Pilot study of the efficacy of eye movement desensitization and reprocessing (EMDR) intervention for injured Division I student-athletes

Authors: Jay Trenhaile¹.  Thayer Trenhaile², and Thayne Munce

Pilot study of the efficacy of eye movement desensitization and reprocessing (EMDR) intervention for injured Division I student-athletes 

ABSTRACT 

Four NCAA Division I student-athletes, who had previously been injured, volunteered to participate in Eye Movement Desensitization and Reprocessing therapy (EMDR) and completed both pre and post test measures. The sessions ranged from five to eight treatments and results on the Profile of Mood States 2nd Edition – Adult Short (POMS 2-A Short) indicated notable decreases on Total Mood Disturbance and Tension/Anxiety scales. Increases were found on the Vigor/Activity scale (Positive Mood State). The student-athletes who participated in the study achieved “personal records” in 11 of the 17 potential areas of measure for a “personal record” in their sport. In addition, some student-athletes achieved multiple “personal records” in some of their events. Utilizing EMDR therapy with student-athletes who are experiencing distress or declining performance should receive notable consideration by mental health clinicians who are providing therapeutic services to collegiate student-athletes.     

Key Words: Recovery from injury; Eye Movement Desensitization and Reprocessing; Mental Health;  Sport Performance; Student-Athlete Performance;  Trauma 

INTRODUCTION 

INTRODUCTION 

Every year there are an estimated seven million sport and recreation-related injuries (17). This includes a number of students and student athletes at colleges and universities who suffer from injuries, such as torn ligaments, broken bones, concussions, etc. Sometimes these incidents result in surgeries and/or require extended physical therapies or related treatments.   

In addition to the physical injury, student-athletes may experience Post-traumatic stress disorder (PTSD) and other trauma-related/mental health disorders (1). PTSD can be the result of direct physical injury, witnessing a traumatic event (i.e. injury to a teammate) or relationship dynamics within the sport (i.e. coaches, teammates). Aron (1) also found student-athletes experienced PTSD at a 13-25% higher rate than the general population. Similarly, Houston (6) found that college student-athletes experienced lower levels of health-related quality of life (HRQOL) after injury, but injured athletes who were able to participate had a higher HRQOL than those who were injured and unable to participate.    

After an injury, another common psychological reaction is reinjury anxiety (16). In fact, reinjury anxiety is reported as the most common reason for athlete’s inability to return to a sport after anterior cruciate ligament (ACL) surgery (12).   

A well-known, effective psychotherapy designed to treat anxiety, post-traumatic stress disorder, and similarly stressful situations is Eye Movement Desensitization and Reprocessing (EMDR) (14). The main focus of the EMDR approach is to efficiently alter distressing memories from the past into something useful (14). The effectiveness of the EMDR approach is predominately due to its adaptability and applicability to other therapeutic approaches. EMDR is considered to be complex and consists of multiple phases that incorporate eye movement into a well-rounded approach (11). 

Incorporated within the EMDR treatment are bilateral stimulations (15). These important parts of the intervention process include eye movements, tactile taps, and/or auditory tones. Due to its adaptability and applicability, the EMDR approach can be effectively used to treat a wide variety of distressing and traumatic symptoms. This was illustrated in a meta-analysis completed by Chen (2), which found that EMDR significantly reduced the symptoms of PTSD, depression, anxiety, and subjective distress.    

Limited EMDR research with subjects experiencing concussions and brain trauma (10) has noted a significant positive impact on clinical conditions, such as scores on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Improvement on the positron emission tomography (PET) and electroencephalography (EEG) assessments also indicated favorable metabolic and electrophysiological changes accompanying EMDR.  

Depression, fatigue, irritability, confusion, and general mood disturbance are frequently reported after cerebral concussion necessitating more thorough examination of post-concussive emotional disturbances empirically, and clinically (8). On a positive note, research conducted by Gil-Jardine (5) found that persistent symptoms after concussion (PSaC) can be prevented in up to 75% of patients with a brief, early EMDR treatment session. Given that 10 – 20 % of individuals who experience a concussion develop PSaC, including emotional symptoms, treatments such as EMDR that can decrease the negative disturbances should be studied more and evaluated for clinical utility.  

Research supporting the use of EMDR in a variety of scenarios continues to grow and provides support for using this therapy with recovering collegiate student-athletes experiencing distress and/or declining performance post injury. This pilot-study with four student-athletes provides initial support for further study and utility of this therapy with collegiate student-athletes and supports findings of Reynoso-Sánchez (13) and Curdt (3) (4) who used EMDR as a treatment to reduce anxiety and increase self-confidence in athletes.    

METHODS 

Study Design 

The primary researcher was trained through EMDR Consulting, which is an EMDR International Association (EMDRIA) Approved training entity. This researcher completed half of the training face-to-face and the other half was completed virtually.  

Participants 

Student-athletes at an NCAA Division I institution with a previous injury were solicited to participate in the research study. In order to protect research participant anonymity, limited demographic information is presented in this article.   

Participants were recruited through flyers placed in the main athletic training facility and the academic study room. Athletic academic advisors and athletic trainers served as referral sources for the research study as well. Another referral source was graduate students within the academic Counseling and Human Resource Development program on campus.        

Two of the student-athlete participants had experienced chronic lower leg injuries, which was shared in their initial meeting with the researcher and cited as the primary reason for volunteering to be in the research study. Two other participants had experienced concussions within the previous 12 months prior to enrollment in the study and cited those experiences as the majority of motivation for participation. Another participant had been experiencing shortness of breath episodes that had been limiting their ability to complete practice and accompanying workouts, but was unable to be included in the final results because the mood disturbance questionnaire was not completed at the treatment conclusion. And, one participant dropped out of the study after the initial meeting. No student-athlete was denied participation in the research study and all participants were traditional college-age student-athletes with three being at least 21 years of age and academically meeting the criteria as an upper class student (i.e. junior or senior).  

Measures 

The Profile of Mood States 2^nd Edition – Adult Short (POMS 2-A Short) was utilized to provide self-report information identifying levels of mood disturbance and positive mood states (7). The POMS 2-A Short provides a scale score on Negative Mood States and includes individual scales for Anger-Hostility, Confusion-Bewilderment, Depression/Ejection, Fatigue-Inertia, and Tension-Anxiety. Positive Mood States provide a scale score, which includes Vigor-Activity. An affective state scale of Friendliness is also provided as a measure of adaptability and quality of life. The pre-test was completed during the initial research meeting with the individual student-athlete and researcher. A post-test administration of the POMS 2-A Short was requested of the participants after they had completed the EMDR therapeutic interventions (see below for additional details).    

Results from the participants’ sports competitions during the semester they received the EMDR therapy was reviewed to provide performance indicators of the research participants. Specifically, the number of times the student-athlete achieved a “personal record”, as reported in the official news releases from the sports information department, was tabulated.  

Intervention and Procedure 

  The EMDR protocol that EMDR Consulting used in their trainings served as the therapeutic intervention. After a standard intake questionnaire was completed, the student-athletes completed Shapiro’s Calm/Beautiful Place activity along with some other tools such as Four-Square Breathing, 4-7-8 Breathing, and the 5-4-3-2-1 grounding technique (9). Grounding techniques and other resourcing tools provided the student-athlete completing the EMDR therapy with skills and techniques to manage strong emotions or traumatic memories related to the injury. The student-athletes were strongly encouraged to practice these interventions prior to their second visit (i.e. approximately one week after the initial meeting). During the second meeting, the presenting complaint was reviewed along with the negative core beliefs as well as the positive core beliefs. Unrestricted processing was utilized after the researcher was confident of the student-athletes’ resourcing ability (i.e. use of calm place or breathing interventions).     

RESULTS 

Pre-, Post-, and Follow-Up Measures 

Four of the participants completed both pre and post POMS-2A Short surveys. In addition to the individual scale scores provided for each student-athlete, percent change, and the average score for the participants was provided. Percentages were rounded to the nearest tenth. Results on the Total Mood Disturbance found the average of the participants decreasing from a score of 60.3 to a score of 43.5. Two of the participants’ ratings dropped from a classification of “elevated” to a classification of “low”. Complete results are identified in Table 1 including the percent change. 

Table 1 

 POMS 2-A Short Total Mood Disturbance Pre and Post Test Results 

STUDENT-ATHLETE	Total Mood Disturbance  (Pre Test)	Total Mood Disturbance(Post Test)	Change (%)
1	67	56	-16.4
2	44	40	-9.1
3	61	39	-36.1
4	69	39	-43.5
Total	241	174	-27.9
Average	60.3	43.5	-27.9

Results on the individual scales of Anger-Hostility and Confusion-Bewilderment all found mean decreases with the largest decrease in Anger-Hostility, which decreased an average of 16.75 points. Table 2 provides the breakdown of the results including percent change. 

Table 2 

 POMS 2-A Short Anger-Hostility; Confusion-Bewilderment; Pre and Post Test Results  

STUDENT-ATHLETE	Anger – Hostility (Pre Test)	Anger – Hostility (Post Test)	Change (%)	Confusion- Bewilderment (Pre Test)	Confusion – Bewilderment (Post Test)	Change (%)
1	60	51	-15	55	50	-9.9
2	40	40	0	40	38	-5.0
3	51	40	-22.6	62	40	-35.5
4	53	40	-24.6	62	42	-32.3
Total	204	171	-16.2	219	170	-22.4
Average	51	42.8	-16.2	54.8	42.5	-22.4

The Depression-Dejection and Fatigue-Inertia scales provided similar decreases as noted in the other scales on the POMS 2-A Short, with the largest mean decrease in Fatigue-Inertia, which decreased 22 points on average.  Results from these two scales are provided in Table 3.   

Table 3 

POMS 2-A Short Depression- Dejection; Fatigue-Inertia; Pre and Post Test Results  

STUDENT-ATHLETE	Depression-Dejection (Pre Test)	Depression- Dejection (Post Test)	Change (%)	Fatigue – Inertia  (Pre Test)	Fatigue – Inertia  (Post Test)	Change (%)
1	53	53	-0	67	59	-12.0
2	41	43	0.5	46	44	-4.4
3	43	41	-10.9	50	34	-32.0
4	60	46	-23.4	59	36	-39.0
Total	200	183	-8.5	222	173	-22.1
Average	50	45.8	-8.5	55.5	43.3	-22.1

 

The Tension-Anxiety scale had the largest decrease of any scale on the instrument as the mean decreased 26 points.  Results from the Tension-Anxiety scale are shown in Table 4 

Table 4  

POMS 2-A Short Tension-Anxiety; Pre and Post Test Results 

STUDENT-ATHLETE	Tension – Anxiety  (Pre Test)	Tension – Anxiety   (Post Test)	Change (%)
1	61	48	-21.4
2	51	43	-15.7
3	61	46	-24.6
4	71	43	-39.5
Total	244	180	-26.3
Average	61	45	-26.3

In the Positive Mood Disturbance, scores in the Vigor-Activity area increased after the intervention. However, scores on the Friendliness scale were generally unchanged. Table 5 provides the breakdown of those scales including the percent change.   

Table 5 

POMS 2-A Short Vigor-Activity; Friendliness; Pre and Post Test Results 

STUDENT-ATHLETE	Vigor – Activity  (Pre Test)	Vigor – Activity (Post Test)	Change (%)	Friendliness (Pre Test)	Friendliness      (Post Test)	Change (%)
1	49	56	14.2	45	50	11.1
2	54	61	12.9	61	58	-5.0
3	44	56	27.2	42	47	11.9
4	49	61	24.4	50	50	0
Total	196	234	19.3	198	205	3.5
Average	49	58.5	19.3	49.5	51.3	3.5

An analysis of the news releases from the sports information department during and after the study found reports of “personal records” for all four of the student-athletes who completed the pre and posttests in the study. In addition, the results from the student-athlete who participated in the study but didn’t complete the post-test were reviewed. Of the 17 potential areas of measure for a “personal record”, the student-athletes who participated in the study achieved “personal records” in 11 of those areas. Some student-athletes achieved multiple “personal records” in some of their events.   

Student-Athlete # 1  

This student-athlete reported multiple concussions as a participant in a different sport and was beginning participation in a new collegiate sport. After four sessions, notable decreases were identified in Total Mood Disturbance and Anger/Hostility and Tension/Anxiety on the POMS-2. Being considered somewhat of a beginner in their new sport, they were identified in news and press releases with nine “personal records” in five different events during or after completing EMDR treatment. However, this individual’s novice status needs to be taken into account, as being new to a sport provides more opportunities for improvement and thus, new “personal records”.  

Student-Athlete # 2  

Student # 2 was experiencing chronic lower extremity pain and had minor changes on the Total Mood Disturbance scale at the conclusion of EMDR treatment. A total of eight sessions were completed and scores in Vigor/Activity (Positive Mood State) did increase from the “average state” to “elevated”. News and press releases cited this student-athlete with two “personal records” in their sport out of five events/activities possible.  

Subjective Units of Distress (SUD), which is used in EMDR therapy to serve as a measure of the disturbance of negative emotional thoughts related to the traumatic experience, were described by this student-athlete as a “weight on my shoulders….the weight feels like the opinions of others….I’m waiting for something bad to happen…”. These descriptive emotional thoughts were also reported in academic activities at times as well as during athletics.  

Student-Athlete # 3  

This student-athlete reported a chronic lower extremity injury along with difficulty with reoccurring thoughts regarding the injury. After treatment, notable decreases were found on the Total Mood Disturbance scale of the POMS-2 along with lower scores in the Confusion/Bewilderment and Tension/Anxiety scales. Student-athlete # 3 completed eight sessions as part of their EMDR treatment process and achieved “personal records” in three different events/activities as noted in press releases or the news. They participated in four events/activities in their sport.  

When describing the SUD, this student-athlete’s comments ranged from “I feel anxious just thinking about it” to “I’m feeling more in control of my thoughts and how they make me feel”. The Validity of Cognition (VOC) is used in EMDR therapy as a measure of belief in the process of establishment of positive memory related to the events/situations. When processing the Validity of Cognition (VOC), this student-athlete described more positive thoughts as they progressed from, “I’m feeling a bit tense” to “I’m excited…my shoulders feel better…”.   

Student-Athlete # 4 

Student # 4 described a general lack of confidence after experiencing a bout of depression and a concussion within the previous 12 months. Scores on the POMS-2 scales of Total Mood Disturbance, Confusion/Bewilderment, and Tension/Anxiety decreased a substantial amount, while the Positive Mood State scale (Vigor/Activity) increased at a notable level. This student-athlete had a “personal record” reported in news or press releases for one event out of a potential two events/activities.  

When asked to respond to the SUD as part of the EMDR treatment protocol, this student-athlete began by reporting, “I can remember that feeling” to, “I’m starting to think…why did I think that in the first place…”. Strengthening of the VOC was noted after an initial response similar to “I thought a lot about the feeling of success…”.  Comments related to a higher level of the VOC toward the latter stages of the EMDR treatment included, “I’m picturing myself being successful…I feel athletic…I’m feeling relief and confidence when I’m successful…”.  

DISCUSSION 

The results of the study present positive preliminary data demonstrating an association between EMDR and improvements in mood state and athletic performance for injured student-athletes. The study builds on research conducted by Reynoso-Sánchez (13) who found athletes reporting decreases in anxiety and somatic symptoms after a single-session of EMDR and groundwork by Curdt (3) (4) who used EMDR to decrease anxiety and increase self-confidence in professional golfers with traumatic athlete memories. While many athletes define “successful return” to sport after injury as competing and training at pre-injury levels and standards, improvement on pre-injury levels is often not identified as a goal (12). Based on the promising research with EMDR and realistic goals of post-injury performance, a definitive need for additional research exists to examine the impact of EMDR on injured and recovering student-athletes.  

Given the high levels of Post-traumatic stress disorder (PTSD) and related mental health disorders among student-athletes as found by Aron (1), the use of EMDR therapy has notable implications. Further, based on research by Houston (6), supporting a return to competition after injury will likely result in a higher health-related quality of life (HRQQL).  

As noted in the results section, both the categories of tension-anxiety and anger-hostility were quite high among the participants at the initial stages of therapy, but returned to the average or low range at the conclusion of therapy. The initial stages of EMDR therapy coincide with “resource training”, including grounding technique, 4-7-8 breathing, etc. It is certainly possible that the impact of the “resource training” made a significant impact without the full complement of the EMDR therapy. Especially since it is not uncommon for those resources to be used alone, outside of EMDR treatment.    

Limitations 

This study was limited by sample size and necessitated the results being reported as a pilot study. More participants and the inclusion of a control group would be beneficial to confirm the efficacy of EMDR as a regular treatment intervention for student-athletes after an injury, surgery, or similar experience. Additionally, the use of additional outcome measures and instruments could elucidate broader health domains that may be positively influenced by EDMR.   

CONCLUSIONS 

The results from this study provided strong supporting evidence for the need to continue studying the utility of EMDR therapy for injured and recovering student-athletes. Future studies with a greater number of participants and more researchers are needed to provide supporting evidence for the utility of EMDR as a therapeutic intervention and potential to be integrated into a standard protocol for post-injury treatments.      

APPLICATIONS IN SPORT 

Coaches, parents, and athletic trainers need to acknowledge the psychological impact of injuries and how they can negatively impact mental health and student-athlete performance. Recommending appropriate treatment and referrals to a mental health provider trained in EMDR therapy with a sport background and knowledge in the area should strongly be considered by those who work with collegiate student-athletes. Not only can positive treatment decrease distress, but it can improve overall mood, quality of life, and sport performance.  

Acknowledgments 

This study was funded in part by Sanford Health, Sioux Falls, South Dakota. Special thanks to Shea Campbell for helping recruit volunteer participants and in telling the story of the project.     

Correspondence concerning this article should be addressed to Jay Trenhaile, Counseling and Human Development, South Dakota State University, Thompson Center, Brookings, SD 57007.  Email:  [email protected]  

Declaration of conflicting interests 

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.  

REFERENCES