The Multiply Injured Versus the First-Time-Injured Athlete During Rehabilitation: A Comparison of Nonphysical Characteristics

Transcription

1 Journal of Sport Rehabilitation, 1996, 5, O 1996 Human Kinetics Publishers, Inc. The Multiply Injured Versus the First-Time-Injured Athlete During Rehabilitation: A Comparison of Nonphysical Characteristics Urban Johnson Research on rehabilitation of multiply injured athletes shows no convincing evidence that physiological factors exclusively can explain injury-proneness in sport. Neither can any single psychological factor characterize the injuryprone athlete. Injury-proneness seems to be best explained by a complex web of extrinsic and intrinsic risk factors. The present study focused on a comparison of mental factors and coping strategies of high-level athletes with sport injuries. Apsychological profile of 25 multiply injured athletes was compared to 14 first-time seriously injured athletes. Factors such as impulsiveness, risktaking attitude, introaggression, and psychic anxiety did not differentiate multiply injured athletes from other athletes with injuries. The first-time-injured group, however, had psychological difficulties associated with long-term injuries or other serious life crises. The first-time-injured athletes tended to experience the rehabilitation period as stressful, and they showed less self-confidence and scored lower on an overall mood scale than the multiply injured athletes. Competitive sport today places extreme physical strains on the body, especially on the muscles and ligaments. About 5-15% of highly competitive or elitelevel athletes are absent from training or competition for at least 1 month each season (9). Thus, the chances of being injured traumatically within competitive sport are statistically high. In addition, some athletes are injured more frequently than others. These athletes are referred to as multiply injured or injury-prone. Researchers studying multiply injured athletes have attempted to identify physical factors (e.g., muscle mass or physical status) that could be involved in the pathogenesis of an injury and to explain why certain individuals are more frequently injured than others (20, 22). However, there has been only very modest evidence to support the assumption that traumatic injury is directly related to the athlete's physical characteristics. Although the role of physical factors is not yet fully understood, researchers recognize more and more the multifaceted pathogenesis of injuries (1 8). This line of research has led to a general acceptance that Urban Johnson was with the Department of Applied Psychology, Lund University, at the time of this study and is now with the Department of Social and Behavioral Science, Halmstad University, Box 823, S Halmstad, Sweden.

2 294 Johnson there are two types of risk factors: (a) extrinsic, related to type of sport, the way it is practiced, contextual factors, and equipment, and (b) intrinsic, related primarily to the individual's physical and psychological features. It is still not completely clear, however, how certain physical and psychological factors or combinations of these predispose some athletes to having more injuries than others. Lysens et al. (19), who studied injury-proneness in sport, concluded that "accident proneness is not a stable, constant characteristic of a person. The vulnerability to accidents will fluctuate over time, according to the events in a person's life" (p. 285). One line of research, based on psychodynamic or psychoanalytic theory (2, 33), considers unconscious psychological motives such as self-destructiveness to cause repeated injuries. According to this view, dysfunctional behavior is the result of the subject's attempts to handle an unconscious conflict. In psychodynamic terms, the subject's ambivalence toward aggressiveness is a determining factor in whether he or she experiences tension and anxiety. This ambivalence is nourished by the fact that physical aggression is encouraged in two areas: war and competitive sport. For many individuals this produces a classical conflict situation, one of approach-avoidance (27). On the one hand, an athlete may wish to participate (approach) in the competition since it can offer victory and prestige. On the other hand, an athlete may wish to avoid competition since it may result in an outflow of self-assertive aggression, this in turn creating an unconscious need for punishment, for example, through succumbing to injury. The tension and wony associated with an unconscious conflict can negatively influence performance, increasing the risk of injury (an actual injury or a faked one), this representing an unconscious defense. According to Sanderson (28,29), the athlete who is tension-oriented may well use defense mechanisms in order to maintain psychological homeostasis. Sanderson considers athletes who are tension-oriented to be characterized by emotional vulnerability and poor impulse control, to often be restrained by fears and phobias, and to think negatively. Alexander (2) argued that injury-prone individuals often have feelings of guilt, which they endeavor to reduce by self-imposed suffering and punishment. Ogilvie and Tutko (23), in turn, claimed that the behavior of the injuryprone athlete originates in introaggression. A different approach to studying pathogenesis in the injury-prone athlete is to consider personality variables, often through use of questionnaires, by specifically examining the personality characteristics of individuals who are injured more frequently than others. Jackson et al. (13) and Thomas and Reilly (33, using the Catell 16PF questionnaire, found that "tender-minded athletes more often seek medical help for acute injuries and that "detached or "absent-minded" athletes are particularly prone to serious sport injuries. Lysens et al. (17,18) found that the personality characteristics of many multiply injured athletes resemble those of the "ordinary" accident-prone person, concluding that such traits as extroversion, dominance, strong risk-taking behavior, and high psychic tension, aggression, and hostility seem to predispose athletes who have these traits to a higher risk of injury (see Reference 12 for an extended discussion). Still another line of research has involved possible relationships between injury-proneness and stress. Bramwell et al. (4) investigated the relationship of injury-proneness to psychological well-being in a broad sense, focusing on different socially stressful events as identified through the Social and Athletic Readjustment Rating Scale (SARRS). The longitudinal study included 82 American football players. At the end of the first season the athletes were divided into an injured and

3 Multiple vs. First-Time lnjuly 295 a noninjured group, with the injured group subdivided into low-, medium-, and high-risk groups on the basis of SARRS scores. It was found that 30% of the players in the low-risk group, 50% in the medium-risk group, and 73% in the highrisk group had lost time from practice because of injuries. Many other researchers, like Blackwell and McCullagh (3), Coddington and Troxell(5), Cryan and Alles (7), Lysens et al. (17), May et al. (21), Kerr and Minden (14), and Passer and Seese (24), have used similar approaches and modified versions of either SARRS or the Life Experience Survey (LES). Within this line of research it is hypothesized that athletes who are subject to acute sport injuries, particularly serious and complex injuries, have experienced major changes in lifestyle to a greater extent than athletes with fewer injuries. There appears to be no convincing evidence that physiological factors can exclusively explain injury-proneness in sport or that any single psychological factor characterizes the injury-prone athlete. Injury-proneness would seem instead to best be explained by a complex web of extrinsic and intrinsic risk factors. Psychological risk factors that appear important are high psychic tension, low self-confidence, stressful living, risk taking, and aggressiveness. There is a fairly extensive literature on psychological risk factors that may explain why some athletes are injured considerably more often than others. However, there has been little study of how the multiply injured athlete experiences rehabilitation and how he or she copes with injury during rehabilitation. The present investigation considers the following question: Do multiply injured athletes on a high competitive level differ, in their behavior and way of coping during rehabilitation, from a group of athletes of the same level who are seriously injured for the first time? Subjects and Definitions Method and Materials From February 1992 to September 1994, data were collected from 8 1 highly competitive or elite-level athletes (i.e., Swedish national and international level), who had acute, long-term injuries and were treated at two sport injury centers in the south of Sweden. The injuries had all occurred during training or competition. Subjects either came to the center at their own initiative or were referred by a physiotherapist specializing in sport injuries. Subjects received no monetary compensation for participating in the study. Out of the 81 athletes, 80% (n = 65) participated in team sports such as soccer (n = 43), European handball (n = 12), volleyball (n = 5), ice hockey (n = 4), and American football (n = 1). The individual sport athletes, constituting 20% of the total number (n = 16), practiced trackand-field sports (n = 7), gymnastics (n = 2), and other individual sports in single numbers. The most common type of acute injury was knee injuries (79%), followed by foot/ankle injuries (7%) and shoulder injuries (5%). The athletes were tested on two occasions: at the beginning and at the end of the rehabilitation period. The mean time between Tests l and 2 was 19 weeks. By the second testing 4 subjects had dropped out, mainly due to further injuries. Criteria for inclusion in the study were as follows: participation at a highly competitive or elite level, 18 years of age or older, and unable to either train or compete for a minimum of 5 weeks according to the physiotherapist's evaluation. The time limit of 5 weeks is equivalent to the classification of severe sport injury according to Lysens et al.

4 296 Johnson (19). The criterion for being multiply injured was that a subject had had at least three acute, long-term injuries. The first-time-injured subjects, of course, had had no prior acute, long-term injury. The athletes in both groups were diagnosed by physiotherapists as having the same injury severity with a need for approximately 22.9 (SD 12.7) weeks (multiply injured) and 22.9 (SD 10.8) weeks (first-time injured) of rehabilitation before return to sport. The multiply injured and the first-time-injured groups were equivalent as to the proportion of team and individual sports. There is no standard definition in the literature concerning what constitutes injury-proneness in terms of frequency and extent. Lysens et al. (18), who used a descriptive statistical technique (analysis of correspondence) to study accidentproneness in athletes, used two or more accidents as a criterion for accident-proneness. In addition, other research has indicated that an athlete seldom experiences more than three severe sport injuries during his or her sport career (9, 26). Thus, the multiply injured athletes examined in the present study seemed to be a fairly homogeneous group. The athletes seriously injured for the first time met the criterion of having had no previous severe sport injury. Within the total group of athletes with long-term injuries (N = 81), two subgroups emerged: 25 multiply injured and 14 first-time-injured athletes. At the beginning of the rehabilitation period (first testing), the multiply injured group consisted of 20 men and 5 women with a mean age of 25.2 years, whereas those injured for the first time were 9 men and 5 women with a mean age of 22.2 years. Some comparisons were made with a "normally-injured" group, that is, athletes in the study who were neither multiply nor first-time injured, which consisted of 42 athletes (35 men and 7 women) with a mean age of 24.5 years. At the end of the rehabilitation period (second testing), the multiply injured group remained unchanged, whereas the first-time-injured group consisted of 13 athletes (8 men and 5 women) with a mean age of 22.7 years. The normally injured group consisted at that time of 39 athletes (32 men and 7 women) with a mean age of 24.6 years. Measurements Following are descriptions of the various instruments used for measuring habitual, personality-related factors of vulnerability, coping strategies, and situational mood variables. Three psychological questionnaires were employed at the first testing: the Mood Adjective Checklist (MACL), the General Coping Questionnaire (GCQ), and the Karolinska Scales of Personality (KSP). An interview was also conducted on this occasion. At the second testing, the instruments employed were the MACL, the Sport Injury Questionnaire, and the Diagnostic Checklist. MoodAdjective Checklist (MACL). This inventory, constructed by Svensson (34) and Sjoberg et al. (31), consists of 71 adjectives with four symmetrical response alternatives. The adjectives are distributed on six bipolar mood dimensions: (a) hedonic tone (e.g., pleasure, satisfaction vs. discomfort, dissatisfaction), (b) activity-passivity (active vs. idle), (c) tension-relaxation (tense, nervous vs. calm, relaxed), (d) extraversion-introversion (extrovert vs. introvert, especially in social situations), (e) positive-negative social orientation, and (f) control-lack of control (self-confident vs. insecure). Cronbach alpha was calculated at.88. Norm data were available from 504 Swedish men and women with a mean age of 42.1 years. In earlier studies, researchers found that the MACL correlated with various coping

5 Multiple vs. First-Time Injury 297 strategies following major surgery (1). It has also been found that many of the variables are clearly related to various aspects of behavior as people adapt to and cope with stressful life events. General Coping Questionnaire. This inventory was constructed by Persson (25) to assess different coping strategies that people use in stressful situations. It has been standardized in tests involving 174 Swedish men and women with a mean age of 30.5 years. The inventory, which employs a four-response scale, consists of 61 items concerned with 13 dimensions: 1. Cognitive reappraisal: trying to see a problem from a more positive point of view or as a challenge instead of as a threat 2. Substitution: trying to avoid a problem by mentally or physically engaging in something else 3. Wishful thinking: hoping that the problem will solve itself 4. Problem-solving: actively dealing with a problem through goal-setting and long-term planning 5. Self-confidence/humor: being self-reliant and attempting to see the problem from a positive or humorous point of view 6. Resignationfacceptance: giving up and accepting the situation as it is 7. Seeking social support: seeking advice, support, and encouragement from others in immediate surroundings 8. Social comparison 9. Religion 10. Catharsis 1 1. Self-blame 12. Drinking 13. Seeking professional help Cronbach alpha for this questionnaire is calculated at.70 (25). Karolinska Scales of Personality (KSP). This inventory, constructed by Schalling and Edman (30), consists of 134 statements concerning 15 variables. A four-response scale of agreement or disagreement is employed. KSP has been standardized on 169 men (M = 26.7 years) and women (M = 26.6 years). The Cronbach alpha is calculated at.67 (15). The aim of the test is to measure "personality correlates as well as biological correlates of some psychiatric disorders, in order to define vulnerability factors which might help to identify individuals at risk (30, p. 2). The 15 variables are as follows: somatic anxiety, psychic anxiety, muscular tension, social desirability, impulsiveness, monotony avoidance, detachment, psychasthenia, socialization, indirect aggression, verbal aggression, irritability, suspicion, guilt, and inhibition of aggression. Interview Guide. The interview guide consists of six semistructured questions concerned primarily with Folkman and Lazarus's (11) cognitive appraisal theory. One of the questions-to be answered yes or ndeals with the respondent's main perception of the injury as being predominantly stressful (irrelevant = positive). The other questions deal primarily with the impact of the injury on the respondent's life and personal well-being. The athletes' answers were coded according to the categories provided by Folkman and Lazarus (11) for assessing response to a stressful event (primary appraisal). Sport Injury Questionnaire. This questionnaire consists of 21 questions with partly open and partly closed answer alternatives. It is divided into five sections. Four

6 298 Johnson of the questions are used in the present study, because the background information they provide is useful in interpreting the psychological questionnaires and also because they yield information concerning how the athletes experienced rehabilitation. The following four questions were employed to this end: How do you feel your rehabilitation has proceeded up till now? Do you consider yourself to be fully rehabilitated physically since your injury? Do you consider yourself to be fully rehabilitated psychologically since your injury? Did you establish any kind of guidelines to speed up rehabilitation? Diagnostic Checklist. This checklist, which is divided into two sections, consists of eight questions with partly open and partly closed alternatives. Two questions on the checklist were used in this study. They concern the treating physiotherapist's opinion of the ongoing physical rehabilitation, and they provide background information for evaluating answers to the Sport Injury Questionnaire. The two questions are, How do you feel that the physical rehabilitation has worked out for your patient? and Do you consider your patient physically recovered and able to go back to competitive sport without risk? Statistical Analysis Student's t test (two-tailed) was used to examine differences between the groups on the psychological questionnaires. Fisher's Exact Test was used to analyze frequency distribution differences between the groups in their answers to questions from the Interview guide, the Sport Injury Questionnaire, and the Diagnostic Checklist. Results Comparisons at the Beginning of Rehabilitation A comparison of the multiply injured athletes and the normally injured athletes showed that the subjects in the multiply injured group tended to accept their current situation to a higher degree (showing high scores on Resignation/Acceptance) than did those in the normally injured group. They also tended to have lower scores than the normally injured group on Psychic Anxiety and Monotony Avoidance (see Table 1). The multiply injured group also showed a higher overall mood level than the group injured for the first time (high scores on Hedonic Tone, Activity, and Social Orientation), and they showed a greater urge to suppress anger and irritation (higher scores on the vulnerability variable Inhibition of Aggression; see Table 2). Interview Guide. Results obtained from the interview guide questions at the first testing revealed that subjects in the multiply injured group were less likely to regard their injury situation as stressful than those in the first-time-injured group (5120 vs. 1014, p =.006). No significant differences between the multiply injured and the normally injured group were found. Comparisons at the End of Rehabilitation MACL. At the second testing, the multiply injured athletes rated themselves higher on the mood variables Social Orientation and Activity than did the firsttime-injured athletes (see Table 3).

7 Multiple vs. First-Time Injury 299 Table 1 Differences in Means Between Multiply Injured (n = 25) and '?Normally7' Injured (n = 42) Athletes at the Beginning of Rehabilitation (t Test, Two-Tailed) Multiply injured Normally injured Measurement Variable M SD M SD p value General Resignation coping acceptance KSP Psychic anxiety KSP Monotony avoidance Table 2 Differences in Means Between Multiply Injured (n = 25) and First-Time- Injured (n = 14) Athletes at the Beginning of Rehabilitation (t Test, Two-Tailed) Multiply injured First-time-injured Measurement Variable M SD M SD p value MACL Hedonic tone ,048 MACL Social orientation MACL Activity KSP Inhibition of aggression Table 3 Differences in Means Between Multiply Injured (n = 25) and First- Time- Injured (n = 13) Athletes on the MACL at the End of Rehabilitation (t Test, Two-Tailed) Multiply injured First-time-injured Measurement Variable M SD M SD p value MACL Social orientation MACL Activity Sport Injury Questionnaire and Diagnostic Checklist. At the end of the rehabilitation period, certain striking differences between the multiply injured and the first-time-injured athletes were revealed by the Sport Injury Questionnaire and the Diagnostic Checklist. Although the treating physiotherapist considered the athletes in the two groups to have equally good chances of returning to competition (see Table 4,

8 300 Johnson Question 2b), none of the subjects in the first-time-injured group considered themselves to be physically restored from their =.016) and less than 50% considered themselves psychologically restored (Table 4, Questions lb and lc). It was also found that the first-time-injured athletes worked toward their recovery less, in terms of guidelines or plans aimed at returning to their sport quickly following the injury. No significant differences between the multiply injured and the normally injured groups were found in this respect (see Table 4). Table 4 Results From the Sport Injury Questionnaire and the Diagnostic Checklist at the End of Rehabilitation Measurement1 questions Answer category A B C A/C A/B I. Sport Injury Questionnaire (a) How do you feel your rehabilitation has proceeded up till now? (b) Do you consider yourself to be fully rehabilitated physically since your injury? (c) Do you consider yourself to be fully rehabilitated psychologically since your injury? (d) Did you establish any guidelines to speed up rehabilitation? 2. Diagnostic Checklist (a) How do you feel that the physical rehabilitation has worked out for your patient? (b) Do you consider your patient physically recovered and able to go back to competitive sport without risk? Verygoodl NS NS good Very poor poor Yes NS.016 No Yes NS NS No Yes NS,049 No Betterlover NS.039 expectations Worselunder expectations Yes NS NS No Note. A = multiply injured (n = 25); B = first-time-injured (n = 13); C = "normally" injured (n = 39). P value for Fisher's Exact Test (two-tailed).

9 Multiple vs. First-Time Injury Discussion As a review of the literature indicated, attempts have been made from a number of psychological perspectives to explain the tendency of some athletes to be injured frequently. Psychodynamically oriented studies suggest that such factors as introaggression may provide an explanation. Other studies point to high psychic tension, risk taking, and a stressful lifestyle in general. To examine how multiply injured athletes experience and master rehabilitation as compared with a group of normally injured athletes and a group of first-time-injured athletes, a prospective study was carried out involving 8 1 highly competitive or elite-level athletes with acute, long-term injuries. Comparisons of the multiply injured group and the normally injured group at the beginning and at the end of rehabilitation (19 weeks later) revealed few although unexpected differences. The results indicated that the multiply injured group had a greater capacity to cognitively accept the injury situation, a higher level of social orientation and activity, and a lesser tendency toward psychic anxiety. Earlier research has pointed at certain seemingly opposing psychological traitsparticularly high anxiety, extraversion, aggression, and risk-taking behavior-as characteristics for injury-proneness in sport. One explanation of this apparent lack of clarity could be that no criterion has yet been constructed that is broad enough to adequately represent the concept of injury-proneness in sport. At the same time, a considerable number of differences emerged in comparing the multiply injured group with the first-time-injured group. The multiply injured athletes appeared more goal oriented and more determined to return to competitive sport as quickly as possible. An indication of this was their pronounced tendency to work according to a mental or cognitive goal-setting scheme during rehabilitation. The group seemed to experience injury as less stressful and less threatening than did the first-time-injured athletes. It may be that experience with severe injuries helped the multiply injured subjects to establish a "habit" of mastering being injured; learning to selectively activate the coping strategies that best contributed to successful recovery made them feel less threatened by the situation and accordingly put them in a higher overall mood state. At the end of rehabilitation, the multiply injured group appeared to be the more homogeneous and more socially oriented, especially as compared with the first-time-injured group. The first-time-injured subjects' low ratings of their physical and psychological well-being at the end of rehabilitation are noteworthy. Crossman and Jamieson (6) noted that first-time-injured athletes rate themselves low in general well-being and tend to overemphasize the consequences of an injury. Remarkable also was the disinclination of the first-time-injured group to actively develop and follow a mental plan for the rehabilitation period aimed at enabling them to return quickly to training and competition. The results of the study suggest that previous experience with serious sport injuries (or lack of it) governs the rehabilitation process more than do personality traits. That some athletes are more "vulnerable" and appear to be more injury-prone than others may be due to a combination of situational factors and to extrinsic and intrinsic psychological and physiological risk factors. This is in line with Lysens et al.'s (19) conclusion that injury-proneness is not a stable quality but tends to shift with time and in accordance with the situation. Certain apparent inconsistencies in earlier research support this contention. In terms of stage models, like the Kiibler-Ross (16)

10 302 Johnson sequential grief-response theory, the athletes in the multiply injured group were able to use their experience with previous injuries and move through the different grief stages in a shortened and more adaptive course. However, some scientists (see, e.g., 8, 36), taking a more interactionistic standpoint, claim that grief-response theories represent the coping stages of the terminally ill and may not be applied to the stages experienced by injured athletes. In accordance with the interactionistic theory, the multiply injured athlete's perception of being injured appears to provoke less stress and anxiety, most likely due to the experience of earlier "positive" rehabilitation. It may be that the first-time-injured athletes' lower age (3 years younger) and consequently less life experience prolonged their anger and hostility phases. Smith et al. (32) also noticed this connection. When serious injury occurs, psychological and psychosocial factors such as belief in one's own inherent capacity, the power to actively cope with and master the stressful situation, and the ability to uphold good contact with friends and relatives seem to come to the fore more frequently for the multiply injured athletes than for the first-time-injured athletes. Thus, it may be that experience with injuries reduces both psychological and physiological problems in the case of serious injury. At the same time, it is reasonable to assume that the positive effects of experience with injuries will not increase linearly as the number of injuries increases but eventually will be succeeded by dispiritedness and resignation in light of the probable termination of a competitive sport career. An interesting conclusion is that the multiply injured group may serve as a potential resource group for physiotherapists, sport physicians, and others working with the rehabilitation of first-time-injured athletes. At some centers for the treatment of sport injuries, successfully rehabilitated patients are utilized as positive models for recently injured patients (10). The results suggest that such formally defined risk factors as introaggression, impulsiveness, risk taking, psychic anxiety, and self-confidence do not differentiate multiply injured athletes from other athletes with injuries. However, the firsttime-injured group seems particularly exposed to the psychological difficulties inherent in acute and long-term injuries. The athletes in the first-time-injured group showed a stronger tendency to experience the rehabilitation period as stressful, to be less self-confident, and to display a lower overall mood state than the multiply injured athletes. The physiological recovery of the first-time-injured athletes seemed to also proceed much more slowly, in the view of those treating them. The firsttime-injured athlete thus could benefit during rehabilitation from the personal experience and the constructive attitudes of multiply injured athletes. References 1. Agren, B., 0. RydCn, P. Johansson, and P. Nilsson-Ehle. Rehabilitation after coronary bypass surgery: Coping strategies predict metabolic improvement and return to work. Scand. J. Rehabil. Med , Alexander, E The accident-prone individual. Public Health Rep. 64: , Blackwell, B., and P. McCullagh. The relationship of athletic injury to life stress, competitive anxiety and coping resources. Athl. Training , and T.H. Holmes. Psychosocial factors in

11 Multiple vs. First-Time Injury Crossman, J., and J. Jamieson. Differences in perceptions of seriousness and disrupting effects of athletic injury as viewed by athletes and their trainer. Percept. Mot. Skills 61: , Cryan, P.D., and W.F. Alles. The relationship between stress and college football injuries. J. Sports Med. Phys. Fitness , Daly, J.M., B.W. Brewer, J.L. Van Raalte, A.J. Petitpas, and J.H. Sklar. Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. J. Sport Rehabil. 4:23-30, Engstrom, R., C. Johansson, M. Tornkvist, and M. Forssblad. Does a major knee injury definitely sideline an elite soccer player? Am. J. Sports Med. 18(1): , Flint, F.A. Seeing helps believing: Modeling in injury rehabilitation. In Psychological Bases ofsport Injuries, D. Pargman (Ed.). Morgantown, WV: Fitness Information Technology, 1993, pp Folkman, S., and R.S. Lazarus. Stress, Appraisal and Coping. New York: Springer, Friedman, H.S., and S. Booth-Kewley. The "disease-prone personality": A meta-analytic view of the construct. Am. Psychol. 42: , Jackson, D.W., H. Jarret, D. Bailey, J. Kausek, M.J. Swanson, and J.W. Powell. Injury prediction in the young athlete: A preliminary report. Am. J. Sports Med. 6:6-12, Kerr, G., and H. Minden. Psychological factors related to the occurrence of athletic injuries. J. Sport Exerc. Psychol. 10: , av Klintberg, B., D. Schalling, and D. Magnusson. Self-report assessment of personality traits. Data from the KSP inventory of a representative sample of normal male and female subjects within a development project. Individual development and adjustment. Report 64, Kiibler-Ross, E. On Death and Dying. New York: Macmillan, Lysens, R., Y.V. Auweele, and M. Ostyn. The relationship between psychosocial factors and sport injuries. J. Sports Med. Phys. Fitness 26:77-84, Lysens, R.J., M.S Ostyn, Y.V. Auweele, J. Lefevre, M. Vuylsteke, and L. Renson. The accident-prone and overuse-prone profiles of the young athlete. Am. J. Sports Med. 17(5): , Lysens, R.J., W. de Weerdt, and A. Nieuwboer. Factors associated with injury proneness. Sports Med. 12(5): , Macintosh, D.L., T. Skrien, and R.J. Shephard. Athletic injuries at the University of Toronto. Med. Sci. Sports 3(4): , May, J.R., T.L. Veach, S.W. Southard, and M.W. Saening. The effects of life change on injuries, illness, and performance in elite athletes. In The Elite Athlete, T.T. Gushikin and B. Zarins (Eds.). Jamaica, NY Spectrum, 1985, pp Nicholas, J.A. Injuries to knee ligaments. Relationship to looseness and tightness in football players. JAMA 212: , Ogilvie, B.C., and T. Tutko. Problem Athletes and How to Handle Them. London: Pelham, Passer, M.W., and M.D. Seese. Life stress and athletic injury: Examination of positive versus negative events and three moderator variables. J. Human Stress 9:ll-16, Persson, L-0. Strategier att bemota stress: Presentation av ett frigefomull [Strategies for handling stress: Presentation of a questionnaire] (Department of Psychology, University of Goteborg). Swedish Reports 5, Reif, A.E. Risk and gains. In Sport Injuries: The Unthwarted Epidemic, P.E. Vinger and E.F. Hoerner (Eds.). Littleton, MA: PSG, 1986, pp

12 304 Johnson 27. Roth, E., and L.J. Cohen. Approach, avoidance, andcoping with stress. Am. J. Psychol. 41(7): , Sanderson, F.H. Psychology of the injury prone athlete. BK J. Sports Med , Sanderson, F.H. The psychology of the injury prone athlete. In Sports Fitness and Sports Injuries, T. Reilly (Ed.). London: Faber and Faber, 198 1, pp Schalling, D., and G. Edman. Personality and Vulnerability to Psychopathology: The Development of the Karolinska Scales of Personality (KSP). Manuscript in preparation, Sjoberg, L., E. Svensson, and L. Persson. The measurement of mood. Scand. J. Psychol 20: 1-20, Smith, R.E., S.G. Scott, W. O'Fallon, and M.L. Young. The emotional responses of athletes to injury. Mayo Clin. Proc. 65:38-50, Suchman, E.A. Accident and social deviance. J. Health Soc. Behav. 11 :4-15, Svensson, E. Mood: Its structure and measurement. Goteborg Psychological Reports 6, Thomas, V., and T. Reilly. The relationship between anxiety variables and injuries in top-class soccer. In British Proceedings of Sports Psychology, G.J.K. Alderson and D.A. Tyldesley (Eds.). Edinburgh, UK: British Society of Sport Psychology, 1975, pp Weise-Bjornstal-Smith, D.M., and A.M. Smith. Counseling strategies for enhanced recovery of injured athletes within a team approach. In Psychological Bases of Sport Injuries, D. Pargman (Ed.). Morgantown, WV: Fitness Information Technology, 1993, pp