Exploring the Psychological Aspects of Sport Injury Assignment

Case Study Jackson

Jackson is an 18-year-old national-level high jumper who has recently sustained an ankle injury during training. Prior to the injury, he had been going through a difficult time after a relationship breakdown and having to move back into his parents’ house. On top of this, after some recent performance difficulties, Jackson was concerned that he might not get selected for the national junior team, which he was also hoping to captain. He is highly committed to athletics, and it is a significant part of his life – he trains every day, and most of his friends are based at the track where he trains.

Following the injury, Jackson experienced feelings of frustration and low mood. He was angry at himself for sustaining the injury due to what he described as a ‘simple foot turn’ and felt frustrated that he was unable to train, compete, and fight for his place on the national team. The consultant has advised him that he won’t be able to compete for around six weeks and will not be able to undertake any jump-specific training for 3–4 weeks. This has led Jackson to feel very isolated from his friends and fellow athletes, and he is experiencing symptoms of depression. He is becoming increasingly anxious about his ability to fully recover and feel confident to jump with power and land safely when he returns to training. He is currently in a very negative mindset and often makes negative comments to his physiotherapist and coach about his recovery (e.g., ‘What’s the point? I’m never going to jump like I used to’). This appears to be impacting his adherence to his rehabilitation programme as his physiotherapist has reported that he has missed a few of his sessions and doesn’t always seem motivated in those he has attended.

Your report should be split into five parts (refer to the guidance section for more detailed information about what should be included in each part):

Introduction

Explain the focus of the report and any assumptions you have made about the case study.

• Psychological causes of Jackson’s sport injury (
• Identify and explain the key psychological factor(s) that may have contributed to Jackson sustaining his injury.
• Psychological responses to sport injury
• Explain Jackson’s psychological responses to injury in relation to at least one relevant model.
• Psychological intervention/skills programme (900 words, 30 marks)
• Identify three psychological interventions that could aid Jackson’s sport injury rehabilitation, and justify and explain why you have selected them for him.
• Conclusion

Summarise your main points and conclusions.

Option 1

• You should write your answer under the five distinct parts detailed in the Option 1 task details on the previous page. Additional guidance on each of these parts is provided below.
• Your report should be applied to the case study; that is, ensure that all parts of the report are applied specifically to Jackson rather than giving a more general overview or analysis.
• As with all assignments, it is important that you support your work with references and evidence from the module or BOC materials. The BOC author is Heaney, C. (2019). Guidance on referencing can be found in Section 5.3 titled ‘Referencing’ in the E235 Assessment Guide and the Sport and Fitness subject website.
• Although this EMA draws primarily on Study Topics 5 and 3, you may also draw on content from other study topics.

• Part: Psychological responses to sport injury
  • In this part, you should identify Jackson’s psychological responses to injury and apply his case study to at least one relevant model from the study materials (e.g. a grief response model or cognitive appraisal model).
  • You should critique the model that you select, outlining any research in support of it and any limitations of the model.
  • You may find it useful to refer back to Sessions 5 and 6 of the BOC and Unit 18 of Study Topic 5 (Sections 18.2 and 18.3).
• Part: Psychological intervention/skills programme
  • Identify which three interventions might be useful to help Jackson through his sports injury rehabilitation.
  • Explain why these interventions would be beneficial, and provide supporting research evidence.
  • You should discuss the interventions specifically in relation to Jackson’s case study.
  • You may find it useful to refer back to Sessions 7 and 8 of the BOC and Unit 18 of Study Topic 5 (Sections 18.4 and 18.5).

• Part: Introduction
  • Use the introduction to briefly outline the focus of your report; that is, what you intend to cover, and how.
  • As the case study only gives a limited amount of information about Jackson, you can make additional assumptions or inferences about him (e.g. background, experiences), but you should use the introduction to state these.
• Part: Psychological causes of Jackson’s sports injury
  • In this part, you should identify any psychological factors that could have increased Jackson’s risk of injury.
  • You may find it helpful to consider Jackson’s injury risk in relation to the stress and injury model (Session 3 of the BOC). Information below

Session 3 of BOC:

1. Causes of sports injury

Sport injuries can be caused by a wide variety of factors. These factors can be grouped into four main areas: physical, environmental, socio-cultural and psychological (Wiese-Bjornstal and Shaffer, 1999) as illustrated in Figure 1.

Causes of Sports Injury:

• 1:Physical- Fatigue, overuse, muscle imbalances
• 2:Enviromental- Slippery surfaces
• 3: Socio-cultural: No Pain, no gain
• 4:Psychological- Stress, personality

Figure :1: Causes of sport injury (Wiese-Bjornstal and Shaffer, 1999)

Physical and environmental factors are perhaps more obviously associated with injury, but the links between socio-cultural and psychological factors and injury are less obvious. Socio-cultural factors relate to the culture and attitudes that are often adopted within sport, which could encourage the development of a sports injury. Some examples of the attitudes that could increase the risk of injury include: the belief that pain tolerance demonstrates strength and toughness, an acceptance that pain and injury are part of sport (‘no pain, no gain’), and an unwillingness to seek medical treatment for fear of appearing weak (Wiese-Bjornstal and Shaffer, 1999).

Meeuwise et al. (2007) suggest that the risk factors for developing an injury can be split into intrinsic risk factors and extrinsic risk factors:

• Intrinsic risk factors are those that are internal or personal to the individual and can include physical variables (such as age, strength, flexibility, and previous injury) and psychological variables (such as self-concept and personality) (Brewer and Redmond, 2017).
• Extrinsic risk factors are those external to the individual and can include sport-related variables (such as type of sport, rules, opponent/teammate behaviour), equipment and weather conditions (Brewer and Redmond, 2017).

 Next you’ll look at psychological factors in more detail.

2. Which psychological factors increase injury risk?

In the previous section, you identified that there are various factors that can increase the risk of developing a sports injury, including psychological factors. In this section, you will begin to explore what these psychological factors are and how they can potentially increase the risk of injury. There are two main psychological factors that have been identified as potential antecedents of sport injury – stress and personality. These both feature in a key model in this field – the Stress and Injury model (Williams and Andersen, 1998).

The Stress and Injury model (Figure 2) can be used to explain how psychological factors increase the risk of sport injury. When exposed to a potentially stressful situation the individual’s stress response will dictate whether or not an injury occurs. This stress response is influenced by three key things – personality, history of stressors and coping resources – and can be mediated through the use of interventions.

Case study: Applying the Stress and Injury model to Travis’s injury

In the weeks leading up to his injury, Travis had been under a lot of pressure at work as he had been promoted into a new role and was in charge of bidding for a new contract for his company. This led him to feel very stressed, and he didn’t feel that he was coping very well with the stress of his new job role. Travis has always found it difficult to cope with high-pressure situations. He has been finding it hard to switch off from work and was consequently feeling very tense. He had been experiencing muscle tension in his shoulders and had been short-tempered at home in the days leading up to his injury.

He came to the gym following an argument with his husband, Trevor, on the day that he sustained his rotator cuff injury during a heavy weight lifting session. When talking to his physiotherapist,t Lydia, he said that he had been quite distracted thinking about both the argument and the contract he was bidding on at work (the main source of his work-related stress). He felt that this caused him to use poor technique when lifting the bar, which may have led to the injury.

Discussion

If you apply the Stress and Injury model to Travis’s case study, you can see that Travis’s new job and being in charge of bidding for a new contract at work is a potentially stressful situation that Travis has cognitively appraised as being stressful. This appraisal has caused attentional changes (Travis was distracted when lifting weights as a result of thinking about the argument and the contract) and physiological changes (muscle tension in his shoulders) that could have led to his injury.

As the model shows, Travis’s cognitive appraisal and stress response has been influenced by personality factors (it seems that Travis is prone to finding it difficult to cope with high pressure situations), history of stressors (e.g. the change in job, argument with his husband) and a perceived lack of coping resources (he doesn’t feel he was coping well with the stress of his new job). The model suggests that interventions (strategies or techniques to help him manage stress) may have reduced his risk of developing an injury. As Travis didn’t use any such interventions, the injury was more likely to occur. You will explore interventions to help reduce injury in the Session.

 Having explored the Stress and Injury model, you’ll now examine some of the mechanisms to explain how stress can lead to injury.

3. How can stress increase the risk of injury?

You have seen that stress can be a significant predictor of sport injury, but how exactly can stress lead to a sport injury?

In this section, you will explore some of the mechanisms proposed to explain this relationship. The core of the Stress and Injury model (Figure 3) that you explored in the previous section indicates that physiological/attentional responses are responsible. More specifically, three key mechanisms were proposed by Andersen and Williams (1988) in the original version of the model:

• Distraction

I was so preoccupied by the argument I’d had with my husband before I went to the gym that I just wasn’t concentrating on lifting properly.’ (Travis)

This mechanism suggests that when people are stressed they fail to pay attention to vital cues (e.g. the position of other players) in the sport or fitness environment around them. This can lead to injury when a missed cue leads to an event such as a misstep (Brewer and Redmond, 2017).

•  Attention narrowing

I was so stressed that I wasn’t focusing on what was going on around me and I just didn’t see the tackle coming.’ (Nala, rugby player)

Stress can lead to narrowing of the peripheral field of vision. This means that individuals may miss vital cues in their periphery, which can increase the risk of injury (e.g. an incoming tackle) (Andersen and Williams, 1988).

•  Muscle tension

I was so stressed that I had a lot of tightness and tension around my shoulders when I walked into the gym that day.’ (Travis)

It is suggested that stress can lead to the somatic (i.e. physiological) response of muscle tension, which interferes with flexibility, coordination and fluidity of movement, thus increasing the risk of injury (Brewer and Redmond, 2017). This inefficient movement may also lead to greater perceptions of fatigue, which could also increase the risk of injury.

3.1 Other proposed stress-injury mechanisms

In addition to distraction, attention narrowing and muscle tension, other mechanisms have also been proposed to explain how stress can lead to sport injury, including: immunosuppression, disrupted tissue repair, sleep disturbance and altered self-care (Petrie and Perna, 2004). These are summarised in Table 2 below.

As you will see, some of these factors are linked to each other as well as to the mechanisms of distraction, attention narrowing and muscle tension discussed earlier. For example, sleep disturbance may lead to distraction. It is important to recognise that in practice it might be multiple mechanisms acting together that lead to the development of a sports injury.

Table 2 Other stress-injury mechanisms (adapted from Brewer and Redmond, 2017, pp. 35–36)

Immuno-suppression: Chronic (long-term) stress has been linked to suppression (reduced functioning) of the immune system which can increase injury risk.

Disrupted tissue repair: Stress can increase the secretion of the hormone cortisol, which can inhibit processes involved in healing muscle and other body tissues.

Sleep disturbance: Stress can interfere with the quality and duration of sleep. This can lead to factors that might cause an injury such as reduced reaction time, increased aggression, reduced concentration, distraction, or impaired decision-making.

Altered self-care: Stress can cause an individual to take less care of themselves. As a result, they may fail to engage in activities that help prevent injury, such as healthy eating, hydration or adequate warm-up.

How can personality increase the risk of injury?

Most research exploring the effect of psychological factors on injury risk has examined the relationship between stress and injury. However, much research has also been undertaken examining the link between personality and injury.

 As you saw in Section 2, personality is also a component of the Stress and Injury model (Figure 2) where it is suggested that personality factors (e.g. competitive trait anxiety) can be a moderator of the stress response, influencing for example how likely someone is to perceive (cognitively appraise) a situation as stressful. These personality characteristics can be split into:

• Positive personality traits – traits that allow the individual to perceive a situation as challenging rather than threatening, thus resulting in a lower stress response and lower risk of injury, and
• Negative personality traits – traits that lead an individual to perceive a situation as threatening, thus resulting in a higher stress response and higher risk of injury (Appaneal and Habif, 2013).

A wide range of personality characteristics have been investigated as being linked to sport injury risk. In their review of forty-five research studies, Appaneal and Habif (2013) identified more than twenty personality characteristics but suggest that three have received the most attention – anxiety, locus of control and mental/emotional states. You will explore these in the next activity.

The main learning points from this session are:

• Injuries can be caused by physical, environmental, socio-cultural, and psychological factors.
• Stress and personality are the two main psychological factors that have been investigated.
• The Stress and Injury model (Williams and Andersen, 1998) explains the links between stress, personality,y and injury.
• Stress can potentially increase the risk of injury by various mechanisms such as distraction, attention narrowing, muscle tension, immunosuppression, and sleep disturbance.
• Personality factors such as competitive trait, anxiety, and negative mood may increase the risk of injury.

Why would psychological interventions work?

You begin your investigation of psychological interventions to prevent or reduce the risk of sport injury by reflecting back on what you have learned so far and considering how and why psychological interventions might work.

As you saw in Session 3, those with greater levels of stress are at higher risk of developing a sports injury. Therefore, it is intuitive to think that stress management strategies aimed at helping the individual to control their stress levels would reduce their risk of injury. Research evidence supports this (Gledhill, Forsdyke, and Murray, 2018), as you will examine later in this session. The Stress and Injury model (Williams and Andersen, 1998) (Figure 2 of Session 3) identifies ‘coping resources’ as mediating the stress response. Coping resources can be defined as ‘behaviours and social networks that help the individual deal with the problems, joys, disappointments and stresses of life’ (Andersen and Williams, 1988, p. 302).

Stress management strategies can therefore be thought of as a coping resource. Such strategies can work by either:

• changing the perception of an event (i.e. not perceiving an event as stressful), or
• by buffering the effects of a stressful event (i.e., minimising the symptoms of stress).

You will examine a range of stress management strategies in the next section. As distraction and attention narrowing are two proposed mechanisms for how stress can lead to an injury,y you may also have thought that psychological techniques aimed at improving concentration could be beneficial. Concentration training may improve the individual’s focus and prevent them from being distracted and missing important cues.

There is debate around whether personality traits (characteristics) can be changed, but stress management strategies may also help to reduce characteristics such as anxiety and anger that you looked at in Session 3

What psychological interventions?

A wide range of psychological interventions has been used to reduce the risk of injury (Brewer and Redmond, 2017), including those summarised in interactive 

Imagery

Imagery can be defined as the process of ‘using one’s senses to re-create or create an experience in the mind’ (Vealey and Forlenza, 2015, p. 240).

Goal setting

Goal setting refers to the process of setting goals, and a goal can be defined as the object of a person’s effort which involves attaining a specific standard of proficiency in a task (Gould, 2015).

Relaxation techniques

Relaxation techniques are interventions that aim to reduce physiological arousal and anxiety symptoms (Hanton et al., 2015)

Social support

Social support can be defined as ‘an exchange of resources between two individuals perceived by the provider or the recipient to be intended to enhance the well-being of the recipient’ (Corbillon et al., 2008, p. 94).

Positive self-talk

As its name suggests self-talk refers to the things people say to themselves (their internal dialogue) and can occur out loud or in your head (Williams et al., 2015).

Cognitive restructuring

Cognitive restructuring refers to the reinterpretation of symptoms from a negative (debilitative) to positive (facilitative) (Hanton et al., 2015).

Biofeedback training

Biofeedback is where people receive information about one or more of their physiological processes (e.g. muscle activity, heart rate, skin activity) to encourage greater self-awareness and control (Brewer and Redmond, 2017).

Stress inoculation training

Stress inoculation training involves using a variety of techniques (imagery, self-talk, and relaxation) together to progressively rehearse exposing the individual to increasingly stressful situations whilst practising relaxation to gradually desensitise or ‘inoculate’ the individual to the stressful situation (Hanton et al., 2015).

The exact techniques that a sport and exercise psychologist would recommend would depend on the individual’s needs as Amir demonstrates in the quote below.

I would always recommend psychological interventions on an individual basis. What’s right for one person isn’t necessarily right for the next person. I like to find out about the individual and conduct a kind of needs analysis first. When prescribing stress management strategies, I often try to match the type of symptoms with the intervention. For example, if the individual is experiencing somatic or physical 

symptoms such as muscle tension then I might prescribe a physically based intervention like controlled breathing. Likewise, if the individual is experiencing cognitive or psychological symptoms like negative thoughts, I might prescribe a more cognitive intervention like functional self-talk. Often, though, it’s not as simple as that, and people experience a combination of symptoms. (Amir, sport and exercise psychologist)

 Are psychological interventions effective? Various studies have indicated that psychological interventions are effective in reducing the risk of sport injury. For example:

• In their systematic review of psychological interventions to reduce sport injury, Gledhill et al. (2018) reviewed thirteen papers and found that 93% reported a reduction in injury rates. These studies predominantly involved stress management-related interventions and used the Stress and Injury model as a framework.
• Similarly, a meta-analysis (a study which statistically combines the results from multiple research studies) of fifteen studies by Tranaeus et al. (2015) concluded that psychological interventions have a large effect on injury reduction.
• A further meta-analysis by Ivarsson et al. (2017) revealed decreased rates of injury in the treatment groups (those who used interventions) compared to the control groups (those who didn’t use interventions) in the seven injury prevention studies they examined.

In the next activity,you will explore one particular study in more detail by reading the box below.

Box 1 Research: The effectiveness of a stress management intervention

 Purpose:

To measure the effectiveness of a three-month stress management programme designed to reduce the incidence of sport injury.

Participants:

63 male youth football players aged 17–19 years from four Spanish national youth league teams. 35 of these participated in a stress management programme (intervention group) and 28 did not (control group).

Stress management programme intervention:

The stress management programme was designed to teach the players to cope with stress. It required the players to attend a weekly one-hour session for three months and included the following modules:

• linking thoughts and emotions
• progressive muscle relaxation, breathing, imagery, passive and differential muscle relaxation
• self-instructional and attention-focus training
• stress inoculation training

It was based on a method called Stress Inoculation Therapy (SIT), which aims to teach people about stress and how to manage it. SIT aims to progressively expose the individual to stressful situations, gradually ‘inoculating’ the events that might trigger a stress response in order to increase the participant’s ‘resistance’ to stress.

Findings:

The average number of sports injuries experienced per month was recorded before and after the stress management programme intervention. Before the intervention, the number of injuries was similar for the intervention and control groups, but following the stress management program, the intervention group experienced significantly fewer injuries than the control group.

(Olmedilla-Zafra et al., 2017)

 The main learning points from this session are:

• As stress is considered to be a potential cause of sports injury, any intervention aimed at reducing stress (or the individual’s response to it) could potentially reduce injury risk.
• A wide range of interventions have been used, including imagery, positive self-talk and relaxation techniques.
• There is strong research evidence to support the role of psychological interventions in reducing injury risk.

Unit 16

 The challenges of researching injury prevention

In Session 4 of the BOC you were introduced to a range of psychological interventions that could potentially reduce the risk of developing a sports injury. As part of this we briefly examined the findings of three review papers (Tranaeus, Ivarsson and Johnson, 2015; Ivarsson et al., 2017; Gledhill, Forsdyke and Murray, 2018), which all concurred that psychological interventions are effective – but how easy is it to measure how effective a psychological intervention is at preventing sport injury? Imagine you have been tasked with conducting some research to examine the effectiveness of a particular psychological intervention on injury prevention. 

Interventions to reduce injury vulnerability

 

1. The literature review resulted in 48 published studies containing 161 effect sizes for injury prediction and seven effect sizes for injury prevention. Seven studies found fewer injuries in the intervention groups in comparison to the control group, with the greatest reductions occurring when at-risk populations are targeted.

2. What interventions did Johnson et al. (2005) provide and find?

Johnson et al. (2005) provided six intervention sessions and two telephone contacts consisting of treatments such as stress management skills, somatic and cognitive relaxation, goal-setting skills, and attribution and self-confidence training.

• You may find it useful to refer back to Sessions 3 and 4 of the BOC and Unit 16 of Study Topic 5.

• Part: Psychological responses to sport injury
  • In this part you should identify Jackson’s psychological responses to injury and apply his case study to at least one relevant model from the study materials (e.g. a grief response model or cognitive appraisal model).
  • You should critique the model that you select, outlining any research in support of it and any limitations of the model.
  • You may find it useful to refer back to Sessions 5 and 6 of the BOC and Unit 18 of Study Topic 5 (Sections 18.2 and 18.3).

Session 5 BOC BELOW

How does a sports injury make people feel?

If you have ever experienced a sports injury, you will have firsthand experience of how having an injury can make people feel. Being involved in sport can become a significant part of people’s lives. In fact, some people have a very strong athletic identity, where their personal identity is strongly attached to being a sportsperson (Brewer et al., 1993). When an injury occurs, and sports participation is consequently either restricted or stopped, that identity can be lost, which can lead to several psychological reactions.

England footballer Danny Rose described feeling very angry and experiencing depression after a knee injury that occurred in 2017, which took him away from playing for eight months.

I was getting very angry, very easily. I didn’t want to go into football, I didn’t want to do my rehab, I was snapping when I got home; friends were asking me to do things, and I wouldn’t want to go out, and I would come home and go straight to bed.

(Danny Rose in Kelner, 2018)

1. What are some of the psychological responses Helen has experienced in response to sport injury?

1. Helen describes various psychological responses to sport injury. These include feelings of isolation, fear, anxiety and hopelessness. She also discusses feeling a loss of identity when not being able to play hockey, which links to the concept of athletic identity discussed at the beginning of this section. As a full-time hockey player, Helen might be expected to have a strong athletic identity and to see a large part of her identity as a hockey player.

2. What other negative psychological responses might a sport injury elicit?
3. Common negative psychological responses to injury include:
4. • loss of identity
   • anger
   • fear
   • depression
   • reduced motivation
   • grief
   • loneliness
   • stress
   • anxiety
   • low self-esteem, and 

Predicting how individuals will respond to sports injury From the bottom quarter of the picture, a man looks upwards to a blackboard on which is drawn a large think bubble. This large think bubble is connected to the man’s head by small bubbles.

Figure 2: Responses to sport injury

This is where models of psychological response to injury are beneficial. They provide a framework to aid our understanding of how individuals respond to injury and the impact this might have. There are two groups of models that you will explore in this course:

• grief response models, and
• cognitive appraisal models.

You will look at one example of a grief response model (Kübler-Ross, 1969) and two examples of cognitive appraisal models (Brewer, 1994; Wiese-Bjornstal et al., 1998).

1. What are grief response models?

Grief response models assume that injury constitutes a form of loss to the individual and thus the onset of a grieving process. They suggest that an individual will respond to injury in the same way in which people respond to other significant losses, such as the death of a loved one (Brewer, 1994; Evans and Hardy, 1995). This involves progressing through a series of sequential stages. The number of stages varies from model to model, but in Kübler-Ross’s (1969) Grief response model – which has been most commonly applied in the sport injury psychology literature (Walker et al., 2007), there are five stages.

2. What are cognitive appraisal models and how do they differ from grief response models?

In contrast to grief response models, cognitive appraisal models take individual differences into account. They do not assume that everyone will react in the same way to injury. Instead, they suggest that how an individual interprets or appraises the injury (cognitive appraisal) will determine their psychological reactions. This allows two people to exhibit entirely different psychological responses to the same injury. Therefore, it is the perception of an injury that affects psychological responses, rather than the injury itself.

3. What are the differences and similarities between the two cognitive appraisal models examined in the video?

Both cognitive appraisal models suggest that how an individual interprets or appraises their injury is influenced by two key variables – personal and situational variables – and that cognitive appraisal influences emotional and behavioural responses to injury. The main difference between the models is that the Integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998) is a more comprehensive model – this model also incorporates psychological factors that increase the risk of injury. The Integrated model has been widely applied within the sport injury psychology literature (Brewer and Redmond, 2017).

Case study: Lois’s longer-term response to her sports injury

When Lois first became injured, she was extremely upset and angry as she felt that her world had fallen apart. Her whole life was centred on athletics and her goal of being a successful athlete. She was angry because she felt that the injury was taking her dreams away from her. Initially, she refused to accept the diagnosis and was adamant that she would return to training and competition long before her physiotherapist suggested.

Gradually, she has grown to accept that the injury will cause her to miss a long period of training and competition. She finds this very frustrating and feels jealous when she hears other athletes talking about training sessions or competitions they have undertaken. She is trying to focus her attention on her rehabilitation programme, but she is feeling very demotivated and down as she finds her rehabilitation programme very boring in comparison to athletics training. Consequently, her adherence to her rehabilitation sessions has not been very good.

Lois is also starting to experience doubts about her ability to recover from the injury and to regain her pre-injury form when she does return. She is looking forward to eventually returning to training but is worried about re-injuring herself and sometimes experiences flashbacks of when the injury occurred.

Reveal Discussion: 

As you examine Lois’s case study, you can probably see some evidence of all five stages of Kübler-Ross’s (1969) model, although the stages do not necessarily occur in the specified order (for example, anger seems to come before denial). The main limitation of grief response models is their rigidity: they assume that every person is the same and that consequently, all people will react to a sports injury in the same stereotypical way. In practice, this is not the case – Lois may react in a completely different way to her injury than another athlete with the same injury. Due to these limitations, cognitive appraisal models have come to be more widely accepted as models of psychological reaction to injury than grief response models, as they allow for individual differences.

The two cognitive appraisal models demonstrate that Lois’s poor adherence is likely to be a consequence of her individual cognitive appraisal of the injury and her subsequent emotional responses (e.g. frustration, jealousy, boredom). It is important to note that the appraisal of an injury is not static, and neither are its consequences. Appraisals are likely to change as the injury progresses and possible setbacks are experienced. This is demonstrated in Lois’s reactions to her injury, which progressively changed over time.

You will find that Wiese-Bjornstal et al.’s (1998) Integrated model is a far more extensive model that considers a wealth of personal and situational factors that can influence cognitive appraisal and consequent recovery outcomes. Unlike the other models you have explored in this session, this model also incorporates (at the top) psychological factors that increase the risk of injury. It is therefore a comprehensive model that incorporates both psychological factors that may increase the risk of injury and psychological reactions to injury.

The models you have explored indicate that our psychological responses to a sport injury can shape our behavioural response (e.g. our adherence to rehabilitation sessions) and our recovery outcomes (e.g. how the injury heals). You will explore this more in the next session.

Exploring the psychological aspects of sport injury

Following her injury Lois has been feeling quite down. She is struggling with not being able to train and compete, and is missing being part of her training group. Her coach, Wilm, has noticed that she has been withdrawn and quiet and not her usual bubbly self. Lois has told Wilma that, as well as being frustrated about not being able to run, she feels socially isolated, as most of her friends are athletes.

Wilma has also learned that Lois has not been attending all of her rehabilitation sessions at the sports medicine clinic. In the last few weeks, she has only been to fifty per cent of her scheduled sessions. The physiotherapist has noted that she doesn’t seem very motivated in these sessions and isn’t working as hard as she could. Additionally, Lois has not been engaging in her daily rehabilitation exercises at home. The physiotherapist has referred her for a session with the sports psychologist at the clinic to try and get her back on track.

When Wilma asked Lois about the rehabilitation sessions, she seemed very depressed and her response was, ‘What’s the point? – My career is probably over anyway. This does not match with the physiotherapist’s diagnosis, who believes she can make a full recovery 

Reveal Discussion:

It appears that Lois’s low mood is negatively impacting on her adherence to her rehabilitation programme, which in turn will slow her recovery from the injury. Because Lois is feeling down, she doesn’t have the motivation to work hard on her rehabilitation. As the cognitive appraisal models show, Lois’s cognitive appraisal of the injury results in a negative emotional response and an inappropriate behavioural response (poor adherence). This, in turn, is having a negative impact on her recovery outcomes (slowed recovery).

Discussion:

Travis is really missing the buzz of going to the gym every day and can’t wait to get back to full fitness and resume his normal fitness regime. He has experienced feelings of sadness, anger and frustration about being injured, but is now determined that he is going recover as quickly as possible. He is in denial about the extent of his injury and believes that he will recover much quicker than his physiotherapist, Lydi, has suggested.

Travis turns up on time for every rehabilitation session and works hard in every session, but Lydia is concerned that he is pushing too hard and ignoring her advice to slow down. She believes that he is doing his rehabilitation exercises at home more frequently and at a higher intensity than she has prescribed. She recently saw him leaving a circuit training class, even though he had agreed that he would take two weeks off from the class. She is concerned that if he doesn’t take her advice, he will aggravate his shoulder injury and consequently delay his recovery even further.

Reveal DISCUSSION:

Discussion

Travis appears to have the opposite problem to Lois – over adherence. While Lois has lost her motivation, Travis is highly motivated, but to his detriment because he is trying to do too much too soon.

This is very similar to the wrestler Adam Coon in the video who slowed his recovery by working too hard. If you relate this to cognitive appraisal models, you could say that Travis’s cognitive appraisal of his injury (‘it’s not that bad’) is resulting in an inappropriate behavioural response (over-adherence). This, in turn, is having a potentially negative impact on his recovery outcomes (re-injury and slowed recovery). 

Do reactions to injury change over time?

Time may be a great healer, but is that true of sports injuries? Do psychological reactions to injury change over time?

Grief response models suggest that they do, but as you have seen, grief response models have limitations. It is intuitive to believe that over time,e an individual may feel differently about their injury, and indeed this does seem to be the case. For example, Forsdyke et al. (2016) found in several of the studies they reviewed that as rehabilitation progressed closer towards the point where individuals returned to sport, they began to develop a more positive mood. However, Forsdyke et al. (2016) also found that performance-related anxiety often increased as individuals prepared to return to sport following injury.

Similarly, Ardern et al. (2013), in their review of eleven studies, found that while emotions generally become more positive as rehabilitation and recovery progress, fear is a prominent emotion when an individual returns to sport. Emotions can fluctuate and therefore, as an individual progresses through their sport injury journey, they will likely experience highs and lows and fluctuating psychological states.

Next, you will explore how Lois’s feelings about her injury have changed over time.

Case study: Lois’s rehabilitation progress

Since having a session with her sport psychologist Amir, Lois has started to feel a bit more motivated. Amir has helped her to put things in perspective and to focus on developing a more positive attitude towards her recovery. Lois has begun to accept the injury and has become more determined. As a consequence, her adherence to rehabilitation sessions has drastically improved and she is starting to see some progress. This is making her feel more optimistic about her recovery.

Amir has taught Lois some techniques she can use to help her manage her emotions and to get through difficult times. To address her feelings of isolation from her training group, Lois now does her rehabilitation exercises at the track while they are training. She is also helping Wilma to coach some of the younger athletes.

Reveal Discussion

Lois appears to have moved from a negative mindset to a more positive one. She was previously feeling quite down (Activity 1). The session with the sports psychologist has boosted her motivation and increased her adherence to her rehabilitation sessions, which will, in tur,n have a positive impact on her rehabilitation outcomes. Sport injury-related growth. Before concluding this session, it is important to note that sports injury can lead to positive as well as negative experiences. You have learned that responses to injury can be positive rather than negative, for example, where an injury is interpreted as providing a break from intensive training or as an excuse for poor performance. Individuals who have positive responses may not want to recover quickly and consequently may not engage with rehabilitation activities and are sometimes termed ‘malingering athletes’ (Brewer and Redmond, 2017). Positive experiences can, however, also be derived by individuals who interpret injury as negative. This can be termed ‘sport injury-related growth’ and can be 

defined as ‘perceived changes that propel injured athletes to a higher level of functioning than that which existed before their injury’ (Roy-Davis et al., 2017, p. 36).

Research has consistently demonstrated that positives (growth) can be derived from the negative experience of sport injury (Salim and Wadey, 2018). In a study by Wadey et al. (2013) eight coaches were interviewed about the growth they perceived injured athletes to experience. Four categories of growth were identified:

1. Personal growth – development of beliefs, attitudes, knowledge, priorities, outlook and general qualities
2. Psychological growth – development of sporting qualities and coping skills
3. Social growth – development of social support
4. Physical growth – development in strength and conditioning.

 

Those who have experienced sport injury often find that being injured can lead to several negative psychological reactions. However, despite this, it is also possible for these individuals to derive positive benefits (growth) from their injuries. In this activity you will explore some of these potential benefits.

Watch Video 2 below in which former heptathlete Jessica Ennis-Hill discusses some of the positive consequences she derived from being injured. As you watch the video:

1. Categorise each of the positive consequences she mentions under one of the categories of sport injury-related growth identified by Wadey et al. (2013):
   • personal growth
   • psychological growth
   • social growth
   • physical growth.
2. Identify any further examples of positive benefits that injured athletes (including Lois and Travis) may experience that would fit under these four categories.

The video starts with Jessica Ennis-Hill stating that she believes injury made her stronger and concludes with her saying that her performance improved as a result of injury. This demonstrates that she experienced sport injury-related growth.

Some of the comments she made in the clip have been integrated into the table below, along with some examples of quotes from Travis and Lois that also fit under the four categories of sport injury-related growth identified by Wadey et al. (2013). You may have come up with several other examples of your own.

Category- Personal growth ·         it just gave me a bit of time to, you know, step back from the sport and really think about what I’d achieved so far, and also what I wanted to achieve from my career. (Jessica Ennis-Hill) ·         I now know that I can overcome injury. (Travis) ·         Being unable to train just made me appreciate how important athletics is to me and how much I love it. (Lois) ·         The break gave me a chance to develop my identity outside of my sport. (Lois) Psychological growth- ·         coming back this year just made me even more hungry for a medal. (Jessica Ennis-Hill) ·         My motivation to train has increased dramatically. (Travis) ·         My imagery skills have developed. (Lois) ·         I feel mentally stronger than ever before. (Travis) Social growth- ·         My relationship with my coach has got even stronger as a result of being injured. (Lois) ·         As a consequence of being injured I’ve developed a stronger network of people to support me. (Travis) Physical growth- ·         also gave me time to just take a step back and let my body freshen up and just take a rest … (Jessica Ennis-Hill) ·         I feel like my fitness has actually improved through being injured (Travis) ·         Being injured has given me the opportunity to really develop my upper body strength (Lois)

 

Whilst there is evidence to suggest that psychological interventions are beneficial to recovery from sport injury, the use of such interventions is relatively low. In their study of 1283 injured athletes from three countries (United States, United Kingdom, and Finland) Arvinen-Barrow et al. (2015) found that only 27% had used psychological interventions during sport injury rehabilitation. However, the vast majority (72%) of those that used such interventions felt that it helped them to recover quicker, with the three most commonly used interventions cited as goal-setting, positive self-talk, and imagery. 

Psychological intervention in sport injury: mechanisms

The previous section has demonstrated that there’s considerable evidence to show that interventions such as imagery, self-talk, relaxation techniques, goal-setting and social support can benefit sport injury rehabilitation, but how do they do this? What are the mechanisms?

 Various studies have identified that social support from key people such as sport medicine staff (Yang et al., 2014) and coaches (Newman and Weiss, 2018; King et al., 2023) enhance sport injury rehabilitation. Two main mechanisms have been proposed to explain how social support benefits sport injury rehabilitation – ‘stress buffering’ and ‘main effects’ (sometimes called ‘direct effects’) (Mitchell, 2011). As its name suggests, the stress buffering mechanism proposes that the presence of social support during rehabilitation can protect against the stresses of rehabilitation thus influencing the injured person’s cognitive appraisals (Forsdyke and Gledhill, 2014). The main effects mechanism proposes that social support has a more direct effect on psychological and physical well-being by, for example, offering the potential for more realistic recovery expectations and better rehabilitation compliance irrespective of stress levels (Clement and Shannon, 2011; Forsdyke and Gledhill, 2014). Various studies have found support for both mechanisms, including Mitchell et al. (2014) whose research is summarised in the box below.

Research summary (Mitchell et al., 2014)

Stressors, social support, and tests of the buffering hypothesis: Effects on psychological responses of injured athletes

• Part: Psychological intervention/skills programme
• Identify which three interventions might be useful to help Jackson through his sport injury rehabilitation.
• Explain why these interventions would be beneficial, and provide supporting research evidence.
• You should discuss the interventions specifically in relation to Jackson’s case study.
• You may find it useful to refer back to Sessions 7 and 8 of the BOC and Unit 18 of Study Topic 5 (Sections 18.4 and 18.5).

The benefits of sport psychology intervention

Using psychological interventions for people with a sports injury can lead to several benefits, such as:

• increased adherence to rehabilitation programmes
• more positive attitude towards recovery
• increased motivation
• pain management
• enhanced coping skills
• reduced stress, anxiety and depression, and
• enhanced healing.

(Petitpas and Danish, 1995; Heil and Fine, 1999; Wiese-Bjornstal and Shaffer, 1999; Williams and Scherzer, 2006)

1. Watch the video below of 2016 Olympic hockey champion Helen Richardson-Walsh. What are some of the psychological strategies she used to aid her recovery from injury?

Helen describes three key strategies that she used, all of which are discussed in either this session or in Session 8. First, she used goal setting to help her focus. Second, she visualised herself achieving her goal of becoming Olympic champion (imagery), and finally she used a blog as a way of sharing and articulating her experience and connecting to other people (social support).

2. Reflect on any role you have in supporting individuals with sport injury (e.g. coach, instructor, team mate, partner). Which aspects of your work could be considered to be psychological strategies or techniques? If you don’t hold such a role think about how you have been supported when you’ve been injured or how you might like to be supported if you were injured.

You might find that you tend to use a lot of psychology in your day-to-day practice without even realising it. Sometimes this use of psychology is explicit (for example, recommending the use of psychological techniques or referring someone to a sport and exercise psychologist), and sometimes it is less explicit (for example, the way in which you choose to speak to an individual about their injury).

Imagery in sport injury rehabilitation

In sport you often see athletes appearing to run through a performance in their mind before executing it (for example, a high jumper before a jump). This is an example of imagery A female in everyday clothes is standing with crutches in a dingy room. She is in profile, facing to the right. On the wall behind her is her shadow, which shows her running. The implication is that she is remembering with regret her time before she was injured.

Figure 2 Imagery can aid sport injury rehabilitation

Imagery can be defined as the process of ‘using one’s senses to re-create or create an experience in the mind’ (Vealey and Forlenza, 2015, p. 240). Imagery can be a useful technique for individuals to use during sport injury rehabilitation. It can be used in many different ways, including those outlined in Figure 3.

 Those who are injured to the extent that they are unable to physically practice their sports skills can mentally practice, in order to minimise losses of skill that naturally occur in the absence of physical practice. There is evidence to suggest that mental practice is better than no practice at all and that mental practice stimulates the muscles involved (Green and Bonura, 2007).

Stress and anxiety are common responses to sport injury, but imagery is an effective way to combat them. Imagery of being in a relaxing place (for example, lying on a beach) can be used as a stress management or anxiety control technique.

Individuals can be encouraged to undertake imagery to distract them from the pain of treatment. For example, imagery of placing an ice pack on an injured area may help with pain management.

There is some evidence to suggest that imagining injured tissues healing can actually speed up the healing process. An individual might, for example, imagine healing blood cells being delivered to the injured area or tissues re-aligning. This might involve anatomically correct imagery or representative imagery (e.g. imagining an army of soldiers rebuilding your injured tendon). 

Use Imagery to help the 2 athletes below:

 Select one of our two case studies below (Lois or Travis) and read up on their progress. Make a list of how they could use imagery during their recovery from injury.

 Lois has gone to see her sport psychologist Amir. They have been discussing how difficult she finds it to cope with the pain of the treatment that she is having on her Achilles tendon during physiotherapy sessions.

Lois has asked Amir if he can recommend any techniques to help her as the pain is so intense that it’s causing her to tense up which makes it much harder for the physiotherapist to work on the injured area.

Case study: Travis

Travis has been experiencing a lot of stress and anxiety due to his injury. Normally he would use exercise as a way of dealing with stress, but the injury is preventing him from exercising as he would like. He therefore needs to find an alternative way to relax and unwind.

Discussion

All four examples of imagery in Figure 3 could be effective for both Lois and Travis. Pain management imagery would be particularly appropriate for Lois, while relaxation imagery would be particularly useful for Travis. Here are their thoughts on using these techniques:

I tried using the pain management imagery Amir suggested during my physiotherapy session today. I used it right at the point where the physio was really digging her fingers into my tendon which is when I normally tense up or flinch. I was amazed how well it worked – I coped with the pain so much better and the physio was able to do more work on it than normal.

(Lois)

I’ve started doing relaxation imagery every evening. At first it felt a bit weird but now I’m getting used to it and it’s really working. When I get in from work, I’m often feeling stressed and need to unwind, so now I lie down and take myself to my relaxing place in my mind and it calms me.

(Travis)

3.1 Self-talk in practice

According to Hardy (2006) there are two main types of self-talk:

• instructional (or cognitive) self-talk – this tells or reminds people what to do (e.g. ‘relax’), and
• motivational self-talk – this encourages people in some way (e.g. ‘I can do this’).

It is suggested that instructional self-talk is effective in enhancing or directing attention, while motivational self-talk is effective in increasing confidence and motivation and regulating effort. Below are some examples of motivational and instructional self-talk used by our case studies Lois and Travis:

When the physio is about to do some painful treatment on my Achilles, I take a deep breath and say the word ‘relax’ to myself.

(Lois – instructional self-talk)

Every morning now I wake up and say ‘I will get back to fitness’ to myself.

(Travis – motivational self-talk)

When I’m coaching at the track I look at the other athletes running fast and think ‘I will be back running with them soon’.

(Lois – motivational self-talk)

Discussion

1. In the video Kally Fayhee describes three main stages:
   • paying attention to her thoughts (self-awareness)
   • slowing down and thinking about what she would say to a friend (rationalising), and
   • reframing her thought into a positive one (identify and reframe).
2. Think of a time when you have said negative things to yourself (for example, when you have been lacking confidence about a particular task, or when you have been injured). Write down some of the negative statements you have said to yourself in the first column of the table below, then write down a counteracting positive statement that you could have said to yourself instead.

Discussion

2. It’s a useful exercise to think about when you yourself might be using negative self-talk and to consider the impact those negative thoughts have on you. Being able to counteract negative statements with positive statements is a useful tool. Try using this technique next time you catch yourself saying negative things to yourself. Injury is a time when negative thoughts can be common and therefore this can be a useful strategy to counteract them

Relaxation in practice

Progressive muscle relaxation (PMR)

PMR involves tensing and relaxing various muscles in the body in a sequential order. The technique aims to help the athlete recognise the difference between tension and relaxation, thus making relaxation easier.

Relaxation imagery

As you saw previously, imagery of being in a relaxing place (e.g. lying on a beach) can also be effective in producing a relaxation response.

Music

Music has a great capacity to induce a relaxation response and therefore playing music in your treatment room could be beneficial.

If you use music, it is worth discussing music preferences with the individual as what is relaxing for one person may not be for another! There are many commercially available relaxation CDs and music downloads.

Controlled breathing

Our breathing rate is generally increased when we are stressed or anxious. Controlling and slowing down our breathing normally triggers a relaxation response.

Therefore, breathing exercises can help us to relax and control anxiety. There are lots of different breathing exercises including:

• rhythmic breathing (e.g. breathing in for a count of four and breathing out for a count of four) and
• ratio breathing (e.g. breathing in for a count of four and breathing out for a count of eight).

Select one of the relaxation techniques from Figure 6 and then watch the associated video and undertake the technique. Evaluate how effective you found the technique by answering the following questions:

• How did the technique make you feel? Was it effective in making you feel relaxed?
• How easy or difficult did you find it to undertake the task?
• Do you think you would use this technique to help you relax? If so, in what circumstances would you use it?
• Do you think it would be a useful technique for an injured athlete or exercise participant? Why?

• Discussion

• It is useful to try a technique to fully understand its effectiveness and potential application for those with a sport injury. You may find that some relaxation techniques are more effective for you than others.
• As with all techniques, individuals will have a preference for particular relaxation techniques over others. The most appropriate relaxation technique will also depend on the situation. For example, if you only have a very short period of time to relax, a short breathing technique will likely be more appropriate than a full PMR routine. In comparison to the other techniques, which are cognitive in nature – PMR has a physical (or somatic) component which might make it particularly suitable for individuals who are experiencing muscle tension.
• All of these techniques have received research support for use in the treatment of sport injury, but there has been some wider debate about the effectiveness of PMR. A systematic review (Pelka et al., 2016) concluded that PMR was ineffective in enhancing performance. It should be noted, however, that this review was specifically investigating the direct effect of PMR on measures of sports performance (e.g. tennis strokes, reaction time, muscle strength, aerobic performance), while the benefits of PMR in relation to sport injury are likely to be more indirect. For example, PMR has been shown to improve sleep which could indirectly reduce injury risk (e.g. improved recovery from training, reduced stress and anxiety) (McCloughan et al., 2016).

Coping with sport injury

Sport injury rehabilitation can be negatively influenced by psychological factors. Consequently, putting in place interventions to help people cope with injury can enhance the rehabilitation process. In the next activity you will explore athlete experiences of coping with injury.

The video provides more evidence of how difficult it can be for a sports performer to cope with injury and the importance of psychological intervention. The athletes in the video point towards the importance of the two interventions you are going to explore in this session. For example, Kyle Brown (rugby player) talks about the need to set realistic rehabilitation goals, and JP Duminy (cricketer) talks about the role of social support when stating the importance of receiving ‘support of family, friends and team mates’.

Effective goal setting

Obviously, the goals you set need to be appropriate – goals that are unrealistic can have a negative impact on motivation. In the next activity you will examine some principles of effective goal setting

1. Look at the following examples of goals set by our case study Lois. Decide whether each of Lois’s goals (a, b and c) is a process, performance or outcome goal:
   • Goal: to return to the track by September
   • Goal: to increase my personal best on calf raises
   • Goal: to focus on staying high on my toes as I run.
2. What is SMART? Using SMART, try to improve the wording of the goal below, set for our case study Travis:
   • Goal: to improve fitness.
3. Why do you think it is important to set both short-term and long-term goals?

Injury rehabilitation can be unpredictable – this can sometimes make goal setting a difficult task, and at times goals won’t be achieved. In these situations, it is important that you try to frame positively in order to maximise the individual’s motivation and positive attitude towards rehabilitation. Therefore, it is recommended that where necessary you focus on the degree of goal attainment rather than absolute attainment. For example, if an individual hasn’t fully achieved a goal you might emphasise the progress made towards it instead – focusing on the improvement from last time rather than the failure to achieve the target.

3.1 Social support in practice

Forsdyke et al. (2016) identified that having trust in the rehabilitation provider, feeling wanted by others and satisfaction with social support were associated with positive rehabilitation outcomes. Social support is considered to be a multidimensional construct with different categories of social support possible, including (Arvinen-Barrow and Pack, 2013):

• emotional
• technical
• informational
• tangible, and
• motivational support.

Esteem support :Enacting behaviours that bolster an individual’s self-confidence, sense of competence, or self-esteem, perhaps through the provision of positive feedback or by demonstrating belief in the individual’s ability to cope with injury.

Listening : Actively listening to the individual whilst refraining from giving advice or making judgments. This should involve sharing both positive (e.g. joys of rehabilitation success) and negative (e.g. setback frustrations) thoughts and feelings associated with rehabilitation.

Emotional support :  Providing an individual with impartial assistance during emotionally difficult times and demonstrating acceptance, empathy and encouragement should they experience setbacks, thus facilitating a sense of comfort and security.

Emotional challenge:  Challenging the individual to do their utmost to overcome obstacles to goal-achievement, and structuring support so as to facilitate motivation toward rehabilitation.

Shared social reality:  Acting as a ‘reality touchstone’ by verifying an individual’s perception of the current situation and social context, thus potentially providing a sense of ‘normalisation’.

Sub Type- Technical

Technical appreciation Demonstrating an acknowledgement of an individual’s achievements, or reinforcing effort and intensity during a rehabilitation session.

Technical challenge: Encouraging individuals to achieve more, to be excited about their work and progress, and to seek new ways in which they might rehabilitate.

Sub Type- Informational         

Personal assistance Providing advice, guidance and assistance in the form of time, skill, knowledge, and expertise targeted directly at problem-solving or feedback relating to rehabilitation.

Sub Type- Tangible

Material assistance: Providing tangible assistance such as the provision of transport to rehabilitation, assistance with general household duties, and financial support thus directly facilitating an individual’s chances of goal achievement.

Technical challenge: Encouraging individuals to achieve more, to be excited about their work and progress, and to seek new ways in which they might rehabilitate.

Sub Type- Motivational

Motivational, Encouraging individuals to overcome, or give in to various barriers during the rehabilitation process. Interestingly, both Lois and Travis have identified a mixture of personal and professional relationships. Different people can provide a range of different types of social support, but you might expect a partner (here, Dave or Trevor) to particularly provide emotional, tangible and motivational support. You might have thought that a coach or trainer would particularly provide technical, informational and motivational support. However, with an established coach–athlete relationship such as that between Lois and Wilma, there would likely be emotional support too. Coaches are considered to be an important source of social support during sport injury (Newman and Weiss, 2018). A sport psychologist would likely predominantly provide emotional, tangible, informational and motivational support. A physiotherapist would be expected to predominantly provide technical, informational and motivational support, but a good physiotherapist would also provide emotional support. Reflecting like this is a useful way to consider how what you have learned in this course can be applied to your everyday life. Hopefully, the course has led you to consider the psychological aspects of injury rather than just the physical aspects of injury. You may have reflected on how you can integrate more sport psychology into your practice in your professional role (e.g. coach, instructor, sports therapist), or you may have thought about the need to include a sport psychologist into your professional network.

 Conclusion

The purpose of the conclusion is to summarise the main points you have made in your report. For example, summarise the key psychological factors you have identified in the case study and the interventions you have recommended, with a sentence or two about their expected impact on Jackson. You have only a limited number of words available, so this needs to be concise. No new teaching material should be introduced in the conclusion.