Mindfulness Practice Is Associated With Improved Well-Being and Reduced Injury Risk in Female NCAA Division I Athletes

Abstract

Background:

Injury in sport is an inherent risk to participation, and it can have devastating consequences for the athlete, both mentally and physically. Previous research has found that impairments in well-being can increase the risk of injury, and that various forms of mindfulness training and practice can improve well-being and mental health in various populations.

Hypothesis:

Mindfulness would be associated with greater well-being and lower risk of injury.

Study Design:

Cohort study.

Level of Evidence:

Level 3.

Methods:

A total of 21 female Division I athletes underwent a formal 6-week mindfulness training program and were encouraged to continue mindfulness exercises. The athletes completed daily surveys on their smartphones in relation to mood, muscle readiness (soreness), readiness to train, energy level, daily training load, and whether they had participated in mindfulness training that day. Linear mixed effects models were used to evaluate well-being variables and mindfulness state, and separate mixed effects logistics regression models were used to evaluate injury incidence and wellness variables.

Results:

On days with mindfulness practice, athletes reported higher mood (19.6 [18.8-20.3] vs 19.4 [18.6-20.1, P = 0.03), muscle readiness (18.9 [17.8-20.0] vs 18.6 [17.5-19.6], P = 0.03), readiness to train (78.7 [75.9-81.5] vs 77.4 [74.7-80.2], P < 0.01), and energy level (19.3 [18.6-20.1] vs 18.8 [18.1-19.5, P < 0.01) than on the days when they did not participate in mindfulness training. Mindfulness practice was associated with significantly reduced likelihood of suffering an acute injury the following day (odds ratio, 0.42; 95% CI, 0.42-0.43; P < 0.01).

Conclusion:

On an individual level, participation in mindfulness by female collegiate athletes was associated with a dramatic reduction in injury risk the following day. In addition, mindfulness was associated with significantly improved mood, muscle readiness, readiness to train, and energy level.

Clinical Relevance:

These findings suggest that mindfulness training in athletes may improve well-being and reduce the risk of injury among high-level athletes.

Sports-related injuries can have far-ranging consequences for athletes, from mental health effects such as anxiety and depression symptoms, social consequences such as loss of peer group participation, and long-lasting physical consequences such as pain and loss of participation in sport.^13,25 In fact, there is consistent evidence that athletes who suffer a physical injury exhibit more symptoms of anxiety and/or depression than those who are uninjured.^3,17,22 Sports-related injuries are an inherent risk of participation. In a study conducted by the Centers for Disease Control and Prevention on injury incidence among Division I collegiate athletes between the years of 2009 and 2014, there were 210,674 injuries, approximately 6.0 injuries per 1000 athlete-exposures. ¹⁶ While many injuries are hard to avoid, student-athletes experience stressors that can increase their risk of injury, including high competition stress, increased demands on their time, injuries that affect physical wellness, and increased mental load. ¹⁸ As a result, student-athletes can experience stress that can result in sleep deprivation and illness, resulting in elevated risk for injury. ²⁷ Although much of the focus of an athlete’s training is to hone physical skills and fitness, there is momentum to focus on the mental aspect of an athlete’s training to improve performance, reduce injury risk, and improve athlete mental health.

Research has shown that athletes have many risk factors, both intrinsic and extrinsic, that may predispose them to injury. ¹⁹ Acute sports injuries are caused most often by direct impact or the application of force that is greater than the body can withstand, though they are often avoidable, and proper recovery, warm-up, and decision-making during play can affect injury risk.^6,11 However, there are other factors related to athlete well-being that have been identified as being associated independently with elevated risk of injury in athletes. Previous research has demonstrated that injury risk is significantly higher in collegiate athletes who slept less, had worse mood and sleep quality, and greater fatigue, stress, and soreness before the injury. ¹² Another study found that higher training load and worse mood were independent predictors of injury in youth athletes. ²⁶ These previous findings provide support for interventions that improve athlete well-being, and in turn may have a protective effect against injury.

In an effort to improve athlete mental health and outcomes, mindfulness-based interventions for athletes have recently increased in popularity. ² Mindfulness-based mental training involves the application of techniques, strategies, and procedures, including attention to one’s own bodily sensations, emotional reactions, mental images, self-talk, and perceptual experiences of external stimuli. ⁴ Mindfulness training allows a person to be aware of internal and external information that is occurring around them, and thus be able to change their relationship to automatic reactions. It has also been shown to successfully decrease a person’s rumination, working memory, and sustained attention, ⁵ and shows great promise in more specific populations. Mindfulness training is a tool that has been used successfully in athlete populations, and is intended to allow athletes to make better decisions and be in the moment, potentially reducing the risk of injury. The objective of the current study was to identify the association between mindfulness training on several wellness and training variables, including mood, muscle readiness, readiness to train (RTT), energy level, and total daily training load. We also sought to determine the association between engaging in a mindfulness exercise on the risk of suffering acute injury in sport the following day. We hypothesized that engaging in a mindfulness exercise would reduce the risk of injury and improve wellness variables.

Methods

A total of 21 female National Collegiate Athletic Association (NCAA) Division I volleyball athletes participated in the study. Participants underwent a formal mindfulness training program before the beginning of the study, guided by an expert with >10 years of experience in mindfulness teaching. The program consisted of 6 weekly, half-hour structured, in-person mindfulness training sessions including procedural and declarative instruction in mindfulness practice. The curriculum was informed by the Healthy Minds Framework, and included elements of awareness, connection, insight, purpose, attention, positive outlook, appreciation, and in-body purpose (Figure 1). Sessions were coordinated with sports coaches and strength and conditioning coaches. Introductory sessions were required training and happened during NCAA allowed training time. Coaches were often participants in the sessions. Session length was 30 minutes and sessions were held weekly. Participants were encouraged to practice mindfulness training outside of in-person sessions, including listening to recorded practices tailored to their athletic department, using a mindfulness app (e.g., Calm, Headspace, Healthy Minds, etc), self-guided practices based on the skills learned in the foundational training including concentration, awareness, positive outlook, and embodied purpose using practices that could be done as movement-based practices, stillness practices, or as integrated practices into their daily activities.

Figure 1.

Mindfulness intervention curriculum.

From September 2020 to December 2021 (except May through August 2021), athletes completed daily online surveys every evening regarding mood, muscle readiness (soreness), readiness to train, energy level, total daily training load, and whether they had participated in mindfulness training that day. This time period was after the onset of the first format mindfulness training was introduced to the athletes, but in-person sessions were still being performed. Self-reported mood, muscle readiness, and energy level where reported on a scale of 1 to 5, with 5 being good. Daily training load was a product of minutes of exercise and rating of perceived exertion (1-10 scale, with 10 being most difficult). Readiness to train was calculated using 8 health indicators, and weighted using an algorithm to determine a readiness to train score, where a higher score was better. During the same time period, injuries were recorded by the athletic training staff. Acute injuries were included in the analysis, defined as injuries that occurred suddenly during training or competition and required attention from the athletic training staff.

This study was approved by the Institutional Review Board at the University of Wisconsin - Madison.

Statistical Methods

Separate linear mixed effects models were used to predict each well-being measure (mood, muscle readiness, energy level) with mindfulness practice (yes, no) as a fixed effect and the athlete as a random effect. Least squares means were then used to compare the variables on days when a mindfulness session was or was not reported. This was intended to determine whether well-being measures in the evening were associated with mindfulness participation earlier in the day, while adjusting for the repeated measures from each athlete. The association between mindfulness practice and injury the following day was determined using separate mixed effects logistics regression models to predict injury including mindfulness as a fixed effect and the athlete as a random effect. This tested the relative ability of mindfulness participation reported in the evening to predict the likelihood of injury the following day, while adjusting for the repeated measures from each athlete. Statistical significance was determined a priori at the 0.05 level, and all tests were 2-tailed. All statistical analyses were performed in R. ²³

Results

A total of 21 female Division I varsity athletes aged 18 to 22 years participated in the study. A total of 22 acute injuries were suffered during data collection, including 5 knee (23%), 5 wrist/hand (23%), 5 head/concussion, 3 lower extremity (14%), 3 elbow (14%), and 1 hip (4.5%). A total of 5765 daily entries of well-being and mindfulness activity were reported by athletes, with an overall compliance rate of 78% with daily data entry. Daily mindfulness activity reporting during the study period is represented in Figure 2. Missing data did not seem to be meaningfully associated with athlete or date and were treated as missing at random.

Figure 2.

Mindfulness sessions reported per day by athletes during the data collection period.

On days when a mindfulness training was performed, athletes reported significantly better mood, muscle readiness, readiness to train, and energy level than on the days when they did not participate in mindfulness training (Figure 3). We also found that mindfulness practice was found to significantly decrease the likelihood of suffering acute injury the following day (odds ratio, 0.422; CI, 0.42-0.43; P < 0.01).

Figure 3.

Well-being and fitness variables on days when athletes practiced mindfulness versus no mindfulness. ns, nonsignificant.

Discussion

In this study of female Division I athletes, we found that mindfulness practice reduced the risk of acute injury the following day by 58%. This finding expands on past reports that have shown promise that mindfulness may reduce the risk of injury in athletes.^15,20,21 In the present study, the mindfulness intervention relied on the downstream effects of mindfulness practice, which include body awareness, affective chronometry, increased proactivity, a greater understanding of one’s body, and greater advocacy for the athlete’s body and needs.

We also found that participating in a mindfulness activity was associated with better mood, greater muscle readiness, higher readiness to train score, and higher energy level that same day. Our findings are in support of past research that has found that mindfulness can improve mood and energy levels.^8,28 However, the athlete-specific relationship that we found between mindfulness practice and muscle readiness and readiness to train are novel findings in the literature. Athlete readiness, or “readiness to train,” describes an athlete’s subjective fatigue, is often based on self-report, and has been found to be tied to performance and functional overreaching.^7,24 Muscle readiness is another subjective measure of athlete readiness that has been demonstrated to be significantly related to jump height and physical performance. ¹ Both “readiness to train” and “muscle readiness” are improved through athlete recovery and preparation, respectively, but our findings suggest that mindfulness practice may also improve these metrics in athletes.

Because of the potentially devastating consequences of injury on athlete mental and physical health, the promising use of mindfulness practice in sport to reduce injury is important. A recent review on the use of psychological interventions to reduce the risk of injury in athletes concluded that there is sufficient evidence supporting the use of psychological-based interventions by athlete support staff to reduce injury incidence among athletes. ¹⁰ Although Ivarsson et al ¹⁴ found that a group of athletes that completed mindfulness training suffered fewer injuries than the group that did not undergo mindfulness training, our study demonstrated that a single mindfulness practice the day before a practice or competition event significantly reduced the risk of injury. Taken together, there is evidence that after a single mindfulness activity, an athlete has a lower risk of injury. By including several wellness-based metrics in athletes’ daily reporting, we attempted to begin to explore mechanistic insight into the drivers behind the potential protective effects of mindfulness on injury risk.

Factors contributing to athlete injury are numerous, and often difficult to predict. However, in a 1994 paper, Meeuwisse et al ¹⁹ proposed a multifactorial model on athlete injury etiology, where there are intrinsic and extrinsic risk factors that an athlete faces in play and competition that increase risk of injury. We propose an adapted model that includes intrinsic risk factors as mood, energy level, training load, soreness, and readiness to train, and the potential mediating variables of mindfulness as affective chronometry, interoception, body awareness, full focus on the activity, meta-awareness of thoughts and emotions, reduced rumination about mistakes, greater skill in positive outlook, and embodied purpose (Figure 4). In this model, an athlete, who is fully immersed in play, has meta-awareness of automatic mental and emotional reactions and has skills to rely more on positive affect in affective chronometry, ⁹ is more likely to have better decision-making because of a less emotional response to play, and thus have better judgment in critical, and dangerous, moments of play.

Figure 4.

Multifactorial model of athlete injury and mindfulness. RTT, readiness to train.

Limitations

This study has major limitations that should be noted including the very small number of participants. While we believe that a strength of our study was that athletes could choose the mindfulness practice activity at will, we did not document what those activities were, and thus cannot assess which mindfulness activities were of most benefit. We also chose to include only acute injuries in our analysis, due to the fact that it would be hard to identify the relationship between a daily instance of mindfulness and a chronic or overuse injury that developed over time. However, overuse and stress injuries are very disruptive to athletes and can lead to even longer time away from play, and further study should examine the relationship between mindfulness practice and chronic injuries. There are also potential confounders that likely affected wellness and injury risk outcomes that we were unable to account for in our analysis. Sleep, social relationships, nutrition, training load, and competition could have been either influenced by mindfulness, or influenced the outcomes of our study more directly. Finally, mindfulness was not assigned to athletes randomly, making it difficult to exclude the possible roles of confounding variables.

Conclusion

Engaging in a mindfulness exercise significantly reduced the risk of injury the following day in female collegiate volleyball athletes. Furthermore, it was associated with improvements in mood, muscle readiness, readiness to train, and energy level. These findings suggest that mindfulness training may represent a low-cost, low-risk, scalable intervention to improve health outcomes in competitive athletes.