Personality Factors

In the stress-injury model, the authors assert that certain personality characteristics influence the stress response. Various personality characteristics have been studied over the years, yet only a few are believed to temper the effects of stress, including hardiness, locus of control, trait anxiety, motivation, and sensation seeking. More recently, Johnson conducted a review of the literature for empiric findings from studies investigating personality variables in the stress-injury model and determined that personality characteristics may serve to moderate the effects of stress for some athletes and, for others, predispose them for risk for injury. This review of the literature revealed evidence in support of the following personality variables as antecedents of sports injury: locus of control, competitive trait anxiety, perfectionism, mood states, and self-confidence/self-esteem. Competitive anxiety has received the most attention, with athletes having high trait anxiety being more prone to injury.

Stressors

A large body of knowledge supports the relationship between life stress and risk for injury. Although terminology such as stress and stressors is widely used, it is always helpful to convey clarity with reminders of their meanings. Selye defined stress as “the nonspecific response of the body to any demand.” The stimulus that evokes a stress response in individuals is what is referred to as a stressor. There are two types of stressors, acute and chronic. Acute stressors are associated with stressful life events, such as the death of a loved one, natural disasters, or terrorist-related activity. Chronic stressors are longer lasting, with the stressor lasting for months or years. Examples of chronic stress include homelessness, loss of job, or living in a neighborhood with high crime. Athletes experiencing increased stress levels may turn to alcohol, substance use/abuse, disordered eating, high-risk behavior, or other injurious stress-relieving activity.

Assessment of an athlete’s history of stressors provides crucial information about key variables related to life events, daily stressors, and previous history of stress. Holmes and Rahe developed the well-known Social and Readjustment Rating Scale in 1967, and it has been widely used to assess an individual’s level of stress. This early work laid the groundwork for the development of instruments to assess stress in athletes, such as the Social and Athletic Readjustment Rating Scale and the Athletic Life Experience Survey, as well as the Life Events Survey for Collegiate Athletes, to measure an athlete’s history of stressors. See Box 1-1 for examples of positive and negative stress factors.

To further understand the relationship between stress and injury, Nideffer developed a model to describe two potential scenarios, the first being the injured athlete and subsequent considerations regarding the rehabilitation process and the second concerning the athlete with anticipatory anxiety around the possibility of injury. This model ( Fig. 1-2 ) attempts to depict the impact of situational stressors, physiologically and psychologically, as well as potential performance problems. Nideffer contends that athletes’ performance will be hindered if they are worried about the possibility of sustaining an injury or getting reinjured. These situational stressors are thought to have a direct impact on physiologic and psychologic flexibility, which in turn has a negative impact on concentration. This cycle can become a chronic condition resulting in an increase in frustration and anxiety and lower performance for the athlete.

Physical and psychologic changes accompany increases in pressure as a result of injury or the fear of injury. Problems in performance resulting from stress and reduced physiologic and psychologic flexibility can become chronic. Disturbances in physical flexibility affect concentration, and as the athlete becomes upset at his or her own failure (frustration or anxiety increases), the attentional and physiologic disturbances become stronger and more intractable.

(Modified from Nideffer, R.M. [1983]: The injured athlete: Psychological factors in treatment. Orthop. Clin. North Am., 14:373–385.)

Coping Resources

Cohen and Lazurus define coping as “efforts, both action-oriented and intrapsychic, to manage (that is, master, tolerate, reduce, minimize) environmental and internal demands, and conflicts among them, which tax or exceed a person’s resources.” Individuals have two ways of coping. The first, problem-focused coping, is coping by managing the stressor—that is, reducing the demands being made on the athlete. The second, emotion-focused coping, is managing the feelings related to the stressor, which requires the acquisition of additional skills for working with stress. Coping resources refer to coping behavior, social support, and psychologic skills and are believed to moderate the effects of stress and therefore reduce the risk for injury; they can be used for both problem-focused and emotion-focused coping. Box 1-2 lists some of the commons signs and symptoms associated with stress.

Coping behavior encompasses a wide range of behavior and can serve to potentiate the stress response when the athlete lacks good coping behavior. For others, it appears to enhance their ability to cope with stress as a result of using effective ways of coping. An assessment is initiated with an intake interview conducted by a mental health professional. The use of assessment instruments may assist in this process. An appraisal of coping behaviors often includes behaviors associated with health-related factors, such as nutrition and sleep; personal attributes that have an impact on academic success, such as study skills and time management; and overall self-esteem.

A wealth of evidence-based research supports the significance of social support as it relates to health and well-being. In addition, numerous studies have explored social support and risk for injury. Study findings have shown that athletes with high social support have fewer injuries than athletes with little or no social support. Social support is defined as “an exchange of resources between at least two or more individuals perceived by the provider or the recipient to be intended to enhance the well-being of the recipient.” The Social Support Survey (SSS) assesses an individual’s perception of social support on eight scales. Key support factors measured on the SSS include listening support, emotional support, assistance, and reality confirmation. Social support typically comes from key persons in the athlete’s family, circle of friends, teammates, coaches, and medical staff. Begel and Baum contend that the potential for increased social support may be jeopardized because athletes spend numerous hours each week on their sport, which in turn places them at risk for social isolation.

Coping resources also include psychologic coping skills. Examples of psychologic skills that may reduce the risk for sports injury are having the ability to concentrate, remain positive, and regulate arousal states. Social support has been shown to have a positive influence on rehabilitation and recovery. Given the significance of social support, it is essential that key players on the rehabilitation team provide the injured athlete with ample support and connection to additional support resources to ensure better health outcomes.