Psychological Issues Related to Illness and Injury in Athletes and the Team Physician: a Consensus Statement—2016 Update

Definition Team physicians must address the physical and psychological issues related to athletic activity. This athletic activity may result in illness and injury, and produce a variety of psychological responses, some of which may negatively affect sports participation. Additionally, psychological factors, especially stress, may be an important antecedent to injuries. These factors may play an important role in injury treatment and rehabilitation and contribute to successful return-to-play (RTP). Several psychological issues, including stress/anxiety, depression, eating disorders, and substance use disorders can have illness or injury as triggers and/or have unique presentations in the athletic population. Some athletes may be predisposed to certain psychological issues. This document will address select psychological issues and in particular focus on issues related to the team physician and their role in recognizing athletes at risk and providing referrals for additional care. Goal The goal of this document is to help the team physician improve the care of the athlete by understanding the relationship between psychological issues and athletic performance, illness, injury, treatment, and RTP. To accomplish this goal, the team physician should have knowledge of and be involved with: Psychological and sociocultural antecedents and risk factors of athletic illness and injury. Psychological issues accompanying athletic illness and injury treatment, rehabilitation and RTP. Recognition of salient features of select psychological issues and how these may present in athletes and affect health and wellness. Select psychological issues in athletes: ○ Stress/Anxiety ○ Depression ○ Attention Deficit/Hyperactivity Disorder (AD/HD) ○ Disordered Eating/Eating Disorders (DE/ED) ○ Substance Use Disorders Identification and collaboration with the mental health care network (e.g., clinical or counseling psychologists, neuropsychologists, psychiatrists, licensed clinical social workers, psychiatric mental health nurses, licensed mental health counselors, primary care physicians with core competencies to treat mental health disorders) (10). Encourage, coordinate and facilitate referrals to a member of the mental health care network as part of a comprehensive treatment plan. Summary This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are the American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. Executive Committee Stanley A. Herring, M.D., Chair, Seattle, Washington W. Ben Kibler, M.D., Lexington, Kentucky Margot Putukian, M.D., Princeton, New Jersey Consultant: David B. Coppel, Ph.D., Seattle, Washington Expert Panel Angela C. Cavanna, D.O., Middletown, New York Cindy J. Chang, M.D., San Francisco, California Tal S. David, M.D., San Diego, CA R. Robert Franks, D.O., Marlton, New Jersey Eugene Hong, M.D., Philadelphia, Pennsylvania Peter Indelicato, M.D., Gainesville, Florida Matthew J. Matava, M.D., St. Louis, Missouri Jason Matuszak, M.D., Amherst, New York Bradley J. Nelson, M.D., Minneapolis, Minnesota Amy P. Powell, M.D., Salt Lake City, Utah Psychological Antecendens of Athletic Injuries Psychological and sociocultural factors (Table 1) have been identified as key components in the biopsychosocial model of sport injury risk factors (15). These factors are personalized to the athlete and may vary over time and by circumstance.Table 1: Examples of sport injury risk factors.Psychological factors and other sociocultural factors alone do not reliably predict athletic injury risk. However, there has been a consistently demonstrated relationship between one psychological factor—stress—and athletic injury risk. Stress may be defined as the demands of a situation exceeding the resources to respond to those demands (see Table 2). Athletes who experience high levels of stress, whether on or off the field, are at greater risk of being injured. Certain subpopulations of athletes, such as those experiencing high life stress and low personal coping skills, may be at an even greater risk of sustaining athletic injury. Stress causes attentional changes (e.g., narrowing of attention, general distraction, increased self-consciousness, mental fatigue) that interfere with an athlete’s performance. Stress has been shown to cause increased muscle tension and coordination difficulties which increase the athlete’s risk of injury. Teaching athletes stress management techniques has been shown to reduce injury rates over a season of participation. Athletes who have high resiliency, optimism, self-efficacy (belief or expectation in one’s ability to succeed or affect change), and a supportive social network have more effective methods of responding to stress.Table 2: Selected signs and symptoms of stress.It is essential the team physician: Recognize that psychological and sociocultural factors may play a role as antecedents to athletic illness and injury. Specifically recognize that stress is related to athletic injury risk. It is desirable the team physician: Promote monitoring by the athletic care network (team physician, certified athletic trainers and other health care providers) of major life events and stressors (e.g., death in family, divorce, change in peer relationships, life transitions) that may place athletes at greater risk for injury. Understand stress may reveal or exacerbate underlying mental health issues. Recognize signs and symptoms of stress. Prepare strategies to address psychological factors that may contribute to the risk of athletic illnesses and injuries including: ○ Education of coaches and parents regarding the effects of attitudes and behaviors that equate illness and injury with worthlessness (e.g., “go hard or go home,” “no pain, that may increase stress and increase injury risk. ○ and to the team regarding injury and and ○ Education of coaches and parents regarding and in athletes. ○ Recognition of and life coping skills, and resources and ○ Identification of and collaboration with the mental health care network to psychological (e.g., stress and peer Psychological Athletic To an athlete, an illness or injury can be a life and may affect the athlete’s and The athlete’s and of the illness or injury may their which may affect the of the treatment, such as goal and to the treatment (see Table Examples of to injury athletes to and medical to their illness and injury. The athlete will in regarding treatment including and and to treatment, and RTP. are will be personalized to the athlete, may be or and may vary over time and by are or of the of the athlete in treatment may the These may of of and These are and on other factors, including antecedent psychological and sociocultural athletes, and sports as a primary coping and for with psychological issues and may be a major of their these athletes, an illness or injury may result in a more symptoms are over time and/or the of the symptoms (Table Depression is an especially It other and may illness or injury. to address are more successful in treatment and are in Examples of that the athlete’s to illness and injury should be as and and may over are that have been developed to the athlete’s may a of the Use of these may improve between the athletic care network and the athlete, a and of the athlete’s and increase the athlete’s It is essential the team physician will athletic illness and injuries and may vary over time and by These may It is desirable the team physician: Promote monitoring of by the athletic care Encourage, and facilitate referrals to a member of the mental health care network as part of a comprehensive treatment plan. athletes, and parents regarding to illness and injury Promote of a supportive social network in illness and injury Psychological of Athletic and and Psychological factors are to play key in the athlete’s to illness and injury and affect of the illness or injury of the illness or injury on and athletic activity life of sport for treatment and with the athletic care athlete’s psychological may regarding treatment and may and injury and treatment, and The team physician and the athletic care network to be of these factors and effective treatment for of and for psychological factors that have been shown to be important in illness and injury treatment and are and psychological and to can result in an mental regarding or and/or the active of of of or These factors can negatively affect and can be in the injury and are to affect treatment and by These to rehabilitation and increased use of consistent relationship has been between the of optimism, to illness and injury, and successful illness and injury treatment levels of pain, on and to sport and low self-efficacy are with as by rehabilitation and to of symptoms and physical activity. and stress and to the athlete in the injury, and can treatment and The and of social can the of stress and and may affect the of and the and The major of these is on the in rehabilitation and the of athletic the major of social may be team and the of athletic of may psychological referrals and treatment and and is a of with rehabilitation and of in of rehabilitation and have been developed to psychological factors, which may affect illness and injury treatment, of these are to the athletic population. Examples the of and Disorder may a of the in the of illness or injury or of may to the mental health of of of of injury and to and about the team on physical New to illness or injury with the of have the use of psychological strategies such as goal and is with These strategies may be by stress and coping and social of factors should be athletes. These factors and with the or is not only to a medical to and the athlete’s the athlete about the illness or injury. It is that of illnesses or injuries be in the athlete can for the athlete to an understanding and and about the and treatment, and RTP. about the illness or injury. athlete may a variety of (e.g., that may contribute to and the athlete’s social It is important to the athlete’s social network as as the athlete’s of the and peer (e.g., providing to athlete who has a illness or the use of stress coping athlete may experience stress the injury and rehabilitation Psychological and techniques will coping (Table and other for the injury the athlete’s these people should be that an injury is best on an coaches should be to help the athlete the with other can be in to the athlete and and facilitate to the mental health Some athletes may to the mental health It is essential the team physician: Recognize psychological factors play a key role in illness and injury treatment and Understand athletic illness and injury treatment and rehabilitation should psychological as as It is desirable the team physician: a comprehensive rehabilitation that physical and psychological issues, including of psychological as and facilitate the athlete’s in goal to practice and play to psychological an athlete’s social athletes, and about the of a supportive social Psychological and Psychological is one for including a of and may an athlete’s RTP. athletes who a illness or injury have about being about illness or and about their of athletic Selected techniques for coping with psychological are with issues of illness or or to to levels of activity of as they to of social increased to they they are these may general health and interfere with performance, and increase the risk of illness and/or and should in these The team physician should not only physical factors, responses, the with medical care, the supportive social network can help reduce the and stress accompanying an injury and Athletes who have to injury, in the of illness or injury, or of may a to the mental health these these may be in the It is essential the team physician to may not with psychological Psychological factors may be key components in the an illness or injury. It is desirable the team physician: the athletic care network to the psychological of athletes who are to or have and facilitate to the athlete’s with the team to psychological of psychological and sociocultural on the a for the of psychological factors in the the athlete for psychological factors that may affect treatment and Encourage, and facilitate referrals to the mental health care network to the of psychological factors treatment and RTP. Select Psychological in The management of illness and injury with athletic activity is one of the of the team physician This understanding psychological issues athletes may experience that mental health and and illness and injury. in place for mental health and mental health referrals is important (10). This key features of mental health issues the team physician should recognize and The and of Stress/Anxiety Definition Stress may be defined as the demands of a situation exceeding the resources to respond to those Stress can be as a to or such as injury, which the stressors is an of stress that may and have or disorders (e.g., features of and and related factors, including and factors (e.g., substance with stress to produce these Examples of stress for the athlete to do with the athletic including and demands of and regarding demands of the athlete’s including team and issues (e.g., team of the athletic including and personal relationships, stressors for such as regarding sport performance, performance, or relationships, can to reveal or exacerbate depression, and other mental health issues. The of symptoms is to difficulties in and of athletes symptoms are by for The psychological issues have been as and The of disorders in to and is in of and of athletes the of in the to and in is by and for at six and with at of these or being on muscle and has been with is a that as a of a a of and a general of and can a and may or or a and or symptoms are of more they a change the athlete’s that can be to help with the of the of symptoms the the and the can be to levels of and athletes. which is the treatment of for symptoms and The goal of is to the focus and to to in the of on the to and have been in the Athletes with have a to such as and to triggers of and the and may be in the treatment of and are an to may affect athletic performance. Psychological factors have been identified to including: optimism, and or to a goal of including and or to not on social the athletic care network It is essential the team physician: Recognize the signs and symptoms of stress and Understand that not is related to sports performance. the of the relationship the athlete, with or in the athlete a to or and/or to It is desirable the team physician: Encourage, and facilitate to the mental health care the athletic care network about the symptoms of stress and as as mental health to athletes who are in and an athlete’s social Understand the effects of that may be to treat and with other Understand that athletes may for to health substance use Recognize that with a injury, may reveal or exacerbate underlying mental health issues. the of a team of athletic sport mental health of or to stress and mental health Depression Definition Depression is one of The of major and/or and at of the symptoms a or in or or or of death or result in or in or other important of These are not to the effects of substance or other medical (e.g., to the of the with at one major in one the of is to The for in athletes is of symptoms in athletes may be to athletes are at greater risk for symptoms athletes risk factors in athletes: and sport (e.g., and of and of athletes is to in the to and in factors in athletes may increase the risk for ○ and injury ○ ○ management ○ as an athlete to symptoms of and athletes may experience other symptoms of (e.g., low or of substance that can be to help with the of the of the the Depression and for Athletes may symptoms of and be to treatment for and about Depression may be a risk for in athletes. is the cause of death in athletes and the cause of death in treatment for in the general is a of and (e.g., including is to treatment strategies in athletes. The psychological factors that stress and may in It is essential the team physician: Recognize the signs and symptoms of depression, including risk for or athlete for Understand that not is related to sports performance. the of the relationship the athlete, with or in the athlete a to or and/or to It is desirable the team physician: Encourage, and facilitate to the mental health care the athletic care network about the symptoms of depression, as as mental health to athletes who are in family, and certified athletic trainers about their important role in to mental health and an athlete’s social Understand the effects of that may be to treat and with other Understand that athletes may for to health substance use the of a team of athletic sport mental health of or to and other mental health for in athletes. Recognize that may injury and interfere with successful RTP. Definition Attention Deficit/Hyperactivity Disorder (AD/HD) is by a of shown to be more those at of The of some or symptoms (Table must be present symptoms must in more one is in or a for is for this symptoms of Deficit/Hyperactivity Disorder (AD/HD) has Attention Deficit/Hyperactivity Disorder Attention Deficit/Hyperactivity Disorder Attention Deficit/Hyperactivity Disorder is in to of and of is a greater in of with have symptoms that and a of to the of is by a licensed mental health care a of and comprehensive clinical to for the of the and by alone is not as may have is in a These may be more by (e.g., Psychological major depression, substance use and Athletes with may be in coordination with the mental health care network as as the team physician, and nurses, and some may improve and and management and techniques are a of treatment, by of are the and may be in certain may a use and may be with to in the and and have and monitoring and are It is essential the team physician: Recognize signs and symptoms of It is desirable the team physician: Encourage, coordinate and facilitate to the mental health care or resources to the athletic care network about the to treat this and including the risk for and related issues. Understand that with certain may be for the athlete to the by (e.g., Understand the of may peer relationships, increased of substance use disorders, and increased of Disordered Eating/Eating Disorders Definition Disordered eating on a the of to reduce This and/or and (e.g., to eating disorders, such as eating and other eating or Athletes in sports and are at particular risk for the of eating and eating disorders are with other medical and psychiatric disorders are psychiatric disorders which have a of with and medical of to to a low ○ for by social with and/or of ○ of by of or and in the in which one’s or is ○ especially with is with important at or or an to injury or other medical and has been to ○ ○ in or sports by a to low and a the ○ is on to to and Medical and health issues, and of eating by of the ○ an of that is in a of ○ of of over eating the behaviors to or other is by and may be or may or for or is on of of behaviors to psychiatric and disorders substance use increased of and Medical issues and are other eating disorders including and other eating or disorders, which some not features of and Athletes are at risk for ○ athletes, to for to to of ○ athletes is ○ to and and of ○ of in or sport athletes. in sports such as and are at greater risk. a to The is ○ experience of rates may be in who are a to is ○ of of of in athletes and in a of and medical of the of eating ○ or for ○ or for and ○ Stress (e.g., (e.g., (e.g., depression, risk factors for to and/or Psychological factors, such as low coping skills, of depression, of and related to (e.g., that can be to help are the and Disorder and clinical in illness and injury and have been shown to the an These are psychiatric and not to a member of mental health care network is may Medical monitoring (e.g., of which may be in select may or The of is especially important in athletes of have been developed to risk and in the of in and athletes These may be as regarding of will to be on a components of the are not to eating of stress medical and of as as other psychological of is one for and for eating Athletes with should be to a member of the mental health network and with a team that a The of athletes to to in their sport can in their are the sport may only contribute to the eating and there will be a to the athlete the The goal is to the athlete in their to even that or an athlete their The of athletes with and the medical of those behaviors are to in and of the team should be involved not only in the treatment of the athlete, in of those athletes of play to be on the a the treatment and of activity ○ the athlete’s health their of activity may be ○ is in the time of play may to be or It is essential the team physician The of eating and how the can in sport and in and athletes. The of and of the of It is desirable the team physician: and facilitate to a member of the mental health care Understand the and treatment of the athlete with Understand the of the athletic care or for the and of ○ of behaviors with ○ athletes and coaches on the risk factors and signs and symptoms of and the role team may play in the of eating disorders, in to and ○ coaches to the athletic care network regarding of their athletes. risk factors the and clinical including the use of for (e.g., athletes and including to about and athletic performance. Substance Use Disorder Definition Substance use is defined as or of a or that has or for the of or Substance use disorders result use is or with such as health or to major at or and with social or use by athletes may such as or to treat the symptoms of illness or injury such as for pain, or or to with and performance, including and Substance use and substance use disorders are in the and including athletes at levels (Table Substance use in and Substance use may and to and to the of illness or injury, or with and substance use may be an to on the Athletes may be such as or a injury. Athletes with such as and are with increased risk for use of and levels of athletic team are with and and of and ○ Athletes in sports are as to and use high ○ Substance use in athletes is and for to be on the to in and more athletes substance use is in and athletes. in one is six in one in and one in at in a Athletes who are substance and especially those with substance use disorders are more to have with including and that to injuries the use and athletes in sports to team is the use and of ○ use in high is with a increased risk of high ○ in sports are as to be as to and as to use for ○ one in athletes use and about of those use a or (e.g., ○ of for and ○ of of of ○ ○ of and of are with use of is with psychological and increased eating and of athletes use of with a ○ and the the of and of athletes for Substance use disorders are by a variety of physical and signs and including change in or and a change in social physical signs may are not to and and Athletes with substance use may be in coordination with the mental health care Some treatment and and treatment, treatment, and peer to and for substance use and such as Use Disorder Identification Use Disorders Identification (10). It is essential the team physician: Recognize the signs and symptoms of substance use recognizing issues substance use disorders are It is desirable the team physician: Encourage, and facilitate referrals to a member of the mental health care network for the of a team of athletic sport mental health of and substance and Understand that substance use disorders are a in the athlete population. of the risk for substance use and substance use with the athletic care network to athletes on the of substance use and the for substance use substance use and clinical to substance athletes. Understand that substance use may be an to and/or performance. It may a coping in to illness and injury. Athletes to the Athletes experience to illness and injury, and of these are The athletic care network and social network are effective in the athlete with these issues. However, athletes with risk factors and/or who treatment should be to a member of the mental health care The important is that the is to a licensed to mental health these in the care and treatment of athletes and the of sport (e.g., life may be by licensed or However, licensed mental health have the and by their and are the only mental health licensed to treat (Table 2). athletes, there are levels of with to licensed mental health to general of mental health treatment, of of and of mental health to and issues related to may serve as to Team physicians and other of the athletic care and of with mental health issues may have an and on an athlete’s to mental health care. and responses, athlete is of particular It is essential the team physician: of the mental health care network to facilitate athlete recognizing psychological issues are It is desirable the team physician: of the mental health care network the illness and injury treatment team (team certified athletic trainers and other health care the of mental health and to the athletic care treatment for mental health issues. Encourage, and coordinate referrals to the mental health care of the mental health care network in and for coaches and athletes about mental health and wellness.