (and, ultimately, injury risk) on athletes included sport-related variables (e.g., type of sport, exposure, nature of event, opponent and teammate behavior [a social factor!], rules, referees’ application of rules), venue (e.g., state of floor or ground, lighting, safety features), equipment (e.g., sport implements, protective gear, shoes, clothing), and weather conditions (e.g., temperature, relative humidity, wind). Limitations were noted in this stresscapacity conceptualization of sport injury etiology by W. van Mechelen et al. (1992). As a result, they added a dynamic element, introduced the concept of strain, and incorporated an active role for the athlete into the process in order to explain the occurrence of acute and overuse injuries. Specifically, they suggested that • stress from external factors produces strain, which, if substantial enough in relation to capacity, produces acute injury; • repetitive and accumulated strain over time results in overuse injury; B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Antecedents of Sport Injury   21 • capacity can change over time and can be affected by external stress, such as when fatigue impairs motor skills; and • athletes can reduce external stress by altering their involvement in the sport activity. events that incite acute injury (e.g., colliding with another athlete) may differ in nature from those that incite overuse injury (e.g., excessive training volume). More recently, the multifactorial model has been further modified in important ways by Bahr and Krosshaug (2005) and by Meeuwisse, Tyreman, Hagel, and Emery (2007). Bahr and Krosshaug focused their efforts on the incitingevent portion of the model, with an eye toward describing more fully the mechanisms of sport injury. Specifically, they proposed that descriptions of inciting events should address The multifactorial model was next expanded by Meeuwisse (1994), who made several key modifications. As shown in figure 2.1, he retained the temporal component added by W. van Mechelen et al. (1992), as well as the concepts of internal and external risk, but abandoned the stress–strain–capacity terminology and introduced in its place the concepts of predisposed athlete, susceptible athlete, and inciting event. In this iteration of the model, an athlete is predisposed to injury if her or his vulnerability is increased by one or more internal risk factors that are necessary, but typically not sufficient, to produce injury. Such an athlete is susceptible to injury when exposed to external risk factors. This susceptible athlete is considered more vulnerable to injury than a predisposed athlete, but generally not so vulnerable that injury happens without an inciting event. Meeuwisse (1994) described the inciting event as “the straw that breaks the proverbial camel’s back” (p. 169), in that it is not sufficient to cause an injury on its own but wreaks havoc on a susceptible athlete and tips the balance from susceptibility to injury. Inciting events are applicable to both acute and overuse injuries, but • the playing situation, • the behavior of athletes and their opponents, • gross biomechanical characteristics, and • detailed biomechanical characteristics. In this version of the model, both internal and external risk factors were considered as potentially interacting with the characteristics of inciting events to make injury more or less likely. For example, a volleyball player with poor neuromuscular control (an internal risk factor) who collides with a teammate (an inciting event) is more vulnerable to an ankle injury than an athlete who experiences a similar collision but possesses better neuromuscular control. Meeuwisse et al. (2007) advanced the model even further by building on an elaboration Exposure to external risk factors Intrinsic risk factors Predisposed athlete Inciting event Susceptible athlete Risk factors for injury (distant from outcome) Injury Mechanism of injury (proximal to outcome) Figure 2.1 Multifactorial model of sport injury etiology. Meeuwisse, 1994 B.W. Brewer and C.J. Redmond,E5665/Brewer/F02.01/541446/MattH-R2 Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 22 Psychology of Sport Injury of the inciting event proposed by Bahr and Krosshaug (2005) and on the following suggestions by Gissane, White, Kerr, and Jennings (2001): • Internal risk factors can vary over time. • The model should address what takes place after the occurrence of injury. • The process by which athletes sustain injuries is not linear, as posited in an earlier version of the model (figure 2.1), but cyclical. As displayed in figure 2.2, this updated model contains a number of modifications of the version shown in figure 2.1. First, among the sample intrinsic factors, it replaces flexibility and somatotype with neuromuscular control and strength; this change is mostly cosmetic. Second, this version depicts the possibility that susceptible athletes may encounter potentially injurious situations and not get injured. For example, injury may be averted due to tissue adaptation, use of protective equipment, or another factor (internal or external) that modifies the athlete’s injury risk. Third, the updated version incorporates the possibility that athletes who sustain an injury may not recover sufficiently to return to sport participation. Fourth, and perhaps most important, the “dynamic, recursive” nature of the model is highlighted by the arrows indicating the continuance of sport participation after noninjury or the return to sport after recovery from injury. When an athlete continues or returns to sport participation, he or she does so with the strong possibility that internal or external risk factors have changed since the athlete last progressed through the cycle. For example, as noted by Meeuwisse et al. (2007), fatigue that lingers to the next day of sport participation can alter an athlete’s neuromuscular control and therefore constitutes a change in the athlete’s Repeat participation Adaptation? Exposure to extrinsic risk factors (e.g., equipment, environment, etc.) Events (e.g.) Age Intrinsic risk factors Neuromuscular control Previous injury Predisposed athlete No injury Susceptible athlete Strength Recovery Inciting event Injury No recovery Removed from participation Risk factors for injury (distant from outcome) Mechanism of injury (proximal to outcome) Figure 2.2 Updated multifactorial model of sport injury etiology. Based on Meeuwisse et al. 2007 E5665/Brewer/F02.02/541455/MattH-R2 B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. Antecedents of Sport Injury   23 internal risk profile entering the second day of participation. Therefore, if all other factors in the model remain the same as they were on the first day of participation, the athlete’s risk of injury is greater on the second day than it was on the first day. Stress–Injury Model In response to the proliferation of research on psychological and social predictors of sport injury in the 1960s, 1970s, and early 1980s, M.B. Andersen and Williams (1988) proposed a model of sport injury occurrence that incorporated the accumulated research findings and provided a framework to guide subsequent research. As shown in figure 2.3, the central thesis of their model posits that the stress response is a proximal cause of sport injury. Furthermore, the model hypothesizes that contributors to the stress response include three broad categories of psychosocial factors—personality, history of stressors, and coping resources—each of which acts either directly or through its relations with the other two categories. (The same investigators later updated the model [J.M. Williams & Andersen, 1998] by making the Personality arrows between the three categories bidirectional.) Interventions directed at the stress response are thought to alter the likelihood of injury occurrence. The centerpiece of the stress–injury model is the stress response, a process in which people cognitively appraise the environmental demands placed on them in potentially stressful situations (i.e., stressors), the resources they possess to manage those demands, and the consequences of succeeding or failing at managing the demands. These cognitive appraisals are thought to influence and be influenced by physiological and attentional changes (e.g., general muscle tension, narrowing of visual field, distractibility) that place athletes at increased risk for injury. Thus, according to the model, athletes who perceive themselves as overwhelmed and helpless in the face of a stressful sport situation may experience tense muscles, “tunnel vision,” or inattention to the sport environment—all of which make them more susceptible to injury. On the other hand, athletes who perceive themselves as possessing the resources necessary to manage the demands of a potentially stressful sport situation are considered less likely to experience History of stressors Coping resources Stress response Potentially stressful athletic situation Cognitive appraisals Physiological or attentional changes Injury Interventions Figure 2.3 The stress–injury model. Adapted, by permission, from M.B. Andersen and J.M. Williams, 1988, "A model of stress and athletic injury: Prediction and prevenE5665/Brewer/F02.03/541461/MattH-R2 tion," Journal of Sport & Exercise Psychology 10: 294-306. B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics. 24 Psychology of Sport Injury the physiological and attentional changes that increase the risk of injury. Let us now examine the three interrelated categories of psychosocial factors— personality, history of stressors, and coping resources—that are hypothesized to contribute to the stress response. Personality consists of enduring, stable patterns of thinking, feeling, and behaving. The personality characteristics that M.B. Andersen and Williams (1988) considered relevant to the stress response, and to sport injury occurrence, include locus of control (how much control one perceives oneself as having over life events), competitive trait anxiety (tendency to get anxious in competitive situations), and hardiness (resilience). Presumably, these characteristics interact with an athlete’s history of stressors and coping resources to affect the athlete’s cognitive appraisals of stressors, as well as his or her physiological and attentional changes in response to stress. An athlete’s history of stressors consists of the threatening or challenging events that he or she has experienced, whether recently or in the more distant past. Stressors typically involve change of some sort, and change can occur on multiple levels. The broadest level of stressors is made up of catastrophes—largescale, cataclysmic events that generally affect many people at the same time (e.g., war, natural disaster, nuclear accident). The intermediate level consists of major life events that exert a pronounced effect, whether positive or negative; examples include divorce, death of a close friend or relative, high school and college graduation, and legal trouble. The micro level consists of minor life events, which might be referred to as daily hassles when negative and as daily uplifts when positive. Examples of daily hassles include encountering heavy traffic, waiting in line at the grocery store, and getting a bad grade on a school assignment. Examples of daily uplifts include acing an exam, receiving an unexpected gift, and getting praised by a colleague. In formulating the stress–injury model, M.B. Andersen and Williams (1988) focused primarily on the latter two types of stressor— specifically, major life events and daily hassles—as most relevant to the stress response and to sport injury occurrence. The model also specifies previous injury as a stressor of particular importance. For one thing, incomplete rehabilitation increases an athlete’s risk of reinjury; in addition, past injury experiences can promote negative cognitive appraisals and fear of reinjury, both of which can exacerbate the stress response and elevate the likelihood of reinjury. The third category of variables posited to influence the stress response is that of coping resources, which includes behaviors and social networks that help athletes handle stress. For example, athletes can cope better with stress if they engage in behaviors such as getting enough sleep, eating nutritious foods, and managing time effectively. It is also helpful to use cognitive strategies for calming anxiety, maintaining focus, and appraising stressors in ways that prompt adaptive physiological and attentional responses. Along with the use of stress management techniques (e.g., relaxation, imagery, and meditation), another important coping resource is social support—that is, athletes’ relationships with people who care about them, both inside and outside of the sport environment. These relationships are thought to affect injury vulnerability both by dampening the effects of stressful events and by directly altering an individual’s stress response. Thus, having a close friend to rely on can make stressful events less stressful and minimize maladaptive physiological and attentional responses, all of which, theoretically, can reduce an athlete’s injury risk (M.B. Andersen & Williams, 1988). Since its unveiling in 1988, the stress– injury model has guided numerous investigations into the relationship between psychosocial factors and sport injury occurrence, and several modifications have been proposed. Wiese-Bjornstal (2004), for instance, adapted the model to youth sport participants by tailoring its variables in developmentally appropriate ways. Petrie and Perna (2004), meanwhile, added elements to the physiological portion of the model’s stress-response component and ad- B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 1–Sport Medics.