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The Injury Experiences and the Psychological Responses of Student Athletes as a result of Sports Injuries
The aim of this study was to further explore the phenomenon of sports injuries, five university students were interviewed regarding their injury experiences, in particular the psychological responses they had when their injury had occurred. In order to obtain this information, in-depth semi-structured interviews were conducted, questions were formed on the base of Wiese-Bjornstal et al’s (1998) integrated model of injury and the rehabilitation process and were related to the five categories with the model. From the interviews with participants, themes such as social support, re-injury anxiety, frustration were evident. Two themes which were not anticipated were unrealistic optimism, meaning that participants had not expected their injuries to occur despite the risk of injury being constant. The other unanticipated theme was mirror-touch synesthesia, which refers to participant’s bodies reacting to others potentially dangerous movements via observation. Future research recommendations include examining both unrealistic optimism and mirror-touch synesthesia in a sporting context.
Chapter 1 – Introduction
This section will aim to provide a critical review of research which has reviewed the psychology of sports injury and the psychological responses to injury. It aims to describe the work of Wiese-Bjornstal, Smith, Shaffer and Morrey’s (1998) integrated model of response to sport injury. This section will also aim to review the research which focuses on certain parts of psychological responses post-injury (i.e. self-esteem and self-efficacy) Conceptual issues as well as methodological issues which occur within the literature will also be reviewed.
It has been argued that many athletic injuries can often be anticipated before they occur. Groves (1987) suggests that some athletes are more likely than others to take risks, some through participating in high risk sports or Cohen and Young (1987) argue that by putting themselves in in perceived dangerous situations for example rock climbing, there is potential to become injured. Feltz (1984) states that the anxiety levels can also sometimes play a role in injury occurrence and suggests that athletes who seen as ‘injury prone’ may have high levels of anxiety in sport. Gordon (1986) suggests that ‘injury prone’ athletes are insecure and are anxious or worried and in some manner, and as a result can potentially induce their own injuries.
Timpka, Jacobson et al (2014) explained that there are many ways to define a ‘sports injury’, the most general meaning is the loss of bodily function or structure that is the object of observation in clinical exams. If an athlete feels an immediate sensation of pain, or a loss of functioning that is the object of athlete self-evaluations, this is defined as a ‘sports trauma’, for example an athlete experiencing leg cramps whilst running. ‘Sports incapacity’ has been defined as the side-lining of an athlete because of health evaluations made by a legitimate sports authority. An example of this could be George North, a professional rugby union player, who finds himself constantly being observed for concussion after a string of incorrect tackling techniques. ‘Sports impairment’ is caused by excessive bouts of physical exercise, meaning ‘sports disease’ (overuse syndrome). This may mean simply training more than what is deemed necessary and as a result the aches and pains from a usual session may intensify and become more painful. When an athlete experiences feelings of pain or loss of functioning along with repeated periods of physical load during sports training or competition without recovery periods, the sensation can then be acknowledged by the athlete as irregular body function. This is known as ‘sports illness’.
When an athlete experiences an injury, it may be argued that athletes think of only the physical recovery and when they are able to compete again. Moen et al. (2014) explained that after an acute hamstring injury, the most common and primary question asked by the athlete and the coaches is how long it will take to return to play. However, Seligman and Csikszentmihalyi (2000) concluded that “treatment is not just fixing what is broke, it is nurturing what is best”, in regards to an athlete’s recovery, while its of importance for the athlete to recover physically it is of equal importance that the athlete is psychologically ready to return to competitive play. Wiese and Weiss (1987) concluded that “returning physically recovered athletes to competition before they are mentally and emotionally prepared might increase their risk of becoming injured again” (p.319).
Much research has been conducted on how athletes respond psychologically to injury. Weiss and Troxel (1986) argued that the response athletes have to an injury is similar to the reaction of stress or grief and proposed that injured athletes pass through four stages of response to injury. The first stage is ‘what’, this refers to the injury as a stressor, which in turn leads to the other response stages. The second stage is ‘think’, the cognitive appraisal of the injury and the athlete’s ability to deal with this stressor, this appraisal influences the third stage as the athlete’s appraisal may be negative or positive. Athletes may feel that they have disappointed their coaches, family and teammates or may feel that the injury is severe enough to stop competing for the season or even permanently. The third stage is ‘feel’, which is how the athlete feels about what has happened, how these feelings such as worry, anxiety or physiological arousal can affect the athlete’s training. These reactions can often refer to the athlete’s physically through the actual pain from the injury. (Nideffer, 1980). The final stage is ‘do’, which refers to the athlete’s adherence to their rehabilitation programs, whether they want to recover successfully from their injury or not. While these response stages do offer a valid explanation, it seems to be too simplistic and almost unrealistic to conclude that all athletes go through the same responses to injury and that these stages flow efficiently without any bumps in the road.
Another process of grief response was proposed by Kübler-Ross (1969), The first phase of grief response is characterised by a sudden shock-like state, which is done in immediate response to the injury. The common emotions during this phase include anger, denial and bargaining behaviour. The second phase involves preoccupation with the injury; during this phase the athletes may experience insomnia, fatigue or even guilt about leaving their team. During this time, depression is often the most reported emotion. The third phase is reorganisation, which is based upon displaying renewed interests and return to sport or previously important activities such as employment or studies. While Kübler-Ross (1969) does offer a basis to grief response processes, it may be suggested that it is too simplistic and moving through each phase may not be the case, instead an individual may fluctuate from one stage to another or fall back into another phase.
In regards to sports injury, Evans and Hardy (1995) argued that loss does not necessarily link to the bereavement of a significant other, but it can be linked to the loss of any object deemed significant by the individual. Peretz (1970) states that loss is a state of deprivation, this loss is both a real event and a symbolic event as it poses a potential threat and representation of future loss. In relation to sport injury, this may mean that an athlete who has broken their leg, this loss may also represent the threat that their athletic career may be over and this transition may be perceived as a loss. Peretz (1970) suggests that there are different types of loss, within a medical sense. The first is the loss of a significant valued person, this in a sports setting may entail a loss of contact with coaches or teammates. The second type of loss is the loss of some aspect of the self, when an individual gets injured, as aspect of themselves can change, which can intensify the feelings of loss experienced through injury, this may be a loss of self-esteem or confidence. The third kind of loss, is the loss of external possessions, this may refer to money or properties, such loss may only refer to athletes who perform at a high level. The fourth loss is developmental loss referring to human growth, those who participate in high intensity sports for example, in gymnastics, male gymnasts often lose their range of movement as they grow older.
Athletes who experience an injury will have some form of emotional reaction, understandably the emotions felt by athletes are predominantly negative. Much research has been conducted regarding negative emotions felt during injury and recovery. Quackenbush and Crossman (1994) for example, found that when an injury occurred, individuals experienced negative emotions such as anger and frustration when the injury occurred and the following day, the negative experiences of being irritable and unhappy were reported by participants. If an athlete has become less mobile through their injury, they may become more irritable and miserable as they are unable to train and compete or complete day-to-day tasks. Similarly, these feelings may heighten when the athlete finds out the full extent of their injury and its prognosis. Participants reported feelings of negative emotions such as feeling unhappy and frustration decreasing and feelings of optimism and enthusiasm increasing as they progress through their recovery. Feelings of frustration still remained at stage four, although it is possible that they feel frustration as they are unable to perform at their pre-injury level.
Udry, Gould, Bridges and Beck (1997) found that injured athletes experience a range of emotions (e.g. anger and frustration) and as a result may find themselves acting out. Findings suggested that anger and apprehension are prevalent after injury onset and during the rehabilitation phase frustration occurs. Granito (2001) conducted a study to describe the athletic injury experience from the perspective of injured athlete and student athletic trainers. Results found that all injured athletes and student trainers reported frustration and anger were present during injury experiences. “One word for me that seems so important in dealing with my injuries is frustration” (p.77).
Wiese-Bjornstal et al., (2008) introduced a model of response to sport injury, who argued that after an injury has occurred, athletes may evaluate many things, such as their ability to cope with their sport injury experience also their self-esteem and their self-confidence. This psychological response is known as cognitive appraisal.
Studies examining the self-confidence of athletes after injury has produced mixed results. For example, Podlog and Eklund (2004) reported that athletes experienced a decline in confidence during their comeback season and found that athletes made negative comparisons for example “losing to someone I used to beat”. (p.257)
In terms of an athlete’s self-esteem, Leddy, Lambert, Ogles (1994) found that when researching the differences in physical self-esteem scores in injured and later injured athletes, recovered athletes and non-injured athletes Results shown that the injured and later injured runners had significantly lower physical and total self-esteem than runners who had not been injured or had recovered from an injury. A possible methodological issue within this study is that only male students were used, while the authors had noted that had they used both male and female participants, there would be a limited number of sports although it is unclear what ten sports the athletes were participating in. It would be interesting to see how gender could have an effect on the athlete’s psychological response to injury.
Quinn and Fallon (1999) argue that athlete’s doubts and anxieties become apparent when returning to sport, these feelings can lead to one or more detrimental effects, or example re-injury or injuring another body part, which can in turn lower confidence which can decrease motivation to recover or return to participation. Although during this study, injured athletes had high confidence in keeping up with the programs which were given to them. Quinn and Fallon’s (1999) argument is supported by Bianco et al (1999) and Johnston and Carroll (1998) who found that a combination of high performance expectations and disappointing results resulted in a decline in confidence during the comeback season. This may be the athlete’s own performance expectations or the expectations of the athlete’s coaches or teammates.
There has been a significant amount of research conducted regarding gender differences and injury experiences. Granito’s (2001) study found that comments were made by 28.6% of athletes and 87.5% of student trainers who commented on how male and female athletes react differently to their injuries with regards to differences with sports opportunities and the nature of male and female athletics. A student trainer reported males will try and help their teammate by trying to prove to them that their injury is not that serious, whereas females are more encouraging to each other in helping them through the recovery process first. Another study by Granito (2002) focused primarily on gender differences and found that female athletes tended to be more concerned about how the injury could influence their health in the future. Another of the categories Granito (2001) had identified was how injuries had effected relationships with others, there were five significant relationships which were identified (trainers, teammates, coaches, other injured athletes and parents). All student trainers and 71.4% of athletes reported their relationship with trainers after injury occurrence had regulated how the athlete dealt with the injury. Relationships with other injured athletes may have influenced how the athlete dealt with the injury as some of the student trainers had stated introducing other injured athletes with a similar or the same injury as the athlete in order to see how their treatment and recovery would progress over time. The athletes saw the value in connecting with other injured athletes “It’s like a support group” (p.73). Relationships between athletes and teammates varied, the athletes perceived the relationship as either positive, in that their teammates could support them through their injury, or negative which refers to the pressure an athlete may feel to return when it may be too soon for them both physically or psychologically. The relationships coaches had athletes had a noticeable impact on the athlete’s emotional state. Athletes commented that the relationship could be either supportive or non-supportive. A number of athletes did not feel that their coaches supported them through the injury process. One athlete stated “My coaches are the ones who don’t believe me, they’re sick of it as much as I am. Now they’re blaming me for being hurt.” (p.73). The relationships with parents were noted by 87.5 percent of athletes and 62.5% of student trainers, athletes had reported feeling pressured by their parents concerning recovery from injury. The trainers had noted that many times the parents could be a source of stress during the rehabilitation process. These relationships can be seen to have an impact on an athlete’s recovery process, some may felt pressurized by their perceived social support to return to sport when they are not physically or psychologically ready to do so. From research conducted, it can also be seen that coaches have a larger influence on an athlete’s recovery and there are many studies which show that an injury has a detrimental strain on the athlete-coach relationship.
The rationale for this study was to gain further information of what athletes go through both psychologically and physically when injured. Within this study, there is no specific research question per se as it is based on a phenomenological approach, as injuries are an extensive phenomenon in sport. Based on the integrated model of psychological response to the sport injury and the rehabilitation process (Wiese-Bjornstal et al., 1998), in-depth interviews were conducted to obtain information with regards to the five responses (personal, behavioural, situational, emotional and cognitive appraisal) of the integrated model, such information which reflects the responses within the model includes, their behavioural coping, any frustration or tension the injured athlete may feel with regards to the situation itself or to others and whether teammates have influenced the athlete in terms of their recovery. The following chapter will discuss the methodology of the study, justifying the use of in-depth semi-structured interviews over quantitative measures and will introduce each participant in more detail.
Chapter 2 – Methodology
This section will provide information with regards to the nature of qualitative methods for this research. It will provide a rationale for the study as well as participants sampling method, the methods used for data collection, the procedure and the data analysis. Through this method, trustworthiness of the research will be ensured by abiding to Guba’s (1981) criteria, ensuring credibility, confirmability and dependability. In order to understand the psychological responses of injury through experiences of injured athletes, qualitative research methods are employed in order for the reader to fully understand the athletes’ experiences with injury and how psychologically they have overcome this injury.
Sofaer (1999) concluded that the use of qualitative research methods is of more value than the use of quantitative methods as these methods provide rich descriptions of phenomena such as injury. Denzin and Lincoln (2000) defined characteristics of qualitative research, which is concerned with the richness of description, gaining more information on the individual’s perspective and also that within qualitative research, there is greater detail reported with regards to the individual participants than there would be if quantitative methods were employed. The goal of qualitative research is to develop concepts which help readers understand phenomena in natural settings, placing emphasis on the experiences and views of the participants. Within this study, it would be more beneficial to use qualitative methods over quantitative methods as it allows for more descriptive answers, whereas a questionnaire usually implies on how much a participant agrees with a statement or not, qualitative answers provides more meaning. Elliott (1995) concluded that the purpose of qualitative studies aim to understand the perspectives of participants and to define phenomena, whereas quantitative methods are more concerned with testing proposed relationships or causal explanations and evaluate the reliability and validity.
The sample for this study consisted of five students all of whom had competed in sport for over five years. These participants displayed a variation of sporting experiences and have competed at different levels. All participants are currently involved in physical activity. To ensure confidentiality of the participants, false names are used throughout this study. Mark had played both football and rugby union since school, but predominately focussed on football after a leg injury in rugby. After playing football for two years, Mark sustained a leg injury during a 50-50 tackle. Due to a lack of confidence and re-injury anxiety, which will be discussed later in Chapter 3, Mark now does not take part in football, but has more recently taken up playing golf.
Nick had been taking part in sport since starting secondary school, predominantly rugby union and athletics. When Nick had moved onto college, his focus was primarily on playing rugby, this continued when Nick progressed to university until during summer break while playing for their local rugby team and tore his hamstring after receiving a low pass. Since Nick’s injury, it was advised that he take up coaching instead to put less pressure on the injury. As well as coaching their local team, Nick has taken up long distance running, and regularly participates in half marathons with the ambition to complete a marathon in the near future.
Taylor had been taken part in gymnastics from the age of five. Prior to the injury which had been discussed, Taylor reported other injuries in their wrists and sprained ankles. This injury in particular had occurred whilst landing a vault, causing ligament damage. Since Taylor’s injury, it was recommended that Taylor start coaching gymnastics to children and to stop competing to lessen the risk of further or new injuries and has also started running and swimming to maintain overall fitness.
Lauren had taken part in most sports for their school team, and had played hockey for their college team until the injury occurred. Lauren’s right knee was dislocated whilst running towards the ball in a short corner situation. As a result of this injury, Lauren could no longer participate in games due to re-injury anxiety and is currently running to maintain fitness levels and is training for a half marathon.
Ella has been taking part in gymnastics for twelve years, and has broken her left arm twice since competing. Ella has stated that she has had scoliosis on the spine which had caused Ella pain whilst performing gymnastic floor routines, this pain lead Ella to decide to take a break from gymnastics and returned the following season continuing sessions with a chiropractor and physiotherapist.
All participants were recruited through purposive sampling; this was better suited to this study as the participants were recruited based on the specific information they were able to discuss with the researcher. Karmel and Jain (1987) compared results of a model-based purposive sampling method and a random sample with intention of advocating random sampling. Purposive sampling did better than the random method. Students were recruited as this sample were easily accessible and are almost always widely available and willing to participate. (Foot and Sanford, 2004) Students were used rather than participants who are currently using physiotherapy services in a hospital, which may not have been as easily accessible due to ethical implications, for example, distress on these injured patients, who are currently seeking rehabilitation.
Interviews were used for this study as they allow for more and better quality information to be given than through the use of a questionnaire or an observation. Smith (2015) concluded that the use of a semi-structured interviews facilitate empathy and help build a rapport, allowing for greater coverage and tends to produce good quality data. The interviews were semi-structured as opposed to structured interviews as it enables the researcher to build a rapport with the participants and the interview can continue with discussion of the participant’s views and concerns. Semi-structure interviews also allow for the researcher to ask more probing questions in terms of interesting points which may arise as the interview progresses. McNamara (2009) highlighted that the use of semi-structured interviews helps ensure that the same general areas of information are collected from each interviewee; this provides more focus than a conversational approach, but still allows a degree of freedom and adaptability in getting information from the interviewee.
The types of questions used were open-ended questions such as “What was the nature of your injury?” and “What was your first thought after the initial pain?”, these questions needed to be probing in order to gain a further understanding of the participant’s injury experiences.
The participants were provided with an information sheet and an informed consent form (see Appendix 1) which provided the full information of the study, also with the reassurance that any information they provide will remain anonymous under pseudonyms. Prior to the interviews, the participants signed a consent form which showed that they fully understood, the participants signed a consent form which showed that they fully understood the details of the study, were over the age of eighteen and were willing to participate in the study.
Each participant took part in one semi-structured interview, these interviews lasted between forty-five minutes and an hour. The participants were initially asked to take part in one interview, in order to gain as much information as possible regarding their injury experiences. A follow-up telephone interview was also conducted, the researcher briefly discussed the topics which were discussed in the initial interview, in order to allow the participant was able to clarify and elaborate on any comments made, which were unclear in the first interview. A telephone interview was used as it allows for participants to feel relaxed and disclose sensitive information, which participants may have felt uneasy about discussing in the first interview. Chapple (1999) and Sturges and Hanrahan (2004) concluded that qualitative telephone data have been seen to be rich, vivid, detailed, and of high quality.
All interviews began with ‘icebreaker’ questions, this was done in order to relax participants who may have felt anxious about being interviewed and to build a rapport. For example, “How long have you been playing your sport?”, “Is there any particular reason why you decided to play your sport?”. After these ‘icebreaker’ questions, the interview continued with the question “What was the nature of your injury?”, “How long were you unable to play for?”. There were other questions which followed which were done in order to help further the themes and questions for example, “How much of an emotional effect did the injury have on you?” and “Did these feelings prevent you from doing things you did before the injury?” All interviews were audio-recorded and transcribed. The follow-up interview was conducted before the analysis of the data as participants could be contacted regarding their comments to ensure that these comments were not misconstrued.
This study ensured trustworthiness through Guba’s (1981) criteria for trustworthiness. These include credibility, which refers to the research and how believable the findings are. These findings which the researcher had established and the views of the participants need to be compatible in order for the results to be valid and credible. This was done through the follow up interview, which was conducted after the data analysis. In order to develop a rapport with participants, ‘icebreaker’ questions were used.
Transferability refers to the extent to which any findings or conclusions can be transferred to similar situations with similar participants. Potentially, this could be the case as injured athletes from different sports, in different parts of the world could have the same psychological experiences as what these participants had experienced. There are many different methods which aid in ensuring trustworthiness. The researcher developed detailed description of the researcher’s steps from the beginning through to the end of the research process. Member checks had also taken place, returning to the participants for feedback on the researcher’s understanding of their data and to avoid any misunderstanding. A peer review had also taken place in order to provide a fresh perspective. Krane and Barber (2005) concluded that using a qualitative method not only informs about the facts but also the emotions, meanings and intentions of participants.
The data analysing process occurred after the follow up interviews with all participants had taken place. A systematic, thematic process was used to analyse the data. Thematic analysis is beneficial as it allows themes to become more clear throughout the analysis process. This analysis process will follow the process concluded by Braun and Clarke (2006) following through each phase and repeating phases if deemed necessary. The first step was for the researcher to familiarise themselves with the data, which entails reading and re-reading the data, listening to the transcriptions which was audio-recorded. The second stage was to code the data this involved generating brief labels for the important features of the data in concordance to the research question, for example one of the labels used during the analysis was “frustration/anger”. The third stage was to search for the themes within the data, Braun and Clarke (2006) explain that this process is to identify codes within the codes. The fourth stage was to review the themes, this is done to ensure that the themes “work” with regards to both the coded extracts and the entire data set. The researcher also reflected on what the themes entails and also explains the relationships between themes, for example athletes who had believed that they could injure themselves again and their confidence levels had a clear link. The fifth phase was to define and name each of the themes, this refers to the researcher having to write a detailed analysis of each theme. The sixth theme is to write up the data, this involves linking the analytic narrative with extracts of the data which tells the reader a compelling story about the data, and how it fits with the current literature. The themes identified within this study were re-injury anxiety, social support, frustration, unrealistic optimism and mirror-touch synesthesia.
The next chapter will elaborate further on each of the themes identified and an interpretation of these, this chapter will also aim to discuss these themes with regards to previous research and to discuss any differences within this study which may contradict prior research findings or conclusions or any findings which support the current literature. The two themes which were not anticipated will also be discussed in further detail and linked to existing research.
Chapter 3 – Analysis, Interpretation and Discussion
Each of the five interviews generated a wealth of information regarding participant’s injury experiences and how each individual had stated how their injury has affected them both in the physical and psychological sense. Within this section, which will entail detailed analysis and interpretation of each participant’s experiences of injury. Each participant has provided their own insight of how they had responded to their injuries and as a result themes had occurred, which were Re-injury anxiety, frustration, unrealistic optimism, social support and mirror-touch synesthesia. Each of these themes will be discussed in further detail throughout this chapter.
From the very first interview, the theme of re-injury anxiety was strong, reading through each interview multiple times, it became more clear in most participants how they felt regarding re-injuring themselves and in turn the possibility of making their injury worse. While it was previously stated in the Introduction chapter, it is also ever-present that re-injury can occur for an injured athlete and an athlete who has recovered from an injury (Heil, 1993). Taylor and Taylor (1997) suggest that a fear of re-injury can occur from a lack of confidence and trust in the injured area following an injury. Pargman (1999) goes so far to say that the fear of re-injury can be detrimental to performance when an athlete returns to competition. Within this study, many of the participants could identify some form of re-injury anxiety they had faced during their experiences. Mark found himself doubting his ability with regards to returning to football, and questioned his athletic identity with regards to the kind of player he was.
“Would I be the same type of player going back to the sport… It [injury] preventing me from doing, being an aggressive player… It’s just doubt in your mind at all times, is it going to happen again? Is it going to be worse?… Mentally, I had doubts into the challenges so I don’t think I could commit 100% back, to the game… I weigh up the options, is it worth the risk about going to play not just football but any type of sport.”
In Lauren’s case; “I was quite reluctant to put 100% into it… I wasn’t quite the same, I was anxious about hurting myself again making my knee worse than it already was… It felt weird and frustrating not being able to go full throttle and always being conscious of hurting myself again… I was too afraid to even go and tackle another player in case history would repeat itself and my knee would mess up again, but like how could I be a defender in hockey when I couldn’t even tackle an opponent? … I was too worried about hurting myself again, which was constantly on my mind when I was playing.”
With Taylor it was also a case of not being able to reach her pre-injury levels due to her re-injury anxiety. “I wouldn’t say I got back to the standard of gym I was originally at, which obviously was very annoying for me, because I knew I could do better… I was quite nervous then to um get myself to do things just because I was more worried that I was going to worsen the injury… I was very nervous when it came to re-introducing stuff.”
With Nick, his injury lead to the decision to stop playing rugby to which he attributed to his injury; “I know hamstrings can be quite notorious for career-ending injuries, which it kind of did with my rugby playing.” Initially it may have been due to the extent of the injury however, it could also a result of re-injury anxiety. Heil (1993) suggested that re-injury anxieties can often prevent otherwise healthy return to sport. It may also be suggested that re-injury anxiety can negatively influence an athlete’s post-injury performances, it is possible that a decrease in strength, de-conditioning can impact on an athlete’s come-back performance (Podlog, Eklund and Miller, 2011). However, Podlog, Eklund and Miller (2011) suggest that an injured athlete’s attentional focus can be altered due to re-injury anxiety and as a result can create a sense of hesitation within the athlete. This can be seen as evident in the participants previously discussed.
Mark and Lauren, due to the comments they had made during their interviews, it could be suggested that they both had displayed some form of kinesiophobia, which Kori, Miller and Todd (1990) had defined as “an irrational and debilitating fear of physical movement resulting from a fear of vulnerability to painful injury or re-injury” (p.37). As both participants had reported a decline in physical performance due to their injuries and these injuries had contributed to reluctance to engage in activities which could potentially lead to further injury or re-injury of the same body part. This is supported by Vlaeyen et al (1995) who found that participants who had chronic lower back pain and had reported having more fear of movement or re-injury had showed more fear and avoidance when shown to a simple movement.
Due to what the participants had said during their interviews, the basis that injured athletes would have a degree of re-injury anxiety is evident. The feeling of getting another injury or worsening the current injury was clear among the majority of the participants. Tripp et al (2007) found that athletes’ confidence in returning to their sport was reduced, and was more evident in athletes who had reported a greater negative mood and had greater fear of re-injury, these factors led to a decrease sporting activity return. Results from Tripp et al’s study (2007) concluded that athletes who had expressed the most concern with regards to suffering multiple injuries had generally reported lower levels of participation in sporting activity. All participants from this current study had all reported giving up their sport in pursuit of something else, with the exception of Ella who showed no evidence of having re-injury anxiety as she has scoliosis which is chronic and therefore re-injury may not have necessarily been an issue but Ella did not indicate any other anxiety with regards to injuring another part of her body, despite breaking her left arm twice and having tendonitis in her knee, she continued to compete in gymnastics.
Multiple research has shown that frustration is evident in injured athletes. Quackenbush and Crossman (1994) found that negative emotional responses of frustration was highly apparent during their study and 28% of participants reported being frustrated after returning to training and competition as they could not perform at their pre-injury level. This was evident in Taylor’s interview;
“I wouldn’t say I got back to the standard of gymnastics I was originally at, which obviously was very annoying for me, because I knew I could do better so mainly I would say that…I was bored all the time, so obviously that wasn’t great, so I was kind of down all the time for that reason… It [recovery] was a very slow process getting back in so um, I was just wanting to develop a lot quicker than I could… I think I tried to rush myself a bit getting back into training because obviously the lack of training was quite frustrating for me.”
In terms of recovery, Nick also felt the same frustration about their recovery; “I’m the type of person I get frustrated when I can’t train and I can’t play.”
In Lauren’s case, the frustration was not directed at not performing at their pre-injury level but more general day-to-day routine…It was just frustrating really. I couldn’t just run upstairs to grab something or just go for a run or do anything while on my crutches.”.
Johnston and Carroll (1998) concluded that frustration was one of the most commonly reported emotion along with anxiety, depression. Participants who had lower limb injuries had reported having deep frustration with regards to the daily hassles. Lauren’s other reported frustrations were related more to watching others performing;
“But at times, when I could see the person who was playing my position and be like frustrated at all the little mistakes she was doing”.
Mark also reported feeling frustrated at other players; “You think you can do a better job than them on the pitch because I was there before them, so I thought I could do a better job and it did eat you up inside.”
This type of frustration may be linked to Cole and Montero (2007) who had interviewed paralysed individuals, one of whom had reported that observing others performing tasks, had intensified their feelings of frustration. Similarly, Gould et al (1997) found that participants’ frustrations were often a result of losing to competitors that they used to defeat in competition. Mainwaring (1999) stated that athletes have certain expectations that the coaches, teammates or sport medicine team to provide social support and it is when these expectation are not met, the athlete expressed frustration and more rarely depressed. It was also noted that gestures were not often taken in the right way, while they were offered in good faith and supportive, participants felt more frustrated as a result. This can be related to Ella’s reports of frustration referred more to feeling frustrated with others more so than with the injury itself;
“They [family, friends and coach] would realise that I was pushing myself too much and they would be like ‘okay slow down’, like telling me what to do and it was kind of a little bit frustrating because you just want to and you know carry on.”
The phenomenon of unrealistic optimism was not anticipated to become apparent within this study, the basis of unrealistic optimism was introduced by Weinstein (1980) who stated that it was the tendency to think that negative events were less likely to happen to oneself than to others. There has been much research with regards to susceptibility to illnesses such as cancer or injuries as a result of train collisions (Dolinski, Gromski and Zawisza, 1987). Job et al (1995) examined drivers and the precautions they take, results showed that unrealistic optimism has a relationship with reduced use of safety precautions. The drivers who had showed increased unrealistic optimism were more likely to report using less safety precautions. Therefore it could be suggested that within sports, this could help explain why athletes fail to follow the correct warm-up procedure or use the protective equipment such as gum shields or shin pads. Caponecchia (2010) hypothesised that unrealistic optimism would be present within occupation health and safety, participants reported that they felt that certain events such as suffering a life-threatening injury or causing an injury to a colleague or obtaining an injury after not using protective equipment is less likely to occur to them than it was to others.
There has been very little research regarding sport-related injuries or risks, however Middleton, Harris and Surman (1996) found that novice bungee jumpers had perceived that their risk of obtaining an injury was less likely than the typical bungee jumper. However, research regarding sport-related injuries have been insufficient and more research needs to be conducted.
Many of the participants displayed their disbelief regarding injury occurrence, some individuals went so far to transition from one sport to another. Therefore, it could be argued that the transition over from one sport could be a way to lessen the risk of injury, however this may be unrealistic optimism as the athletes believe that moving from one sport to another will lessen if not eliminate the chance of injuries rather than lessen it.
While Lauren, Nick and Taylor moved from one sport to other physical activities for rehabilitation purposes. Mark had moved from playing rugby to football, prior to the injury we had discussed in his interview, “After an injury in rugby I decided to take up football for hopefully less injuries.”.
Nick and Lauren had reported not anticipating a serious injury due to their age;
“Um shocked I suppose, disappointment really because I was only 22” (Nick),
“I was almost in shock, like I couldn’t quite believe what had happened… It wasn’t an injury I had expected to happen at least not when I was 17, it still baffles me how a hockey ball to my knee came to more than just bruising, which was what I thought was probably worst-case scenario, but to knock it out completely, it just seemed like freak accident almost.” (Lauren)
“I was always, kind of grew up with a kind of, a little bit of back pain and it was until I was getting older and obviously and being in gymnastics that I figured out something was seriously wrong.”
Ella having scoliosis and waiting to see what the problem was can also be an example of unrealistic optimism as she almost accepted the back pain and did not go to get it checked until a more serious problem had occurred which was unrelated to her back pain. Almost as though she wanted to ignore what her body was telling her, thinking it was just a part of growing up and it would go away on its own or taking part in gymnastics was giving her back pain. Weinstein (1983, 1984) stated that people continue to partake in their unhealthy behaviours are as a result of making the wrong assumptions with regards to risk and susceptibility. Weinstein concluded that there were four cognitive features which contribute to unrealistic optimism. The first is having a lack of experience with the issue, the second is that the issue is preventable through a change in an individuals behaviour. The third feature is the illusion that if the problem has not already appeared, it is highly unlikely to appear in the future. The fourth cognitive feature is the belief that the problem is uncommon. In Ella’s case it could potentially be that she has a lack of experience with the issue as Ella believed that the pain she was experiencing was part of growing up and perceived it as normal.
Pearson (1986) proposed that social support can facilitate the coping process by providing additional resources such as advice, information or material responses which can increase an individual’s coping resources. These social support networks can influence the athlete’s emotional reaction to injury, each participant had experienced some form of social support, this came from family, friends, teammates and coaches.
Richman, Rosenfield and Hardy (1993) concluded that there were eight types of social support, most of which were present within this study and this support came from family, coaches and teammates. The first type of support is listening support, which is defined as another listening without giving advice or passing judgement. This can be seen as several participants reported feeling frustrated and some reported that they took this frustration out within their social support network.
Lauren reported these feelings of frustration and not being able to do daily tasks or simple tasks;
“It was just frustrating really, I couldn’t just run upstairs to grab something or just go for a run or do anything while on my crutches… I think my frustration was quite noticeable, and so people like my friends and family were picking up on it. But my mother in particular, was really helpful”.
The second type of support was emotional support, which is the perception that another is providing comfort and caring and indicating that they are on the individual’s side, this can be present within everyone’s interviews.
“I had different aspects coming from different directions… Caring from my girlfriend.” (Mark)
“My mother had the brunt of it, but very supportive I suppose um, urged me not to push myself too quick, too soon”. (Nick)
“They [family] were all really supportive, like my family were quite helpful in telling me what I could and couldn’t do and telling me not to push myself too hard and too fast”. (Lauren)
“My family and coaches that they were there for me… They were encouraging and supportive, which was a very positive thing to come out of my injury”. (Taylor)
“I feel like I learned that my coach is more lenient than I thought she was so she was more caring about how my recovery was going and like more careful with me if that makes sense”. (Ella)
The third type of support was emotional challenge, this refers to a person challenging the individual to evaluate their attitudes, values, and feelings. This is relevant to Mark’s interview;
“Some very caring, others were telling me to give up sport and were more concerned in that type of way for a long period of time”.
Challenging the individual’s logics regarding a task or an activity in order to motivate the individuals to greater involvement. This is present in Nick’s interview;
“The coaches I had at the time, they suggested that I go into a coaching role… So that’s what I’ve done that now since the injury”.
Personal assistance was present throughout many of the participant’s injury experiences, others providing with regards to being driven to appointments. While there are many types of support, it is possible that some types are better suited to different social support. It may be that it is in the best interest of the participant to be driven to appointments and to be provided with emotional support by the individual’s families and friends. Other kinds of support may be more predominantly used by coaches or teammates. Support including, reality confirmation which refers to a person similar to the individual, a teammate for example who has had the same experiences as the individual. Other support may include task challenge as previously discussed or they may offer reality confirmation which refers to a person, a teammate for example who has had similar experiences such as injury as the individual and can relate to what the injured athlete is feeling. There was much reported in terms of teammates support by both Nick and Mark;
Mark had reported that initially his teammates were not supportive as they did not know the extent of his injury;
“Initially, they weren’t very caring because they didn’t think I’d done that much damage, after the next day when I spoke to them, they were quite upset for me because they weren’t very caring at the time.”
The majority of the social support was positive, although it was noted that some had advised him to give up sport.
“I had different aspects coming from different directions… Caring from my girlfriend, to rest and then from the teammates point of view they pushed me more to the physio to get me back on my feet… They [teammates] helped me to the road of recovery… They helped me with my basic skills again and just getting my confidence back again… I don’t think I would have been able to back if they weren’t as supportive as they were… A team sport it is, you’re not alone you do have the support of the team.”
Mark spent a long amount of time discussing the support he had from his teammates, this links with Suitor et al., (1995) who explained that teammates can encounter similar demands and situations, as they may offer empathy and can also offer the most appropriate support. Corbillon et al., (2008) concluded that teammates are valuable sources of both esteem support and emotional support.
However, while Mark overall had experienced positive social support, there were family members who were urging him to leave sport due to the amount of injuries he had over the years.
“Some were very caring, others were telling me to give up sport and were more concerned in that type of way for a long period of time.”
Similar to Mark, Nick found that his teammates were supportive throughout his recovery process;
“My teammates, they keep, what the word for it? I suppose they give me a bit of stick about it but kind of the whole rugby ethos of having a bit of banter so I’m kind of just a brunt of a joke… Having a joke and mentioning my injury but other than that I know they’re very supportive of it so.”
From both Mark and Nick’s remarks it is evident to see that teammate’s support can influence and facilitate the recovery process.While the majority of social support was positive amongst participants. There were some social support experiences which were negative, typically from participant’s coaches. Lauren reported that her coach was not entirely supportive throughout her recovery.
“I think my coach would have been so happy to see me back playing with my crutches to be honest… My coach’s reaction didn’t really change, initially she asked how I was doing and how long it may take for me for come back. But once I knew the full extent and when I realised I needed more time it was like she did not care and wasn’t really that bothered if I stayed or if I went… She [coach] didn’t seem that bothered like she was over it… It would have been nicer to see my coach care a little bit more…”
This is not an uncommon finding within the literature of social support within injury. Research by Granito (2001, 2002) who found that females had tended to perceive the coaches as more negative with regards to how their coaches treated them following their injury. It was concluded that the coach and athlete relationship can affect the athlete’s emotional state. Within Granito’s study (2001) many athletes did not feel that their coaches had supported them through the injury process, similar to what Lauren had felt with regards to her coach.
Another theme which was not anticipated from this research was that some participants would feel painful sensations not through an injury but by observing others in potentially risky situations similar to what the participants themselves were in when their injury had occurred. Nick reported these feelings as did Lauren.
“I’d look at certain players doing certain movements and I can almost feel my hamstring tightening really, it was quite a weird feeling for the first week especially um and I still get it from time to time, if I see a player bend a certain way or sprint I do feel as if I like a little queasy almost I suppose. (Nick)
“There were times where I could see that the ball would go up in the air at some speed maybe only half a metre or a metre up looking as though it was going toward someone’s body and it was almost as if my knee would react to it and tense up. Really weird feeling.” (Lauren)
There are many explanations as to why the participants experienced these sensations. One explanation is mirror-touch synaesthesia, which is a condition where seeing other individuals experiencing somatosensory sensations causes the same sensation in the observer. The most recognised theory is that normal people have the somatosensory mirror system in which is moderately observed and felt touch, has activations that are below a certain threshold, when these activations are below said threshold a person can sense the observed touch. Blakemore et al. (2005) states that in motor neuron synesthesia the mental imitation is strong enough that it crosses the threshold into a near-tactile sensation, which is sometimes distinguishable from the observer’s own. This condition has been seen in patients who have suffered a stroke with loss of sensation and amputees where visual stimuli produced a tactile sensation, in particular results found that developed synesthesia could potentially be linked with sensory loss, which develops after amputation and those who were highly empathetic could be predisposed to strengthening the pre-existing pathways between observed touch and felt touch. (Goller, 2013). Osborn and Derbyshire (2010) explain that observing someone in pain produces a shared emotional experience that predominantly activates brain areas processing the emotional component pain. Much research has been conducted which links vicarious pain to somatosensory processing, implying shared emotional and sensory pain components, which heightens the chance of pain being experienced due to vicarious observation, as the participants reported experiencing.
Giummarra and Bradshaw (2008) suggest that expressions of pain differs from gender to gender. Male expresses pain as producing increased activity in emotion related areas, which includes the amygdala, perigenual anterior cingulate cortex and primary somatosensory cortex, this can produce a threat related response from the observer. Females express pain as decreasing activity in these same areas. This suggests that the defensive response is inhibited, and instead promotes helping behaviour (Simon, Craig, Miltner and Rainville, 2006). Giummarra and Bradshaw (2008) explain that most people generally can identify with feelings that an individual’s leg muscle become tense at the moment they see a teammate perform a specific task, for example talking a penalty kick, this may be the feelings both Nick and Lauren had identified in their interviews. Research has found that people can identify feelings of pain by simply witnessing it not necessarily in person but via the use of pictures. Salvia et al (2016) found that participants reported feelings of pain and empathy. These feelings of empathy may be related to participants in this study as they can recognise and relate to what other athletes may be feeling. Within this research, it is rather limited within the sporting context and further research with regards to mirror-touch synesthesia and injured athletes should be conducted. Other recommendations for future research will be discussed further in the next chapter along with a summary of this study along with its shortcomings and recommendations.
Conclusion, Future Recommendations and Reflections on Study.
To conclude, the findings from this study found further support for the re-occurring themes in the existing literature, such as re-injury anxiety, both positive and negative experiences of social support and the reports of frustration which were reported by participants. Other findings from this study were not predicted, some athletes had reported that they had not anticipated their injury, due to the sport they took part in or due to their age. Weinstein (1980) stated that these superficial factors such as age influence individual’s beliefs regarding events and as a result can often fail to see the significant similarities between themselves and those who have experienced an event such as injury. Another theme which was not expected was that some participants reported feeling some painful sensations while observing others taking part in their sport, known as mirror-touch synesthesia.
Limitations of the Investigation
Within this study, there were some limitations within the details of the interviews themselves. Within the male participants, they were more concerned with the physical aspect of recovery, rather than the psychological aspect. Nick in particular, made little discussion regarding his social support systems. A possible explanation of this, may be that males are less likely to disclose sensitive information, especially with regards to an injury and how they had coped with said injury. Jourard (1963) discussed that females tend to disclose more than males as the male sex role impedes male’s self-disclosure as males are perceived to be tough and unsentimental and highly unlikely to express their emotions.
Within the interviews themselves, as the researcher had very limited experience interviewing participants, it was more than likely that the last interview would be of better detail than the initial interview. Therefore, in order to enhance the efficiency of the interviews conducted, a pilot study should have been implemented in the early stages of this process. Teijlingen and Hundley (2001) concluded that a pilot study provides issues within the research process, it can determine whether the methods were not appropriate.
Based on what the participants had discussed, it would be suggested that further research be conducted within the themes of unrealistic optimism and mirror-touch synesthesia. Unrealistic optimism literature within the sporting world is fairly non-existent and as a result much research could be conducted in the future in terms of how likely athletes were to anticipate their injuries while it widely accepted that injury is ever present in an athlete’s career. Future research may include examining athletes who have unrealistic optimism regarding injury and their reactions when they had obtained an injury, this may be beneficial in order to educate athletes about the risks of injury when taking part in sport.
Possible research within the topic of mirror-touch synesthesia could be to examine any differences between injured and non-injured athletes in terms of experiencing somatosensory sensations while observing video clips of athletes obtaining injuries, such research may offer some further support within the research of empathy and possibly help further understanding of phantom limb in amputees.
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