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It Pays to Pay Attention: A Mindfulness-Based Program for Injury Prevention

With Soccer Players
Article in Journal of Applied Sport Psychology · January 2015

DOI: 10.1080/10413200.2015.1008072
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MINDFULNESS AND INJURY PREVENTION 1
1 It Pays to Pay Attention:
2 A Mindfulness-Based Program for Injury Prevention with Soccer Players
3 Andreas Ivarsson
4 Halmstad University, Sweden; Linnaeus University, Sweden
5 Urban Johnson, Mark B. Andersen, Johan Fallby, and Mats Altemyr
6 Halmstad University, Sweden
8
9
10
11
12 2015-01-13
13 Accepted for publication in Journal of Applied Sport Psychology
14 doi: 10.1080/10413200.2015.1008072
15
16 This article may not exactly replicate the final version published in the journal. It is not the
17 copy of record.
18
19
20 Author note
21
22 The authors want to thank the Swedish National Centre for research in Sports for
23 financial support. The authors would also like to thank all the players participating in the
24 study. Johan Bergström, B.Sc is acknowledged for his help with the planning and execution of
25 the control condition presentations.
26 Correspondence concerning this article should be addressed to Andreas Ivarsson,
27 Centre of research on Welfare, Health and Sport, Halmstad University P. O. Box 823, 30118
28 Halmstad, Sweden
29 Email: [email protected]
1
2 Abstract
3 The aim of this study was to examine the extent to which a mindfulness-based program could
4 reduce the number of sports injuries in a sample of soccer players. A total of 41 junior elite
5 soccer players were randomly assigned to the treatment or the attentional control group. The
6 treatment group took part in a 7-session program based on the mindfulness, acceptance, and
7 commitment (MAC) approach (Gardner & Moore, 2007). The attentional control group was
8 offered 7 sessions of sport psychology presentations with a particular focus on soccer. There
9 were no statistically significant differences in injury rates between the two groups (U (39) =
10 149.50, z = -1.77, p = .077), but there was a medium effect size (adjusted Cohen´s d = - 0.59,
11 approx. 80% CI for d = -0.37 – - 0.74). Moreover, 67% of the players in the mindfulness
12 group remained injury-free in comparison to 40% in the control group. This result suggests
13 that an intervention program focusing on strategies for improving attention could decrease
14 injury risk. Recommendations include applying mindfulness exercises in athletes’ daily
15 training to help lower injury risk.
16
17 Keywords: MAC approach, RCT, sport injuries, clinical vs. statistical significance
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26
1 It Pays to Pay Attention:
2 A Mindfulness-Based Program for Injury Prevention with Soccer Players
3 Recent data from Swedish elite football (soccer) show that approximately two-thirds
4 of players incur at least one time-loss injury (i.e., an injury that takes the athlete out of
5 training or competition for at least one session) per season (Hägglund, Waldén, & Ekstrand,
6 2009). Time-loss injuries have been shown to influence athletes’ psychological and emotional
7 states. For example, acquiring an injury is often associated with feelings of loss and grief,
8 anger, and depressed mood (Mainwaring, Krasnow, & Kerr, 2001; Wiese-Bjornstal, 2010).
9 Injuries have also been found to be associated with team performance in soccer. More
10 specifically, an 11-year longitudinal study, based on European elite soccer clubs, showed that
11 higher injury rates were related to poorer team performances (Hägglund et al., 2013). Also,
12 the economic burden for time-loss injuries, especially for elite teams, is substantial. One
13 example from professional European soccer is Ekstrand’s (2013) estimate that having a first-
14 team player injured for one month will generate a financial loss of approximately €500,000.
15 But it is not just at the elite team level where sport-related injuries have an economic impact.
16 A number of studies have also reported the influence of sport injuries on costs to the health
17 care system (for a summary see Frisch, Croisier, Urhausen, Seil, & Theisen, 2009). For
18 example, Yang et al. (2007) reported that in the United States, hospitalization costs associated
19 with sport injuries, for youth athletes (aged 5-18 years), was $485,000,000 over a 4-year
20 period. The high injury rates in elite soccer have substantial associations with emotional
21 distress, financial loss, and team performance. Investigating the potential effects of preventive
22 strategies aimed to decrease injuries and risks for athletes would seem to be a path to helping
23 make sport a safer place, in terms of injury risk, than it currently is.
24 Until recently, most of the interventions related to injury prevention have been based
25 on physiological and/or biomechanical programs (e.g., Almeida, Olmedilla, Rubio, & Palou,
1 2014; McBain et al., 2012). Nevertheless, psychologically-based intervention programs have
2 been suggested to potentially reduce injury risk among athletes. For example, one of the most
3 cited theoretical frameworks, the model of stress and athletic injury (Williams & Andersen,
4 1998), developed to explain psychological variables’ associations with injury risk, proposes
5 that psychological interventions aimed to decrease injury risk can follow both physiological
6 (e.g., decrease muscle tension) and psychological (e.g., cognitive strategies, attentional
7 control techniques) pathways to reduce stress responses that may lead to injuries (Williams &
8 Andersen, 1998). More specifically, in the Williams and Andersen model, stress responses
9 (e.g., attentional disruptions, cognitive anxiety, narrowed peripheral vision, generalised
10 muscle tension) are suggested to be the link between psychological variables and injury risk.
11 Even though the model of stress and athletic injury is the most commonly used framework in
12 injury prediction and prevention studies, some shortcomings have been noted. Most of the
13 suggested limitations of the model, presented in previous studies, are related to the model not
14 fully addressing emotional (e.g., mood states) as well as environmental factors (e.g.,
15 motivational climate, training venue conditions) that may have influences on injury risk (e.g.,
16 Hackfort & Kleinert, 2007; Kleinert, 2007; Steffen, Pensgaard, & Bahr, 2009). Also, the
17 model does not clearly address how overt behaviors (e.g., motor behavior) may play a part in
18 the stress-injury relationship (Hackfort & Kleinert, 2007).
19 Psychological Interventions for Injury Reduction
20 Based on Williams and Andersen’s (1998) stress and athletic injury model, a few
21 psychologically-based intervention programs have been empirically tested during the last 20
22 years (Johnson, 2007; Johnson, Ekengren, & Andersen, 2005; Johnson, Tranaeus, & Ivarsson,
23 2014). One of the first studies (Kerr & Goss, 1996) conducted aimed to investigate a program
24 based on psychological skills training (PST; e.g., imagery, relaxation, positive self-
25 statements) and its potential effects on injury frequency among gymnasts. The results showed
1 that the gymnasts in the treatment group incurred fewer injuries than those in the control
2 group. The difference was not statistically significant, but the results had obvious practical
3 and clinical significance. Andersen and Stoové (1998), in a comment on Kerr and Goss,
4 suggested that the authors’ over-reliance on p < .05 as a measure of “significance” led them to
5 err on the side of being too conservative when interpreting their results. Also, Kerr and Goss
6 reported a Cohen’s d of .67, which is between a medium and large effect. Andersen and
7 Stoové also reported that the authors used a formula for calculating d for independent means,
8 but the study was a matched pairs design, and they should have used the formula for matched
9 pairs. This error likely resulted in Kerr and Goss underestimating their effect size. To focus
10 primarily on p values when interpreting the results from a study has also been heavily
11 criticized by other researchers (e.g., Wilkinson, 2014; Ziliak & McCloskey, 2008).
12 Other studies that have used interventions based on PST techniques have reported
13 promising results. For example, Johnson et al. (2005) conducted a study with a sample of
14 competitive soccer players (N = 32) where the intervention group took part in a 7-session
15 program based on relaxation and other stress management techniques (e.g., critical incident
16 diary). The results showed a substantial difference in injury frequency between the
17 intervention and the control groups with the participants in the treatment group experiencing
18 only three injuries during the season. In comparison, the participants in the control group
19 incurred 21 injuries. The clinical significance of these findings is clear. Other studies that had
20 interventions based on PST have also shown fewer injuries in treatment groups compared to
21 control groups (e.g., Maddison & Prapavessis, 2005; Noh, Morris, & Andersen, 2007).
22 Interventions based on cognitive-behavioral therapy have also been used in injury prevention
23 studies (Edvardsson, Ivarsson, & Johnson, 2012; Perna, Antoni, Baum, Gordon, &
24 Schneiderman, 2003). In line with the PST-based intervention studies, the results from both
25 these studies showed fewer injuries in the treatment groups in comparison to the control
1 groups. In the Edvardsson et al. (2012) study, 27 junior elite soccer players were assigned to
2 either an intervention or a control condition. The participants in the intervention condition
3 took part in a 7-session program based on cognitive-behavior therapy techniques and
4 biofeedback training. The results showed no statistically significant differences between the
5 two groups. Nevertheless, the participants in the treatment group incurred only 5 injuries
6 compared to 14 injuries in the control group (Cohen´s d = .89, a large effect). Again, with
7 results like these, the clinical significance and real-world meaning of the differences are
8 apparent. If participation in a treatment could lessen the burden of injury by close to 60%,
9 then such interventions may have substantial positive effects on athletes and their teams.
10 Moreover, to get down to truly practical and economic issues, such results provide evidence
11 and a solid rationale for sport administrators to consider paying sport psychologists for injury
12 prevention services.
13 Concerning the designs of previous intervention studies, some patterns have emerged.
14 First, a majority of the studies have used quasi-experimental designs with no attentional
15 control groups (e.g., Edvardsson et al., 2012; Johnson et al., 2005; Kerr & Goss, 1996;
16 Maddison & Prapavessis, 2005; Tranaeus, Johnson, Engström, Skillgate, & Werner, 2014).
17 Second, most of the studies have used traditional PST techniques (e.g., imagery, relaxation,
18 goal setting; Johnson et al., 2005; Kerr & Goss, 1996; Kolt, Hume, Smith, & Williams, 2004;
19 Maddison & Prapavessis, 2005; Tranaeus et al., 2014). Third, some of the studies have also
20 screened athletes, before the intervention started, to choose participants who fit at-risk profiles
21 according the Williams and Andersen (1998) model of stress and athletic injury (e.g., Johnson
22 et al., 2005) so as not to water down the effects of the intervention by including athletes who
23 may not be likely to become injured. The design that we chose included an attentional control
24 group, but we did not pre-screen to find at risk participants because we did not have the large
25 sample size needed to complete that process.

1 Mindfulness in Sport
2 Mindfulness has been described as “openhearted, moment-to-moment non-judgmental
3 awareness” (Kabat-Zinn, 2005, p. 24). In the sporting context, a number of different
4 mindfulness interventions have been conducted (Gardner & Moore, 2012). One of the most
5 common programs is the mindfulness, acceptance, and commitment (MAC) approach
6 (Gardner & Moore, 2007). The MAC approach is “a theoretically and empirically derived
7 acceptance-based behavioral intervention for the purpose of enhancing the performance and
8 psychological well-being of competitive athletes” (Moore, 2009, p. 291). More specifically,
9 the MAC approach is based on the assumption that athletes who have non-judgmental
10 moment-to-moment awareness increase their chances of paying attention to task-relevant
11 stimuli and making decisions in practice and competition that lead to better performance
12 (Moore, 2009). Investigations, both inside and outside of sport, have indicated that
13 mindfulness practice has the potential to enhance several psychological processes such as:
14 awareness, executive functions, and attention (for a summary see Moore, 2009). Mindfulness
15 in sports is nothing new, and most applied sport and exercise psychologists, in some manner,
16 help people pay attention to what is important. Mannion and Andersen (2015) suggested:
17 Many of the interventions in the canon of psychological skills training (PST) in sport
18 psychology (e.g., relaxation, self-talk, imagery, concentration) are, at heart, mindful
19 practices. When instructing exercisers and athletes in progressive muscle relaxation,
20 we encourage them to take a passive attitude (e.g., “don’t try to relax; just go with
21 whatever happens,” “when your mind wanders, just come back to focusing on your
22 muscles”) and intentionally and nonjudgmentally pay attention to what is happening
23 when they tense and relax muscles, right now, in the present moment. Sport and
24 exercise psychologists have been involved in mindful practices for decades, and
25 mindfulness is not something new and foreign, but rather, something that sits at the
1 heart of what many practitioners use in PST. (p. 4)
2 Paying attention to what is happening right here, right now has had tremendous
3 survival value. Being mindful is part of our evolutionary heritage, but with our complex, and
4 negatively-oriented brains we constantly slip out of being present and drift to times and places
5 that actually set us at risk for all sorts of unhappiness including sport injuries (e.g., Cozolino,
6 2010; Siegel, 2010).
7 The promising results with the PST intervention for injury prevention studies also
8 raise the question: Which parts of the PST programs were the "effective ingredients"? A
9 variety of psychological skills (e.g., relaxation, imagery, goal setting) have been taught in past
10 intervention studies, but it has not been possible to determine which parts of the different PST
11 interventions were most helpful. In choosing a mindfulness-based program, there is a much
12 narrower focus to the intervention than there is in PST approaches, and that is: paying
13 attention and constantly bringing attention back to the present moment. Because attentional
14 disruption/distractibility is one of the core variables in the model of stress and athletic injury
15 (Williams & Andersen, 1998) associated with injury outcome, investigating a mindfulness-
16 based program targeting attentional processes may help determine if focusing specifically on
17 improving attention/concentration will lower injury risk. This line of reasoning is based on
18 several studies that have shown that mindfulness practice can positively influence both
19 individuals’ appraisals of stressful situations (e.g., Weinstein, Brown, & Ryan, 2009) and
20 their stress responses (e.g., Cozolino, 2010). More specifically, studies have found that after
21 mindfulness practice people appraise fewer situations as stressful than they did before the
22 intervention (Weinstein et al., 2009), and they increased their abilities to focus on task-
23 relevant stimuli (Jha, Krompinger, & Baime, 2007). Both cognitive appraisals and stress
24 reactions (e.g., disrupted attentional processes) are at the core of the model of stress and
25 athletic injury, and we hypothesized that mindfulness practice would decrease injury risk
1 (most likely through changes in appraisals and improved attentional processes). The central
2 aim of this study was to examine the extent to which a mindfulness-based program could
3 reduce the number of sports injuries in a sample of players in a Swedish elite soccer high
4 school.
5 Method
6 Participants
7 Participants were 41 male (n = 31) and female (n = 10) junior elite soccer players,
8 aged between 16-19 years (M = 16.97, SD = 0.79). All the participants were recruited from
9 one Swedish soccer high school that is certified by the Swedish Soccer Association. To be
10 certificated, the schools must offer an education that has a clear elite perspective in terms of
11 both sport-specific training as well as access to professional services (e.g., specialists in sport
12 medicine, sport psychology, and nutrition). The participants engaged in soccer activities (i.e.,
13 practice, games) between 10 and 18 hours a week. Of the participants, 17 % played at the
14 senior elite level (first or second team in an elite club), whereas 41% belonged to senior
15 squads in clubs that played in different competitive level (3rd to 6th division). The rest of the
16 players (42%) competed at the highest junior level in Sweden.
17 Injury Recording
18 Sport injuries have been classified based on their severities. In past soccer research
19 (e.g., Fuller et al., 2006), the following classifications have been suggested: 0 days of
20 restricted participation in practice (slight); 1-3 days of restricted participation in practice
21 (minimal); 4-7 days of restricted participation in practice (mild); 8-28 days of restricted
22 participation in practice (moderate); > 28 days of restricted participation in practice (severe);
23 and termination of all participation (career ending). In this current study, injury recording was
24 in line with previous studies within the field of soccer and sports medicine (e.g., Hawkins,
25 Hulse, Wilkinson, Hodson, & Gibson, 2001; Le Gall et al., 2006; Price, Hawkins, Hulse, &
1 Hodson, 2004) and was defined as a condition meeting the following two criteria: (a) it
2 occurred as a result of participation in a soccer practice or game, and (b) it resulted in four
3 days or more of restricted or no practice including the day of injury were reported. One reason
4 for excluding slight as well as minimal injuries from the definition was that many minor
5 injuries do not lead to time loss (missing organized soccer sessions) and might not be
6 presented to the physiotherapist (see Faude, Rössler, & Junge, 2013) employed by the soccer
7 high-school in the present study. Also, the fact that there are a great number of minor injuries
8 and “niggles” in soccer, which do not lead to noteworthy constraints for the athlete (Kisser &
9 Bauer, 2012), is another reason for our adopting the above criteria because, in general, such
10 minor injuries will have little meaningful impact on either the athlete (Green & Weinberg,
11 2001) or the club. Also, playing and training with minor injuries is expected and part of
12 cultural traditions in most soccer and other “football” codes (cf. Tibbert & Andersen, 2015).
13 Physiotherapists were instructed to record all injuries that met our operational definition using
14 a schedule with: (a) date of injury occurrence, (b) injury location, and (c) date of return to full
15 participation in practice. One injury event was not correctly reported and was therefore
16 excluded from the data analyses.
17 Procedure
18 The study was first reviewed and approved by the Regional Ethical Review Board,
19 Lund University, Sweden (#2013/802) before any data were gathered. To gain access to the
20 players we contacted the soccer high school coach and arranged a time and a place for a
21 meeting. At the meeting the coach gave us permission to present the study to the student
22 athletes. All players were then informed about the study design and the ethical standards. All
23 players who agreed to take part in the study signed an informed consent form. In loco parentis
24 consent was received from the coach and dean for all players who were under 18 years of age
25 (a common and accepted practice for research with 16- and 17-year-old participants in
1 Sweden). All players were, in the beginning of 2014, matched in pairs based on gender and on
2 previous injuries (i.e., matched on number of injuries that had occurred during the August
3 through December season in 2013 and gender).Males and females were ranked separately in
4 two groups by number of injuries. In terms of number of injuries, the top two males and
5 females were randomly assigned to the treatment and attentional control groups, and then the
6 procedure was repeated for the next top two males and females, and so forth until all
7 participants were assigned to groups. This random assignment resulted in 21 players in the
8 treatment group and 20 players in the attentional control group. The treatment group took part
9 in a 7-session mindfulness program based on the MAC approach, and the control group was
10 offered 7 sessions of sport presentations on team psychology with a particular focus on
11 soccer. Prior to the first session/presentation, both groups were divided into three smaller
12 groups (containing 6-7 participants). The reason for this procedure was that large groups tend
13 to have fewer interactions among participants, and we wanted to enhance the possibility that
14 the participants could be actively involved in discussions and exercises during the sessions.
15 All sessions took place in classrooms at the soccer high school. Between January and June of
16 2014, all injuries that occurred were recorded by the high school’s athletic trainer and
17 reported to the researchers.
18 Treatment group (mindfulness practice). The participants in the mindfulness
19 condition met, in their smaller groups, once weekly for 45 minutes. The program for each
20 session was developed based on the MAC approach (Gardner & Moore, 2007). The first
21 author, who has expertise in sport psychology and mindfulness, delivered the program. All
22 sessions started with a short introduction to a specific topic in line with the topics presented in
23 the MAC manual (Gardner & Moore, 2007). During the rest of the time, short talks about the
24 mechanisms of the MAC approach were combined with discussions between the participants
25 regarding their own reflections that were related to the sessions’ topics. All sessions also
1 contained experiential mindfulness exercises. More details of each session are provided in
2 Table 1. At the end of each session the participants were given a homework assignment (e.g.,
3 listen to an audio file with a mindfulness exercise) that was sent electronically to each
4 player’s e-mail address. During the program, all athletes in this group were encouraged to
5 listen to their audio recorded mindfulness exercises at a minimum of 3 days a week.
6 Control group (sport psychology presentations). The participants in the control
7 condition met following the same schedule as the participants in the mindfulness condition.
8 Their weekly sessions also lasted for 45 minutes. During these sessions a sport psychology
9 consultant gave presentations about sport psychology topics that were relevant to soccer. The
10 main focus of the topics selected was group psychology (e.g., team communication, team
11 cohesion). The reason for selecting this focus was to ensure that there was minimal overlap
12 between the topics relevant for mindfulness training (e.g., concentration, relaxation, self-
13 regulation). An overview of the topics for the control-group sessions is provided in Table 1.
14 Statistical Analysis
15 When it comes to thinking about, reporting, and interpreting results of quantitative
16 studies, Cohen (1990) suggested:
17 The primary product of a research inquiry is one or more measures of effect size, not p
18 values . . . having found the sample effect size, you can attach a p value to it, but it is
19 far more informative to provide a confidence interval. . . . I don’t think that we should
20 routinely use 95% [confidence] intervals: Our interests are often better served by more
21 tolerant 80% intervals. (p. 1310)
22 We have taken to heart Cohen’s advice, have reported our results accordingly, and, in the
23 discussion section, we have added one step: explaining what these results might mean in the
24 real world of soccer. A major problem with injury prevention research is that it is time
25 consuming and expensive. It is often not feasible to do studies with large Ns, and research in
1 this area has often been underpowered, but several studies have shown clinically (not
2 statistically) significant effect sizes.
3 Because the data were substantially skewed (i.e., a majority of the players reported 0
4 injuries), the non-parametric Mann-Whitney U test, equivalent to the parametric independent t
5 test, was used to investigate if there was a statistically significant difference in injury
6 frequencies between the treatment and the control group. A result where p < .05 was
7 considered statistically significant, but as stated above, a p value was not the focus of this
8 investigation.
9 Cohen´s d effect size, with approximated 80% confidence interval (CI), was calculated
10 for the difference between groups. To calculate the Cohen´s d effect size for the non-
11 parametric U test, the z value was first transformed into a point-biserial correlation effect size
12 (rpb) using the formula rpb = z/√N. Then the effect size estimate rpb was used to calculate the
13 Cohen´s d value, by the formula d = 2r/√(1- rpb 2) (see Ivarsson, Andersen, Johnson, &
14 Lindwall, 2013). The Cohen´s d effect size was then adjusted to account for the potential
15 sampling error variance (for formulas, see Vacha-Haase & Thompson, 2004).
16 Program Evaluation
17 In the last session the participants in the experimental group were asked to complete a
18 brief written evaluation of the program where they answered open-ended questions about if
19 and how they perceived that the program changed the ways they act or think, both inside and
20 outside soccer. A short summary of the results from the evaluation are included in the
21 discussion section to give the reader information about what the participants thought about the
22 program.
23 Results
24 The participants experienced 23 injuries in total during the 6-month study period. The
25 time-loss due to injuries ranged between 4 and 33 days for the participants in the treatment
1 group (M = 5.57, SD = 11.50), whereas the range in the control group was between 4 and 89
2 days (M = 12.70, SD = 21.39). Of the participants in the treatment group, 14 of 21 (67%)
3 remained injury-free, but only 8 of 20 (40%) in the control group had no injuries at the end of
4 the 6-months data gathering period.
5 The result from the Mann-Whitney U test showed no statistically significant
6 difference in injury occurrence during the study period between the intervention and the
7 control group U (39) = 149.50, z = -1.77, p = .077, but there was a medium effect size,
8 adjusted Cohen´s d = - 0.59 (approx. 80% CI for d = -0.37 – - 0.74). Moreover, the
9 participants in the treatment group experienced fewer injuries (total = 8) than the participants
10 in the control group (total = 15).
11 Discussion
12 In the light of Cohen´s and other researchers’ (e.g., Cohen, 1994; Gigerenzer, 2004;
13 Loftus, 1996) arguments about the differences between statistically significant and
14 practically/clinically significant results, we argue that the study produced some promising
15 findings. First, 14 of 21 (67%) players in the mindfulness group remained injury free, but only
16 8 of 20 (40%) in the control group had no injuries during the 6 months that injury data were
17 collected. Second, the mindfulness group had almost half the number of injuries of the control
18 group. These results suggest that the intervention had an effect on injury occurrence that
19 would be meaningful for soccer athletes, coaches, and sport administrators. Several studies
20 have shown that injuries have negative effects on both athlete (Mainwaring et al., 2001;
21 Wiese-Bjornstal, 2010) and team performance (Hägglund et al., 2013), and a decrease in
22 injury rates could have a substantial influence at both individual and team levels. For
23 individuals to experience loss and grief-related symptoms after injuries might have negative
24 impact on both function and quality of life (Zisook & Shear, 2009). By lowering injury rates,
25 more athletes will be able to have possibly healthier lives both during and after their sport
1 careers. Another example of the positive aspects of lowering injuries is that a decrease in the
2 number of injured athletes could have the potential to help teams achieve higher standings in
3 their leagues because more of their players would be available for competition. A third
4 example is that fewer injuries will save money for sport clubs. As stated earlier, Ekstrand’s
5 (2013) estimate of the medical expenses and lost revenue due to top player injuries at the
6 professional level of soccer in Europe is substantial. At the professional and semi-professional
7 levels, any injuries that take players out of the game impose financial burdens. In light of
8 these arguments, any preventive interventions, including the one in this study, that are able to
9 show meaningful decreases in injury frequencies are of personal, financial, and clinical
10 interest for players, coaches, administrators, whole teams, and national governing bodies (e.g.,
11 Frish et al., 2009). We acknowledge that this study contains a fairly restricted sample that
12 may limit generalization of the results, but similar effects with related psychological
13 interventions have been found across a variety of sports (e.g., Kerr & Goss, 1996)
14 There are several potential explanations for the mindfulness group having fewer
15 injuries, as well as more non-injured players, than the control group. One possible explanation
16 could be that mindfulness practice leads to functional changes in the brain’s different attention
17 systems (Fox, Corbetta, Snyder, Vincent, & Raichle, 2006). For example, research has shown
18 that mindfulness practice will generate changes in the anterior cingulate cortex where
19 executive attention is housed (Hölzel et al., 2007). These changes might increase the players’
20 ability to pay attention to the relevant stimulus during competition. In line with this argument,
21 Jha et al. (2007) found that participation in an 8-week mindfulness-based stress reduction
22 course enhanced performance in directing attention to specific subsets of possible stimulus.
23 Given that previous studies have found changes in perception and attention (e.g., peripheral
24 vision narrowing) to be related to sport injuries (e.g., Rogers & Landers, 2005), it is likely that
25 if players are better in directing their attention towards important stimuli, the probability of
1 them being injured will decrease. Another possible explanation is that mindfulness practice
2 may lead to reduced emotional interference during practice or competition. More specifically,
3 research findings have shown that an 8-week program in mindfulness can produce a right-left
4 shift in the medial prefrontal cortex, which corresponds with moving from avoidant and
5 anxious responding to curiosity and approach modes and a general lowering of anxiety (for a
6 review see Hölzel et al., 2011). These prefrontal changes, coupled with hippocampal
7 modifications, help to downregulate activation in the amygdala (the flight, fight, or freeze
8 center; see Cozolino, 2010; Goldin & Gross, 2010). The above suggestions are speculative,
9 but they seem plausible.
10 The results of this study and the known neurological correlates of mindfulness fit well
11 with the Williams and Andersen (1998) model. In the model, stress responses in the form of
12 cognitive disruptions (e.g., distractibility, intrusive worrisome cognitions), perceptual changes
13 (e.g., peripheral vision narrowing) as well as physiological reactions (increased generalized
14 muscle tension) are suggested to influence injury risk (Williams & Andersen, 1998).
15 This study, however, is not without its limitations. First, all participants were students
16 at the same soccer high school, and there might be a problem with cross-contamination
17 between the participants in the two groups that, in turn, could have decreased the magnitude
18 of the differences in injury occurrence between the two groups. Second, the result was not
19 statistically significant (according to our pre-specified cut-off for statistical significance).
20 Nevertheless, numerous researchers besides Cohen (1990) have stressed that p values are
21 problematic (e.g., highly dependent on sample size; Kruschke, 2013), largely uninformative,
22 and have little, if anything, to say about the real-world meaning of the results (e.g., Cohen,
23 1994; Gigerenzer, 2004; Loftus, 1996; Wilkinson, 2014). To interpret the real-world meaning
24 of the result, we followed the recommendations of Andersen, McCullagh, and Wilson (2007),
25 who emphasized that test statistics (e.g., mean values, effect sizes, difference scores) should
1 be discussed in the light of the study’s context, and the context here is the psychological,
2 medical, emotional, and financial costs of sport injuries. Lowering the burden of injury for a
3 team by almost 50%, or more conservatively, reducing injuries by even 25% through a
4 mindfulness intervention, would be something in which most athletes, coaches, and
5 administrators would be interested. Third, because the quality of the relationships between
6 practitioners and clients has been shown to influence a variety of intervention outcomes (e.g.,
7 Andersen & Speed, 2010), the fact that two different consultants delivered sessions for the
8 two conditions (experimental and control) may have influenced the quality and types of
9 interactions in each group.
10 Fourth, even though determining what is clinically significant has been suggested to
11 be important when discussing the meaningfulness of intervention results (see Wilkinson,
12 2014), this procedure is not without concerns. Because establishing clinical significance is a
13 subjective procedure, where the researcher interprets the statistics in relation to the context
14 (e.g., Welsh & Knight, 2014) this process could be highly influenced by the researcher’s
15 biases. Therefore, it is important that researchers explain the rationale for their interpretations
16 of clinical significance. Doing so helps readers decide for themselves whether they hold with
17 the researchers’ reasoning.
18 Fifth, our operational definition of injuries excluded those that resulted in less than 4
19 days of time loss from participation in soccer might be seen as a limitation. Nevertheless, the
20 reasons for this decision are all related to the impact that different lengths of rehabilitation
21 time have on athletes and clubs (for more elaboration on this issue see the Method section).
22 Sixth, that there were no formal checks of how many times the participants in the
23 intervention group practiced the recorded mindfulness exercises they were given is a
24 limitation because the amount of practice might have influenced the results.
1 The study was designed to be as rigorous as possible to capture the potential influence
2 of mindfulness practice on injury risk, and we used an RCT design with pairs matched on
3 number of previous injuries, as well as gender, along with an attentional control condition.
4 The reason for matching on number of previous injuries was that several studies have shown
5 that previous injuries are often strong predictors of both re-injury and new injuries (for a
6 summary of the studies that include previous injury data, see Johnson et al., 2014). To
7 minimize the potential influence of a Hawthorne effect between groups we used an attentional
8 control condition. The sessions for the participants in the control condition were delivered as
9 traditional presentations (instead of more applied sessions), but we selected topics that were
10 relevant for them as soccer players.
11 To evaluate the MAC program, the participants in the mindfulness group completed
12 an evaluation form during the last session. In this evaluation, the participants were asked to
13 answer open-ended questions related to what they had learned during the sessions and in what
14 way (if any) the program had influenced them in soccer practice. The responses showed that
15 most of the players (76%) had started to think more about their abilities to select what
16 behaviors they should perform in order to achieve their goals (e.g., to perform well in soccer).
17 Other frequent answers were that the players had learned how to relax (24%) and had
18 increased their abilities to focus during longer period of times than they did before the
19 program (81%). These answers support the explanation that the mindfulness group
20 experienced fewer injuries possibly due to attentional changes.
21 We did not screen for players at risk, such as in the Johnson et al. (2005) study, and
22 the effect size we found is lower than Johnson et al. probably due to many players in our
23 sample having low likelihoods of becoming injured (based on psychological risk factors). The
24 results in this study would suggest that the attentional/mindful-like components of PST
25 interventions (e.g., autogenic training) may account for a significant amount of variance in
1 injury outcomes, and the clinically relevant effect that the intervention in this study had
2 supports the proposition that mindfulness practice could be a viable alternative when
3 designing injury prevention programs for a group of athletes. Mindfulness exercises, such as
4 mindful breathing and mindful body scans, could easily be incorporated into pre-, during, or
5 post-practice periods. For a good example of how mindfulness is incorporated into
6 professional sport, see Jackson and Delehanty (2006). Also, with so many people having
7 access to the Internet, it is easy to incorporate mindfulness into daily life using any of the
8 huge number of relatively inexpensive (or free) apps for tablets and smart phones that provide
9 guidance in mindful practices.
10 Almost 50% of elite soccer players retire due to injuries (Drawer & Fuller, 2002), but
11 decreases in career-long injury risk through mindfulness may help some players enjoy longer
12 careers than they might otherwise have had. To pay attention to what is happening right now
13 would also seem to be a beneficial way to approach sport participation and competition on a
14 variety of levels well beyond injury prevention. The evidence for the usefulness of
15 mindfulness practice in medicine, psychotherapy, and education is solid and impressive. In
16 the future, we hope that there will be more studies into mindfulness and injury prevention
17 with a variety of athletes across a wide range of sports.
18
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9
Table 1.
Description of the Topics for the Intervention and Control Groups’ Sessions.
Session Intervention Control

1 Topic: Education/information about the theoretical Topic: Short introduction to sport psychology. During the
and practical aspects of the intervention. session a broad introduction to sport psychology was delivered
Content: including examples of different psychological concepts (such as goal
- The participants were informed about the ethical setting and self-efficacy).
guidelines for the study as well as the structure for
the full MAC program.
- Presentation of the definition of mindfulness and the
content of the MAC approach, based on the first
chapter in Gardner and Moore (2007).
- Discussion about thoughts and emotions related to
the participants’ best and worst performance. –
- Mindfulness exercises (e.g. mindful breath).
2 Topic: Introduction to mindfulness and cognitive Topic: The psychology of soccer. In this presentation
defusion. information about the psychological variables (e.g., perception) that
Content: are central in soccer was presented. This session was based on the
- Discussion about the participants’ reflections of the book See the Game (Fallby & Alm, 2010).
last session.
- Short presentation about thoughts and cognitive
schemes.
- Discussion- about the participants’ experiences of
schemas both within and outside sports.
- Mindfulness exercises.
3 Topic: Introduction to values and values-driven Topic: Group dynamics. The 5-step model of group
behaviors. development was presented. In the presentation concepts as roles,
Content: communication, norms, and rules were included and discussed in
- Discussion about the participants’ reflections of the relation to team performance. Also psychological aspects of team
last session. cohesion were presented.
- Short presentation of the relation between goals,
values, and behaviors..
- Discussion about the differences between values-
driven vs. emotion-driven choices.
4 Topic: Introduction to the concept of acceptance Topic: Group dynamics. The participants did some brief
Content: exercises with focus on teamwork. These brief exercises were based
- Discussion about the participants’ reflections of the on MTA. After the exercises discussions about their performance in
last session. the exercises were held.
- Short presentation of the acceptance concept.
- Discussion about the differences between acceptance
and avoidance. The participants were encouraged to
describe situations where they had experienced
avoidance.
5 Topic: Introduction to how to work to enhance Topic: The concepts of talent development. The focus of this
commitment. lecture was to provide information about important aspects to
Content: consider when working with talent development. More specifically,
- Discussion about the participants’ reflections of the different studies within the area of talent development research were
last session. presented.
- Presentation of the concepts motivation and
commitment and their relationships to behaviors. –
- Discussion about the difference between motivation
and commitment.
- Reflection of what behaviors that are related to

commitment.
6 Topic: Introduction to how to combine mindfulness, Topic: Motivation. The focus of this lecture was to describe
acceptance, and commitment in practice central aspects of motivation and how this will influence us both in
Content: sports and in everyday life.
- Discussion about the participants’ reflections of the
last session.
- Practical exercise (see p. 161-162 in Gardner &
Moore, 2007).
- Discussion about if and how the players had started
to integrate the topics we had discussed in previous
sessions within their lives (both inside and outside
sport).
- Mindfulness exercise.
7 Topic: Discuss how to maintain and enhance Topic: Summary of the topics that had been presented during
mindfulness, acceptance and commitment. the previous weeks. Written evaluation of the sessions.
Content:
- Discussion about the participants’ reflections of the
last session.
- Discussion about the possibility to integrate
mindfulness into the participants’ soccer practice.
- Written and oral evaluation of the program was held.
- Mindfulness exercise.
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It Pays to Pay Attention: A Mindfulness-Based Program for Injury Prevention

Article in Journal of Applied Sport Psychology · January 2015

Andreas Ivarsson Urban Johnson

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1 It Pays to Pay Attention:

2 A Mindfulness-Based Program for Injury Prevention with Soccer Players

4 Halmstad University, Sweden; Linnaeus University, Sweden

5 Urban Johnson, Mark B. Andersen, Johan Fallby, and Mats Altemyr

6 Halmstad University, Sweden

13 Accepted for publication in Journal of Applied Sport Psychology

25 the control condition presentations.

26 Correspondence concerning this article should be addressed to Andreas Ivarsson,

14 injury risk. Recommendations include applying mindfulness exercises in athletes’ daily

15 training to help lower injury risk.

1 It Pays to Pay Attention:

2 A Mindfulness-Based Program for Injury Prevention with Soccer Players

1 2014; McBain et al., 2012). Nevertheless, psychologically-based intervention programs have

9 (e.g., attentional disruptions, cognitive anxiety, narrowed peripheral vision, generalised

18 the stress-injury relationship (Hackfort & Kleinert, 2007).

19 Psychological Interventions for Injury Reduction

2 either an intervention or a control condition. The participants in the intervention condition

3 took part in a 7-session program based on cognitive-behavior therapy techniques and

25 sample size needed to complete that process.

2 Mindfulness has been described as “openhearted, moment-to-moment non-judgmental

3 awareness” (Kabat-Zinn, 2005, p. 24). In the sporting context, a number of different

5 common programs is the mindfulness, acceptance, and commitment (MAC) approach

8 psychological well-being of competitive athletes” (Moore, 2009, p. 291). More specifically,

10 moment-to-moment awareness increase their chances of paying attention to task-relevant

18 psychology (e.g., relaxation, self-talk, imagery, concentration) are, at heart, mindful

19 practices. When instructing exercisers and athletes in progressive muscle relaxation,

22 muscles”) and intentionally and nonjudgmentally pay attention to what is happening

1 heart of what many practitioners use in PST. (p. 4)

6 2010; Siegel, 2010).

11 interventions were most helpful. In choosing a mindfulness-based program, there is a much

16 players (42%) competed at the highest junior level in Sweden.

20 restricted participation in practice (slight); 1-3 days of restricted participation in practice

22 participation in practice (moderate); > 28 days of restricted participation in practice (severe);

16 excluded from the data analyses.

10 offered 7 sessions of sport presentations on team psychology with a particular focus on

17 reported to the researchers.

18 Treatment group (mindfulness practice). The participants in the mindfulness

5 listen to their audio recorded mindfulness exercises at a minimum of 3 days a week.

6 Control group (sport psychology presentations). The participants in the control

15 When it comes to thinking about, reporting, and interpreting results of quantitative

16 studies, Cohen (1990) suggested:

21 tolerant 80% intervals. (p. 1310)

2 statistically) significant effect sizes.

4 injuries), the non-parametric Mann-Whitney U test, equivalent to the parametric independent t

2 days (M = 12.70, SD = 21.39). Of the participants in the treatment group, 14 of 21 (67%)

4 the 6-months data gathering period.

5 The result from the Mann-Whitney U test showed no statistically significant

10 in the control group (total = 15).

6 professional level of soccer in Europe is substantial. At the professional and semi-professional

22 course enhanced performance in directing attention to specific subsets of possible stimulus.