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Athletic Injury Experience: A Qualitative Focus Group Approach.

The current theory on response to injury is based on an appraisal process in which the athlete makes an interpretation of the meaning of the injury. The purpose of this study was to describe the athletic injury experience, focusing on the meaning of the injury from the perspective of injured athletes and student athletic trainers. The qualitative focus group method was utilized, with the main data coming from the transcribed interactions of participants (Morgan, 1997; Stewart & Shamdasani, 1990). There were four focus groups: two groups of student athletic trainers (N=8) and two groups of injured intercollegiate athletes (N=7). The interview data were inductively analyzed following procedures outlined by Tesch (1990). Seven categories of responses were identified from the data, including personal factors, effects on relationships, sociological aspects, physical factors, daily hassles, feelings associated with injury, and rehabilitation. Conclusions focused on the results in relationship to theoretical models, limitations, and possible future directions.

An injury can be one of the most difficult experiences in an athlete's career. A serious injury and subsequent rehabilitation time period could alter the athlete's mood state and elevate stress levels. Brewer and Petrie (1995) found that injured college football players had higher depression and life stress scores than uninjured players. These results are consistent with previous research demonstrating an increase in mood disturbance for injured athletes (Grossman & Jamieson, 1985; Leddy, Lambert, & Ogles, 1994; Smith et al., 1993). For these reasons, sport psychology research has focused on the psychological consequences of injuries sustained by athletes (Heil, 1993; National Athletic Trainers' Association, 1998; Pargman, 1999; Ray& Wiese-Bjornstal, 1999; Taylor & Taylor, 1997).

The current model to explain how athletes respond to an injury is based on how the injury is perceived by the athlete (Brewer, 1994; Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998). This "cognitive appraisal" approach suggests that an interaction between personal factors made up of injury aspects and individual characteristics, and situational factors made up of sport related factors, social aspects, and environmental conditions influence the thought process the athletes have about the injury (Wiese-Bjornstal & Shaffer, 1999). This cognitive response then influences the emotional response (e.g., anger, denial, depression, shock, etc.), and the behavioral outcomes (e.g., adherence to rehabilitation, use of social support networks, use of coping skills, etc.). The Wiese-Bjornstal et al. (1998) version of this model also emphasizes that the response to injury is dynamic and can change over time.

A number of research projects have supported aspects of the cognitive appraisal model, with a large number of variables hypothesized to be related to how an athlete will respond to an injury (See reviews by Wiese-Bjornstal et al., 1998; Wiese-Bjornstal, Smith and LaMott, 1995). The majority of these studies utilized traditional quantitative research methodologies, however, some authors have argued that this approach may not capture the entire injury experience, or fail to illustrate the complexity of the phenomenon (Evans & Hardy, 1995). One of the strengths of the cognitive appraisal approach is the explanation made for the individual differences in response to the injury, which may not emerge from traditional methodologies (Brewer, 1994). The response to injury is different for each athlete, with a number of factors contributing to the overall experience. Qualitative methodologies might be more successful in explaining the experience of athletes dealing with injuries.

There have been a couple of qualitative studies conducted that allowed athletes or performers to talk about their experiences. Rose and Jevne (1993) used a grounded theory methodology with a variety of athletes (amateur, collegiate, and professional) to document the process of the injury experience. They found a four-phase process: 1) getting injured, 2) acknowledging the injury, 3) dealing with the impact, and 4) achieving a physical and psychosocial outcome. Shelley (1999) found similar results with a study that utilized a phenomenological research design. Results from this study indicated that athletes' perceptions about injury change over the course of the injury process and emphasized the importance of the influential significant others (e.g., coaches and teammates) on the emotional response.

A major qualitative research project was conducted focusing on the psychology of injuries among skiers on the United States Ski team (Gould, Udry, Bridges & Beck, 1997a; Gould, Udry, Bridges & Beck, 1997b; Udry, Gould, Bridges & Beck, 1997a; Udry, Gould, Bridges & Tuffey, 1997b). This project consisted of in-depth interviews with 21 elite skiers who sustained season ending injuries. The investigators found a number of general dimensions associated with psychological response: perceived benefits of the injury, stress sources associated with rehabilitation, coping strategies, and social ties with significant others. Bianco, Malo, and Orlick (1999) also interviewed elite skiers from the Canadian Alpine Ski Team. They found that the injury process took place over three distinct phases (injury-illness phase, rehabilitation-recovery phase, and return to full activity phase), each of which was characterized by a set of events that influenced the emotional and cognitive responses.

The purpose of the current study was to provide a description of intercollegiate athletes' experiences with and response to, injury. This study differs from previous research, by compiling a dual perspective of the injury experience: injured athletes and student trainers. Examining the points of view from both perspectives can help draw a more complete picture of athletic injures. A qualitative approach was chosen because of the number and complexity of factors contributing to the overall experience. Potentially, the information from this study can provide further explanations on the athletes' response to injury.

Method

Design

This study utilized a focus group approach, which is a form of group interview that allows members to interact with each other (Morgan, 1997). The main data source for focus groups are the interactions and responses by participants on a topic introduced by a moderator (Morgan, 1997; Stewart & Shamdasani, 1990). The focus groups allows for participants to react, agree or disagree, build on, and provide further insight into the comments made by other participants (Stewart & Shamdasani, 1990). The qualitative data from a focus group design is unique to the participants that make up the group, and it allows the researcher to clarify information from the participants (Morgan, 1997; Stewart & Shamdasani, 1990). This method has been utilized in other sport psychology contexts (i.e., Gould, Damarjian, & Medbery, 1999).

Participants

A total of four focus groups were conducted: two groups of student athletic trainers and two groups of injured intercollegiate athletes. All participants came from the same university. The university competes at the NCAA Division II level and is located on the West Coast No parameters were developed to limit the type of student trainer or athlete that volunteered for the study. Potentially, this could be a limitation to the conclusions drawn because years of experience on the part of the trainers, and type or severity of the injury by the athletes might result in different answers.

The first two focus groups consisted of eight student athletic trainers (four in each group) who work directly with the athletes. Student athletic trainers were selected for the study for a number of reasons. First, student trainers at this university were assigned to an individual team for the entire season. The student trainers were present at all practices and competitions, and they traveled with the teams to away contests. This increased the likelihood of forming a personal connection with the athletes. The certified trainers worked with all the athletes and had less one-on-one time with any particular individual. As one student trainer stated:

In many cases, there is also a stronger bond made between peers as opposed to the adults that serve as certified trainers (Walk, 1997). Athletes will offer more personal information about themselves to someone around their own age, as compared to a certified trainer who might be perceived as being associated with the coaching staff (Walk, 1997). Finally, the student trainers in this study were required to work in the training room as part of their curriculum in athletic training. This provided the participants the opportunity to observe a wide variety of contexts around the injury experience.

We traveled basically every weekend on road trips or plane trips, and you sit there and talk to them. I know so many personal problems now, whether it's about their sport, their school, their girlfriend, or their parents. We would sit there at these 14-hour tournaments, and I know I didn't stop myself at the superficial level with the injury. (Female, Trainer, Age 21)

There were four male student trainers and four female student trainers, with two males and two females in each group. All the student trainers were college seniors except for one junior, with the average age being 22.9. All the student trainers had completed at least 126-quarter units toward their degree. Furthermore, each student trainer had been assigned to an individual team. In order to be assigned to a team, students need to have completed a variety of classes such as human anatomy, beginning athletic injuries, advanced athletic injuries, human physiology, clinical exercise physiology, tissue mechanics, and exercise testing, as well as informal seminars on therapeutic modalities, gait analysis, and muscle testing. The academic program that the student trainers were enrolled in, provided course work and internships designed to build the necessary competencies to pass the National Athletic Trainers Association's certification examination. The student trainers in this study averaged 22.1 hours of work in t he training room per week, with a range of 15-30 hours a week.

The second two groups were comprised of seven injured athletes (four in one group, and three in another group) who competed at the NCAA Division II level. There were four males and three females, with an average age of 20.6. The athletes represented the sports of football (1), track (1), cross-country (1), wrestling (1), baseball (1), and soccer (2). There were three seniors, two juniors, one sophomore, and one freshman. The injuries were 3 torn anterior cruciate ligaments in the knee, I second degree ankle sprain, I torn hamstring muscle, I torn medial glenohumeral ligament in the shoulder, I torn latissimus dorsi muscle in the back. There were four athletes that required surgery as a result of their injury. Five of the participants listed their injury as major and two indicated the injury was moderate (moderate = absent from practice or competition for more than a week, but less than a month; major = absent from practice or competition for more than a month). For three of the athletes, this was their first significant injury, while the other four had dealt with multiple significant injuries.

Procedures

Student athletic trainers and athletes volunteered as participants in the focus group research. All four focus groups were held in the same classroom located at the participant's university. The focus groups started with the reading and signing of the informed consent form. Participants were given information on the nature of focus groups and a brief introduction of the topic. Each focus group session was audiotaped using two tape recorders to ensure that information was complete and accurate. Each focus group started with an introduction of the moderator and participants. A semi-structured interview comprised of open-ended questions was used to elicit information related to the athletes' injury experience. Sample questions include; "describe your experience of being injured", and "how has the injury affected your life". Open-ended questions were chosen as opposed to a more structured interview to guard against shaping of responses (Patton, 1990). Each group lasted approximately an hour and a half, and refre shments were provided to the participants.

Data Analysis

The researcher transcribed the audiotapes verbatim. The transcripts were inductively analyzed following procedures presented by Tesch (1990) and Creswell (1994). The analysis was designed for reducing information, and then building themes or categories by finding relationships and grouping similar topics. The eight-step procedure begins with the researcher reading through the entire transcriptions and writing down thoughts that come up during the reading. The focus group transcripts yielded 87 typed pages of single spaced text. The researcher next identifies topics by examining switches or transitions in topics. The third step involves clustering similar topics and organizing the topics into three columns (major topics, unique topics, and leftovers). The fourth step consisted of using topics from the "major topics" and "unique topics" columns, and reanalyzing the transcriptions by writing the code name next to the corresponding text. The next step was to develop categories by decisions on the best abbreviati on for each category. The text belonging to each category was then placed together in one place. The final step involves re-coding existing data if necessary (Creswell, 1994; Tesch, 1990).

The analysis was submitted to an outside source for the purpose of assigning the statements from the original transcripts to the different categories developed. Additionally, the outside source was asked to examine the early phases of analysis, including determining transitions in topics, developing clusters into the three columns, and creating the categories and themes. A reliability coefficient was calculated by generating a percentage between the number of agreements (researchers and outside source) and the total number of transcripts analyzed by the outside source. An 89.3% agreement rate was found between the researcher and the outside source. Any differences between the outside source and researcher were discussed until a consensus was obtained. This resulted in a few changes to the items contained in each category, but not a change in the actual categories.

Results/Discussions

The inductive analysis identified seven general categories of responses related to athletic injury, with a number of sub-themes within each category. The four groups of athletes and student trainers mentioned all seven categories; however, some categories were more prevalent for either injured athletes or student trainers. Although questions were not designed to directly ask about factors of the Wiese-Bjornstal et al. (1998) model, elements of the model did show up in the results. The seven categories include: personal factors (i.e., personality of the athlete, athletic identity, and role on the team), effects on relationships, sociological aspects (i.e., gender differences and subculture), physical factors (i.e., pain, physical deconditioning, surgery, and use of painkillers), daily hassles (effects on life), feelings associated with injury, and rehabilitation (See Table I for percentages).

The transcripts yielded two types of experiences about athletic injuries: direct and indirect. The athletes were able to provide direct insights into the injury experience, and the student trainers offered a perspective of individuals who work closely with the athletes on injury. This would account for the differences in percentages between the miscellaneous categories (See Table 1). For example, a higher percentage of trainers commented on the sociological aspects and personal factors than athletes. This may be due to the fact that trainers see and work with more injured athletes and have access to a greater range of experiences. Conversely, the athletes had a higher percentage of responses to the daily hassle category. This would be due to the direct experience by the athletes and the fact that trainers cannot observe what is happening outside the training room. The following is a description of the seven categories that emerged from the focus groups, and the relationship to the WieseBjornstal et al. (1998 ) model.

Personal Factors

The first types of moderating variable included in the Wiese-Bjornstal et al. (1998) model are the personal factors of the athletes. These factors, in addition to the situational variables, have a direct influence on the cognitive, emotional, and behavioral responses toward the injury (Wiese-Bjornstal & Shaffer, 1999). This category was more prevalent for the student trainers (N=8; 100%), than it was for the athletes (N=4; 57.1%). There are many personal factors related to how an athlete will experience an injury. The transcripts revealed that individual reactions can differ based on the personality of the athlete, the extent of identification to the athletic role, the value sport participation has in the life of the individual, and the role the individual plays on the team.

Personality of the athlete. Eight student trainers (100%) and one athlete (14.3%) made comments on how the personality of the athlete can influence the psychological and emotional response. They also discussed how the injury could change the athlete's personality or view of himself or herself. Two examples of this theme are:

It was funny because you see different personalities. Some people will be in therapy as much as they can and be very positive, and others will just go through the motions if they're even in the training room at all. Different personalities respond to it [injury] differently. (Female, Trainer, Age 23)

As soon as they injure themselves to the point where they cannot practice anymore, their self esteem just drops. I'm not good enough, or I'm not healthy enough to help anybody out. Self-esteem and self-confidence is definitely part of it. (Male, Trainer, Age 28)

Athletic identity. Sport psychology researchers have long discussed the importance of examining athletic identity and psychological response to injury (Brewer, 1993). Three athletes (42.9%) and seven student trainers (87.5%) commented on this sub-theme. The results of this analysis also revealed identity and the importance the sport has in the athlete's life as an individual factor. The next set of quotations showed the relationship between athletic identity and response to injury:

I think it just really bummed her out, because she had been doing it for so long and that becomes part of who she was. When that's not who you are anymore, then you're kind of lost. (Female, Trainer, Age 21)

The way I think about it is that if I didn't have a sport it probably would just be another day. Right now I have ten football games left in my life, and that's all I have. If I injured myself tomorrow and miss just one of those games, then that's 10% off my life, and it's costing me what I love to do the most. (Male, Football, Age 21)

Role on the team. The final aspect of the personal factors theme is the role they play on the team. This might be a valuable member of the team, or a senior athlete with limited eligibility left in a career. The student trainers (N=7; 87.5%) identified this issue more often than the athletes (N=4; 57.1%), but it was a theme discussed by both types of participants:

He's a senior; the only senior on the team, and the only person most likely will go to nationals. There were high hopes for him, so the injury was devastating. (Male, Trainer, Age 22)

If it's an acute injury, and boom, it's the fourth quarter and it's their senior year and they just sustained a knee injury, then yeah you see a lot of emotions. If it's a senior, then this is it, "I'm not going on to play pro ball. I am done." They get really frustrated and angry. If I'm a red-shirt freshman or red-shirt sophomore, I have some chance of coming back from this, and still able to compete at the college level. (Female, Trainer, Age 23)

Effects on Relationships

The relationship category was one of the largest cited by this sample. Wiese-Bjomstal et al. (1998) hypothesize that relationships with significant others serve as situational, moderating factors influencing the response to injury. The relationships in this investigation were perceived as either positive (supportive) or negative (pressure). The sport psychology literature documents the importance social support plays in the recovery process of injured athletes (Hardy, Crace & Burke, 1999), however, researchers have suggested that instead of focusing only on social support, it may be more useful to examine the social interactions (either positive or negative) of injured athletes (Bianco & Eklund, 1999; Peterson, 1997; Udry, 1997; Udry, 1999; Udry et al., 1997b). In each of these studies relationships were viewed as either positive or negative. These results are important given the impact trainers (Fisher, 1999; Walk, 1997), teammates (Shelley, 1999; Udry etal., 1997b), coaches (Bianco & Eklund, 1999; Granito, 1999; Udzy, 1997, 1999; Udryetal., 1997b), and family members (Udry et al., 1997b; Zimmerman, 1999) can have on the injury rehabilitation process.

All the members of the four groups (100%) spoke of how the injury affected the relationships between the athletes and the significant people in their lives. The five significant relationships that were discussed throughout the course of the focus groups were trainers, teammates, coaches, other injured athletes, and parents.

Trainers. The first relationship involved the connection between the trainer and the athlete. All eight student trainers (100%) and five (71.4%) athletes spoke on this relationship. This relationship seemed to regulate how an athlete deals with an injury. For example, the trust and confidence an athlete has for the athletic trainer can enhance the rehabilitation process. This perception was stronger for the trainer than for the athletes. As two trainers stated:

It helps to build a trust between the athlete and us, so that they do believe in us. That can affect their injury (Male, Trainer, Age 22)

Letting the athlete talk to someone who understands them and their injury, whether it be a student trainer or the head trainer...that's a huge part to the injury, if they understand exactly what's going on, then they can understand how to get better. (Female, Trainer, Age 21)

I think team support is huge, because if the teammates are always asking, "how is your rehab going" and "how is it going", then that shows the athlete that they need them. That makes them want to work harder to get back, whereas if people don't care if someone is hurt then the person is going to have problems. (Female, Trainer, Age 23)

Teammates. Relationships with teammates also are affected by the injury and influence how the athletes respond to the injury. The teammate sub-theme was mentioned by four (57.1%) athletes and five (62.5%) student trainers. The athletes perceived these relationships as either positive (support) or negative (pressure). The following quotation was from an athletic trainer who commented on the relationship with supportive teammates:

A number of athletes noted how the teammates could either support them through their injury or create pressure that hinders the healing and recovery process. The comments of two athletes illustrated this point (one positive, one negative):

My teammates have been pretty supportive. It's cool if you're not feeling good about yourself or bummed about not being out there, they support you. (Female, Track, Age 18)

I'd go out to practice and the players wouldn't say, "hey don't worry; just get better." They'd say, "When the hell are you going to play, because we need you and because we planned on you playing because you're an impact player on the team." (Male, Football, Age 21)

Coaches. The coach can have a significant influence on athletes throughout the athletic injury experience. Five athletes (71.4%) and four student trainers (50%) spoke about the relationship with the coach. The relationship between coach and athlete can affect the athlete's emotional state. The athletes perceived this relationship as being either supportive or non-supportive. A number of athletes did not feel that their coaches supported them through the injury process. As one athlete stated, "My coaches are the ones who don't believe me. They're sick of it as much as I am. Now they're blaming me for being hurt" (Male, Baseball, Age 21).

Other injured athletes. One relationship that seems to be very helpful for the athletes is the connection made with other injured athletes, especially those with similar injuries. All seven athletes (100%) and seven student trainers (87.5%) spoke about this relationship. In fact, some trainers use this as an approach to working with athletes. As one trainer stated:

I'd have them sit down and have the athlete who had the injury first tell the other athletes about the therapy. Then they ended up talking throughout the season. There ended up being about five wrestlers and it became like a knee injury club, and they helped each other through it. (Female, Trainer, Age 23)

The athletes certainly saw the value in connecting with other injured athletes. The following quotations are reflections by two athletes about the relationship with other injured athletes:

Everyone in the training room knows you, and everyone knows your injury. It's really personable which I think is a huge plus. (Female, Cross-Country, Age 21)

Anyone who is in the training room, it doesn't matter what sport, supports you. It's the same faces every day. It's almost like you go through this whole process with people. It's like a support group. (Male, Football, Age 21)

Parents. A number of trainers and athletes spoke on how the injury changed the relationship with the parents. Six of the seven athletes (85.7%) felt their parents pressured them concerning recovery from the injury. The trainers (N=5; 62.5%) also noted that many times the parents could be a source of stress during the rehabilitation process. As one trainer stated, "the kid feels the pressure of letting their parents down. You should never feel that way, but it happens a lot" (Male, Trainer, Age 23). Two examples of direct experiences from athletes are illustrated in the following quotations:

My parents were just a fiasco. My parents were calling every week to see how my knee was and I'm telling them "I don't know". (Female, Soccer, Age 21)

Sociological Aspects

The thing that bugs me the most is that I'll call home and 75% of my conversations with my parents deal with how my ankle is or how my arm is. (Male, Baseball, Age 21)

Another situational, moderating factor that emerged from the sample was the sociological aspects that influence the injury response. This sociological aspect category might suggest that cultural factors and social influences can mediate the way an athlete experiences and talks about pain and injury (Coakley, 1998; Young & White, 1999). Wiese-Bjornstal et al. (1998) has included sociological dynamics in their model of response to sport injury. For this sample, gender and subculture differences emerged as possible factors toward understanding the distinct individual responses. Future studies could explore the existence of subculture issues and gender differences, and how these factors mediate the emotional response from the injury. Three of the seven athletes (42.9%) spoke about these gender differences and subculture issues, and all eight of the student athletic trainers (100%) commented on these issues. This might suggest that this theme is easier to recognize when observing larger numbers of athletes, as in the case of the student trainers.

Gender differences. The athletes (N=2; 28.6%) and student trainers (N=7; 87.5%) felt that male and female athletes respond differently to their injuries. The comments were based on differences between sexes, sport opportunities, and the nature of male and female athletics. The interaction between focus group members brought out some very interesting explanations for gender differences:

A lot of times guys have post college stuff to look forward to. It's starting to increase with women too, but the women will be more like, "don't push it, because you have the rest of your life to live." (Female, Trainer, Age 23)

Subculture. There also seems to be a difference in how injury is perceived by athletes from different sports. One athlete (14.3%) and seven student trainers (87.5%) described issues related to subcultures with the teams and sports. It could be possible that the norms for a given sport condition athletes to compete with injuries, or even view injury as a sign of weakness. Members of a given subculture have similar beliefs and values, which influence how the members perceive events related to the sport. Some of the trainers noticed this factor in the work they did with athletes:

With male athletes the team will rag on them a little bit more to try to get them out there, and try to prove that the injury is not as serious as it is. With the girl's teams I have seen, they are more encouraging to each other. You know, "get into therapy and then come out". Where the guys are like, "you could be out here right now." (Female, Trainer, Age 21)

There are certain attitudes with each team, and certain attitudes with players within each team, that you just have to get use to. (Female, Trainer, Age 21)

Physical Factors

With the sport thing, in regards to wrestling...how they're cared for is different in that if they are hurt and they can still participate, then they still perform. Versus soccer or basketball and some other sports, if there is even the slightest doubt that they can't perform then they are cared for immediately. (Male, Trainer, Age 23)

Physiological aspects related to injury have not been discussed in the sport psychology literature, yet with the connection between mind and body (Jaffe, 1980; Suter, 1986), physical factors may have a relationship to the emotional and psychological response. There were a number of physical aspects of the injury that made up this category including, pain, physical deconditioning, surgery, and the use of painkillers. Each of these items could have an impact on the emotional response. For example, pain has been noted as an aspect that has an influence on and individual's emotional state (Heil & Fine, 1999; Taylor & Taylor, 1998; Udry et al., 1997a). Furthermore, some of these items make up the cognitive response (decision to have surgery) and the behavioral outcomes (use of painkillers). Future research should focus on individual physiological factors and the connection to the psychological responses.

Pain. Pain was a theme that all seven athletes (100%) and seven of the student trainers (87.5%) talked about. The athletes talked about the pain involved with the sustaining the injury, immediately following the surgery, and the rehabilitation process. The following quotations are examples of the pain theme:

I had, had some sharp pains in my lower back, but I thought they would go away. We had one workout and we ran an hour and a half. We got back and I was in so much pain, my whole back just hurt really badly, it was just cramped up. (Female, Cross-Country, Age 18)

It (shoulder) was so weak from the ten to fifteen weeks of football, not working out with it. It was dead, completely dead. It was dead for about six weeks. Very little feeling, and severe pain. I couldn't move it any direction. (Male, Football, Age 21)

Physical deconditioning. One of the most difficult aspects of dealing with an athletic injury is the loss of physical conditioning due to the lack of participation. Six athletes (85.7%) and six student trainers (75%) talked about this aspect. Athletes put in hours each day for years to attain an optimal state of conditioning, only to lose that following an injury. Among the comments on this area were:

She felt she was getting a good workout, which I think is very, very important for a lot of athletes. Because a lot of athletes when they're out of their sport for a while, they don't feel they're getting the same workout in the training room, as they do on the field. (Male, Trainer, Age 22)

If you don't get to work out, you feel just horrible. I know if I don't work out one day, I feel so lazy, and out of it. I feel so out of shape. I feel like I can't do anything. (Female, Cross-Country, Age 18)

All the weights and working out, that was a waste of time because that's all gone. You're leg just goes down. I lost 12 pounds in three weeks. I just watched the wall. (Male, Wrestling, Age 22)

Surgery. The decision to have surgery can be a very uncomfortable experience, especially for athletes who rely on their physical ability to do the things they love. Four of the athletes (57.1%) and all of the student trainers (100%) talked about the surgery process. Two examples of the surgery experience:

I had the surgery done about eight weeks ago. It was really tough. Actually, I had no idea what to expect. Nobody really told me you're going to need to stay off it, and take it easy. (Female, Soccer, Age 20)

The toughest part about the whole thing...getting hurt was nothing...tearing my ACL was nothing compared to the surgery. (Male, Wrestling, Age 22)

Painkillers. A number of athlete (N=5; 71.4%) and student trainers (N=5; 62.5%) commented on the use of painkillers to allow the athletes to continue participation. The trainers spoke of cortizone shots to numb injured areas. Two athletes spoke of the use of painkillers:

O.K., I hurt mine in mid-October, on a slide tackle. My knee hit the ground and it popped in and out. I just played the rest of the season on it and loaded up on Advil to kill the pain. (Female, Soccer, Age 20)

I just go around and keep the leg stretched, with ice afterward. It's not working, so I don't know. I feel a lot of frustration, but you know I use painkillers to keep me going. (Female, Soccer, Age 21)

Daily Hassles (Effects on Life)

Seven athletes (100%) and three student trainers (37.5%) spoke about how the injury influenced other aspects of the athlete's life. These factors illustrate how injuries can hinder the day-to-day lives of the athlete, and in some cases change how an individual will approach tasks others take for granted. This category represents some of the ways in which injured athletes think about and perceive information related to the injury. Wiese-Bjornstal, et al. (1998) would classify this category as part of the cognitive appraisal process, for which the individual athlete assesses their ability to cope. Daily hassles included getting around on crutches, trying to focus at school, avoiding activities that may reinjure or aggravate the current injury, and disruption of daily life tasks. The following quotations are examples of this theme:

It [the injury] affects every part of your life because it's constantly in the back of your mind. (Female, Soccer, Age 20)

Feelings Associated with Injury

I couldn't get up to get food; I couldn't do anything for myself. That was the hardest thing for me. Someone had to do everything for me. (Male, Wrestling, Age 22) Every aspect of my life was affected by my shoulder injury. I can't describe it. Every aspect. My school, I couldn't write. I couldn't take tests. I had to have people write for me. The things that you do every day that you just got up and did. Going to school may take four times longer. You can't comb your hair; you can't brush your teeth, whatever, it takes forever. (Male, Football, Age 21)

There were many entries that described the athlete's feelings associated with the injury, with all seven athletes (100%) and eight student trainers (100%) commenting on this category. Documenting the feelings connected to the injury is important, because of the potential relationship to rehabilitation adherence (Brewer, 1994). Frustration was a feeling reported by every athlete and trainer. There were other feelings mentioned, including isolation, boredom, depression, relief, anger, fear, and confusion. The following is an example of a quotation about the "feelings" category from a trainer:

Depression can be a huge part of the injury. Some of them slip into a stage and it can be a day, a week, or a couple of months, depending on their severity of the injury, how well they bounce back, and their attitude about it. Depression is definitely a phase that could be there. (Female, Trainer, Age 23)

The athletes direct experience with the feelings associated with injury are summed up in the following quotations:

One word for me that seems so important in dealing with my injuries is frustration. It's just so frustrating! I know that I have to be different in practice. To know you have to be different around campus, to know that you have to go to the training room when you could be hanging out on the quad or hanging out with friends. It's just so frustrating. (Female, Soccer, Age 20)

It really didn't hit me until later that night. I wasn't quite sure what was going on. I was scared. And that was one of the few times I had ever been scared, because I am really a tough person, and its tough to get to me. But I wasn't sure if this was going to be the last time that I was going to run. (Male, Track, Age 21)

Rehabilitation

The final category was issues related to the rehabilitation process. Wiese-Bjornstal et al. (1998) identify aspects of injury rehabilitation as the main behavioral outcome included in their model. All participants (100%) in the study talked about issues related to rehabilitation. These issues relate to the other categories (e.g., relationships with trainers, sociological aspects, personal factors, etc.), but are distinct to the athlete's rehabilitation. One issue in this section was the immediate response and ease with which these athletes were able to receive treatment for their injuries. Most university athletic departments have an athletic training room, which athletes can use any time of day. Other types of athletes (recreational or high school) may not have the advantage of easily accessible treatment for their injury, and for this reason it is possible that this category is different for other types of athletes. The comments made by the trainers and athletes highlight the complexity of factors associate d with the adherence to injury rehabilitation including, motivation, attitude, personal control, and expected recovery:

It's [training room] totally accessible, it's right there. It's on campus; you don't have to drive anywhere. You don't have to worry about paying a bill every time you go. (Female, Soccer, Age 21)

Getting him into therapy was a little bit more of a challenge. I pointblank said he needed to be in therapy. He came in and did what he needed to do, so he can play. (Female, Trainer, Age 21)

Some are very positive, I mean there can be an injury and they can be in there [training room] all the time, and then there are others who are stubborn and say, "I don't need to rehab." (Female, Trainer, Age 23)

I know it's frustrating for athletes to be injured, but I found that those who have the negative attitudes or a poor mood state, that they are the ones who are continuously in rehab, and having problems making it to rehab. (Male, Trainer, Age 28)

Summary

The purpose of this study was to allow athletes and student trainers to describe the experience of injury. Comments from the focus groups revealed seven categories with a number of issues within each category. The results support the notion that the injury process is an individual experience made up of many elements. The results also support the existence of elements contained in the cognitive appraisal approach (Brewer, 1994). For example, the combination of personal factors, sociological aspects, and physical factors all influenced the feelings and thoughts associated with the injury, as well as the behavioral outcomes (rehabilitation, relationships with others, and daily hassles).

The results from this study also seem to parallel those found in other qualitative research projects with elite level ski teams and college athletes (Bianco, Malo, & Orlick, 1999; Gould, et al., 1997a; Gould, et al., 1997b; Shelley, 1999; Udry, et al., 1997a; Udry, et al., 1997b). Similar categories include, pain, emotional response, physical concerns, quality medical care, and social ties with significant others. However, there were some categories and sub-themes raised by the sample of college athletes and student trainers that might be unique to this population. For example, the athletes talked about the ease and convenience to obtaining rehabilitation services. In most cases, college athletes have a training room located at the school that does not require an appointment time or payment for services. Other types of athletes (high school and recreational) would have more difficulty in arraigning these services, and less opportunities of support from other injured athletes and trainers. Also, college athle tes have the added pressure to perform well in the classroom (Ferrante, Etzel, & Lantz, 1996). Within the daily hassle category, athletes commented how the injury created difficulty focusing on schoolwork.

Caution should be used when interpreting the results due to inherent limitations in the study's design. The small sample sizes of both participants and the number of focus groups limit the extent to which results can be generalized to other populations. The participants all came from the same university and suffered from similar degrees (i.e., major or moderate) of injuries. It is possible that different types of athletes with other injuries would yield different experiences. Also, this study could be replicated with certified athletic trainers, especially in settings where the certified trainers are the main providers of services. No control was made in selecting athletes who were at similar points within the injury rehabilitation process. In this study, some participants provided retrospective data, whereas others were in the middle of the injury experience. Future research should control for this variable. Although the data were submitted to an outside source for analysis, the data collection and data ana lysis were carried out by one individual, which raises the possibility of bias.

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 Categories, Sub-themes,
 and Percentages of Responsess
 Athletes Trainers
Category/Sub-theme N (%) N (%)
Personal Factors 4 (57.1%) 8 (l00%)
 Personality of athlete 1 (14.3%) 8 (100%)
 Athletic identity 3 (42.9%) 7 (87.5%)
 Role on team 4 (57.1%) 7 (87.5%)
Effects on Relationships 7 (l00%) 8 (100%)
 Trainers 5 (71.4%) 8 (100%)
 Teammates 4 (57.1%) 5 (62.5%)
 Coaches 5 (71.4%) 4 (50%)
 Other injured athletes 7 (100%) 7 (87.5%)
 Parents 6 (85.7%) 5 (62.5%)
Sociological Aspects 3 (42.9%) 8 (l00%)
 Gender differences 2 (28.6%) 7 (87.5%)
 Subculture 1 (14.3%) 7 (87.5%)
Physical Factors 7 (100%) 8 (100%)
 Pain 7 (l00%) 7 (87.5%)
 Physical de-conditioning 6 (85.7%) 6 (75%)
 Surgery 4 (57.1%) 8 (100%)
Painkillers 5 (71.4%) 5 (62.5%)
Daily Hassles (Effects on Life) 7 (100%) 3 (37.5%)
Feelings Associated with Injury 7 (100%) 8 (100%)
Rehabilitation 7 (100%) 8 (100%)
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Author:Granito Jr., Vincent J.
Publication:Journal of Sport Behavior
Geographic Code:1USA
Date:Mar 1, 2001
Words:7993
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