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Insights from a collaboration of six major professional associations on the importance of psychological factors in athletic injuries and rehabilitation. Team physicians are encouraged to recognize and address psychological antecedents and reactions to injury, as well as the role of stress in injury risk and rehabilitation. The document also emphasizes the importance of psychological support services and referrals to mental health providers.
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This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization.
This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.
Expert Panel Stanley A. Herring MD, Chair, Seattle, Washington Lori A. Boyajian-O’Neill DO, Kansas City, Missouri David B. Coppel PhD, Kirkland, Washington James M. Daniels MD, MPH, Quincy, Illinois Daniel Gould PhD, East Lansing, Michigan William Grana MD, MPH, Tucson, Arizona Eugene Hong MD, Philadelphia, Pennsylvania Peter Indelicato MD, Gainesville, Florida Rebecca Jaffe MD, Wilmington, Delaware Elizabeth Joy MD, Salt Lake City, Utah W. Ben Kibler MD, Lexington, Kentucky Walter Lowe MD, Houston, Texas Margot Putukian MD, Princeton, New Jersey
Definition Team physicians must address the physical and psychological issues related to athletic activity. This athletic activity may result in physical injuries, and these injuries produce a variety of psychological reactions. Additionally, psychological factors, especially stress, are an important antecedent to injuries, play an important role in injury rehabilitation, and contribute to successful return-to-play. While non-injury psychological issues related to athletic activity exist, they are outside the scope of this consensus statement.
Goal The goal of this document is to help the team physician improve the care of the athlete by understanding the relationship between injury and the psychological issues related to injury. To accomplish this goal, the team physician should have knowledge of and be involved with:
Psychological Antecedents of Athletic Injuries Psychological factors (i.e., stressful life events) may contribute to the risk of athletic injuries above and beyond physical and environmental factors. Personality factors (e.g., introversion/extroversion, self esteem, perfectionism) and other psychological factors (e.g., a supportive social network, coping resources, high achievement motivation) alone do not reliably predict athletic injury risk. There is no “injury-prone” personality type. However, there has been a consistently demonstrated relationship between one psychological factor – stress – and athletic injury risk.
Stress may be defined as the demands of a situation exceeding the resources to respond to those demands ( see Table 1 ). Athletes who experience high levels of stress, whether on or off the field, are at greater risk of being injured. Certain subpopulations of athletes, such as those experiencing high life stress and low personal coping skills, may be at an even greater risk of sustaining athletic injury. Stress causes attentional changes (e.g., narrowing of attention, general distraction, increased self-consciousness) that interfere with an athlete’s performance. Stress has been shown to cause increased muscle tension and coordination difficulties which increase the athlete’s risk of injury. Teaching athletes stress management techniques has been shown to reduce injury rates over a season of participation.
Behavioral Physical Psychological
It is essential the team physician:
It is desirable the team physician:
Psychological Reactions Accompanying Athletic Injury
The levels and types of emotional reactions experienced also change over time; from the initial onset of injury, through rehabilitation, to return-to-play.
A number of factors should be considered when treating injured athletes. These factors include:
Cognitive-Based Techniques
Somatic-Based Techniques Cognitive Behavioral- Techniques
It is essential the team physician:
It is desirable the team physician:
Psychological Issues and Return-To-Play Psychosocial readiness is one criterion for return-to-play [see The Team Physician and Return- To-Play Issues: A Consensus Statement, 2002]. Emotional reactions, including a lack of confidence, apprehension and fear, may accompany an athlete’s return-to-play. These reactions may become problematic, interfere with performance and increase the probability of re-injury. The team physician should assess not only physical factors, but emotional reactions, when making the return-to-play decision. In conjunction with medical care, the supportive social network can help reduce the emotional upheaval and stress accompanying an injury and its rehabilitation.
It is essential the team physician understand:
It is desirable the team physician:
Referring Athletes to Mental Health Providers Athletes experience emotional responses to injury, and most of these responses are transient. The athletic care network and supportive social network are often effective in helping the athlete deal with these issues. However, athletes with problematic emotional reactions who need treatment should be referred to a licensed mental health provider, preferably one with experience working with athletes.
Licensed mental health providers have met the minimum educational and training requirements by their state. These are the only mental health providers licensed to treat problematic emotional reactions (see examples in Table 2). Along with other providers, they may also offer “sport psychology” consultation (e.g., performance enhancement, life skills training, imagery). In treating both transient and problematic emotional responses, athlete confidentiality is of particular importance.
Among athletes, there are different levels of comfort with referral to licensed mental health providers. Obstacles to referral include general apprehension, confidentiality concerns, perception of others, fear of revealing symptoms, and misunderstanding of mental health treatment. Coaches and team physicians’ attitudes towards mental health have an impact and influence on athletes. In addition, accessibility to providers and issues related to reimbursement may serve as obstacles to obtaining treatment.
It is essential the team physician:
It is desirable the team physician:
Conclusion
Selected References:
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Patterson, E., Ptacek, J.T., and R.E. Smith. Moderator Effects of Cognitive and Somatic Trait Anxiety on the Relation between Life Stress and Physical Injuries. Anxiety, Stress and Coping 13: 269-288, 2000.
Petitpas A, Danish S. Caring for injured athletes. In: Murphy SM, ed. Sport Psychology Interventions. Champaign, Ill: Human Kinetics;1995.
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Weinberg RS, Gould D. Foundations of Sport and Exercise Psychology. 3rd^ ed. Champaign, Ill: Human Kinetics; 2003.
Williams JM, Andersen MB. Psychological antecedents of sport and injury: Review and critique of the stress and injury model. J Appl Sport Psychol. 1998;10:5-25.
This Consensus Statement, as well as past statements, can be downloaded from the AOSSM Web site, www.sportsmed.org. Previous Consensus Statements include: Concussion (Mild Traumatic Brain Injury) and the Team Physician (January 2006); Exertional Heat Illnesses (June 2003); Female Athlete Issues for the Team Physician (October 2003); Team Physician and Return-To-Play Issues (July 2002); Sideline Preparedness for the Team Physician (May 2001); Team Physician Consensus Statement (May 2000); and Conditioning of Athletes for Sports (January 2000).