Does Psychosocial Stress Elevate Musculoskeletal Injury Risk? Part II

In previous posts we have highlighted the evidence on connections between psychosocial stress and injury.  (Does Psychosocial Stress Elevate Musculoskeletal Injury Risk?) This connection is especially poignant during the holidays with “off field” stressors mounting and many athletes ending the fall season.  “I was training great until my taper” is a common refrain during championship season and the subsequent holidays with many athletes unsure why a successful campaign was suddenly derailed with no apparent explanation.  (Psychosocial Stress and Immune Function in Athletes)

There are several possible theories on why/how psychosocial stress can be linked to injury:

• Maybe stress causes poor movement/biomechanics/reaction time?
• Stress affects the body’s adaptive reserves to deal with athletic loads .  The body only has so many resources and if they are directed away from the playing field, the athlete is less able to cope
• Mind becomes hypervigilant in these circumstances and it overblows the pain response in relation to the actual underlying damage

Two recent studies to highlight in this area…

McKay (2013) analyzed 316 male hockey players ranging from age 13 through the elite youth.  Subjects were measured in the following: “athletic identity measurement scale, competitive state anxiety inventory-2R, body checking questionnaire, and fear of reinjury questions.”

Notable findings: Athletes who scored low on the athletic identity scale were at greater risk of initial injury but those who scored higher on the athletic identity scale were at greater risk of subsequent injury. 

(A note on "athletic identity"…”beneficial  "athletic  behaviors" (e.g., train- ing) are likely to stem from a strong athletic identity (Callero, 1985). At the same time, a strong athletic identity may promote overtraining (Brewer, Van Raalte et al., 1993)”) (Martin 1997)

One interesting side note…return to play before medical clearance did not predict reinjury with any statistical significance, though authors noted it was a close enough call to warrant future investigation.  Somehow athletes managed to sneak their way back into the lineup before the docs gave them permission!

In a more recent study (from a research team with significant prior work in this area), Ivarsson (2013) analyzed 101 elite junior soccer players over a ten week period.  Each subject completed a Hassles and Uplifts analysis through which each athlete reported their personal stressors and positives in their lives.

Findings:

• "[I]njury occurrence was significantly associated with both the initial level of daily hassle and the change in daily hassle.
• High initial daily hassle levels and a smaller decrease in daily hassles were associated with injury occurrence.
• Moreover, injury occurrence was significantly associated with a greater decrease in daily uplift."

Utilizing “hassles and uplifts” as the psychological benchmark is a nice touch here, as it deals with the daily things athletes bring to the field.  Not as dramatic as deaths or other major stressors, but the more common accumulation of stressors that can wear athletes down over time. 

Conclusion

Despite the links in this area, be careful of taking the rationale too far.  Athletes are often given baldly superficial advice without being given solutions to eradicate the underlying source ("just sign up for hot yoga class and everything will be fine!").  Further, excess attention to stressors can give athletes a convenient excuse for poor performance or substandard effort.  Have some baseline to measure stress, whether that is through questionnaires, heart rate variability, blood testing, or some other metric.  But ultimately, remember that injury is a multifactorial problem requiring attention to the athlete as a whole, not as a mere sum of biomechanical parts.      

References

McKay C, Campbell T, Meeuwisse W, Emery C.  The role of psychosocial risk factors for injury in elite youth ice hockey.  Clin J Sport Med. 2013 May;23(3):216-21. doi: 10.1097/JSM.0b013e31826a86c9.

Ivarsson A, Johnson U, Lindwall M, Gustafsson H, Altemyr M.  Psychosocial stress as a predictor of injury in elite junior soccer: A latent growth curve analysis.  J Sci Med Sport. 2013 Oct 31. pii: S1440-2440(13)00473-8. doi: 10.1016/j.jsams.2013.10.242. [Epub ahead of print]