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Injury Prevention in Sweden: Helping Soccer Players at Risk

Article  in  Journal of Sport and Exercise Psychology · March 2005

DOI: 10.1123/jsep.27.1.32 · Source: OAI

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 Injury Risk 1

Running head: INJURY PREVENTION IN SWEDISH SOCCER

Injury Prevention in Sweden: Helping Soccer Players at Risk

Urban Johnson and Johan Ekengren

Halmstad University, Sweden

Mark B. Andersen

Victoria University, Australia

 Injury Risk 2

Injury Prevention in Sweden: Helping Soccer Players at Risk

In contrast to the rich body of empirical studies investigating psychological factors in

sport injury occurrence, there are few controlled intervention studies examining relationships

among psychological risk variables, prevention treatments, and injury outcomes (Cupal,

1998). Moreover, little attention has been given to those brief interventions that occur

frequently when working with athletes in the field, often referred as brief contact

interventions (see Giges & Petitipas, 2000). In the field of clinical psychology, there has been

interest and research in brief or focused interventions, especially in the cognitive-behavioral

therapies, and particularly for clients diagnosed with anxiety and somatic disorders (Bergin &

Garfield, 1994). Most brief therapies typically range from 5 to 15 sessions (Pinkerton &

Rockwell, 1994) and are commonly organized with close spacing of initial sessions and

gradually increasing inter-session intervals with a planned follow-up or booster session

(Budman & Gurman, 1983). Such brief therapy models seem well-suited for sport

interventions, and have been used, in various forms, in the past.

To date, four documented studies exist aimed at reducing sport injury risk. May and

Brown (1989) used attention control, imagery, mental skills training, team building,

communication, relationship orientations, and crisis interventions for individuals, pairs, and

groups of U.S. alpine skiers in the 1988 Olympics in Calgary. The authors reported that their

interventions led to reduced injuries, increased self-confidence, and enhanced self-control.

Schomer (1990) examined the effects of associative versus dissociative thought patterns with

10 marathon runners. According to Schomer, the consistent body monitoring (associative

thinking) was responsible for the elimination or minimisation of overuse injuries. In contrast,

Davis (1991) focused on prevention treatment (stress management) using imagery with

collegiate swimmers and football players to reduce injuries. The program involved

progressive relaxation combined with imagined rehearsal of swimming and football skills and
 Injury Risk 3

related content during the competitive season. Davis reported an impressive 52% reduction in

swimming injuries and a 33% reduction in football injuries. In a particularly well-organized

study, Kerr and Goss (1996) used a stress-management prevention intervention with 24 elite

gymnasts based on Meichenbaum´s stress inoculation training program (1985) over an eight-

month period. The gymnasts were matched into pairs according to sex, age, and performance

level. Results showed that injuries for the intervention group were substantially less than

those in the control group (not statistically significant, but clinically meaningful, see

Andersen & Stoové, 1998). Furthermore, stress levels were reduced significantly more for the

intervention group than for members of the control group. The Williams and Andersen (1998)

model of stress and athletic injury identified several psychosocial variables that may place

athletes at risk of injury. For example, competitive anxiety, major life events, and coping

resources have been examined in relation to injury outcome. Athletes with high competitive

anxiety, many life events, and low coping resources may, when placed in stressful situations

(e.g., practice, competition), exhibit substantial stress responses (e.g., generalized muscle

tension, attentional disruptions) that place them at higher risk of injury than athletes with

opposite profiles..

The next logical step in prevention research is to identify at-risk athletes (rather than all

athletes on a team) and offer interventions in a treatment-control group design. This approach,

if successful, would point to strategies that would help those who could benefit most, and also

help minimize intervention costs. Our question for this study was: Does a psychologically

based prevention intervention program, organized in a pretest-posttest treatment-control group

design, lower the incidence of injuries for competitive soccer players who have at-risk

profiles compared to a matched control group?

 Injury Risk 4

Method

Participants

The initial pool of participants consisted of 132 male players with a mean age of 22.9

years and 103 female players with a mean age of 20.1 years. The soccer players came from 12

different teams competing at the regional level in southwestern Sweden. The soccer teams

competed on a highly competitive and elite level by Swedish national, as well as international,

standards. After the screening for risk, 32 participants were identified as having high injury-

risk profiles (see Procedure). This risk group was then randomly divided into a treatment and

a control group. The control group consisted of 16 soccer players divided into eight male and

eight female players. The treatment group consisted of 16 soccer players divided into seven

male and nine female players. During the intervention, three male soccer players in the

treatment group dropped out, leaving 13 players.

Instruments

Sport-specific questionnaires were chosen because of their potential to screen for

psychosocial risk factors outlined in the stress and injury model by Williams and Andersen

(1998). Personality variables were captured by the Sport Anxiety Scale (SAS; Smith, Smoll,

& Schutz, 1990). The SAS is a 21-item questionnaire containing three subscales: somatic

anxiety (nine items), worry (seven items), and concentration disruption (five items).

Psychological variables connected to history of stressors were captured by the Life Event

Scale for Collegiate Athletes (LESCA; Petrie, 1992). The LESCA, is a 69-item events survey.

Athletes are asked to indicate which events have occurred in the last 12 month, and then for

each event, to rate the life events impact at the time of occurrence on a 8-point Likert scale

with the anchorings -4 (extremely negative) to +4 (extremely positive). Coping resources were

captured through the Athletic Coping Skills Inventory 28 (ACSI –28; Smith, Schutz, Smoll, &

Ptacek, 1995). The ACSI-28 contains 28 items and seven subscales: (a) coping with adversity,
 Injury Risk 5

(b) peaking under pressure, (c) goal setting/mental preparation, (d) concentration, (e) freedom

from worry, (f) confidence and achievement motivation, and (g) coachability. See the original

articles for the psychometric properties of these instruments.

Injury Recording

Every third to fourth week between February and June (six times total) the head coaches

for every participating team were asked to record each injury that occurred for their soccer

players and indicate the number of days that each recorded injury interfered with regular

training and match game on a structured Sport Injury Frequency Form. An athlete was

considered to have incurred an injury if it was serious enough to cause the athlete to miss

practice or competition, or to modify substantially participation for at least one day. The

dependent variable for the study was “number of injuries incurred.” Other studies have used

number of days missed or modified as a result of injury, usually as some measure of severity.

This tact has problems. For example, is six days missed due to three separate injuries the same

as six days missed due to one injury? The Williams and Andersen (1998) model predicts only

injury outcome (i.e., greater likelihood of being injured); it says nothing about likelihood of

lesser or more severe injuries. Number of injuries seemed to be the cleanest and most

appropriate variable to measure in keeping with the Andersen and Williams model.

Intervention program

The intervention program, in keeping with brief therapy models, consisted of six

different sessions and two telephone contacts between weeks 6 and 26. The researchers met

every individual soccer player in the treatment group twice a month for the first two months

and then in the middle and at the end of the intervention time. The intervention program

involved five distinct treatments: (a) somatic and cognitive relaxation, (b) stress management

skills (the athletes learned how to cope with stressors, using the problem- and emotion

focused coping strategies of Folkman & Lazarus [1984], related to their present situations as
 Injury Risk 6

competitive soccer players), (c) goal setting skills, (d) attribution and self-confidence training,

and, (e) identification and discussion about critical incidents related to their football

participation and situations in everyday life. This last listed treatment, named “critical

incident diary” (CID). A critical incident was defined as a task or a situation that went

unusually well or one that was particularly demanding connected to: (a) their present situation

as soccer players, or (b) situations in every day life. The soccer players were asked to rate

three separate tasks or situations on a printed paper every week during the entire test period.

CID was used as a basis for discussion all through sessions 2 to 6 in combination with the

main focus for each session. All sessions lasted between 45 to 90 minutes and were mostly

situated at the homes of the athletes or in rooms close to the training venues. Each player

received a folder at the first session with written materials, carefully designed with easy-to-

read descriptions for every meeting, including homework and a general time-table over the

intervention period. For more details of the content of the cognitive-behavioral interventions,

contact the first author.

Procedure

In November and December, the head coaches for 12 soccer clubs in the southwest

region of Sweden were contacted in order to establish collaboration. All contacted teams were

interested in participating in the study. The time period of the intervention was five months,

ranging from the end of January to the end of June. This time period is equivalent to the pre-

and first half of the competitive season (Spring season) for soccer players in Sweden. Scores

on the LESCA (Petrie, 1992), the SAS (Smith, Smoll, & Schutz, 1990) and the ASCI-28

(Smith, Schutz, Smoll & Ptacek, 1995) were used to identify athletes at risk. Smith, Smoll,

and Ptacek (1990) found that athletes who rated lower in psychosocial variables such as social

support and coping resources, and had many life events, were the ones more likely to be

injured. We would have liked to have screened athletes who were in the top (or lower as the
 Injury Risk 7

case may be) 33% range of risk factors as Smith et al. did, but screening on more than one or

two variables for risk at that level dropped our potential pool to unacceptably low numbers.

Those soccer players who received scores that represented the highest 50 % of the LESCA

and the highest 50% of SAS (total) were labelled as having high injury-risk profiles. As for

ACSI-28, high scores on five subscales (coping with adversity, peaking under pressure, goal

setting/mental preparation, concentration, and, confidence and achievement motivation)

indicate adaptive coping responses, but low scores on two subscales (freedom from worry,

and coachability) indicate adaptive coping responses. Soccer players who received scores

representing the lowest 50 % on the five ACSI-28 subscales and highest 50% on two ACSI-2

subscales were labelled as having high injury-risk profiles. Participants had to be in the “risk”

50% on all variables. Control and treatment group membership was randomly assigned after

matching in terms of age, gender, and level of competition.

Results

At the time of pretest (end of January), all participants were free from physical injuries

according to their head coaches. During the intervention period, several injuries occurred,

especially for the control group. The control group received altogether 21 injuries (for an

average of 1.31 injuries per person) distributed across 13 different players. Some players had

two or three separate injuries The treatment group incurred altogether three injuries ( for an

average of 0.22 injuries per person) distributed across three different players.

With results that show 10 of 13 in the treatment group remained injury free, but only

three of 16 in the control group had no injuries. There appears to be obvious clinical

significance in these frequencies. The data for analysis were “number of injuries” and all

athletes received scores of 0, 1, 2, or 3. In the treatment group, 10 of the 13 athletes received

scores of zero. These data were not normally distributed and a nonparametric test, the

equivalent of a t test for independent means was chosen for the analysis. The Mann-Whitney
 Injury Risk 8

U test showed statistical significance. The result revealed a significant difference between the

control group and the treatment group, with the control group incurring more injuries than the

treatment group (U, [n1 = 13, n2 = 16] = 44.00, p < .005).

Discussion

The present exploratory study was undertaken to test the assumption that a well-

supported, cognitive-behaviorally based brief intervention program, organized in a treatment-

control groups design, had the potential to lower the number of injuries for an injury-risk

group. We found that soccer players at risk for sport injuries, according to Williams and

Andersen’s stress and injury model (1998), who received the intervention, had dramatically

lower injury rates.

Doing research into intervention outcomes, it is important to have measures of real-world

variables in people’s lives and not just changes in paper and pencil tests (Sechrest, McKnight

& McKnight, 1996). Stress management and relaxation programs may increase coping skills

or lower anxiety, as measured by instruments such as the ACSI and the SAS, but unless those

changes are related to some real-world variables such as injury or recovery, then their

meaning is diminished. Paper and pencil test scores become meaningful when calibrated

against real-world variables such as injury. This study focused on real-world variables and not

much on paper and pencil measures (except for identifying at-risk individuals). That said, we

did measure changes in the psychosocial variables, and those in the intervention group with

the largest positive changes in terms of η2 once baseline differences were accounted for by

analyses of covariance were somatic anxiety and worry from the SAS (η2 = 08 and .09,

respectively, medium effects) and freedom from worry, confidence and achievement

motivation, and coachability from the ACSI-28 (η2 = .07, .15, and .25, respectively, medium

to large effects). The direction of changes in all these variables is in congruence with what

would be predicted as lowering injury risk in the Williams and Andersen (1998) model.
 Injury Risk 9

There are several potential explanations for the treatment group having significantly

fewer injuries during the intervention period than the control group. One contributing factor is

probably that the treatment group received training in somatic relaxation and stress

management early in the intervention period. This intervention strategy, used in a systematic

and planned way, has the potential to buffer stress (Jones, 1993), and may have prepared the

athletes to handle potentially stressful situations in a better way. Kerr and Goss (1996), as

well, highlighted the usefulness of early training in specific skills, such as relaxation, in order

to prevent injury outcome. Another possible explanation could be due to the players every

week making notes in the CID and, thus, were attentive to potential effects of negative events

related to football and everyday life. Such awareness may have help them mentally prepare

for practices or games coming up, or take steps to avoid stressful situations at work and/or at

school. Being aware of negative or stressful situations to come has been shown to help the

person prepare to handle that situation better (e.g. Glass & Singer, 1972). Thus, avoiding the

stressful situations when possible or interpreting them more positively may be conducive to

enhanced levels of health on psychological and physical levels.

An overall conclusion to be drawn from the present study is that injury reduction is

possible to obtain for soccer players having high injury-risk profiles using combinations of

psychological interventions in a brief therapy model. To advance of this area of research, a

strong research design, built on a sound theoretical frame-work, is imperative. We argue that

the stress and injury model (Williams & Andersen, 1998) is a useful foundation for the

prediction and the prevention of injury. We recommend that researchers settle on standard

measures for constructs (e.g., coping, stress) of central interest in this research, and that

researchers use these standard measures in their projects because this approach would provide

a basis on which calibration could proceed and future comparisons could be made. In

addition, separate studies of men and women, as well as between acute and overuse injuries
 Injury Risk 10

would further advance the field. Using a second control group, identified as not having an

injury-risk profile, would help determine if the risk groups were truly more injury prone than

other players in general. Finally, in the future, researchers might want to identify a no-risk (or

extremely low risk) group and include them in the comparisons in order to make some cost-

benefit analyses for targeting all athletes for interventions versus just those athletes identified

at risk.

According to Williams (2001) “The ultimate value of research dealing with

psychosocial risk factors is the potential for using the knowledge to reduce the tragedy and

expenses caused by avoidable injuries” (p. 783). This approach is indeed a valuable research

direction for the field.

 Injury Risk 11

References

Andersen, M. B., & Stoové, M. A. (1998). The sanctity of p < .05 obfuscates good stuff: A

comment on Kerr and Goss. Journal of Applied Sport Psychology, 10, 168-173.

Bergin, A. E., & Garfiled, S. L. (1994). Handbook of psychotherapy and behavior change

(4th ed.). New York: Wiley.

Budman, S. H., & Gurman, A. S. (1983). The practice of brief therapy. Professional

Psychology: Research and Practice, 14, 277-292.

Cupal, D. D. (1998). Psychological interventions in sport injury prevention and rehabilitation.

Journal of Applied Sport Psychology, 10, 103-123.

Davis, J. O. (1991). Sport injuries and stress management. An opportunity for research. The

Sport Psychologist 5, 175-182.

Folkman, S., & Lazarus, R. S. (1984). Stress, appraisal, and coping. New York: Springer.

Giges, B., & Petitipas, A. (2000). Brief contact interventions in sport psychology. The Sport

Psychologist, 14, 176-187.

Glass, D. C., & Singer, J. E. (1972). Urban stress. New York: Academic Press.

Jones, G. (1993). The role of performance profiling in cognitive behavioral interventions in

sport. The Sport Psychologist, 7, 160-172.

Kerr G., Goss, J. (1996). The effects of a stress management program on injuries and stress

levels. Journal of Applied Sport Psychology 8, 109-117.

May, J. R., & Brown, L. (1989). Delivery of psychological service to the U.S. Alpine ski

team prior to and during the Olympics in Calgary. The Sport Psychologist, 3, 320-329.

Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.

Petrie, T. A. (1992). Psychosocial antecedents of athletic injury: The effects of life stress and

social support on female collegiate gymnasts. Behavioral Medicine, 18, 127-138.

 Injury Risk 12

Pinkerton, R. S., & Rockwell, W. J. K. (1994). Very brief psychological interventions with

university students. Journal of American College Health, 13, 344-357.

Schomer, H. H. (1990). A cognitive strategy training program for marathon runners: Ten case

studies. South African Journal of Research in Sport, Physical Education and

Recreation, 13, 47-78.

Sechrest, L., McKnight, P., & McKnight, K. (1996). Calibration of measures for

psychotherapy outcome studies. American Psychologist, 10, 1065-1071.

Smith, R. E., Schutz, R. W., Smoll, F. L., & Ptacek, J. T. (1995). Development and validation

of a multidimensional measure of sport-specific psychological skills: The Athletic

Coping Skills Inventory-28. Journal of Sport & Exercise Psychology, 17, 379-398.

Smith, R. E., Smoll, F. L., & Ptacek, J. T. (1990). Conjunctive moderator variables in vulnerability

and resiliency research: Life stress, social support and coping skills, and adolescent sport

injuries. Journal of Personality and Social Psychology, 58, 360-369.

Smith, R. E., Smoll, F. L., & Schutz, R. W. (1990). Measurement and correlates of sport-

specific cognitive and somatic trait anxiety: The Sport Anxiety Scale. Anxiety Research,

2, 263-280.

Williams, J. M. (2001). Psychology of injury risk and prevention. In R. N. Singer, H. A.

Hausenblas, & C. M. Janelle (Eds.), Handbook of sport psychology (pp. 766-786). New

York: Wiley.

Williams, J. M., & Andersen, M. B. (1998). Psychosocial antecedents of sport injury: Review

and critique of the stress and injury model. Journal of Applied Sport Psychology, 10, 5-

25.
 Injury Risk 13

Author Note

Urban Johnson and Johan Ekengren, School of Social and Health Sciences, Halmstad

University, Halmstad, Sweden; Mark B. Andersen, School of Human Movement, Recreation

and Performance, Victoria University, Melbourne, Australia.

This research was supported in part by a grant from the Swedish National Centre for
Research in Sports (Grant number 19/3).

Correspondence concerning this brief report should be addressed to Urban Johnson,

School of Social and Health Sciences, Halmstad University, Box 823, SE-301 18 Halmstad,
Sweden. E-mail: urban.johnson@hos.hh.se

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