Subjective well-being is associated with injury risk in adolescent elite athletes

ABSTRACT

Objective: The purpose of this study was to explore the association of subjective well-being with injury and injury severity in adolescent elite athletes.

Design: Prospective cohort study.

Participants: Three hundred eighty-six adolescent elite athletes (age range 15–19), participating in seven different sports, were monitored repeatedly over 52 weeks using a valid questionnaire about injuries, substantial injuries, injury severity and subjective well-being (scale 0–100).

Results: A linear mixed model showed that subjective well-being was significantly influenced by injury severity (p < .001, estimate −1.7, 95% CI −1.4 to −2.0) and sex (p = .019, estimate −3.6, 95% CI −6.0 to −0.2). Of all injury reports where the athletes reported a well-being score of less than or equal to 20, 54% reported substantial injury, whereas 9% of the injury reports where the athletes reported a well-being score above 80 reported substantial injuries. In addition, an increase in subjective well-being with a score of 10 decreased the odds of injury with 5.6% (p = .036, 95% CI 89.5 to 99.6) and injury severity with 0.4 points (p = .01, 95% CI −0.6 to −0.1).

Conclusion: Medical personnel need to be aware that young athletes may face well-being challenges while injured and that a low subjective well-being increase the injury risk the subsequent week.

KEYWORDS:

• Athletic injury
• youth athletes
• health

Introduction

Single sport specialization, high training load, frequent competitions with a focus on competitive success and high expectations from coaches, are characteristics of today’s youth elite sports (DiFiori et al., 2014). Adding to the picture of a high injury risk in young elite athletes (Kirialanis, Malliou, Beneka, and Giannakopoulos, 2003; Kolt and Kirkby, 1999; Price, Hawkins, Hulse, and Hodson, 2004; von Rosen et al., 2018a; Westin, Alricsson, and Werner, 2012), it is not surprising that young athletes may experience high stress levels, frustration, depression or daily living problems and thus negative health and well-being consequences (von Rosen et al., 2018b).

In order to pursue sports dreams, young athletes may have to leave their homes, become professional, increase their training volume and participate in a more competitive sport environment (DiFiori et al., 2014). All these changes likely cause increased stress in a young rapidly growing athlete. In a study of young female handball players attending a sport-specialized school, it was found that the athletes were exposed to several stressors due to increased training volume, reduction in sleep volume and development of severe injuries (Kristiansen and Stensrud, 2017).

Young elite athletes are in the beginning of their sport career and still not used to the adult elite sports environment. They may not be familiar with being injured, long-term injury, rehabilitation and missed sports participation. Even injuries with minor severity have been found to have serious consequences in the life of a young athlete (von Rosen et al., 2018a). They may also not be used to handle performance expectations from coaches, parents, competitors (Merkel, 2013) or setbacks following injury rehabilitation. In addition, the self-identity has been showed to be highly associated with being an athlete (Brewer, Selby, Under, and Petttpas, 1999; Grove, Fish, and Eklund, 2004; von Rosen et al., 2018b) and consequently diminish of self-identity may occur along injury. Thus, when a young athlete is injured numerous thoughts regarding identity, continued and future sports participation take place, which may affect their well-being and other aspects of mental health.

All these negative consequences of elite sports participation mentioned above may cause a cascade of consequences on health and subjective well-being, that clinicians need to consider as it likely affects the injury rehabilitation and returns to sports for the athlete (Forsdyke, Smith, Jones, and Gledhill, 2016). For instance, athlete’s thoughts, feelings, and the way the athlete approaches the rehabilitation stages is likely affected by the well-being state of the athlete. Consequently, clinicians facing the injured athlete need to pay attention to both the body and the mind and be aware of that athletes may be emotionally vulnerable and that physical and psychosocial recovery may not occur at the same time. In addition, well-being has been found to influence injury risk (Lavallée and Flint, 1996), making the relationship between injury and well-being complex. Furthermore, the research on well-being and injury is mainly based on adult athletes and a full understanding of the relationship between injury and well-being in young elite athletes is lacking. This knowledge is important for clinicians in an injury prevention and injury rehabilitation perspective. The aim was therefore to explore the association of subjective well-being with injury and injury severity in adolescent elite athletes. A secondary aim was to explore if injury risk and injury severity could be predicted based on subjective well-being score the previous week.

Methods

This study is part of the KASIP-study (Karolinska Athlete Screening Injury Prevention), aiming to understand injury occurrence and associated risk factors in Swedish adolescent elite athletes, and was approved by the Regional Ethical Committee in Sweden (No: 2011/749–31/3). A prospective cohort design was used to explore the association between subjective well-being and injury.

Recruitment process and participants

Data collection has previously been described in details (von Rosen et al., 2017). Briefly, the National Federations of Skiing, Orienteering, Handball and Track and Field were contacted and gave oral permission to conduct the study. A total of 15 high schools were then contacted during 2013–2014. To attend National Sports High Schools, the adolescent athletes must exhibit high national performance achievement in their sport and practice at the highest national level for their age group.

One of the authors visited each school, and the coaches and the athletes were orally informed of the purpose of the study and the voluntary nature of participation. The available cohort consisted of 438 adolescent elite athletes (median age 17 years, range 15–19), of which 386 athletes (88%) responded to the invitation. Written consent was obtained from all athletes. The final cohort (female = 182, male = 204) had a median age of 17 (range 15–19) and represented sports such as athletics (n = 142), cross-country skiing (n = 93), downhill skiing (n = 13), freestyle skiing (n = 13), handball (n = 45), orienteering (n = 68) and ski-orienteering (n = 12).

A questionnaire was e-mailed to all athletes weekly over 52 weeks, consecutively starting between September 2013 and March 2014. If no response had been registered in any week, a reminder e-mail was sent four days later. If no response still occurred, the athlete was contacted again the next week. The Questback online survey software (Questback V. 9.9, Questback AS, Oslo, Norway) was used for data collection. In this study, only data from the first 26 weeks were utilized, making up 5970 injury reports. The average response rate across the 26 weeks was 62%.

Questionnaire

The weekly questionnaire contained the validated and translated version of the OSTRC (Oslo Sports Trauma Research Centre) Overuse Injury Questionnaire (Clarsen, Myklebust, and Bahr, 2013; Ekman et al., 2015) as well as questions used by Jacobsson et al. (2013) in an athletic surveillance study. For this part only the OSTRC Overuse Injury Questionnaire was used as well as the question about the athletes’ subjective well-being. The well-being scale measures life satisfaction and the athlete is told to rate their well-being on a scale 0–100, where zero stands for their worst well-being and 100 their best well-being. The OSTRC Overuse Injury Questionnaire measures injury consequences on sports participation, performance, training, and pain based on four questions with alternative responses. The OSTRC Overuse Injury Questionnaire assesses injuries effect on participation (four alternative responses from “full participation” to “cannot participate”), reduction in training volume (five alternative responses from “no reduction” to “cannot participate”), reduced sporting performance (five alternative responses from “no effect” to “cannot participate”) and experience of pain (four alternative responses from “no pain” to “severe pain”). The completion of the questionnaire took approximately 5 min.

Operational definitions

All injury data were self-reported and injury was defined as any physical complaint that affected participation in normal training or competition, led to reduced training volume, experience of pain or reduced performance in sports (Clarsen, Myklebust, and Bahr, 2013). A substantial injury was defined as an injury leading to moderate or severe reductions in training volume, or moderate or severe reduction in performance, or complete inability to participate in sports. A severity score was determined, by allocating a numerical value from 0 to 25 to the alternative responses in the four questions of the OSTRC Overuse Injury Questionnaire (Clarsen, Myklebust, and Bahr, 2013). The four questions were then summed to a score of 0–100, where 0 represents no injury and 100 the highest level of severity grade associated with severe pain and time-loss from sport participation.

Data analysis

Descriptive statistics for continuous variables are presented as mean and standard deviation (SD). Prevalence measures were calculated for injury variables, by dividing the number of athletes reporting injury/substantial injury by the number of questionnaire respondents. The average value across the 26 weeks was determined along with a 95% confidence intervals (95% CI). A similar calculation was conducted for the average severity score and subjective well-being across the 26 weeks. Student t-test was applied to analyze differences in injury prevalence and subjective well-being by sex. Pearson correlation coefficient was used to identify the association of subjective well-being and severity score. Effect size for differences in injury data and subjective well-being by sex were computed using Hedges’ g calculation and a correlation coefficient of 0.20–0.49, 0.50–0.79 and ≥0.80, was considered as a small, medium and large effect size, respectively (Durlak, 2009).

The risk of reporting injury, injury severity, and substantial injury was explored based on subjective well-being score the previous week using linear and logistic mixed model regression analyses. For these analyses only injury free athletes the previous week, and thereby at risk of injury, were included. In case of being injured, the athlete was left censored until reporting to be injury free. Predicting subjective well-being the current week was also explored using linear mixed model regression analysis, including injury severity as an independent variable. In all models, sex and sports participation were entered as fixed effects and as random effects, intercepts for subjects, sex and sports participation were included. The mixed model regression analyses were applied to account for the correlated data associated with a repeated measured design. Model selection was based on the likelihood ratio tests. Residual plots revealed no obvious deviations from homoscedasticity or normality. Throughout calculations, the significance level was set to p < .05. All analyses were performed using the SPSS software for Windows, version 24.0 (SPSS, Evanston, IL), except the linear and logistic mixed models that were conducted in R 3.4.3 (R Core Team).

Results

Injury data and subjective well-being

The average well-being score across the population was 68 (95% CI 66 to 71), with male athletes reported a significantly (p = .027) higher well-being (95% CI 68 to 73) than female athletes (95% CI 64 to 69). Female athletes reported a significantly (p < .001) higher injury prevalence, substantial injury prevalence, and severity score over the 26 weeks compared to male athletes. A similar pattern was demonstrated between well-being and injury/substantial injury, where a high proportion of injured athletes was associated with a low well-being score (Figure 1). Of all injury reports where the athletes reported a well-being score of less than or equal to 20, 54% reported substantial injury, whereas 9% of the injury reports where the athletes reported a well-being score above 80 reported also substantial injury. In terms of sex differences, a higher proportion of injured female athletes (15%) reported a well-being score above 70, compared to male athletes (7%) (Figure 2).

Figure 1. The association between injured/substantial injured athletes and well-being. Well-being data categorized in 10 groups where a well-being score > 90 equals 100, a score > 80 and ≤ 90 equals 90, etc. Low values for well-being is associated with low well-being

Figure 2. The association between injured/substantial injured athletes and well-being by sex. Well-being data categorized in 10 groups where a well-being score > 90 equals 100, a score > 80 and ≤ 90 equals 90, etc. Low values for well-being is associated with low well-being

Relationship between injury, severity and subjective well-being

A negative association between well-being and severity score was demonstrated (r = −0.32, p < .001), where an athlete reporting injury with a high degree of severity tended to have a lower well-being score. The linear mixed model showed that subjective well-being was significantly influenced by injury severity (p < .001) and sex (p = .019). An increase of severity score by 10 was associated with a reduction in subjective well-being of 2 points (−1.7, 95% CI −2.0 to −1.4) and being a female athlete, was associated with a reduction in subjective well-being of 4 points, compared to a male athlete (−3.6, 95% CI −6.0 to −0.2). Based on the linear mixed model, a female and male athlete with the highest degree of injury severity was predicted to have a subjective well-being score of 55 and 58, respectively, compared to a score of 71 and 74 for an injury free female and male athlete, respectively.

Injury risk and injury severity based on subjective well-being score

The linear and logistic mixed models showed subjective well-being the previous week predicted injury (p = .036) and injury severity (p = .010) the subsequent week, respectively. In specifically, an increase of subjective well-being with a score of 10 decreased the odds of injury with 5.6% (95% CI 89.5 to 99.6) and reduced injury severity with 0.4 points (95% CI −0.6 to −0.1). A logistic mixed model showed substantial injury could not be predicted based on subjective well-being score (95% CI 0.89 to 1.04, p = .317)

Discussion

The results of this prospective cohort study demonstrated a clear relationship between subjective well-being and injury in adolescent elite athletes. Of the athletes with a low well-being, a higher proportion was injured compared to the athletes with a high well-being. A negative small association between well-being and injury severity was further demonstrated, indicating that a more severe injury was associated with a lower well-being score. In addition, a decrease in subjective well-being increased the risk of injury and injury severity the subsequent week.

Injury affects well-being through multiple pathways

Being injured as a young elite athlete has been found to lead to negative psychological responses such as frustration, anger, daily living consequences such as sleep disturbances or study issues, as well as experience of loneliness and self-blame (von Rosen et al., 2018b). Young athletes also tend to feel excluded and experience that their position and role in their training group are changed while injured. Therefore, it is not surprising that injury has a crucial effect on a young athlete’s subjective well-being, where the majority of athletes reporting a well-being score of equal to or less than 20 were injured. In addition, a more severe injury may be associated with more negative psychological responses, absence from sports, greater threat to the self-identity (Brewer and Cornelius, 2010; Grindstaff, Wrisberg, and Ross, 2010; Grove, Fish, and Eklund, 2004) and consequently a larger decrease in well-being.

Reduction in well-being the current week of injury

Following injury, the daily routine of an athlete is changed and a consistent fear of not being able to perform and participate on a sport elite level may arise. Besides, multiple interests exist from the athlete themselves, coaches, medical teams, sport organizations or sponsors to quickly return to sports following injury. Therefore, elite athletes face stress related to returning or the expectance of returning to play as rapidly as possible (Bauman, 2005). This pressure has increased over the last years and now involving even young athletes (DiFiori et al., 2014). All these factors could potentially explain why the well-being is reduced while the athlete is injured. Therefore, medical personnel need to be aware that young injured athletes may face well-being challenges and that the well-being is lower in injured athletes that may affect the outcome of rehabilitation (Forsdyke, Smith, Jones, and Gledhill, 2016).

This study also demonstrated a sex difference in well-being score. Previous research has demonstrated that female athletes report higher levels of self-perceived stress, lower self-esteem and have increased risk of mental illness (von Rosen et al., 2016). In this study, both young male and female athletes’ well-being was found to be associated with injury. In terms of a healthier well-being (score ≥ 80) a higher proportion of female athletes were more injured than male athletes, possibly indicating that injury has a greater effect on well-being in male compared to female athletes.

Well-being predicted injury risk and injury severity

This study confirms the findings of previous research demonstrated an association between well-being and injury risk (Lavallée and Flint, 1996; Watson, Brickson, Brooks, and Dunn, 2017). In specifically, both negative life-event stress (Ivarsson, Johnson, and Podlog, 2013; Johnson and Ivarsson, 2011) or daily hassles (Laux, Krumm, Diers, and Flor, 2015; Lavallée and Flint, 1996; Petrie, 1993), likely associated with subjective well-being, have been found to influence injury risk. In this study, a decrease in subjective well-being increased the risk of injury and injury severity. The effect on injury risk and injury severity was significant, but may be considered to be of small or medium effect size. The wide confidence intervals associated with the estimates may be related to that data on all types of injuries were obtained in this study, including both acute and overuse injuries, and thus resulting that data on a wide range of injuries were recorded. We did not find that well-being predicted substantial injury, perhaps related to that more severe injuries have a weaker association with subjective well-being. Even if well-being may mediate injury risk in a complex relationship, coaches of young elite athletes should consider monitoring subjective well-being as it may be a predictor of injury and injury severity.

Methodological considerations

The strengths of this study are the prospective nature, following a high number of adolescent elite athletes from different sports over 26 weeks. The group of athletes must be considered to be homogeneous since only young elite athletes were included. A valid and reliable questionnaire was utilized that has previously been successful implemented in a young population (von Rosen et al., 2018a). The findings of this study should also be viewed in the light of potential limitations. Many unmeasured factors such as personal events, sports performance achievements or other important life events were not measured that likely influence subjective well-being. In addition, we did not have any data on other medical conditions that may influence well-being. The accuracy of self-report is mainly depended on their content and how they are implemented (Saw, Main, and Gastin, 2015). Subjective well-being is a psychological self-reported construct, whereas injury data could, in addition to self-report, be collected by medical personnel. However, the advantage of self-report data is that all kinds of physical complaints can be collected regardless of access to medical personnel. Blinding was not possible for athletes and investigators and data analysis was conducted by the first author. While monitoring the athletes, they were training and competing as usual. The response rate led to missing number of injury reports that may have affected the analysis of change in well-being along the injury period. The response rate may also have led to an underestimation of the true injury prevalence (Clarsen, Myklebust, and Bahr, 2013). However, the association between well-being and injury was analyzed in each of the nearly 6000 injury reports, supporting the findings of the study.

Conclusion

A clear relationship between subjective well-being and injury in adolescent elite athletes was demonstrated where a low well-being score was associated with injury. A negative small association between well-being and injury severity was further found. In addition, subjective well-being the previous week predicted injury and injury severity the subsequent week. Medical personnel therefore need to be aware that young injured athletes may face well-being challenges and that a low subjective well-being increase the injury risk the subsequent week.

Declaration of Interest

The authors declare no conflict of interest.

Additional information

Funding

This work was supported by the Swedish National Centre for Research in Sports under Grant [FO2016-0009].