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Does Psychosocial Stress Elevate Musculoskeletal Injury Risk?

Many predictors of injury exist in the research literature, from asymmetry, previous injury, to BMI, among others.  Another commonly studied risk factor that’s often ignored in coaching is psychological stress.    One reason psychological stress may be overlooked is that we’re conditioned to “put things out of our mind” when it comes time to perform.   There’s certainly a fine line between being hardass and dumbass.  No one said it was easy, but before you can justify gunning it through a yellow light, you must first know what you’re up against.   

Though the literature is fairly robust on the predictive value of psychosocial markers, it’s less clear on how best to intervene.   In fact, the evidence is unclear whether common stress-relief methods actually help in this context, as they may simply be dealing with symptoms.  (Junge 2000, “According to existing results, the influence of stress-coping strategies is somewhat questionable.”)

From a training standpoint, the first and most important step is to recognize the athlete’s readiness for training and accept the consequence that stress in any form will affect their adaptation ability.  As we discussed in “I was training great until…” performance markers are not the only indication of progress.  In fact, blind adherence to performance markers without reference to psychosocial factors can leave athletes vulnerable to injury.  Just because the athlete gets through the workout with good numbers doesn’t mean they are in condition to absorb the training. 

People often misinterpret discussions on stress, thinking that recognition of stressors may create soft athletes.  Instead, it’s critical to find the right balance.  Not saying it should all be sunshine and roses, as there are times when it’s OK to feel beaten down for a callousing effect.   Most important is to create the right amounts of stress at the right times, and take appropriate action when stress exceeds a permissible range. 

Furthermore, have a way to assess readiness.  There are complex methods such HRV, but qualitative measures are surprisingly reliable.  Mood, appetite, willingness to train, and workout satisfaction are all useful indicators.   This discussion harkens back to Dan John’s Green-Yellow-Red light model:  Impose greatest physical stressors according to the body’s ability to absorb them. 

  • Green light: ready to train hard because the mind and body are free of restrictions and are in the best position to adapt to the imposed stimuli (i.e., summer vacation). 
  • When the body and mind are dealing with other stressors, you’re in a yellow light situation…still can train at reasonably high level, but better watch out to make sure you don’t run into a red light. 
  • If you’re injured, you’re at a red light!

Recently, two Swedish studies looked at soccer players, from high school to Premier league players.  In the high school study (Johnson 2011), authors provided five anxiety questionnaires before the season.  Athletic trainers monitored injury data.  Results showed that life event stress, somatic trait anxiety, mistrust, and ineffective coping could explain 23% of injury occurrence in this population.  In the Premiere league players (n =56) trait anxiety, negative life event stress, and daily hassle-were significant predictors of injury accounting for 24% of the variance. 

Galambos (2005) studied a sample of 845 elite athletes at the Queensland Academy of Sport (Australia).  Based on psychological screenings, vigor, depression, and tension predicted 50% of the variance in stress scores.  Authors found significant relationships between injury with anger, confusion, fatigue, tension, and depression.   The cause of these psychological conditions was unclear, but the correlation to injury was evident.

In one of their many studies in this area, Williams and Anderson, (who created the leading theoretical model of the stress-injury connection), isolated 1/3 of their athlete sample having the lowest social support.  Within this subgroup, “those individuals with more negative life events and greater peripheral narrowing during stress incurred more injuries … those individuals who were low in a variable that buffers stress responsivity (i.e. social support), their negative life events and peripheral narrowing under stress (large and medium effect sizes, respectively) were substantially related to their number of injuries.”  (Anderson 1999)

Though the exact causal mechanisms are unclear, it’s clear that life stress is a risk factor for musculoskeletal injury.  Perhaps the body can’t repair itself from the physical microtraumas of exercise (which are necessary for growth) or perhaps physical function is impaired leaving the athlete unable to react to stimuli.  Consider a study by Gunnoe (2001) on high school football players.  In a two year prospective study of thirteen high school teams (over three hundred players), two significant injury predictors were “Total or negative life change.”  Players who reported major changes or negative changes in their lives were more likely to be injured but life change did not predict length or severity of injury.   Interestingly, having a positive life change off-the-field was not protective from injury.  

The stress/injury link persists even within non-contact sports…Hardy (1998) found that total life change and negative life change (the same markers in the Gunnoe study above) predicted injury in female track and field athletes.  However, there was no link between injury severity and stress levels.

Some other evidence on the link between psychosocial stressors from the gymnastics world…

  • Peterie (1992) studied life stress in collegiate gymnasts and found “negative life stress accounted for 11% to 22% of injury variances in low-support conditions”
  • Kolt (1994) found the best predictors of injury in female gymnasts were anxiousness and tiredness.  Compared to male gymnasts, the injured female gymnasts had scored higher anxiousness, unsuredness, tiredness, confusion, and lower levels self-confidence. 

Unfortunately, the psychosocial/injury link is not limited to high level, mature athletes.  Further, the effect of stress may also be acute as well as chronic.  Laflamme (2004) explored the link between school performance and injury in kids age 10-15. In this sample of 592 kids, perceived failure in school performance almost tripled physical injury risk within up to 10 hours subsequent to exposure.  Authors concluded, “Experiencing feelings of failure may affect children's physical safety, in particular among pre-adolescents. Possible mechanisms are perceptual deficits and response changes occasioned by the stress experienced after exposure.”   In short, psychological stress brought into training is a warning sign that must be treated with proper respect.

Conclusion

While many coaches pay lip service to the correlation between stress and injury risk, they often fail to recognize they may be the ones causing stress!    Although psychosocial risk factors are linked to musculoskeletal injuries, it does not automatically follow that direct psychological interventions are what’s needed.  It may be that training modifications can restore the appropriate psychological state for the athlete to effectively absorb training.  Maybe the person is not a life state to train hard at this point and (gasp!) must “wait their turn” for a more amenable training situation. 

In sum, there’s ample evidence that psychosocial stress, whether caused by training or outside “life factors” leaves the body vulnerable to injury.  We’re still unsure of the exact causation mechanisms, but the correlations are robust.  For coaches and athletes, the implications are straightforward:  Know when to hug and know when to give a kick in the butt!

References

1)      Junge A.  The influence of psychological factors on sports injuries. Review of the literature.  Am J Sports Med. 2000;28(5 Suppl):S10-5.

2)      Ivarsson A, Johnson U, Podlog L.  Psychological predictors of injury occurrence: A prospective investigation of professional Swedish soccer players.  J Sport Rehabil. 2012 Mar 2. [Epub ahead of print]

3)      Johnson U, Ivarsson A.  Psychological predictors of sport injuries among junior soccer players.  Scand J Med Sci Sports. 2011 Feb;21(1):129-36. doi: 10.1111/j.1600-0838.2009.01057.x.

4)      Galambos SA, Terry PC, Moyle GM, Locke SA, Lane AM.  Psychological predictors of injury among elite athletes.  Br J Sports Med. 2005 Jun;39(6):351-4; discussion 351-4.

5)      Andersen MB, Williams JM.  Athletic injury, psychosocial factors and perceptual changes during stress. J Sports Sci. 1999 Sep;17(9):735-41.

6)      Gunnoe AJ, Horodyski M, Tennant LK, Murphey M.  The Effect of Life Events on Incidence of Injury in High School Football Players.  J Athl Train. 2001 Jun;36(2):150-155.

7)      Petrie TA.  Psychosocial antecedents of athletic injury: the effects of life stress and social support on female collegiate gymnasts.  Behav Med. 1992 Fall;18(3):127-38.

8)      Laflamme L, Engström K, Möller J, Hallqvist J.  Is perceived failure in school performance a trigger of physical injury? A case-crossover study of children in Stockholm County.  J Epidemiol Community Health. 2004 May;58(5):407-11.

9)      Kolt GS, Kirkby RJ.  Injury, anxiety, and mood in competitive gymnasts.  Percept Mot Skills. 1994 Jun;78(3 Pt 1):955-62.

10)   Hardy CJ, Riehl RE.  An examination of the life stress-injury relationship among noncontact sport participants.  Behav Med. 1988 Fall;14(3):113-8.

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