Pain-Coping Traits of Nontraditional Women Athletes: Relevance to Optimal Treatment and Rehabilitation

The primary goal of traditional treatment and rehabilitation programs is to return the athlete to full functional capacity as quickly and safely as possible.¹ This goal is achieved with an aggressive program that may range from conservative management and patient guidance to state-of-the-art surgical techniques and effective rehabilitative modalities. Efficacy of the rehabilitation program is improved when the patient is encouraged to remain active and motivated, patient safety is ensured, and existing clinical outcomes (eg, range of motion, strength, patient satisfaction) are complemented.¹

An extensive interaction of physical and psychological risk factors has been discussed in prior research that primarily focused on the individual response to trauma within the natural environment.^2–6 From these paradigms, an emerging body of evidence is providing a clearer picture of the common traits used to cope with trauma. For instance, individuals who have been exposed to increasing levels of physical stress or trauma over time often exhibit more robust coping traits.^7–9 Although this degree of stress inoculation or “steeling effect” may be influenced by numerous factors (eg, level of education, intelligence, genetics, perceptions, self-enhancement and self-esteem, social support), coping traits associated with surviving trauma, such as resilience, diverting attention from discomfort, and increased confidence, provide an individual with the ability to minimize distress and successfully function physically and psychologically.^7–9 Of particular interest is the growing body of research addressing psychological and behavioral attributes specific to sport injury and subsequent performance by professional to organized club-sport athletes.^3,6,10–15

COPING WITH INJURY IN SPORT

When compared with the nonsport setting, a similar level of stress inoculation has also been observed within the sport training and rehabilitative setting. Coping response, outcome expectancy, an athlete's perception of control, and the type and level of athletic challenge or stress have been documented among athletes.^14,16,17 Therefore, an athlete's attitude toward trauma and the subsequent coping disposition and mechanisms that are called upon while experiencing trauma should influence the level of rehabilitative success and return to play.^18,19 Findings, however, have been inconclusive, and limited attention has been focused on factors such as sex or type of sport.

Athletes involved in traditional National Collegiate Athletic Association (NCAA) sports experience unusually high levels of stress, expectations, and physical challenges within a short span of time.^16,20 The psychological stress is exacerbated by the need to adapt quickly to the competitive environment going into the season. Existing coping resources deemed essential for optimal performance may not withstand increasing psychological and physical stressors.^{3,14,16,21,22} In the clinical setting, an athlete may also lose the ability to think clearly, resulting in irrational risk taking, noncompliance, and inadequate attention to the protocols required for successful treatment and rehabilitation, leading to further trauma or the need for extended care.^3,20 Athletes in this environment typically have extensive national or university-governed organizational support systems in place (eg, NCAA), as well as a more coach-dominated, highly competitive training environment than observed in nontraditional sport settings.

The limited research available has provided few insights into coping mechanisms encountered in unique nontraditional environments, especially among the growing number of women participating in these sports.^23,24 The nontraditional athlete is often not extrinsically motivated, typically prefers the solitude and escape that the sport provides, and would still participate regardless of media coverage, the presence of a crowd, or financial gain.^11,25 These athletes frequently participate in less coach-structured, non-NCAA sports characterized by individualism, self-determination, and autonomy.^13,15,26 Such nontraditional activities are often associated with adventurous or extreme sports such as downhill and telemark skiing, martial arts, rock climbing, rodeo, or skydiving. Further investigation is warranted to compare women involved in nontraditional sports (eg, rock climbing), who typically demonstrate intrinsic motivation, individualism, and the sheer enjoyment of participation, with traditional-sport athletes, who focus on competing and dominating others.^24–28

Prior research efforts have typically addressed the psychological response after injury. Given the increased stress within the sport environment and a concomitant rise in the number of severe injuries among today's female athletes,^12,18,21 an a priori approach would provide more meaningful insight into the psychological resolve that an athlete possesses, rather than primarily characterizing the psychological response after physical trauma of an athlete within the competitive environment. This would enhance awareness and triage procedures that reduce potential patient-related risk factors in the clinical setting and optimize recovery and return to play.^{4–6,12–14,18,19,21} Therefore, this study was conducted to quantify and compare pain-coping traits among individual-sport women athletes participating in nontraditional sports versus traditional NCAA-structured competition, with relevance to optimal treatment and rehabilitation. We hypothesized that women athletes participating in nontraditional, individual-sport activities would reveal a less pronounced pain-coping response than women participating in traditional coach-structured, individual NCAA sports.

METHODS

Data Analyses

Data were grouped for analyses with the SIP subscales and composite according to type of sport athlete (nontraditional, traditional). Multivariate analyses of variance (MANOVAs) and Wilks' λ tests were performed using the general linear model procedures of SPSS (version 19; SPSS Inc, Chicago, IL) to determine significant main effects. Data screening revealed no violations of assumptions related to sample size, bivariate linearity, multivariate normality and outliers, multicollinearity, singularity, or size of the correlations.³¹ Because of unequal numbers of observations to assess differences among variables, we conducted least squares means procedures. Univariate post hoc procedures were performed when significant main effects were observed. Statistical significance was determined a priori at the .05 level. To make the data more meaningful, we converted raw SIP scores to normalized standard scores (T-scores) with a mean of 50 and a standard deviation of 10 (Figure). The use of T-scores is a commonly accepted psychometric procedure that allows comparisons of scales containing different numbers of items.³¹

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RESULTS

Because descriptive variables such as age, number of career injuries, and number of years of sport experience can have a profound or statistically confounding effect on subsequent psychological responses, we initially used MANOVA with Wilks' λ criterion to determine possible differences. Wilks' λ criterion indicated no significant main effect (F_3,294 = 0.106; P = .957; n − β = 0.069) between nontraditional and traditional individual-sport athletes, respectively, for age (20.2 ± 0.1 versus 20.2 ± 0.1 years; P = .848), number of career injuries (2.3 ± 0.2 versus 2.3 ± 0.2; P = .644), or number of years of sport experience (7.3 ± 0.4 versus 7.2 ± 0.4 years; P = .861).

Multivariate analyses of variance were then conducted to compare SIP scores of women athletes involved in both nontraditional and traditional individual sports. Wilks' λ indicated a significant main effect for type of sport competitor (F_6,291 = 12.922; P = .0001; n − β = 1.000; Figure). Post hoc procedures (mean ± SE) indicated that nontraditional athletes scored lower in COP (P = .0001), COG (P = .0001), CAT (P = .0001), and TCR (P = .0001) than traditional athletes. No differences were observed in AVD (P = .707) or BOD (P = .450) responses. When we compared our findings with SIP norms (T-score mean = 50; Figure), nontraditional athletes in this study demonstrated lower scores across most subscales than athletes in traditional sports.¹⁹

DISCUSSION

Although psychometric testing has been successfully used to assess skill level, injury response, rehabilitation compliance, and stress in studies with various athletic populations,^13,19,32 no authors, to our knowledge, have addressed coping disposition in a unique group of competitors involved in sports typically characterized by intrinsic motivation, individualism, self-determination, and autonomy. Therefore, this study was conducted to quantify and compare pain-coping styles among individual-sport women athletes participating in nontraditional versus traditional NCAA-structured competition with relevance to optimal treatment and rehabilitation.

The higher scores in COP, COG, CAT, and TCR among the traditional individual-sport group may reflect the training environment, coaching influence, sport socialization, or perceived unforeseen but controlled challenges (or a combination of these). Prior findings, however, have been limited and equivocal with regard to a woman's perception and response to discomfort. Early studies indicated that women athletes sometimes shifted to a more aggressive, achievement-oriented mentality in response to more demanding challenges,³³ whereas others have reported either a more emotion-based response among women with subsequent negativity to impending stress¹⁷ or perceived stress similar to men, albeit with different coping styles.²⁴ Women in traditional sports may be encouraged by coaches to attempt challenges beyond their physical capabilities, ultimately exposing themselves to greater potential for musculoskeletal trauma and subsequently greater stress inoculation than nontraditional women participants.^20,28 Apart from the conjecture, most researchers have pointed to a higher pain threshold, greater tolerance of physical tasks, more cognitive pain adaptation, and greater treatment and rehabilitation responses among women athletes who have experienced a greater number and severity of physical traumas.^19,34 Again, the significantly higher degree of coping response exhibited by the traditional-sport group may be a function of the inherent nature of the highly competitive, coach-influenced environment; clinical staff need to be cognizant of these factors to avoid encouraging or rewarding excessive efforts of traditional athletes during treatment and rehabilitation.

The nonsignificant difference in AVD between groups is not surprising. Individual-sport competitors are solely responsible and accountable, and thus, cannot avoid the challenge in front of them or receive assistance from a teammate. Only the nature of the challenge differs, whether it is a human in tennis or an animal adversary in rodeo, or whether the competition is conducted on a standard course as in golf or is a geographic challenge as in rock climbing.

The nonsignificant difference in BOD between traditional and nontraditional athletes may reflect an analogous, instinctive understanding or sensitivity to the task at hand; that meeting the challenge primarily resides within them, a challenge that cannot be shared with or alleviated by others during competition, and a challenge that requires an internalist mentality—a mentality that win, lose, or draw, the outcome is solely dependent on them. A limited number of studies have touched upon defining locus of control among nontraditional athletes.^25,28 Further efforts, however, are warranted to confirm this theory.

As opposed to traditional individual sports, for which extensive national or university-governed organizational support systems are in place, the unique nature of nontraditional individual sports often requires that the athlete compete under adverse climatic conditions without optimal protection, facing challenges beyond his or her control (eg, difficult terrain, dysfunctional equipment, uncooperative livestock), and encountering delayed or compromised medical and rehabilitative care.^15,17,26,35 Although the literature suggests that these uncontrolled experiences resulted in substantial adaptation to future challenges beyond what would be considered normal, our findings indicated more positive pain-coping mechanisms among traditional women athletes. These results also contrast with those of a prior study²⁸ that demonstrated similar responses in traditional and nontraditional competitors pain coping.

FINDING A NONTRADITIONAL APPROACH

Based on the findings of this study, today's athletic trainer is in a unique position to optimize rehabilitation outcomes and return an injured player to activity by (a) approaching the nontraditional athlete from a biopsychosocial rather than a biomedical model, (b) understanding what drives the nontraditional athlete, and (c) adjusting the standard rehabilitation mentality to optimize return to activity with this unique nontraditional population.^12,36–38

CONCLUSIONS

The successful treatment and rehabilitation of athletes is contingent upon many factors. In this study, we investigated the pain-coping styles of nontraditional women athletes in a variety of individual-sport activities and demonstrated differences between nontraditional and traditional athletes. The attenuated pain-coping style in this population has not been reported elsewhere, to our knowledge. The findings also support our hypothesis that women participating in nontraditional sport activities would reveal less pronounced pain-coping styles than women participating in more traditional coach-structured sports. We hope these results will be used to stimulate continued research into the pain-coping responses of nontraditional populations during treatment and rehabilitation.