One of the great dangers an athlete can face, if not the greatest, is the risk of getting injured. That’s why its prevention and treatment constitute an essential part of the medical and performance department of the clubs. However, a part not yet explored about this risk has to do with the athlete’s psychological and social factors.

Andreas Ivarsson, PhD in psychology at the University of Halmstad, in Sweden, and Head of Psychology and personal development at Arsenal F.C., gave a talk about the latest advances in this field and its importance during the Barça Sports Medicine Conference organized by the Barça Innovation Hub. We spoke with him about this matter.

The influence of psychological and social factors on the risk of getting injured seems more evident every day. Is there any evidence on the quantitative importance they have on this risk? Is there any kind of injury more susceptible to this type of factors?

As you said, the interest in the psychosocial factors related to the risk of injuries has increased during the last two years, but it is difficult to weigh the importance of just one risk factor. In a recently published meta-analysis, approximately 7% of the variance in the appearance of injuries could be explained by psychosocial factors (Ivarsson et al., 2017). However, this is not the same as saying that 7% of the injuries can be explained by psychosocial factors What it does indicate is that psychosocial factors might be one of many factors that can influence the injury risk.

Concerning different types of injuries, most of the research published has focused on acute/traumatic injuries. Also, a few studies have focused on psychosocial risk factors of overuse injuries. The results have shown that there are both similarities and differences in what factors might influence the risk of these two types of injuries.

What are the main mechanisms by which stress increases the risk of injury? During the talk, you mentioned the importance of poorer decision-making. Is this the main factor?

There are a few main mechanisms for the relationship between stress and injury risk. One of these is that stress will negatively influence the athlete’s abilities to take high qualitative decisions due to a narrowed peripheral vision. Another proposed mechanism is that stress is likely to generate higher levels of psychophysiological fatigue. An increase in fatigue might, in turn, increase the risk of becoming injured.

You also mentioned three factors that affect the risk of injury: those related to the personality, interpersonal relationships, and cultural aspects. Could you explain this and how it can affect the injury risk?

In previous studies, personality traits are one main category of psychosocial factors that can influence injury risk. Examples of traits that have been found to increase the likelihood of becoming injured are sport-specific, as well as general anxiety, worry, and stress susceptibility. These personality characteristics have been suggested to increase the likelihood of an athlete perceiving situations as stressful, as well as increase the magnitude of the stress responses.

In the meta-analysis we were talking about earlier, you observed that the stress response and the athlete’s stressors background were clearly associated with the risk of injury, but the personality type was not significant. Is that so?

That is correct. One potential explanation for this result is that personality (e.g., anxiety) might not have a direct influence with the injury but will, instead, influence an athlete’s likelihood of perceiving more situations as stressful.

On the history of stressors: which are the most important risk factors? And how do you study them or group them, taking into account that, as you said, there are up to 640 different stressors described?

It is difficult to say which stressors are the most important, but a category of stressors that have been frequently researched are the interpersonal relationships (with the coach, teammates, family, friends, etc.) This category of stressors seems to have a relationship with an increased risk of getting injured. In most of the studies investigating the history of stressors, the athletes are asked to, from a list of potential stressors, indicate how much of a stressor the item has been during the last week/month/year. There are often also open-ended questions in the questionnaire so the athlete can fill in additional stressors that are not included in the list.

There were two aspects you especially insisted on: the relationship with the coach and social-cultural aspects. Could you explain its peculiarities and importance?

Both categories of factors have been suggested to influence injury risk among athletes. One potential explanation for the increased injury risk is that these variables might increase the likelihood of maladaptive behaviours (e.g. playing injured or with pain). Another potential explanation is that the athlete will focus on internal processes instead of relevant stimulus during, for example, a game. This will decrease the likelihood of high-quality decision making.

In the same meta-analysis we were discussing, you also found that, though there are few studies on psychological interventions and the risk of injury, they were all positive. Why are there still so little studies in this field?

I believe there may be several reasons that explain the lack of studies. One general barrier listed by sports coaches, for implementing an evidence-based injury preventive initiative, is the perceived lack of time. Another potential barrier might be related to the psychological aspect. As an example, research has shown, that football coaches and academy directors have expressed six barriers related to the implementation of applied sport psychology.

Was there a therapy which worked better than another? In the talk, you mentioned the fact that, beyond therapy itself, the secret lies in communication. How should this take place in order to be effective?

All the different intervention programs seem to have similar effects on injury risk reduction. Research has shown that a proportion of the effect on psychological intervention research can be explained by common factors (i.e., factors that are similar for different psychological perspectives). The most important common factors are goal consensus, empathy and alliance. To facilitate these factors, it is important to establish an open environment where the athlete can talk about everything and where you, as a psychologist, are listening to the athlete’s stories.

In your final message, you emphasized the importance of monitoring the players’ stress level and their responses to it, together with self-reflexive exercises that should be integrated into the injury prevention work of a team or club. How should this follow-up be and what kind of exercises would be recommended?

I think that one way to monitor stress levels is to combine the use of biofeedback (e.g., HRV —heart variability rate—) with a few self-report questions (for example shared through a mobile app). It is important to not have too many questions but to monitor them frequently. This is important because the most interesting part in relation to injury risk is the change of these variables within the person. The results from these two practices can then be used as a self-reflection exercise.

Finally, how do you see the future in this field? How important will it be and what novelties do you expect to be introduced?

I think (and hope) that psychological techniques will be included in injury prevention programs. Including this new field, will hopefully reduce the injury rates even more. Also, a psychological view or perspective can also be valuable when it comes to implementing other types of injury preventive exercises.

The Barça Innovation Hub team

Complementary literature:

Gledhill, A., & Forsdyke, D. (2018). An ounce of prevention is better than a pound of cure: shouldn’t we be doing EVERYTHING to reduce sports injury incidence and burden? British Journal of Sports Medicine, 52, 1292-1293.

Gledhill, A., Forsdyke, D., & Murray, E. (2018). Psychological interventions used to reduce sports injuries: a systematic review of real-world effectiveness. British Journal of Sports Medicine, 52, 967-971.

Ivarsson, A., Johnson, U., Andersen, M. B., Tranaeus, U., Stenling, A., & Lindwall, M. (2017). Psychosocial factors and sports injuries: Meta-analyses for prediction and prevention. Sports Medicine, 47, 353–365.

Ivarsson, A., Johnson, U., Karlsson, J., Börjesson, M., Hägglund, M., Andersen, M. B., …Waldén, M. (2018). Elite female footballers’ stories of sociocultural factors, emotions, and behaviors prior to anterior cruciate ligament injury. International Journal of Sport and Exercise Psychology. Advance online publication.