Can Injury Affect Others Beyond the Injured Athlete?

Injury research has predominantly focused on the perspectives and experiences of the injured athlete (Grindstaff, Wrisberg, & Ross, 2010; Wiese-Bjornstal, 2010). Whilst injury is undoubtedly a negative experience for athletes, there are other important members of an injured athlete’s support network that research has not yet explored; do these effects of injury go beyond the injured athlete? Research has begun to explore this avenue more widely with models and frameworks being constructed to better understand psychological responses to sport injury (Tracey, 2003). These have primarily examined the personal and situational factors that affect cognitive appraisals, emotional responses and behavioural outcomes (Brewer, 1994).

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Wiese-Bjornstal, Smith, Shaffer, & Morrey (1998) proposed the integrated model of psychological response to sport injury, which is still being widely used to inform research and practice. Although this model has been supported as a significant advancement in injury explanation (Albinson & Petrie, 2003; Walker, Thatcher, & Lavallee, 2007; Wiese-Bjornstal, 2010), it does not consider anyone but the injured athlete. Therefore, it is important to explore beyond the intrapersonal perspective and consider other aspects that may be impacted by injury. Wiese-Bjornstal (2009, p.64-65) acknowledged that “injury affects more than the injured; it often also holds health-related consequences for the network of family, friends, teammates, coaching staff, and even the larger communities”. This lead to the development of a new conceptual model: Multilevel Model of Sport Injury (MMSI; appendix 1) (Wadey, Day, Cavallerio, & Martinelli, 2018). The MMSI extends other models by recognizing and incorporating further aspects that impact or are impacted by injury, reflecting and providing a more critical and holistic understanding of the concept. MMSI proposes five distinct levels of analysis: intrapersonal, interpersonal, institutional, cultural and policy, levels which have not yet been considered in previous theoretical models.

The interpersonal level reflects on social networks and support systems such as, social support, social processes and others’ attitudes towards sporting injuries. With these findings, parents, practitioners, athletes and coaches can better understand the impact of injury and benefit from interventions or support systems that can be put in place to help other’s cope and function effectively. So although sport injury affects multiple dimensions of the injured athletes own health, there is the health of the broader system to consider. This review will now evaluate research informed by the MMSI on how athlete injury can impact coaches, teammates and parents.

The impact of injury on coaches

Whether it is business or sport, leaders (coaches) of high profile teams are responsible for the performance of organisations of teams; they get fired and hired based on their team’s performance outcomes (Jones, 2002). There is no hiding for leaders at this level and with the hours of invested time into their athletes, pressure is induced. So, when an athlete becomes injured, coaches may be expected to support their athletes during the injury process, alongside having to focus on the remaining team (Gould, Dieffenbach, & Moffett, 2002). Drawing from contemporary research and grounded by the MMSI, Wadey et al (2018) explored whether coaches can be impacted by sport injury; coaches reported that expectations of support from injured athletes, team logistics, and emotional elements contributed to negative experiences of injury.

This resonated with research by Thelwell et al (2008) who found that elite coaches view injury as a major stressor within team sports as it changes the structure, dynamics and integration of the team, as well as creating stressors regarding team selection in order for the team to continue functioning effectively. In addition to team organisational stressors, athlete injury was found to affect coaches psychologically. A more recent study on coaches’ personal experiences identified unpleasant emotions and memories of the injury event, and behavioural and cognitive avoidance after injury occurrence (Day & Bond, 2013). It has been explained that vicarious exposure to injury can result in these negative experiences from event-related stimuli and has been recognised by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as part of the Post Traumatic Stress Disorder (PTSD) symptoms (Gabert-Quillen, Fallon, & Delahanty, 2011). Day and Bond (2013) highlighted how this avoidance outcome can restrict coaches’ abilities to disclose information and receive social support, hence increasing the severity of the injury impact.

Furthermore, Martinelli, Day and Lowry (2017) identified that the experience of guilt was a significant emotion suffered by coaches’ when their athletes’ became injured. Abiding to duty of care and the coach’s obligations to the sporting performer, coaches felt blame for injury occurrence. These feelings of guilt and blame could potentially impact coaches’ self-perceptions of their ability of coaching and specific coaching strategies, leading to further distress (Potrac, 2017). This therefore needs to be addressed, as a traumatic event such as injury could perhaps unknowingly have a knock-on effect. The research conducted so far has not involved organisations that have implemented injury programmes. If injury does indeed have this significant impact on athlete’s and those around them, then clubs and organisations should develop a strategy to provide support networks for overall positive mental well-being and performance maintenance. 

The impact of injury on teammates

Suggested by the MMSI, teammates should also be affected by athlete injury. This contention is supported by O’Neill (2008) who suggested that athlete’s whom vicariously experience emotional distress, such as injury, in the same sport, are likely to suffer from injury contagion or traumatic psychological effects. Individual roles are established for each member of the team; injury can result in underachievement (Surya, Benson, Balish, & Eys, 2015), physical incompetence, and confidence difficulties (Mankad, 2009) when faced with challenges, and therefore recommended that coachers and practitioners maintain an awareness of teammates’ emotions after a member sustains injury. Additionally, there is a difference in the psychological affects of injury when the injured athlete is an integral member of a team (Flint, 1998; Frank, Register-Mihalik, & Padua, 2015), producing a negative emotional climate (Mankad, 2009).

However, this may be dependent on timing of injury; the proximity of injury to important events. It would be interesting for research to explore whether these findings are consistent across the sporting season as these findings may only represent affects of injury in the run up to competition. Moreover, if all teammates are experiencing similar emotions due to member injury, then is their support network functional enough to help them cope during that time? Would their level of perceived social support decline? Bianco (2001) emphasises that perceived social support is more effective than actual support as a coping strategy. Across multiple avenues of research, but especially sports medicine and health psychology, ‘perceived support’ has been found critical for recovery of illness, disease and injury (Cohen, 1988; Ell et al., 1992; Uchino, 2009; Salim, Wadey, & Diss, 2015; Rueger, 2016). Interestingly, perceptions of interpersonal factors is something that the MMSI does not reflect, and perhaps if this is more beneficial as consistently suggested in research, then integration of multilevel analysis alongside perceptions of those factors should be addressed. The Meta-Model of Stress, Emotion and Performance (Fletcher, Hanton, & Mellalieu, 2006), for instance, explains how stressors that arise from the environment are mediated by perception, appraisal and coping. Hence, extending the MMSI and adopting a perceptual element could further strengthen injury models.

A way in which this could be implemented is through longitudinal research whereby individuals verbalise their experiences via ‘think-aloud’ protocols, previously used by Nicholls & Polman (2008). This may help identify the perceived frequency and magnitude of stressors experienced over a sporting season, and highlight what coping strategies they currently employ. Qualitative methods such as story completion (Braun & Clarke, 2013) can encourage individuals to speak freely about their injury experiences; developing a deeper understanding and uncovering new insight to sport injury literature, to inform future applied work. This could be beneficial to apply to both teammates and coaches. Furthermore, future research could also consider exploring the interrelationship between individual coping resources and personality to help identify those who may be predisposed to react negatively to others injuries.

The impact of injury on parents

Parents have become more involved in their athlete’s careers (Knight, Berrow, & Harwood, 2017), with their roles and responsibilities not only involving financial support, transportation, organisational demands and time, but also now equally matched by emotional support and motivations (Wuerth, Lee, & Alfermann, 2004). Fredricks and Eccles (2004) emphasise the degree in which these essential roles expected to be fulfilled by parents, especially in youth sport whereby the parents serve as a provider, interpreter and role model to the young athlete.

So with this increase in dedication towards supporting the athlete, they too are experiencing vicariously through their child, their highs and lows, and thus being affected by any negative consequences that the athlete may experience (Knight et al., 2017). Injury is an example of this and has been suggested to have substantial impacts on significant others (Holt-et-al., 2017). Research in this area has been loosely explored; a study examined parents’ perspectives on athlete injuries and return to competition (Podlog et al., 2011). Consequently, it focused on how parents attributed their child’s injury and rehabilitation process and their perceptions of recovery, rather than how they (the parents) were affected by the injury itself. Although this study does not provide understanding for the impact of athlete injury on a more interpersonal level, it does support the contention of parental involvement growth in sport.

Lally and Kerr (2008) found the impact of athlete retirement on parents to be contradictory; retirement resulted in social disengagement and distress, or ‘relief’ as pressures subsided. With this being an important event requiring significant life changes and support, it would be expected that similar findings with injury would be found. Likewise, in Harwood and Knight’s research (2009a; 2009b) they recognised that ‘challenges with injuries’ was a common stressor experienced with being a parent of an athlete, highlighting the importance of exploring this avenue further. Although there is limited empirical evidence at present, the findings so far have indicated that there is a vicarious impact, especially at youth level (Holt et al., 2017).

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Brewer et al (2002) identified that “sport injury rehabilitation does not occur in a vacuum”, implying that a more multifaceted approach to understanding the greater impact of injury is the way forward. It has been demonstrated how the MMSI can be used to consider the implications of injury beyond the athlete and thus identify necessary strategies for those significant others that are impacted.

Additionally, a question for practitioners to ponder is what makes a facilitative rehabilitation environment for all involved? For those organisations that supply rehabilitation programmes, awareness of the wider negative effects of injury should be increased, also supporting the MMSI on an institutional level. By making an organisation or clubs environment more effective in supporting the athlete, coaches and teammates, it could significantly reduce the vicarious effects of the situation. However, if this is not possible due to funding or financial budgets, then something should be put in place to help inform and guide parents and coaches in making the right decisions for the recovery of their injured athlete, and to ensure the rehabilitation process is positive. Practitioners can help parents, coaches and teammates understand the importance of building a social support network prior to injury occurrence. By doing so, coping mechanisms can be put in place to intervene and potentially prevent the negative consequences experienced by the injury.

To conclude, this review provides fresh exploration into the stressors experienced by coaches, teammates and parents involved in sport injury, with similar stressors found across individuals (REF; REF; REF). The integration of empirical research between sports disciplines (sport medicine, sport science, health science and sport psychology) has been advantageous in understanding the sport injury concept more extensively with research recognising challenges and inspiring solutions that can be developed to benefit all individuals within the sporting environment. Thus, it is necessary to focus on interventions beyond the intrapersonal level to target the wider population. In relation to the proposing question, yes, there is research and theoretical support for the argument thatinjury can in fact affect others beyond the injured athlete.

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Appendix

Appendix 1: Multilevel Model of Sport Injury (MMSI)