Abstract
thletes with microtrauma or overuse injuries resulting from an accumulation of repeated small forces may differ from athletes with macrotrauma or acute injuries in their psychosocial responses because of the unique challenges presented by these insidious-onset and often chronic injuries. Our purpose was to use narrative inquiry to examine the psychosocial experiences and responses of 10 long-distance runners who had experienced microtrauma injuries. Qualitative data analysis of interview data led to a chronological timeline of the injury experience and an assessment of the meaning attributed to these injury experiences using a variation of Mishler’s core-narrative approach. Participants reported distinct thoughts, feelings, and behaviors during each phase of the injury—pre-injury, injury onset, and outcome . In the pre-injury period, participants indicated specific running -related goals and attributed their injuries to overtraining or a change in training. During the injury onset phase, participants consistently indicated two themes: self -diagnosis and treatment, and not taking time off. Within the outcome phase of injury, participants acknowledged changed training because of the injury, and lessons learned from their injury experiences. The narratives of microtrauma -injured runners revealed psychosocial distress and behavioral tendencies post-injury that have important implications for runners, coaches, and healthcare professionals. OPEN ACCESS
Sports 2015, 3 160 Keywords: injury; running; chronic injury; sport psychology 1. Introduction Injuries are relatively common consequence of long -distance running. Researchers have found that 79% of long-distance runners will experience an injury during one year of training [ 1]. Long-distance runners who experienced a disruption in training due to a sport injury reported a variety of psychosocial symptoms such as depression and anxiety as well as endorsed low self-esteem and feelings of confusion and frustration [2]. Psychosocial refers to thoughts, feelings, and behaviors experienced by injured runners, as well as the social context in which these responses occur. In line with predictions of the integrated model of psychological response to sport injury [3], these findings provide evidence that long-distance runners experience potentially negative and distressing psychosocial responses to the sport injury process. Given the increased interest in long-distance running in the United States and the associated risk for injury, long-distance runners are an important subset of athletes to study to better understand the chronology of eve nts as well as the psychosocial responses to injuries. Individuals’ responses to sport injuries can vary and, according to Wiese-Bjornstal [4], both personal and situational factors affect athletes ’ cognitive, emotional, and behavioral responses to sport i njuries. Injury type is one of the personal factor s suggested to influence an individual’s responses to sport injury [3]. Injuries are typically categorized as one of two types—macrotrauma or microtrauma. Macrotrauma injuries result from an isolated, sudden impact or force (e.g., strains, sprains, dislocations, and fractures), whereas microtrauma injuries occur as a result of the accrual of repeated small forces over a period of time (e.g., stress fractures, tendinitis) [5]. The majority of evidence suggests that long- distance runners are more prone to microtrauma injuries than macrotrauma injuries. In a systematic review, van Gent and colleagues [6] found that the incidence of lower extremity running injuries was as high as 79.3% during the reporting period for studies reviewed (ranging from one day to 18 months); most of which were microtrauma in nature. Consistent with the integrated model of psychological response to sport injury [3],
injuries than macrotrauma injuries. In a systematic review, van Gent and colleagues [6] found that the incidence of lower extremity running injuries was as high as 79.3% during the reporting period for studies reviewed (ranging from one day to 18 months); most of which were microtrauma in nature. Consistent with the integrated model of psychological response to sport injury [3], Flint [5] suggested that due to the differences in the onset of injury, psychosocial responses of individuals incurring microtrauma injuries might differ from those of individuals who experience macrotrauma injuries. For instance, individuals dealing with microtrauma injuries report a period of gradually increasing pain accompanied by decreased athletic performance during onset [5]. Due to the insidious onset and longevity of microtrauma injuries, athletes may experience significant and prolonged emotional distress (e.g., frustration, sadness), whereas the sudden onset of macrotrauma injuries allows athletes to immediately deal with the injury and rehabilitation process [5]. 2. Context Previous research has supported the suggestion by Flint [5] that differences exist in the psychosocial responses to microtrauma injuries and macrotrauma injuries. In particular, Wasley and Lox [ 7] found that athletes who experienced a microtrauma injury scored more negatively on measures of self-esteem, sought social support less, and reported more avoidance or escape behaviors than athletes who incurred
Sports 2015, 3 161 a macrotrauma injury. Although limited by a small sample size and only presenting preliminary results, the findings suggest that the type of injury an athlete experiences may influence the nature of psychosocial response to a sport injury. Concerning social support, Henert [8] found that individuals with microtrauma injuries rated most types of social support as being more important to their overall well-being than individuals with macrotrauma injuries. These studies highlight two key points. First, psychosocial responses to injury differ based on the type of sport injury an individual experiences. Second, athletes report a discrepancy in the value of social support such that individuals with microtrauma injuries identify social support as being more important to overall well- being [8]; however, these individuals tend to seek social support to a lesser degree than individuals who experience a macrotrauma injury [7]. Because of the limited studies examining microtrauma injuries as well as the discrepancy in findings regarding psychosocial responses based on injury type, the current study wa s exploratory in nature, to better understand the process of psychosocial responses to microtrauma sport injuries. Due to the complex and multi-dimensional nature of psychosocial responses to sport injuries [3], it is important to understand the full experiences of injured athletes. To date, researchers have primarily examined the psychosocial responses of athletes to sport injuries using quantitative methods or semi-structured interviews [9–12]. Another type of qualitative research that can be used to better understand lived experiences of athletes recovering from a sport injury involves narrative research methods; however, these methods have rarely been used in examining the experience of injured athletes. Narrative research methods are effective in studying an individual’s experiences over time [1 3] and provide “coherence and continuity to one’s experience” [1 4]. Thus, narrative research methods may provide a full picture of the injury and recovery process over time. By using this research method with long-distance runners incurring microtrauma injuries, we gain a fuller understanding of the unique aspects of these types of injuries that have been underrepresented in the psychology of sport injury literature to date. Narrative research
experience” [1 4]. Thus, narrative research methods may provide a full picture of the injury and recovery process over time. By using this research method with long-distance runners incurring microtrauma injuries, we gain a fuller understanding of the unique aspects of these types of injuries that have been underrepresented in the psychology of sport injury literature to date. Narrative research methods have been used to better understand the psychosocial responses of individuals with health-related issues [15] and with individuals recovering from non- sport related injuries [16]. In general, narrative research methods allow individuals to provide more thorough, less researcher-directed discussions of psychosocial responses to health issues or injuries as compared to quantitative research methods using self-report questionnaires or even semi-structured interviews. Thus, narrative research methods may help researchers identify responses that have been overlooked by other methods. With respect to sport injuries, Brock and Kleiber [1 0] used narrative research methods to examine athletes who suffered career-ending injuries 20 or more years prior to the investigation. The authors found that sport injuries inevitably led to a mild-to-severe change in both identity and self-esteem. Brock and Kleiber found a regular pattern within the stories that the injured athletes shared. Specifically, each athlete’s story always included a section on the athlete’s emotional response (e.g., feelings of confusion, isolation, anger) that resulted from experiencing a loss associated with the injury. Based on information derived from narrative research methodology in health-related research and sport injury research, we believe that the use of narrative research methodology is a valuable way to gain knowledge of the full experience of athletes who have experienced a microtrauma sport injury. The use of narrative research methods in the present study fills a gap in research by providing a better understanding of the psychosocial responses (defined as thoughts, feelings, and behaviors) that
Sports 2015, 3 162 individuals experience during microtrauma injuries. Thus, the purpose of the current study was to use narrative inquiry and analysis to examine the distinct experiences and responses of long- distance runners who had recently experienced microtrauma injuries. Results are reported for two main research questions: 1. What psychosocial responses do long-distance runners experience surrounding a microtrauma injury? 2. What is the chronology of psychosocial experiences associated with microtrauma injuries in long-distance runners? 3. Method 3.1. Participants A purposeful sample of runners was chosen. This sample was selected because they were able to provide useful information about the phenomenon of study, specifically, microtrauma running injuries [17]. Participant recruitment continued until data saturation was reached. Ultimately, 10 participants (eight females, two males) between the ages of 19 and 37 years of age (M age = 25.1) were recruited from a local running store and a long- distance running group at a large Midwestern university to participate in this study (see Table 1 for demographic and participant injury information). Participants were recruited to participate in this study if they met the following inclusion criteria. Participants must have suffered a microtrauma (defined, for the purposes of the current study, as an injury occur ring due to the accrual of repeated small forces over a period of time as a result of long-distance running training) [5] within the 18 months prior to recruitment. Participants’ injuries were self-reported. Participants also had to be competitive runners, defined for the purpose of this study as having trained for and were planning to, or had run, in at least one five-kilometer race in the preceding 12 months. Participants varied from novice to experienced runners. Additionally, participants had to be between the ages of 18 and 64 at the time of the interviews. Pseudonyms were used for all participants in orde r to maintain anonymity and confidentiality. Table 1. Participant c haracteristics. Pseudonym Gender Age Self-Reported Injury Logan Male 22 Sciatic nerve; shin splints Anne Female 37 Pulled hamstring/illiotibial band; skin pain Grace Female 23 Achilles tendonitis; stress fracture Caroline * Female 22 Achilles tendonitis; knee patella
at the time of the interviews. Pseudonyms were used for all participants in orde r to maintain anonymity and confidentiality. Table 1. Participant c haracteristics. Pseudonym Gender Age Self-Reported Injury Logan Male 22 Sciatic nerve; shin splints Anne Female 37 Pulled hamstring/illiotibial band; skin pain Grace Female 23 Achilles tendonitis; stress fracture Caroline * Female 22 Achilles tendonitis; knee patella femoral Jordan Female 22 Pain on inner right foot; illiotibial band Laura Female 21 Patella subluxation (knee) Jane Female 19 Knee pain, Sacroiliac pain Brad Male 21 Separated shoulder; tibia stress fracture Maryn Female 25 Quadriceps strain; pulled gluteus medius Kathryn Female 19 Illiotibial band; blisters Cynthia Female 20 Runner’s knee (right and left); baby fracture Note: *No audio or video data. Participant’s data not include in data analysis.
Sports 2015, 3 163 3.2. Procedure Institutional review board (IRB) approval was obtained prior to participant recruitment. In order to recruit individuals to participate in this narrative study, advertisements were posted at a local running store and an advertisement was made to a running group at a local university. Advertisements directed participants to contact the principal investigator (PI), by either phone or email , if s/he was interested in participating in the study. Additionally, the advertisements indicated that participants would receive a gift card for a local running store for participating in the study . Upon initial contact with the PI potential participants were asked questions related to the inclusion criteria for the study to determine if they qualified to participate in the study. If they met the inclusion criteria for the study, participants met with one of the researchers to complete the interview. Once the informed consent had been completed, the participants began the interview. Face-to-face interviews were conducted with all participants. Interviews ranged in time from 11 to 33 min. Participants were asked to tell the story of their injury, including events that took place immediately prior to the injury (henceforth referred to as pre-injury factors), the injury itself, and what happened after the injury. Participants were given this interview prompt verbally and in written form to refer to as they told their story. The only specific questions asked by the interviewers were probes to provide further clarification or elaboration on information provided by the participants. All interviews were video- and audio- recorded. Video recording allows the researchers to observe participant’s body language, facial expressions, and other idiosyncrasies associated with the communication of the narrative. In addition, this technique aids the researchers in providing consistency during data analysis and coding, as well as the ability to contribute relevant observational comments, which are critical supporting evidence for the research [17]. 3.3. Data A nalysis The interviewers transcribed each interview verbatim. The researchers then examined video transcripts of the interviews to add additional detail to the transcripts (e.g., crying). As per the example provided by Brock and Kleiber [11] in
and coding, as well as the ability to contribute relevant observational comments, which are critical supporting evidence for the research [17]. 3.3. Data A nalysis The interviewers transcribed each interview verbatim. The researchers then examined video transcripts of the interviews to add additional detail to the transcripts (e.g., crying). As per the example provided by Brock and Kleiber [11] in their modified narrative analysis technique, transcripts were prepared by numbering each new topic as the conversation progressed, for example: 075: P: Um, I’ve talked to my roommate a lot. She’s one of my best friends and I, you know, through talking to her like, I don’t want to, like have a pity party about it. 076: so I’ve just kind of, um, come to the realization that, like, I will finish. Like I will probably have to walk some, like I will…it will tack another hour. Additionally, two different types of statements from the transcript were transferred to two new transcripts: the core narrative and evaluative commentary. The first transcript, labeled core narrative included any statement that contributed to the understanding of the sequence of events relating to the injury. For example statements such as “026: P: Umm I was doing a 5k and it, my leg just all of a sudden started, well, my left butt cheek started hurting it was a throbbing pain, I could literally not run, I would have to walk” were located in the core narrative transcript. The second type of transferred statement was any statement that contributes to the understanding of the sequence of events relating to the injury. This
Sports 2015, 3 164 transcript was called the evaluative commentary. Statements such as “052: but it lingered on for so long, then it was kind of feelings of what is this and is it ever going to go away” and “053: at times it was feelings of, umm, it was frustration” were located in the evaluative commentary transcript. Both the core narrative and evaluative commentaries were analyzed for common themes relating to the two primary research questions for this study. Specifically, the core narrative transcripts were analyzed to examine consistency and divergence in the chronology of the experience of athletes with microtrauma injuries. The evaluative commentary and core narrative transcripts were analyzed for common themes relating to the psychosocial response to the injuries as well as the meaning attributed to the injuries. Data analyses were similar to interpretative phenomenological analysis wherein the lived experiences of participants and the meaning attributed to the experiences are examined [ 18] and following the example provided by Brock and Kleiber [10]. Analyses consisted of the following steps. First, two researchers prepared the core narrative and evaluative commentary transcripts [10] and then reviewed the core narrative transcripts independently. This step involved several thorough readings of the transcripts identifying points of interest [1 8]. Second, researchers independently identified common statements between participants relating to the psychosocial responses to injury and the chronology of events associated with the injury. Third, researchers clustered common statements into overarching themes. Fourth, researchers compared the independently identified themes for consistency and divergence between researchers. Fifth, transcripts were then re- examined by the res earchers to settle any disagreements in emergent themes leading to the final themes relating to the psychosocial responses to injury and the chronology of events. Another researcher then reviewed final themes after reading and re-reading the transcripts and was in agreement with the emergent themes [19]. 4. Results Participants’ stories revealed that their experience s with running injuries had a meaningful impact on their lives. Analysis of the narrative data identified psychosocial responses to injury within the participants’ stories and a consistent chronology of events and responses associated
reviewed final themes after reading and re-reading the transcripts and was in agreement with the emergent themes [19]. 4. Results Participants’ stories revealed that their experience s with running injuries had a meaningful impact on their lives. Analysis of the narrative data identified psychosocial responses to injury within the participants’ stories and a consistent chronology of events and responses associated with injuries. In telling their stories, participants identified common experiences and responses during the pre -injury, injury, and post-injury phases of their injury process 4.1. Research Question 1: Psychosocial Responses In discussing their injuries, participants revealed consistent psychosocial responses to injury. These themes were consistent cross the injury and recovery process. Overwhelmingly, the participants’ responses to their injuries were negative throughout the injury process. Participants noted responses such as being “devastated”, “bummed out”, and “panicked” by the injury. The psychosocial distress experienced by the participants divided into four overarching sub-themes—frustration, fear, general emotional distress, and social influences . Frustration. Microtrauma injuries for runners were described as frustrating. This frustration seemed to be due to the uncertainty or ambiguity associated with microtrauma injury. As previously discussed, microtrauma injuries have an insidious onset and can persist for a long period of time , yet may not be perceived as serious as macrotrauma injuries [5]. These characteristics that distinguish microtrauma injuries from macrotrauma injuries seemed to contribute to the frustration experienced by participants.
Sports 2015, 3 165 For example, Anne described the unpredictable nature of microtrauma injuries and perceptions of injury severity as contributing to her frustration. “I think a little bit of frustration”, she said in describing her feelings associated with the injury, “because every time I would go out running it would hurt and I didn’t want it to hurt but it didn’t hurt enough to stop necessarily.” Similarly, Grace noted that the unpredictable nature of microtrauma injur ies contributed to her frustration, and s he said, “It like kind of feels like a rubber band, you know. …it reappears just randomly and there wasn’t much of a pattern so it would just, it would just get really frustrating.” Even more specific to the nature of microtrauma injuries, Maryn specifically compared the experience with her microtrauma injury to that of a macrotrauma injury in terms of the frustration she experienced. She said, “Even though they’re [running injuries] not as extreme as tearing your ACL, they’re nagging injuries. And they’re kind of... sometimes more irritating because they’re not concrete. You can’t go in and say ‘yea, you have an ACL tear, you need to do this, this, and this.’ You’ve got a muscle strain ... you need to just rest”. Generally, the frustration experienced by participants was closely related to the insidious onset, persistent symptoms, and unpredictable nature of microtrauma injuries. Fear. In addition to frustration, participants also indicated they experienced a great deal of fear associated with their injuries. The theme of fear subdivided into four distinct lower-order themes—fear of not recovering, fear of re-injury, fear of diminished performance, and fear of appe aring weak. Fear of not recovering. In addition to the frustration participants were experiencing in response to the ambiguity in their injury, participants also indicated they feared the uncertainty of the diagnosis and the unpredictability of the recovery, again characteristics that differentiate microtrauma injuries from macrotrauma injuries. Jordan noted experiencing fear about a number of different factors associated with her injury and further demonstrated her fear by identifying some injury-related catastrophic thinking: “I really was freaked out about
Description
This study examines the psychosocial experiences of long-distance runners with microtrauma injuries.