Abstract
s injuries have historically been addressed and treated from a purely physical perspec- tive. Nevertheless, like in many other aspects of sports, it has become evident during the last decades that psychological considerations and consequent interventions are both vital and inevitable in the work with athletes, particularly in the work with junior athletes. Especially in the domains of sports injury prevention and rehabilitation, psychological measures can yield significant benefits for junior athletes. Stress management techniques, cognitive restructuring, mindfulness, motor imagery, or seeking social support have been demonstrated as being highly effective. These techniques, many of them originally intended by sport psychologists to optimize performance, now aid junior athletes in performing at their best while also preventing injury and facilitating a safe return to competition after injury. During injury rehabilitation, sport psychological measures play an important role as well. The purpose of this review is firstly to provide an overview of the psychological factors that significantly support both injury prevention and rehabilitation. We subsequently elaborate on the identification and optimization of these factors by presenting evidence-based psychological interventions and training programs. In addition, we provide science-informed fundamentals that may serve as a basis for the adaptation and/or development of novel psychological measures to support junior athletes during injury prevention and rehabilitation. Keywords:athletes; injury; pain; prevention; psychology; rehabilitation; sport 1. Introduction Sports injuries have historically been addressed and treated from a purely
these factors by presenting evidence-based psychological interventions and training programs. In addition, we provide science-informed fundamentals that may serve as a basis for the adaptation and/or development of novel psychological measures to support junior athletes during injury prevention and rehabilitation. Keywords:athletes; injury; pain; prevention; psychology; rehabilitation; sport 1. Introduction Sports injuries have historically been addressed and treated from a purely physical perspective. With significant progress in the medical field, the advent of new knowledge, and technological advancements, athletes can now return to competition following injury faster and safer than ever before. Nevertheless, like in many other aspects of sports, it has become evident during the last decades that psychological considerations and consequent interventions are both vital and inevitable in the work with athletes, particularly in the work with junior athletes. Especially in the domains of sports injury prevention and rehabilitation, psychological measures can yield significant benefits for both elite and junior athletes [1–6]. Objective evidence suggests that psychological interventions can substantially lower injury risk [7–9]. Notably, stress management techniques, such as breathing exercises, cognitive restructuring, mindfulness, motor imagery, or seeking social support, have been demonstrated as being highly effective [7,10–12]. These techniques, many of them originally intended by sport psychologists to optimize performance in elite athletes, now aid junior athletes in performing at their best while also preventing injury and facilitating a safe return to competition after injury, if indicated. Despite these and other preventative measures, injuries unfortunately remain an existential and inherent threat in the lives of athletes [13]. During injury rehabilitation, Behav. Sci.2024,14, 254.
Behav. Sci.2024,14, 254 2 of 14 sport psychological measures play an important role as well. For instance, if junior athletes respond extremely negatively to an injury and encounter significantly more negative emotions and thoughts than they did prior to injury, this can have devastating impacts on the progress of rehabilitation [14]. The resulting stress leads to poorer recovery via reduced sleep quality, weakened immune system, and deficient cognitions [15], among other mechanisms, which, in turn, often result in harmful behaviors such as avoiding rehabilitation exercises or withdrawing from social connections [16,17]. The purpose of this review is firstly to provide an overview of the psychological factors that significantly support both injury prevention and rehabilitation in junior athletes. We subsequently elaborate on the identification, optimization, and individual variability of these factors, when necessary, by presenting evidence-based psychological interventions and training programs. In addition, we provide science-informed fundamentals that may serve as a basis for the adaptation and/or development of novel, individually tailored psychological measures to support junior athletes. 2. Factors and Predictors Wiese-Bjornstal et al. [18] incorporated Williams and Andersen’s [19] stress-injury model into their response to a sports injury and rehabilitation model. The model distinguishes between personal and situational factors that affect the course and outcome of rehabilitation. A key component of the model is cognitive appraisal, which involves a psychological assessment of the injury itself and one’s ability to cope with it. This evaluation can impact the rehabilitation progress positively or negatively, via affecting athletes’ emotions and behaviors during the process. A positive assessment may involve viewing the injury as a hurdle to be overcome on one’s personal journey. This mindset allows setbacks to be treated as temporary obstacles on the path to growth. Additionally, having a strong sense of self-efficacy can be beneficial. In contrast, in unfavorable evaluations the injury is interpreted as a potential threat or setback, which, in turn, results in undesirable emotional states and behaviors. If junior athletes feel helpless due to their injury, they might abruptly discontinue their training regimen or execute rehabilitation exercises without the necessary commitment. If the targeted goals subsequently have
of self-efficacy can be beneficial. In contrast, in unfavorable evaluations the injury is interpreted as a potential threat or setback, which, in turn, results in undesirable emotional states and behaviors. If junior athletes feel helpless due to their injury, they might abruptly discontinue their training regimen or execute rehabilitation exercises without the necessary commitment. If the targeted goals subsequently have to be modified or delayed, athletes may become further entrenched in their unfavorable evaluation, thereby emotionally spiraling downwards [20]. Unfortunately, appraisal of the situation as a threat or loss is particularly likely in sports injuries [21]. 2.1. Situational Factors Situational factors can be broadly divided into three categories: sport, social environ- ment (relationships), and general environment. Sport includes the type of sport played, the level of competition, and the current situation in the season, all of which can impact rehabilitation. For instance, the season’s circumstances may prompt athletes to return to competition sooner than advisable to contest for a title or stay at a certain level of competition. The social environment encompasses the impact of teammates, coaches, friends, family, and relatives on junior athletes and therefore their rehabilitation process. Furthermore, the support offered by clubs/federations and their approach towards injury management can have a substantial influence on recovery outcomes. This influence is described in more detail in Section Tranaeus et al. [8] highlight the importance of the professional relationship between athletes and sports physiotherapists or other medical professionals. These individuals are in a prime position to offer social support and guide athletes’ emotions and behaviors due to their constant contact and crucial role in rehabilitation. Objective and concise communication between athletes and medical professionals is essential for successful rehabilitation. In the case of junior athletes, this professional relationship is even more important, due to their limited knowledge or (mis)beliefs, causing a greater dependence on
Behav. Sci.2024,14, 254 3 of 14 physiotherapists. In this context, the important role of parents is also worth mentioning, since their influence is particularly strong in junior athletes compared to adult athletes. Finally, the overall environment should also be considered as a relevant factor in the rehabilitation process. The success of rehabilitation is strongly influenced by the availability of specialists, physiotherapists, and other professionals, as well as the necessary equipment to implement prescribed measures. 2.2. Personal Factors Stress is a significant factor in the life of athletes, affecting performance both in desir- able ways (i.e., performance increase) and undesirable ways (i.e., performance reduction) (e.g., Fuchs and Gerber [22]). Up to this point in this article, the term “stress” was generally associated with negativity and has been discussed as a condition that should be minimized and controlled. Negative consequences, however, are mostly associated with experiencing strong, acute, or chronic stress (for a review see Yaribeygi et al. [23]). Moderate stress or stress that occurs only in confined performance situations can actually have positive effects. Activation through a moderate level of stress releases performance reserves that are otherwise not available [24]. Arent and Landers [25] found that participants performed a simple response time task best at 60–70% of maximum arousal. The study further suggests that the inverted U-model of arousal and performance is able to accurately predict results. Thus, moderate stress can lead to an increase in performance. Additionally, dealing with stressful experiences can help in developing coping strategies for stress that can be applied to similar situations in the future, and increase the perceived confidence of junior athletes. The rehabilitation process, however, largely depends on the injury itself. Specifically, the outcomes of rehabilitation are influenced by the severity, type, and injury history. The athletes’ expectation and subjective perception of the success of the rehabilitation significantly affects the course and outcome of the process [26]. 3. Diagnosis of Stress To identify the source of stress and to detect early negative developments, sport psychologists often use subjective self-report questionnaires. These questionnaires come in various forms and may be specifically designed for a particular
history. The athletes’ expectation and subjective perception of the success of the rehabilitation significantly affects the course and outcome of the process [26]. 3. Diagnosis of Stress To identify the source of stress and to detect early negative developments, sport psychologists often use subjective self-report questionnaires. These questionnaires come in various forms and may be specifically designed for a particular domain. Once the origin and severity of the stress have been determined, the athletes can be trained in techniques and tools to alleviate the negative impact of stress. A frequent challenge faced by junior competitive athletes is the double burden of sports and school [27]. In line with this double burden, Hamlin et al. [28] observed that stress levels in university athletes were highest during pre-season and during the examination period. This was attributed to the increases in athletic and academic workload, respectively. Furthermore, due to their usually extremely high drive and motivation, junior elite athletes are already very susceptible to under-recovery. If prolonged, this may necessitate additional rest and seeking professional medical and or psychological care [29]. Moreover, insufficient recovery can heighten the risk of injury and burnout, which could result from overtraining, chronic under-recovery, or other factors. Examples of such other factors that promote injury and/or burnout include social pressure, a one-dimensional identity as a competitive athlete, and a self-esteem that is highly dependent on success in sports [30]. An- other vulnerability factor is a lack of coping skills, or maladaptive coping mechanisms [31]. 3.1. Diagnosis of Stress in Childhood and Adolescence Several diagnostic self-report questionnaires are available to measure stress levels in children and adolescents [24].The Perceived Stress Scale (PSS) by Cohen et al. [32] assesses current stress and the resilience towards stressors in adolescents that are at least 12 years old. There are three versions of the PSS: the original PSS-14, the PSS-10, and the PSS-4. The PSS-10 has shown superior psychometric properties compared to both other versions [33,34]. The PSS-10 includes only 10 questions and can therefore be administered and evaluated in just a few minutes. Another example is the Questionnaire on Resources in Childhood
at least 12 years old. There are three versions of the PSS: the original PSS-14, the PSS-10, and the PSS-4. The PSS-10 has shown superior psychometric properties compared to both other versions [33,34]. The PSS-10 includes only 10 questions and can therefore be administered and evaluated in just a few minutes. Another example is the Questionnaire on Resources in Childhood and
Behav. Sci.2024,14, 254 4 of 14 Adolescence (FRKJ 8-16)by Lohaus and Nussbeck [35]. The FRKJ aims to identify strengths and weaknesses in coping with stress and promote long-term resources appropriately. The questionnaire captures personal resources such as self-efficacy, self-control, empathy, and perspective taking, as well as social resources like peer group integration and parental emotional and social support. The FRKJ assessment takes 20–30 min to complete and 5–10 min to evaluate. An evaluation of 370 adolescents showed that the FRKJ can differen- tiate between adolescents with and without psychosocial deficits [36]. While the FRKJ identifies current competencies and resources, it is recommended to additionally evaluate the existence of psychological and psychosocial deficits. This can assist in identifying junior athletes who may benefit from stress management training the most. For this purpose, the Strengths and Difficulties Questionnaire (SDQ) is an appropriate tool, particularly due to its comparatively shorter completion time (3–10 min) in contrast to other alternatives [24], without compromising quality. The SDQ is available with both self-report and other-report versions, which allows for the inclusion of the athletes’ social environment. Below are some examples of self-report items of the SDQ designed for 11–17-year-olds: “I usually do as I am told”, “I worry a lot”, “I think before I do things”, and “I am nervous in new situations. I easily lose confidence”. 3.2. Stress Management Training and Interventions In this section, we present scientifically tested stress management training tools and provide recommendations on how to best support junior athletes in coping with stress. The ultimate objective of all interventions is to support the development of skills that foster healthy stress management, thereby contributing to athletic growth and injury prevention [7]. Sallen [37] offers a variety of stress management programs tailored for competitive athletes. These stress management methods, which include techniques commonly used in psychotherapy such as cognitive restructuring and relaxation techniques, were found to be beneficial by both the authors and the athletes themselves. Examples of stress management training for competitive athletes include trainings by Krohne and Hindel [38] and Steffgen [39], which were successfully evaluated in table tennis players. Similar
competitive athletes. These stress management methods, which include techniques commonly used in psychotherapy such as cognitive restructuring and relaxation techniques, were found to be beneficial by both the authors and the athletes themselves. Examples of stress management training for competitive athletes include trainings by Krohne and Hindel [38] and Steffgen [39], which were successfully evaluated in table tennis players. Similar training programs for long-distance runners [40,41] and triathletes [42] also exist. More recent developments aim to promote mindfulness, attention, and acceptance[43,44], which are well-established in psychotherapy; for example, acceptance and commitment training (or therapy, a.k.a. ACT) [ One mindfulness-based approach that has received a lot of attention in recent years is Mindfulness-Based Stress Reduction (MBSR) [48,49]. MBSR has been shown to improve key aspects of mental well-being such as mood and anxiety in both healthy [50] and injured athletes [51] as well as increase pain tolerance in injured athletes. Another well- known mindfulness-based approach is Mindfulness–Acceptance–Commitment (MAC). Zadeh et al. [52] used a modified version of the MAC protocol by Gardner and Moore [53] on 23 semi-professional soccer players who subsequently showed significantly lower injury rates than a control group. It should be noted that none of these trainings were specifically developed for children and adolescents. Therefore, intervention strategies for this target group must be tailored accordingly. It is also crucial to consider the variability in individual athlete responses to these psychological interventions. Findings by Moesch et al. [54] emphasize this individual vari- ability. They conducted a case study on six severely injured athletes using a mindfulness- and acceptance-based intervention. While all athletes showed some improvements on scales such as acceptance and well-being, the number of scales that athletes improved on as well as the magnitude of the improvements varied considerably. Fuchs and Gerber [55] provide explicit recommendations for effective stress manage- ment in elite sports, including the following.
Behav. Sci.2024,14, 254 5 of 14 1. Developing an understanding of the concrete factors that can trigger stress in competi- tive athletes across varying career phases, with particular consideration given to junior athletes who may face the added stress of balancing sport and school obligations. 2. Avoiding under-recovery and overtraining and ensuring that junior athletes are adequately recovering, particularly during intensive training and competition phases. To achieve this, it is crucial to identify symptoms of overtraining promptly and monitor the athletes’ recovery–stress balance [56]. 3. Those involved in competitive sports, including team coaches, physiotherapists, and sport psychologists, must be aware of the symptoms and triggers of burnout to create a training environment that reduces the likelihood of burnout. 4. These sports professionals should be familiarized with common stress-resistance training techniques for both elite and junior athletes so they can teach missing stress management skills if needed. 3.3. Fundamentals for Measures to Improve Stress Management Lohaus [24] utilizes Lazarus and Folkman’s [57] transactional stress model as a foun- dation for stress management training for children and adolescents. The model posits that the appraisal of a situation comprises two phases; the amount of resulting stress hinges on the outcomes of these appraisals. In the initial phase, the demand of the situation is evaluated as either irrelevant/positive or unfavorable/difficult, where the two latter evaluations trigger stress. The second phase involves the assessment of available coping resources. Inadequate coping resources entail the occurrence of stress. Lohaus suggests several starting points for interventions based on this model. Initially, athletes should heighten their sensitivity to potential stressors and recognize what triggers stress in them. This allows for the deliberate and specific implementation of coping mechanisms in the future. A second strategy involves engaging in cognitive restructuring to reclassify situations as less threatening. The objective is to label situations either as irrelevant/positive (meaning no stress is elicited at all) or as challenging (which induces stress, but to a much lesser extent than the situation being categorized as threatening). Here, training strategies are utilized to assess different situations in the context of competitive sports. The focus is specifically
to reclassify situations as less threatening. The objective is to label situations either as irrelevant/positive (meaning no stress is elicited at all) or as challenging (which induces stress, but to a much lesser extent than the situation being categorized as threatening). Here, training strategies are utilized to assess different situations in the context of competitive sports. The focus is specifically on positive or challenging aspects of the situation. Lohaus emphasizes that exercises promoting self-esteem are additionally beneficial, as this creates a more positive outlook on many situations. The third and fourth starting points relate to a secondary assessment, which evaluates whether an individual’s coping resources are adequate for the situation. Stress primarily arises when coping resources are evaluated as insufficient. Gomes et al. [58] found that coping appraisal partially mediates the effects of work-related stressors on psychological health. The third point deals with enhancing coping skills, specifically teaching junior athletes new techniques or strategies (see Sections). It is best to train newly acquired resources directly by applying them to specific situations from the athletes’ lives or situations that they are likely to encounter in the near future. Thus, the fourth starting point refers to the training of coping strategies. The fifth and final point involves identifying the symptoms and consequences of stress at an early stage. This is essential for implementing prompt stress reduction measures and because stress reactions can further trigger additional stress. Purcell et al. [59] recommend regular mental health screenings for athletes, particularly during periods of risk such as after a severe injury or both before and after major competitions. 3.4. Examples of Stress Management Training for Children and Adolescents This section will examine the EPHECT (Effects of a Physical Education-Based Coping Training) program as an instance of stress management training that is designed for children and adolescents [60,61].
Behav. Sci.2024,14, 254 6 of 14 The program is uniquely tailored to be incorporated into sports activities and focuses on developing coping strategies. Specific versions of the program already exist for seven sports (soccer, swimming, judo, gymnastics, dancing, roller sports, juggling); adapting it to other sports should also be straightforward. An advantage of this approach, particularly for junior athletes, is that they can apply and reflect on newly learned strategies directly within a sporting context. The EPHECT program comprises the following six modules best conducted at weekly intervals. 1. 2. 3. 4. 5. 6. The program triggers stress reactions in participants through various exercises. By consciously recognizing and reflecting on individual stress reactions, athletes are sensitized towards their own stress reaction as recommended by Lohaus [24]. As this program is conducted in a group setting, it reveals varying degrees of individual stress responses during different exercises, providing athletes with essential information on the situations that evoke high stress levels. Each module lasts only 20 min to optimize training time utilization. The EPHECT pro- gram includes a workbook to supplement the lessons, comprising informative content and brief homework tasks to accomplish following each session. The homework emphasizes the implementation of acquired stress management techniques in various domains of life, specifically education. Thus, the program is aptly designed to tackle athletic and academic pressures simultaneously. When evaluating the EPHECT program, Lang et al. [60] observed an increase in the use of adaptive coping instead of maladaptive coping, along with students in the experimental group rating their emotion-focused coping skills higher than students in the control group. A similar effect was found between students in the experimental group, with students whose homework was regularly checked reporting more adaptive coping and higher self- reported ratings in problem-focused coping skills. This nuance indicates that reflecting the deliberately induced stress reactions is crucial to the program’s success. 3.5. Interventions during Rehabilitation The stress management techniques mentioned up to this point in this article primarily serve the purpose of preventing injuries in youth competitive sports. Nevertheless, injuries may still happen, with prolonged, severe stress potentially increasing the
Description
This review discusses psychological factors supporting injury prevention and rehabilitation in junior athletes.