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Biopsychosocial model of injury

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DOI: 10.4135/9781483332222.n30

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 Encyclopedia of Sport
and Exercise Psychology
Biopsychosocial Model of Injury

Contributors: Renee N. Appaneal & Frank M. Perna

Editors: Robert C. Eklund & Gershon Tenenbaum
Book Title: Encyclopedia of Sport and Exercise Psychology
Chapter Title: "Biopsychosocial Model of Injury"
Pub. Date: 2014
Access Date: March 30, 2014
Publishing Company: SAGE Publications, Inc.
City: Thousand Oaks
Print ISBN: 9781452203836
Online ISBN: 9781483332222
DOI: http://dx.doi.org/10.4135/9781483332222.n30
Print pages: 74-77
This PDF has been generated from SAGE knowledge. Please note that the pagination
of the online version will vary from the pagination of the print book.
ContributorS ContributorS
Copyright ©2014 SAGE knowledge

http://dx.doi.org/10.4135/9781483332222.n30
There are several prevailing models that connect psychological factors and sport injury,
each with slightly different perspective on relevant biological, psychological, or social
factors. Moreover, prevailing models have typically focused either on incorporating
psychosocial factors in predicting and preventing sport injury incidence or upon
identifying psychosocial factors associated with injury recovery and rehabilitation
outcomes. Extensive reviews of these models have been written by Jean Williams and
Mark Andersen, Britton Brewer, and Diane Wiese-Bjornstal. This entry provides an
overview of the mediating biological pathways and physiological mechanisms linking
psychosocial stress to athletic injury and, where appropriate, other adverse health
consequences.

Both historical and recent conceptualizations of psychosocial stress posit wide-

ranging biological effects on health. In this regard, Frank Perna and colleagues have
argued that emotional, behavioral, and physiological aspects of stress response must
be considered together with attention disruption to fully capture potential pathways
mediating the relationship between psychosocial stress and adverse health including
athletic injury. Additionally, since the physical demands of training volume and intense
exercise required in competitive athletics are known to have adverse temporal effects
on immune, neuroendocrine, and skeletal muscle repair response, a primary tenet of a
biopsychosocial model of injury is that psychosocial distress may act synergistically with
high-intensity, high-volume sports training to widen a window of susceptibility to illness
or injury.

The biopsychosocial model of stress athletic injury and health (BMSAIH) is offered
below to illustrate pathways between stress demands and athlete health (see Figure
1). The BMSAIH expands the Andersen and Williams model of psychosocial stress and
athletic injury in three essential ways: (1) It clarifies mediating physiological pathways
between athletes' stress response and adverse health outcomes (e.g., sport injury); (2)
it considers other health outcomes and behavioral factors that impact sport participation
as well as injury; and (3) it integrates the impact of exercise training upon athletes'
health.

Figure 1 A Biopsychosocial Model of Stress and Athletic Injury and Health (BMSAIH)

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The BMSAIH should be considered an independent extension of Andersen and

Williams's classic model of stress and athletic injury, which is reviewed elsewhere
(see also the entry “Injury, Psychological Susceptibility to”). Similar to other generic
models of stress and adverse health consequences, the Andersen and Williams model
posited that a stress response mediated the effect of stressor(s) on the health outcome,
athletic injury, with the stress response being composed of physiological and cognitive
features (attentional perturbations such as peripheral narrowing) thought to predispose
an athlete to injury. While the stress response was conceptualized as being both
physiological and cognitive in nature, the original model and the preponderance of
studies have principally only researched cognitive features (disturbances in attention
and recognition of sport-related cues) thought to predispose an athlete to injury. Yet,
the relationship between psychosocial stress and athletic injury appears stronger for
overuse injuries [p. 74 ↓ ] that are likely less dependent on cognitive processing and
more likely related to physiological processes affecting exercise training adaptation
and recovery. The stress-injury model also proposed a number of factors, such as
personality, history of stress, and coping resources, that may moderate a stress
response, but there was less clarity and exposition of mediating pathways, particularly
those related to stress physiology, by which stress response may increase risk of injury.

Stress Response Mechanisms

Negative life stress and attendant emotional distress, through autonomic nervous
system (ANS) response pathways, is thought to exacerbate the adverse effects of

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prolonged high-intensity and high-volume exercise. Specifically, psychological stress

causes activation of the ANS yielding the release of catecholamines like epinephrine,
norepinephrine, neuropeptides, and glucocorticoids (cortisol). Because target organs,
such as heart, vasculature, muscle, and immune tissue, contain efferent nerves and
have receptors for catecholamine and glucocorticoids, ANS activation affects target
organs either by direct innervation of the parasympathetic and sympathetic nervous
systems (PNS and SNS, respectively) or by hormonal action via activation of the
hypothalamic-pituitary-adrenal-cortex (HPAC) and cortisol release. Cognitive features
related to a person's appraisal of the severity of a stressor and the capacity to cope
with a stressor is known to exacerbate or prolong emotional reactivity and concomitant
physiological response. Direct innervation, particularly by the SNS and catecholamine
release, and hormonal action (e.g., cortisol release) thus provide the mechanistic links
used to explain how the brain and associated cognitive–affective processes attendant
to psychological stress may influence stress physiology and other physical systems,
particularly those of relevance to athlete health like immune and skeletal muscle.

Because the ANS may operate either through direct innervation or hormonal action,
there are a variety of possible neuroendocrine and hormonal patterns (differential
responses to stress) that have evolved to characterize the stress response since Hans
Selye first proposed the general adaptation syndrome, an undifferentiated response
to stress. Moreover, specific ANS patterns are known to be influenced by features of
cognitive appraisal particularly being dependent if an individual views a life event as
a negative stressor or as a challenge. Thus, it is recognized that ANS activation in
response to stress is not always deleterious, and indeed, is necessary. For example,
it has long been known that ANS activation, particularly of the SNS, is associated with
performance of physical [p. 75 ↓ ] and cognitive tasks. Similarly, HPAC activity and
cortisol release are known to potentiate the actions of epinephrine in the completion of
physical tasks and, when not prolonged, cortisol initiates a cascade leading to anabolic
activity necessary for muscle repair following intense exercise.

A thorough discussion of possible hormonal response patterns in response to stress

is beyond the scope of this entry but can be found in work by Trent Petrie and Frank
Perna. In short, three hormonal patterns are thought to result in adverse health
effects. These are thought to occur when individuals (a) experience frequent negative
life stress and concomitant frequent activation of the SNS and HPAC pathways

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involving principally the release of epinephrine and cortisol to a lesser extent, (b) are
hypersensitive to stressors and have an atypically high SNS and epinephrine response
out of proportion to the magnitude of a stressor, and (c) experience chronic stressors
and emotional distress with a prolonged activation of the HPAC and heightened cortisol
release. The latter scenario involving measurement of enduring effects of negative life
events, either in isolation or with their association with cortisol response, has received
the most attention.

In addition to stress mechanisms described above, HPAC activation and possible

concomitant behavioral disruptions (e.g., sleep disturbance) resulting from heightened
negative affect may act in synergy with the demands of heavy exercise to increase
risk of illness and injury. For example, poor sleep has been associated with prolonged
elevation in evening cortisol, immune decrements, and lessened growth hormone
release, all of which may inhibit muscle repair following acute exercise. Negative
emotion-linked increases in stress hormones (cortisol) and behavioral perturbation may
thus widen or prolong a window of susceptibility for illness and injury that is created
by high-intensity and high-volume training. That is, psychological distress may impair
muscle growth and repair processes by prolonging the presence of post-exercise
catabolic hormones like cortisol that also impair immunity and inhibit the secretion and
action of anabolic factors, such as growth hormone and insulin-like growth factors.
Due to cortisol's immunosuppressive and muscle catabolic effects, prolonged training-
induced cortisol elevation may create favorable conditions for viral infection, athletic
injury, and exercise training maladaptation.

Similarly, elevated negative mood state, particularly fatigue and depression, has
been used to identify overtrained athletes. Depressed mood has also been related
to impaired immune function, and this effect may be mediated by cortisol elevation.
Although the physiological strain of exercise training is largely responsible for cortisol
and mood fluctuation, studies suggest that psychological life-event stress (LES) may
also modulate cortisol and health parameters in athletes. For example, elite athletes
with high LES, in comparison to low LES athletes, have been reported to experience
prolonged post-exercise cortisol elevation, which was prospectively correlated with a
greater frequency of physical symptom, such as muscle pain, back tightness, or flu-
like symptoms. Elevated LES has also been prospectively related to increased risk of
athletic injury and viral infection (e.g., common cold). In essence, the BMSAIH suggests

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that health effects of psychosocial stress would be most pronounced when an athlete
was either in or just removed from a high-volume or high-intensity period of training,
and that sport training cycle should be considered to optimally measure the association
between psychosocial stress and athletic injury and adverse health.

Taken together, the literature indicates that independent from intensity and volume of
sports training, psychological stress likely contributes to athletes' neuroendocrine and
immune activity, which may be a mediating pathway linking stress to increased risk for
adverse health effects including athletic injury. However, the effects of psychosocial
stress on health may be more pronounced during periods of high-volume and intense
exercise training. Because athletes must train at high volumes and intensities to make
the physiological adaptations necessary for competitive success, commercially available
exercise recovery monitoring systems have appeared on the competitive sports milieu
and have been extensively reviewed by Michael Kellman. These systems include the
assessment of physical, emotional, and social–contextual stress responses, as athletes
must maintain a delicate balance between demands and recovery to stay healthy, avoid
injury, and ultimately perform optimally. However, athletes' efforts to balance training
and recovery occur within a sport culture that often undervalues the importance of
psychosocial factors, and perhaps also recovery. As a result, the culture of [p. 76 ↓ ]
competitive sport reinforces an imbalance between psychosocial and sport training
factors, which ultimately may affect training adaptation, injury, and overall health. Sport
psychology personnel trained to assist athletes with life-event, precompetitive, and
post-injury stress are also widely available. However, the efficacy of psychosocial
intervention to reduce injury risk, facilitate exercise-training adaptation, and enhance
athlete health has been less extensively investigated.

Psychological Interventions
In the athletic domain, cognitive–behavioral stress management (CBSM) intervention in
the form of psychological skills training is well known to reduce competitive anxiety and
enhance athletic performance. CBSM has also been shown to reduce pain and speed
recovery and return to play following arthroscopic surgery among injured recreational
athletes. In a handful of randomized controlled trials, CBSM improved exercise training
adaptation in the form of lessened fatigue, depressed mood, and cortisol curve during

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a high-volume training period among competitive rowers. Further, CBSM intervention

has also been shown to reduce actual incidence of athletic injury and illness. One of
these trials conducted by Perna and colleagues specifically tested if intervention effects
on cortisol and affect mediated health outcomes. Findings demonstrated that rowers
in a CBSM condition had significantly fewer days injured or ill and half the number of
health and training center visits compared with controls. Mediation analyses indicated
that modulation of affect and cortisol accounted for approximately one half and one
fifth, respectively, of the intervention effect on days injured or ill. Though limited, the
extant literature provides compelling support for the potential value of intervention to
lessen risk of athletic injury and illness and to facilitate sports-training adaptation. Future
research should seek to further elucidate the physiological pathways underpinning the
psychosocial stress and health relationship, and explore biopsychosocial mechanisms
that may be responsible for intervention effects on athlete health.

Renee N. Appaneal and Frank M. Perna

http://dx.doi.org/10.4135/9781483332222.n30
See also

• Autonomic Nervous System

• Injury, Psychological Susceptibility to
• Stress Management
• Stress Reactivity

Further Readings

Brewer, B. W. (2010). The role of psychological factors in sport injury rehabilitation

outcomes . International Review of Sport and Exercise Psychology , vol. 3 ( no. 1), pp.
40–61. http://dx.doi.org/10.1080/17509840903301207

Clow, A., & Hucklebridge, F. (2001). The impact of psychological stress on immune
function in the athletic population . Exercise Immunology Review , vol. 7 , pp. 5–17.

Kellmann, M. (2010). Preventing overtraining in athletes in high-intensity sports and

stress/recovery monitoring . Scandinavian Journal of Medicine & Science in Sports , vol.
20 ( no. Suppl. 2), pp. 95–102. http://dx.doi.org/10.1111/j.1600-0838.2010.01192.x

Page 8 of 9 Encyclopedia of Sport and Exercise Psychology:

Biopsychosocial Model of Injury
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Perna, F. M., Antoni, M. H., Baum, A., Gordon, P., & Schneiderman, N. (2003).
Cognitive behavioral stress management effects on injury and illness among
competitive athletes: A randomized clinical trial . Annals of Behavioral Medicine , vol.
25 , pp. 66–73. http://dx.doi.org/10.1207/S15324796ABM2501_09

Perna, F. M., Antoni, M. H., Kumar, M., Cruess, D. H., & Schneiderman, N. (1998).
Cognitive-behavioral intervention effects on mood and cortisol during exercise
training . Annals of Behavioral Medicine , vol. 20 , pp. 92–98. http://dx.doi.org/10.1007/
BF02884454

Perna, F. M., & McDowell, S. L. (1995). Role of psychological stress in cortisol recovery
from exhaustive exercise among elite athletes . International Journal of Behavioral
Medicine , vol. 2 ( no. 1), pp. 13–26. http://dx.doi.org/10.1207/s15327558ijbm0201_2

Perna, F. M., Schneiderman, N., & LaPerriere, A. (1997). Psychological stress,

exercise, and immunity . International Journal of Sports Medicine , vol. 18 ( no. Suppl.
1), pp. S78–S83.

Petrie, T. A., & Perna, F. M. (2004). Psychology of injury: Theory, research, and
practice . In T. Morris, ed. & J. J. Summers (Eds.), Sport psychology: Theory,
application, and issues (2nd ed., pp. pp. 547–551). Hoboken, NJ: Wiley.

Wiese-Bjornstal, D. M. (2010). Psychology and socioculture affect injury risk, response,

and recovery in high-intensity athletes: A consensus statement . Scandinavian Journal
of Medicine & Science in Sports , vol. 20 , pp. 103–111. http://dx.doi.org/10.1111/
j.1600-0838.2010.01195.x

Williams, J. M., & Andersen, M. B. (2007). Psychosocial antecedents of sport injury and
interventions for risk reduction . In G. Tenenbaum, ed. & R. C. Eklund (Eds.), Handbook
of sport psychology (3rd ed., pp. pp. 379–403). Hoboken, NJ: Wiley.

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