Examining time-loss and fear of re-injury in athletes.

Covassin, Tracey ; McAllister-Deitrick, Jaime ; Bleecker, Alisha 等

Fear of re-injury is a common reason cited by athletes for reduction or complete cessation of participation in sport (Arden, Webster, Taylor, & Feller, 2011; Flanigan, Everhart, Pedroza, Smith, & Kaeding, 2013; Kvist J, Sporrstedt K, & Good L, 2005; McCullough et al., 2012; Podlog, Dimmock, & Miller, 2011; Podlog & Eklund, 2007). Numerous researchers have reported that as athletes approach their return to participation their fear of re-injury increases (Bianco, 2001; Evans L, Hardy L, & Fleming S, 2000;

Gould D, Udry E, Bridges D, & Beck L, 1997; Kvist J et al., 2005; te Wierike, van der Sluis, van den Akker-Scheek, Elferink-Gemser, & Visscher, 2013; Walker, Thatcher, Lavallee, & Golby, 2004). Moreover, athletes have reported re-injury anxiety about returning to sport participation even after they have been medically cleared to compete (Heil, 1993; Ivarsson & Johnson, 2010; Williams J & Andersen M, 1998). Athletes have also indicated that fear of re-injury as their most prominent source of stress when returning to competition (Bianco, 2001; Gould D et al., 1997; Ivarsson & Johnson, 2010).

Fear of re-injury is a serious stressor for injured athletes returning to competition (Johnston & Carroll, 2000; McCullough et al., 2012). Stress can lead to a lack of concentration, decreased confidence and motivation, and can interfere with physical and mental preparation for competition (Asano, 2007). Johnston and Carroll (2000) found that fear of re-injury manifested itself in a multitude of ways which included lower sport confidence, holding back, not giving 100% effect, heavily strapping the injured body part, and being wary of injury-provoking situations. Similarly, Taylor (1985) found that fear of re-injury can lead to attentional distractions which in turn can inhibit sport performance and increase the chance for re-injury.

Arden, Nicholas, Julian, Whitehead and Webster (2013) examined psychological factors and their association to preinjury level of sport following ACL surgery. Specifically, they examined confidence, psychological readiness, mood states, and locus of control at 4 months following surgery to determine if they are associated with returning to preinjury level of sport participation at 12 months following ACL surgery among recreational athletes. Athletes were administered the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)(Webster K, Feller J, & Lambros C, 2008), Tampa Scale of Kinesiophobia (TSK) to measure fear of reinjury (Vlaeyen, Kole-Snijders, Boeren, & Van Eek, 1995), Incredibly Short Profile of Mood States (ISP), Emotional Responses of Athletes to Injury Questionnaire (ERAIQ), (Morrey, Stuart, Smith, & Wiese-Bjornstal, 1999) and Sport Rehabilitation Locus of Control (SRLC) scale(Murphy, Foreman, Simpson, Molloy, & Molloy, 1999) post surgery. Results indicated that recreational athletes' locus of control and psychological readiness predicted return to sport participation by 12 months. Arden et al. concluded that examining psychological response to return to participation throughout the rehabilitation phase could assist clinicians in determining who may be at risk for not returning to play.

McCullough and colleagues (2012) examined reasons for high school and collegiate football athletes to not return to sport participation following ACL reconstructive surgery. In addition this study investigated athletes perception of return to participation 2 years following ACL surgery. Fear of re-injury was reported in 52% of high school athletes and 50% of collegiate athletes. Moreover, over half of the collegiate football players and one third of high school football players did not return to their preinjury sport performance level. Similarly, Asano (2007) has also reported fear of re-injury in two-thirds of athletes recovering from ACL reconstruction surgery. No other types of injuries were examined. It was also found that athletes who separate their shoulder or sprain their ankle may perceive fear of re-injury differently due to the nature of their injury or sport in which they participate. Each of these studies included recreational athletes who may not have the desire to return to sport participation or may take longer to return to sport as they are not under any timeframe unlike National Collegiate Athletic Association (NCAA) athletes who return to sport as quickly as possible.

Relatively few researchers have studied gender differences on the effects of fear of re-injury in sport. Arden et al. (2012) reported that female athletes who had ACL surgery longer than 3 months after injury had a higher fear of re-injury than males. Moreover, female athletes were concerned about environmental conditions (i.e., playing surface) which contributed to their increased fear of re-injury as compared to male athletes. These results are in contrast to Dean, Williams, Ebel-Lam, Brewer, and Birchard (2011) who reported that gender was not associated with confidence levels or fear of re-injury when returning to sport following an ACL injury. Therefore, more research to determine evidence of gender differences among athletes' sport participation or fear re-injury following an athletic related injury is warranted.

Another important consideration when examining the effects of fear of re-injury in sport is time-loss due to an injury. From a generic perspective, time-loss refers to the total amount of day's loss or not played from sport participation. Time-loss includes both practice and competition days missed. Time-loss can be further broken down by classifying an injury as mild (< 7 days), moderate (7-20 days) or major ([greater than or equal to] 21 days) (Powell & Barber-Foss, 1999). Researchers have showed that collegiate football players who incurred an injury with extensive time loss (i.e., >21 days) reported higher life stress (Bramwell, Minoru, Wagner, & Holmes, 1975) or experienced higher levels of life change (Cryan & Alles, 1983; Passer & Seese, 1983), had a greater risk of re-injury than athletes with less than 21 days of time-loss due to injury. In a recent study on time-loss injuries in middle school athletes, girls were more likely to sustain a time-loss injury than boys (Beachy & Rauh, 2014). In addition, severe injuries (i.e., >21 days) were more likely to occur in game situations compared to practice (Beachy & Rauh, 2014). Thus, there is an apparent absence of research that has examined time-loss due to injury and fear of re-injury. Moreover, Beachy et al. did not compare sport type, gender, and severity of injury (i.e., minor, moderate, and major). Therefore, the purpose of this study was to determine the extent to which male and female collegiate athletes who have recovered from an injury feared returning to complete or reinjury. It was hypothesized that athletes who suffered a major injury (>21 days lost due to injury) would have higher fear of re-injury and fear of returning to sport than athletes who experienced a minor injury (<7 days lost due to injury).

Methods

Participants

A total of 350 athletes (males=227, females =123) from two Big Ten NCAA Division 1 Universities located in the mid-west USA participated in this study. Injured athletes ranged in age from 18 to 26 years (M= 20.6, SD=+1.4). A total of 525 injuries occurred over the study period, with male athletes incurring almost two-thirds of all injuries (n=345, 65.7%) while females incurred 180 (34.3%) injuries. Well over half the injuries occurred in practice (n=318, 60.6%) compared to competition (n=150, 28.6%) (see Table 1).

Measures

Definition of injury. Injured athletes were identified via weekly summaries reported from the Sports Injury Monitoring System (SIMS) (Flantech Computer Services, Iowa City, Iowa), an ongoing injury surveillance system used to record injury information and time-loss from sport participation. The original purpose of SIMS was to maintain essential communication between the athletic trainer, who manages care of the team/athlete, and the team physician, who is the medical supervisor for the team/athlete. The SIMS database includes a roster of all team members; a daily log for all team practice and game activities; and a detailed record of all reportable injuries, including the medical attention injured athletes have received. Each team's certified athletic trainers are responsible for data entry. SIMS has been validated and used for injury tracking for over 20 years in high school and collegiate athletics (Powell & Barber-Foss, 1999).

All injuries included in this study met the following criteria: 1) clinical signs of injury were determined by the team athletic trainer and/or team physician, and 2) players were unable to return to practice or the game the same day (NFHS, 2008). All participants suffered an acute or chronic injury and could not complete one practice or game. An acute injury was defined as being caused by a single traumatic impact (Fuller et al. 2006, 2007). Whereas, a chronic injury was defined as a gradual onset injury caused by repeated microtrauma without a single, identifiable event responsible for the injury (Smoljanovic et al., 2009). The team's certified athletic trainer or physician diagnosed and categorized each injury.

Injury severity. Each injury was classified by the researchers into one of three levels of severity based on time-loss from sport participation. Injuries were classified as "minor" for time loss less than 1 week (<7 days), "moderate" for time loss of 1-3 weeks (7-21 days), and "major" for time loss greater than 3 weeks, respectively (Powell & Barber-Foss, 1999). This time-loss classification system has been well established in the literature and used in numerous previously published papers (Powell & Barber-Foss, 1999; Yang, et al., in press; Yang, et al., 2014).

Fear of returning to sport and re-injury. Fear of returning to sport and fear of re-injury was measured by asking the athlete two questions on a Likert-type scale: "How much fear do you have now about returning to sports play?" and "How afraid are you now of being injured again?". This latter question was used synonymously with fear of re-injury. Athletes were asked to rate their fear on an 11-point Likert scale where zero represented no fear of returning to sport/re-injury while a 10 represented the greatest fear of returning to sport/re-injury. Ranging from 0 (not at al) to 10 (ver much) was used as sports medicine professionals typically ask athletes to rate their pain on a 11-point Likert scale (Downie et al.,1978). Face and content validity were determined by researchers and sports medicine professionals prior to data collection. A pilot study was also conducted on 262 athletes with 142 injuries recorded. The pilot study enabled development and testing of protocol (i.e., within one week following return to play) and dependent variables to be used in the proposed research. All athletes had no difficulty or concerns responding to the dependent variables.

Procedures

This study was approved by each participating institution's university Institutional Review Board. Prior to the study, permission was obtained from the Athletic Director, Sports Medicine Director, and coaches at each respective University. Athletes signed an informed consent indicating their voluntary participation in the study. All athletes completed a baseline survey prior to the start of their pre-season. The baseline survey included the athlete's demographics and injury history. Athletic trainers used SIMS to enter daily injury data on enrolled athletes. Any athlete who was unable to participate due to injury for one or more days was included in this study. Athletic trainers would present weekly injury summaries of all injured athletes enrolled in the study to the research team. Included in this weekly summary was the day of the injury, type of injury, body structured injured and day the athlete was cleared to return to their sport. Either the athletic trainer or physician would make the final decision as to when the athlete was allowed to return to participation. Athletes were then contacted by the researchers to complete an injury follow-up survey within one week of returning to sport participation. The return-to-play survey included information on injury setting (game or practice), and fear of returning to sport and fear of re-injury. The return-to-play survey was administered in person in the athletic training room either before or after treatment. The survey took approximately 10 minutes to complete.

Results

A total of 525 injuries were recorded over the study period. Table 1 illustrates gender, injuries by sport, and whether the injury occurred in practice, competition or unspecified. Among the 525 injuries, injuries were fairly evenly distributed by injury severity with 179 (34.9%) minor, 138 (26.9%) moderate and 196 (38.4%) major injuries (see Table 2 for breakdown of injured body region). Over half of the injuries occur to the lower extremity (n=285, 55.6%), followed by the upper extremity (n=97, 18.9%) and head, face, and neck (n=88, 17.2%).

Fear of Returning to Sport

Over half of all the injuries resulted in a score of zero out of ten or no fear of returning to sport (n=276, 53.8%). For one-third of injuries (n=166, 32.4%), the injured athlete rated their fear of returning to sport between a 1 and 3. Almost 10 percent (n=49, 9.6%) of injuries resulted in moderate fear of returning to sport with scores between 4 and 6, and 4.3% (n=22) of injuries where scored between a 7 and 10 (see Table 3 for scores for fear of returning to sport by injury severity).

The dependent variable in this study was score on fear of returning to sport, and the independent variables were injury severity group (minor, moderate, major) and gender. Therefore, a 3 (injury severity group) by 2 (gender) analysis of variance (ANOVA) was conducted to determine if differences existed on fear of returning to sport. Statistical significance for all analyses was set a prior; at p<0.05. Results revealed there was a significant main effect for injury severity group on fear of returning to sport [[F.sub.(3,510)] = 14.4, p<0.001, [[eta].sup.2]= .054, [beta]= .999). Major injuries produced a significantly greater number of injured athletes who feared returning to their sport than moderate (p<0.001) and minor (p<0.001) injuries. In regards to the main effect for gender, there were no significant differences on fear of returning to sport between male and female injured athletes [[F.sub.(1,523)] =.524, p=.470, [[eta].sup.2] = .001, [beta] = . 112],

Fear of Re-injury

Over one-third of the injuries resulted in athletes having no fear of re-injury (n=214, 40.8%) with 36.3% (n=186) of athletes rating their fear of re-injury between a 1 and 3 out of 10. Over 15 percent (n=86, 16.4%) of injuries resulted in moderate fear of re-injury with scores between a 4 and 6, and 7.3% (n=38) of injuries were scored between a 7 and 10 (see Table 4).

A 3 (injury severity group) by 2 (gender) ANOVA was performed for fear of re-injury and yielded a significant between subjects main effect for group [[F.sub.(2,509)] = 11.6, p<0.001, [[eta].sup.2] = .044, [beta] = .994). Athletes who incurred major injuries produced a significantly greater fear of re-injury compared to athletes who suffered only minor (p<0.001) injuries. However, there were no significant differences between athletes who suffered major injuries compared to athletes who suffered moderate injuries (p=.594). There was also no significant main effect for sex on fear of re-injury [[F.sub.(1,522)] = 1.41, p=.235, [[eta].sup.2] = .003, [beta] = .221].

Discussion

The purpose of this study was to determine the extent to which male and female collegiate athletes who have recovered from an injury had a fear of returning to play or afraid of being re-injury. The current study found athletes who incurred major injuries resulted in significantly more fear of returning to sport and fear of re-injury than injured athletes with minor injuries. Almost one quarter of injuries (23.7%) produced a moderate to severe fear of re-injury with 14% of injuries producing a moderate or severe fear of returning to sport.

This study found that injuries with time-loss of greater than 3 weeks (ie., major injury) resulted in greater fear of returning to sport among injured athletes than moderate or minor injuries. Moreover, major injuries also resulted in the athlete fear of re-injury compared to athletes who only incurred a minor injury. Similar findings were reported by Bramwell et al. (1975) who also reported that collegiate football players who had suffered major time-loss from their injury had higher life stress and fear of re-injury. Tripp and colleagues (Tripp, Stanish, Ebel-Lam, Brewer, & Birchard, 2007) reported that individuals who had greater fear of re-injury were associated with lower return to sport participation one year following ACL surgery. Other research suggests that fear of re-injury may be a form of avoidance due to the ain an athlete experiences at the time of injury and throughout their rehabilitation (Vlaeyan, Kole-Snijders, Rotteveel, Ruesink, & Heuts, 1995).

During rehabilitation it is important to help athletes overcome their fear of re-injury and returning to sport participation so that they may have a successful return to competition. Psychological skills training can help athletes alleviate the fear of re-injury and returning to sport while increasing confidence (Bandura, 1997). A number of studies have explored the effect of psychological interventions to assist in reducing fear of re-injury concerns (Evans L et al., 2000; Rotella & Campbell, 1983; Suinn, 1975). Evans et al. (Evans L et al., 2000) used imagery, verbal persuasion, and simulation training with rugby players to help them gain confidence in their injured body part and overcome distractions by injury related thoughts and worries. In another study, Suinn (Suimi, 1975) used imagery and muscle relaxation to help a recreational skier overcome her fear of re-injury following a knee surgery (Suinn, 1975). Bandura (Bandura, 1997) suggests that guided mastery can serve as a way to build confidence in injured athletes, thus, helping to decrease re-injury anxiety. Though a multitude of studies have shown that psychological interventions can be useful in helping aid in reducing fear of re-injury concerns, Johnson and Carroll (Johnston & Carroll, 2000) found that the only way athletes in their study alleviated their fear of re-injury was to test the injured body part through sport involvement. Successfully performing the sport helped to increase confidence and positive affect while performing negatively has the reverse effects (Johnston & Carroll, 2000).

This study has several limitations. First the results are based on injured athletes from two Division I universities and may not be generalizable to other universities or non-collegiate athletes. Second, fear of re-injury and return to sport participation were based on the athletes' self-report. Finally, we examined fear of re-injury within one week after returning to sport participation. Future research should investigate if athletes have a fear of re-injury at different times during the rehabilitation process. Future studies should also include athletes participating at the youth and high school level to determine if fear of re-injury varies with different levels of competition and skill level.

In conclusion, injuries with greater than 3 weeks of time-loss produced significantly greater fear of re-injury and return to sport than injuries with less than 1 week of time-loss. Moreover, almost one quarter of injuries (23.7%) produced a moderate to severe fear or reinjury and 14% of injuries producing a moderate or severe fear of returning to sport. Thus, it is important for health care providers to recognize these athletes who demonstrate a fear of re-injury as this could potentially lead to other more serious injuries, lack of self-confidence, or interfere with their sport performance.

Tracey Covassin, Jaime McAllister-Deitrick, Alisha Bleecker

Michigan State University

Erin O. Heiden

University of Iowa

Jingzhen Yang

Kent State University

Address correspondence to: Tracey Covassin PhD., ATC. Michigan State University, Department of Kinesiology 308 West Circle Dr. East Lansing MI 48824. PH: 517-353-2010 Fax: 517-353-2944

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