John Heil, D.A Psychological Health Roanoke

MEDICAL PROCEEDINGS / LEWIS-CALE CLINIC SUMMER 1993

specific events, while disruptive in and ofthemselves, can precipitate physiologicalchanges. These include increased muscletension and changes in autonomic output.Autonomic effects include increased heartrate as well as other distracting adrenergicmediated symptoms such as tremulousness,nausea, and palpitations. Th~se in tum canamplify the intensity of the emotional responsemaintaining the vicious cycle of effects.

Increasing anxiety may lead to enhancedsensitivity to pain, to the fear of injury, togreater distraction and so on. As the cycle ofelIecrs grinds on, inevitably performance willbe affected which will in tum influence self­confidence. The athlete may attempt tocompensate for diminished self-confidence orspecific concerns about performance byincreasing training intensity or changing motorpatterns. This can lead to overtraining ortraining errors. It is noteworthy that trainingerrors cause micro-traumatic injuries

Psychological Causes of Stress

Psychological stress is attributed to bothsignificant life change events and relativelymild chronic daily hassles. General lifestressors include the following:death of a family member or friend, strainedrelations with spouse or significant others, joband school problems, financial difficulties aswell as the cumulative effect of daily hasslessuch as commuting in heavy traffic or notgetting enough sleep. Examples of spon relatedstressors are: decreased performance by theteam or athlete, troubles with the coachingstaff, change in level of performance (forexample from high school to college),overtraining, staleness, anticipation of anupcoming major competition, and naggingsymptoms of an old injury or a recent minorinjury. In combination these characterize theday-to-day life experience of the athlete, thebackground against which athleticperformance unfolds.

While for preventive purposes it is mostimportant to monitor negative stresses, positivelife change can contribute to the stressresponse as well. The common denominator ofstress is change and the demand to adapt tonew circumstances. For example, beingselected as a team captain is an honor.However it carries new responsibility andmay lead to some changes in relationships withother players. In this sense it can be stressful.Positive life changes are most likely tocontribute to the stress response where there isa Significant degree of simultaneous negativelife change. Ultimately the impact of stress

is most directly influenced by theresourcefulness of the athlete. Those who havegood coping skills and feel comfortable withtheir social support network of family, friendsand teammates are resistant to injury and theother effects of stress (3) (4).

Risky Attitudes and Behaviors

Ideas of athleticism as heroism are wellreflected in the fundamental attitudes andbehaviors upon which sport is built. The roarsof this extend to antiquity. The alleged run ofPheidippides from Marathon to Athens inorder to announce a critical victory of theGreeks over a Persian invasion force concludedby his collapse and death is emulated intoday's marathon. It also reflects theimportance placed on intensity, determinationand sacrifice in modem sport. This ismanifested in expectations regarding playingwith pain, "giving 110%" and taking risks.Related to this is the pursuit of the ideal bodyfor performance. This may tempt lhe athleteinto risky behaviors such as the use of anabolicand other ergogenic aids and weight controlmeasures that may result in eating disorders.These practices not only lead to greater injuryrisk but also carry a potentially broad array ofmedical and psychological effects (5) (6).

The "Injury-Prone" Athlete

All athletes are injury prone by nature of therisks inherent in sport. This is most evident inhigh risk spans such as football, ice hockey,rock climbing and auto racing. It is importantto realize that injury is influenced by a broadarray of factors only some of which are withinthe control of the athlete. Historically theproblem with the "injury-prone" label is that itplaces blame on the athlete while at the sametime doing little in the way of truly construc­tive problem solving. At its worst this label canredirect attention away from the importantroles to be played by proper coaching, rulemaking and officiating. A fixed physical defector an uncorrected deficit in strength orflexibility may increase risk of injury. Andthere is risk posed by the stress response aswell as risky behaviors and attitudes asexplained above. These should be recognizedand addressed.

PSYCHOLOGICAL STRATEGIES TOPREVENT INJURY

Stress due to changes in life and sportexperiences is inevitable and for the most panunavoidable. This includes the chronic

9

SUMMER 1993 MEDICAL PROCEEDINGS / LEWIS-GALE CLINIC

10

cumulative effects of life change and the moremomentary acute competitive distress. The keydeterminant in the ultimate impacl of stresslies not so much in the events themselves butin the way the athlete reacts to them inmanaging the stress response. Mental skillsthat relieve stress, attenuate distractions andoptimize arousal not only enhance perform­ance but also can be reasonably expected todecrease the risk of injury. Injury risk is notonly influenced by the athlete's mental skills,but also by risk taking attitudes and behaviorsand by the reactions and expectations of othersin the athlete's world.

Mental Training

The systematic practice of mental traininghas a "stress inoculation" effect, by interruptingthe potentially vicious cycle of mutuallyreinforcing psychological and physiologicaleffects. Athletic performance is improved at thesame time injury risk is reduced. Whiletraining in these techniques relies primarily onthe sport psychologist, the cooperation andencouragement of the coach and the teamphysician is essential. There are a wide varietyof methods that the sport psychologist canutilize. While important differences existamong the approaches, they share the commonelements of decreasing stress, optimizingarousal and improving concentration. Thesecoping techniques represenr a positivealternative to maladaptive coping strategiessuch as drug use and eating disorders.(1) Relaxation Training - Develops increasedbody awareness, deeper muscular relaxation atrest (general relaxation) and increasedmuscular efficiency (differential relaxationtraining) during performance.(2) Mental Rehearsal - Uses the imagination tocreate a private "theater of the mind" wheresport situations can be rehearsed and replayed.For example one can rehearse use of propertechnique, making an important play at acritical time or alternately practice refocusingof concentration follOWing a distraction duringcompetition.(3) Biofeedback - Utilizes psychophysiologicalinstrumentation to provide quick accuratefeedback about biological events usuallyoutside mental awareness. By providinginformation about subtle changes in muscletension (EMG) or autonomically mediatedevents (e.g. heart rate) the athlete gains greaterself-awareness and self-control over the stressresponse. EMG biofeedback can be especiallyuseful where problems with bracing/guardingpersist following recovery from injury.(4) Self-Talk - Uses brief assertive statements

or affirmations, to improve confidence, cue keybehaviors or focus attention. Alternatively,self-talk may be used to stop or modifythoughts that are detrimental to performance.(5) Hypnosis - Relies on careful focusing ofattention so that suggestions about stress andcoping, athletic ability and perfonmance, andconfidence can be used to guide behavior.Autogenic training is a practical, easily usedmodification of hypnotic technique.

Attitudes and Behaviors

There are other practices that can influencean athlete's reaction to stress and ultimately therisk of injury. The benefits of good morale aredifficult to overestimate. In creating a positivepsychological environment athletes feel bettersupported and are better able to use theircoping skills. While the responsibility for thisrests largely with the coach, the physician is ina unique position for helping shape attitudesand behaviors that influence the likelihood ofinjury. How effective the physician can be inthis roie is greatly influenced by the quality ofthe working relationship with the coach.Athletes face constant temptation to takeshortcuts in acquiring the ideal body forperformance. Awareness of the signs ofanabolic steroid and other drug use as well aseating disorders, and the willingness LO dealwith athletes directly aboUl thesc behaviors iscritical. The physician needs to be open andnon-judgmental in identifying and discussingthese issues but also firm and consistent in theapproach to problem solving. Cooperation ofthe coaching staff 15 necessary since\vithholding the athlete from competitionneeds to be considered as an option whenbehavior change is not forthcoming. Attitudesabout always 'giving 110%" and taking riskscan be examined by the phYSiCian, coach andathlete together so that injury inviting behavioris limited without compromising performance.For example aggreSSive play, like arousal, hasan optimal zone. Too much aggression canimpair judgment and lead to penalties orinjuries. An important but thorny issue thatcan always be better understood involvesdiscussing the difference between the pain ofperformance and the pain of injury. Oftentalked about, this is seldom approached in asystematic way cooperatively by the physicianand coach. When the athlete is known to beunder stress, careful auention to changes intraining activities is warranted. Some athletesmay overcompensate by altering trainingintensity, changing motor patterns, orincreasing risk taking. When this is noted, itneeds to be promptly addressed.

IVLCUlI....t\L rKUl..CCUll~LJ')I LC VV l,)-l...t\.U:' l..Lll~ ll..

CONCLUSION

The ability to remain relatively injury free is animportant athletic skill which is linked tosuccessful performance. Interactingpsychological and physical factors influenceinjury risk. Guidance by the physician andpsychologist can help to reduce injury risk andfacilitate the pursuit of performance goals.

Portions oj this paper are excerptedJrom thePsvcholQg;Y Qj~ Iniul)' by John Heil,published in the spring oj 1993 by Human KineticsPublishers.

References

L Andersen, M.B., WiIliams,j.M. A model ofstress and athletic injury: Prediction andprevention. Journal of Sport and ExercisePsychology 10:294-306;1988.

2. Nideffer, RM. The injured athlete:Psychological factors in treatment.Orthopedic Clinics of North America.14:373-385;1983.

3. Smith, RE., Smoll, F.L, & Ptacek, j.T.Conjunctive moderator variables invulnerability and resiliency: Life stress,social support and coping skills, andadolescent sport injuries. Journal ofPersonality and Social Psychology, 58:360­370;1990.

4. Sarason, l.G., Sarason, B.R, & Pierce, G.RSocial support, personality, andperformance. Journal of Applied SportPsychology, 2(2):117-127;1990.

5. Wadler, G.l., & Hainline, B. Drugs and theathlete. Philadelphia: FA Davis, 1989.

6. United States Olympic Committee. Sportsnutrition: Eating disorders. ColoradoSprings, CO: Author,l987.

,)UIVIlVleK 1~~5

11