64 F isioterapie, S e p te m b e r 1982, d e e l 38, n r 3 STRESS AND THE PREDISPOSITION TO SPORT INJURIES H E I N H E L G O S C H O M E R , B.A. ( H o n s .), M. A. (Psychology)* SUMMAR Y S tre ssfu l experiences lik e accidents a n d d o s e m isses produce d istinct e m o tional responses in those going through them. S h o rt-term stressors o f this k in d m a k e one appreciate the effe cts long-term stressors m ust have on one's capacity to adapt a nd react appropriately a nd sa fe ly to an ever-changing, dem anding environm ent. A cute traum a an d injuries are associated with an increased perception o f persiste n t stressful events. S tu d ie s o f a th letes indicate that the r isk o f injury increases in direct relationship to the accum ulation o f challenging life change events which d e m a n d radical adaptation a n d coping behaviours f r o m the individual experiencing them. L ife change events are situations the in d iv id u a l i n te r p r e t s a s o v e r w h e lm in g , th r e a te n in g , u n sa tisfyin g a n d contradictory. The im pact o f life change events on p sy c hological dim ensions c o n stitu tes no sim ple process; it is c o m plex a n d m ulti-factorial. Im p lica tio n s f o r the prevention a nd rehabilitation o f sport injuries have to be a ppraised with this b a ck-drop in mind. O P S O M M IN G S tre m m e n d e ondervindings soos o n gelitkke en noue on tko m in g e bring duidelike em osionele reaksies voort in diegene wat g eraak word. D iesulke k o rt-te rm y n spanninge laat mens die e ffe k te van lang-term yn spanninge op ’n persoon se verm oe om aan te pa s en toepaslik en veilig te reageer in 'n im m e r veranderende en veeleisende omgewing. waardeer. A k u te traum a en beserings w ord geassosieer m et verhoogde w aarnem ing van aanhoudende, spannende voorvalle. S tu d ie s van a tle te dui aan dat die risiko van besering in d ire k te v e r h o u d in g t o t d i e a k k u m u l a s i e van u i td a g e n d e i lew enservarings styg, wat ra dikale aanpassing en teregkom (coping) gedrag van die individu verg. Lewensveranderende ervarings (gebeurtenisse) is situasies wat die individu as oorweldigend, bedreigend, onbevredigend en ontke n n en d vertolk. Die tre fk ra g van lewensveranderende ervarings op p sigologiese dim ensies is geen eenvoudige proses nie; dit is k o m p le k s en m u h ifa kto rie s. Im p iika sie s vir die voorkom ing en rehabilitcisie van sportbeserings m oet m e t hierdie a gtergrondin gedagte, w aardeer word. Stress is here to stay. M o d e r n m a n lives in a d a n g e r o u s a n d hostile w o r l d in wh ic h the un ex pe cte d is always likely to oc cur . C h a n g e s h a p p e n with cv cr- increasing speed a n d for m a n to survive o u r specics has to be e q u ip p e d with e n o rm o u s ly effective c o p in g strategies. T o c op e mea ns to keep the m in d a n d b o d y in a st ate o f relative eq ui li b riu m , a st ate o f h o m eo s ta si s. A n y t h i n g th a t upsets o u r capa city to m ai n t ai n critical va riables with in a cc ep ta bl e limits (e.g. self- image, esteem, r e la tio n to valued goals a n d ob jects) can be c on ceived as psyc hological stress. T h e m ore violent the c ha nge s i m pi ng in g o n a per son , the long er it takes for the system to re tu r n to a h o m e o s ta t ic state. C h a n g es th at are perceived as t h r ea te ni ng , o v e r p ow er in g , u n p l e a sa n t or irreversible give the m i n d / b o d y few ch an c es to :re tu r n to no rm al. In such s it ua ti on s stress be com es highly d a ng er o us — people refer to such s it ua ti on s as “ the rat race ” o r “ stress o f life” . F o r lon g-t er m stre ssors there are no simple sh or t- te rm sol ut ion s, no easy in st an t remedies, wh e rea s sh or t- te rm stressors are relatively easily dealt with, e.g. sho ul d you dislike the “ no i se ” o n the ra dio , yo u switch it off. F o r a pe r so n to fu n c ti o n at a n o p t i m u m level, m in d a n d bo dy have to act in h a r m o n y . W h en disrup tive stimuli oc cur , the ho m e o s ta t ic sys tem te nd s to induce corrective actions. When the corrective act io ns c a n n o t be m a d e be cause o f ove rload , o r tu rn ou t to be i n a d e qu at e , tens ions re ma in a n d will seek o u t a ch an ne l o f escape, e.g. mild neur osi s may escalate, f T h is p a p e r is b a se d on the talk “ T h e Role o f Psychology in t h e Pr e v e n ti o n a n d R e h a bi lit at io n o f S p o rt I n ju r ie s” held at the Symposium — Management of Sport Injuries, UCT , 17 April 1982, o r g a n iz ed by the SA Society o f P h y s io t h e r a p y ( W es te r n Provin ce Branch). * L e c t u r e r a n d P r a c t i c a l C o - o r d i n a t o r , D e p t , o f Psycho log y, Uni ve rsity o f C a p e T o wn . Received 10 M a y 1982. obsessive a n d depressive states may flourish o r a p a tt e r n of social d r i n k in g may t u r n into alco ho lis m. Stress is at its wo rs t w he n the individual c a n n o t identify its origin a n d it is n o t on ly the suffe rer that is af'fectcd. Feelings o f stress are co nveyed to peo ple close to the p e rs o n co nc er n ed . L o n g ­ term stressors lie at the ro o t o f much o f pe o p le ’s u n ha p p in e ss . L o n g- te rm stress pr o d uc es e n d u r i n g s y m p t o m s which include, o n an e sc ala ti ng scale o f severity, general feelings o f an xiety, sleeplessness, in te r p er s o n al pr o b le m s, m em o r y failure, p h ob ia s , d ep res si on a n d t o ta l m ent al b r e a k d o w n . T he most widely ac c ep te d t h eo r y o f stress is th at of Pr of e ss or H a n s Selye. He in tr o d u c ed the co n cep t o f the general adaptation syndrome ( G A S ) (1980) which defines t h ^ r e spo nse of an ind ividu al to stress agents. T h e response- follows three stages: firstly there is the alarm reaction, the s y s te m ’s initial r es po nse to the stressors: this is followed by the stage of resistance wh e n the m i n d / b o d y a tt e m p t s to deal with the pr o b l em s p re cip ita ted by the stressors; finally the pe rso n shifts into the stage of exhaustion whe re the resistances p ro ve i n a d e q u a t e a n d a mental b r e a k d o w n or severe physical illness ensues. H u m a n beings a r e co ntinu ally e ng ag ed in stages on e o r two in va ry in g degrees d u r i n g wakefulness. St ag e tw o co ns tit u te s w h a t is c o m m o n l y k n o w n as st r e s s itelf. An i n d i v i d u a l ’s p s y c h o l o g i c a l a n d physiol ogical c o n s t it u t io n de te r m in e s h ow long h e /s h e re m a in s in this stage; excessive un re le n tin g d e m a n d on an i n di vi du a l’s c o p in g strategies p ro pe l the system in to stage- three. P e rso ns e x pos ed to a n e n v ir o n m e n t where they ceaselessly experience ch all eng in g events are freq ue n tly ta ke n to their limits. Si m pl e r life styles b as ed o n largely ag riculturally m a n a g e d e co no m ie s tend to reduce the stress risk. C ul tu ra l f actors a lso play a role as societies vary in wha t is d e f in e d as re as on a bl e a n d n o r m a l in regar d to the display o f em o ti o n s. W h er e less inhibi ted displays are the n o r m , pe op le en d up R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e ra p y , S e p te m b e r 1982, vol 38, no 3 65 less stressed, th an th ose w ho c o n f o rm to pre sen t a cool exterior to their fellow citizens. It is widely d o c u m e n t e d th at the onset o f illness is significantly ass oc iat ed with an increase in stress (Rahe eI a ! 1964; Hol m es a n d Ralie, 1967). Illness tends to be preceded by a n e x p a n d i n g a g g lo m e ra t io n o f social events that require high e n e r g y c o p i n g s t r a t e g i e s f r o m th e i n d iv i d u a l ex periencing them . Thes e social events are perceived as being over po wer in g, m enacing, unsa tisfying o r conflict ual. In such situ ation s the ind ividu al is e xp ose d to a high degree o f stress. Bramwell el al. (1978) fo u n d the sa m e significant assoc iatio n t o exist between s p o r t injuries a n d an increased pe rce pti on o f stressful events: the risk o f timc-loss injurv tends to increase in direct r e la tio ns hi p to the a c c u m u l a ti o n of stressful life events. T h e s t u d y c o n c e n tr a t e d on university football tea m mem be rs. T h e following life ch an g e events were perceived by the players to d e m a n d high energy c op in g behav iou rs: d e a t h o f a sp ou s e or close friend, marr iage , divorce, m ari tal se p a ra t io n , j o b loss, pe rso nal injury o r ill­ ness. c h an ge in health of family m e m b e r, b e g in ni ng o r cessa­ tion of formal e d u c a t i o n etc. On the basis o f the n u m b e r an d i m p o rt a n c e o f life c h an ge events ex perienced bv the players du ri n g the past tw o years, players were divided into low-risk. m od er a te -r isk a n d high-risk gr o up s. T h e pl ay e rs’ injury records were th en c o m p a r e d with the risk categories. The analysis was b ase d o n major timc-loss inju ry only; the criteria being: a pl ayer ha d to miss three o r m or e practices a n d / o r one o r more game s due to a specific injury. Missing less than three practices o r o nl y pa rt o f a g a m e reflected m in o r injury co m m o n l y suffered by c o n ta ct s p or t pa rti cip an ts. In the low-risk g r o u p 30 pe r cent o f the players suffered m a j o r time-loss injury; 50 p e r cent in the m od era te- ri sk gro up; a nd 73 p e r c e n t in the high-risk g r o u p . T he higher the risk rating, the high er the p e rc e n ta g e injury suffered by the players. A c c u m u l a t i n g life change events, i.e. c h ro ni c stress periods, tend to h i n d e r a p e r s o n ’s c o n c e n tr a t io n on e nv ir on m en ta l cues th a t arc crucial to o p t im a l p e rfo rm an ce. Previously le a rn ed a d ap ti ve resp on ses fade a n d are totally bl ock ed u n d e r stress. T h e sp o r t p a r t i c i p a n t ’s focus of a tt e n ti o n is w a r p e d by the un c on sc io us tensions within the h o m eo s ta tic system. O f course o n e is de al in g with a mu ltifactorial process here. Very m u ch d e p en d s on the i nd ivi dua l’s i n te r p r e t a ti o n o f the life ch an ge events h e /s h e has been ex per ien ci ng in the recent past. T h e process involved in the comple x in te ra c t io n o f c o n s c i o u s / u n c o n ­ scious a c c u m u l a ti o n s o f stressful events are as yet no t fully explained. Nevertheless, the message is clear: sp ort p a r ti ci p a n ts ex p eri en ci ng a high degree o f c h ro ni c stress are at a p r o p o r t i o n a t e l y hi gh er risk o f s u s ta in in g injuries. One c an n o t h o pe to elim ina te stress c om pl ete ly if o n e lives a real life in a real worl d. T he on ly way o u t w oul d be to lead a vegetable-like existence that never pu ts the individual in any challenging sit ua ti o n. U n d e r such c irc u m s ta nc cs life might be secure a n d safe bu t a lso d e ad ly dull. W h a t o n e has to do is de velop d y n a m i c a d ap ti ve c op in g strategies. Instead o f av oidin g life one can le ar n h o w to m a n a g e it. T h e m ain target o f such tra in in g w o u l d be the sys tem ati c de se nsitiz ation of an individual to stressful events, followed i mm ed iat ely by progressive assertiveness t rai ni ng to face a n d deal with life ch an ge events whe n they occu r, a v oi di ng the a d van ce of c hr oni c stress co nd it i o n s. Of te n it is a m a t t e r o f identifying the ori gin o f a stressful sit ua ti on . Here the role o f a psychologist is ob v io us , t h o u g h a tr u st ed friend can some tim es be o f help in h o m in g in on the sourc e o f conflict g e n er a tin g p r o l o n g e d sta tes o f stress. A psy chologist will inevitably r e c o m m e n d the t r ai ni ng in anxiety m a n a g e m e n t tech niq ues t o s p o r t p a rt i ci p a n ts overtly negatively affected by stress. Su ch tech ni qu es range from progressive r ela xat io n a n d b io fe e d b ac k t r ai ni ng to cognitive c o pi n g strategies such as stim ul us cueing a n d au to ge n ic phras es (Ziegler, 1978). T he ir effectiveness is widely a c k no w le d g ed (Swinn & R i c h a r d so n , 1971: H e n n c n h o f e r & Heil, 1976: S c h om er . 1981). To u n d e r es t i m at e the psych olo gica l pe rim ete r o f spo rt isa costly exercise. P re v e nt io n a n d t r ea tm e nt o f s p or t injuries docs no t only h a p p e n on a p h y s i o lo gi c a l/t ec hn ic a l level. T h e mind is very m uc h in charge. References Bramwell. S.T., M a s u d a M.. W a g n e r . N. N. a n d H ol m es , T. H. (1978). Psychological factors in athletic injuries: De ve ­ lo p m e n t a n d ap p li c at io n s o f the special a n d athletic r e a d ­ j u s t m e n t r ati ng scale (SA RRS ), Ed. S tr a ub , W. F. in: An Analysis o f At hl ete Behaviour. Ma cM ill an , L o n d o n , pp. 1 19-123. H c n n c n h o f e r . G. a n d Heil, K. D. (1976). Angst iiberwinden : S e l b s t b e f r e i u n g d u r c h V e r h a l t e n s t r a i n i n g . R o w o h l t . H a m b u rg. Hol mes . T. H. a n d Rahc. R. H. (1967). The Social R e a d j u s t ­ m en t Ra tin g Scale. ./. P svchosom . Res. 11, 213-218. Rahc. R. H., Meyer. M.. Smith, M., Kjaer. G. a n d H o lm es , T. H. (1964). Social stress a n d illness o n s e t . ./. Psychosom. Res.. 8, 35-44. Selye, H. (1980). T e x t b o o k o f Stress. I n t er n a tio n a l Society for the Pre ve nti on o f Stress, L al n d on . S c h o m er . H. H. (1981). Anxiety m a n a g e m e n t trai n in g t h r o u g h physical exertion a n d p o s i t iv e /n eg a tiv e imagery. S .A . S p o rts M ed.. 12, p. 9. Suinn. R. M. a n d R ic h a rd so n . F. (1971). Anxie ty m a n a g e ­ ment training: A b e h a v i o u r th e r a p y p r o g r a m m e for a n x ie ty c on tr o l. Bell. Ther. a n d Control. 2, pp. 498-510. Ziegler. S. (1978). An overview o f anxiety m an a g e m e n t strategics in sp or t, Ed. S t r a u b , W. F. in: An analysis of athl ete be h av io u r. Ma cM ill an . L o n d o n , p p . 257-264. A S S O C I A T IO N OF P A E D I A T R I C C H A R T E R E D P H Y S I O T H E R A P I S T S T h e Secretary, S o u t h African Society o f Ph ys iot he rap y, P.O. Box I I 151, Jo h a n n e s b u r g , S o u t h Africa. D e a r M a d a m , As Publi c Rela tio ns Officer o f the above Association, I a m intereste’d in establishing co n ta ct with a g r o u p o f paed iat ri c p hy si o th era pi sts in y o u r c ou ntr y, if you have one. I would be most grateful if you could put me in t ou ch with an y o n e w ho could help with regard to e xc ha ng e o f i n fo rm a tio n, etc. I enclose a copy o f o u r Newsletter, a pub lic ati ons list and last ye ar’s progress re p o rt for y o u r interest. I look for wa rd to h ear in g fro m you, Yours sincerely, M. E. C a r r i n g t o n , M C S P (Miss) H o n . P R O A PC P. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )