Application of Theory for Those With Sport-Related Concussion: Understanding the Effect of Athletic Identity on Health Outcomes

Over the past few decades, sport-related concussion (SRC) has emerged as an injury of concern in health care because of increasing rates of injury, the potential severity of symptoms, and the long-term consequences for the brain.¹ It also represents a functional disturbance rather than a structural injury. This makes it distinct from musculoskeletal injuries in which signs and symptoms may present outwardly.² Most individuals who sustain SRCs recover within 1 to 3 weeks.³ However, recovery can extend for much longer and is considered prolonged for any athlete who still experiences symptoms after 4 weeks.⁴ A variety of risk factors, such as age, sex, concussion history, mental health disorders, and learning disabilities, are known to complicate and delay recovery.^5–9 Unfortunately, poor outcomes, such as increased social isolation, minimization of symptoms to allow earlier return to sport, and prolonged symptom duration, have been observed in athletes who sustained SRCs.¹⁰ Additionally, psychological factors are often overlooked variables that may affect SRC recovery and contribute to poor outcomes after SRC.¹¹

Altered mood states are the psychological responses that have received the most empirical attention. Authors of several studies have found an increase in depressive,^8,12–15 anxiety,^16–18 or both symptoms in athletes after SRC that contributed to prolonged recovery. Furthermore, qualitative investigators have indicated that individuals’ perceptions of internal and external pressures to return to sport influenced injured athletes to return to sport before feeling ready to return.¹¹ Other psychological responses, such as fear of reinjury¹⁹ or amotivation,²⁰ have been associated with increased symptoms after SRC as well. Unlike altered mood states, these other psychological factors are often overlooked as part of standard SRC assessment and management. Physical readiness is prioritized despite the potential risk of a prolonged recovery associated with poor psychological responses to injury. Another psychological factor not often considered that has recently received attention concerning its influence on SRC and subsequent recovery is athletic identity.

Athletic identity is defined as the extent to which an individual identifies with the athletic role.²¹ Individuals with a strong athletic identity place high value on and prioritize sport in their lives.²² When defining athletic identity, Brewer et al²² proposed that a stronger athletic identity can act as either a Hercules’ muscle or an Achilles’ heel, reflecting both the positive and negative consequences of such an identity. A stronger athletic identity acting as a Hercules’ muscle has been associated with a number of positive outcomes, including greater commitment to sport participation,^23,24 increased sport motivation,²⁵ better performance across the season when winning,²⁶ and positive well-being.²⁷ Alternatively, a stronger athletic identity acting as an Achilles’ heel indicates too much or sole reliance on this identity,²⁸ which may have negative consequences in the sport domain. Researchers have suggested that athletes with stronger athletic identities may neglect other identities (eg, student) to maintain the athletic role.^29,30 The negative consequences of a stronger athletic identity may be amplified if an athlete becomes injured, as his or her sense of self can be shaken, and some individuals may even dissociate from their athletic identities.²⁹ After an injury, those with stronger athletic identities have demonstrated increased depressive symptoms.^21,31 Although we can consider a stronger athletic identity to be a necessary and beneficial trait for sport participation, we must also consider and explore the consequences of having a stronger athletic identity, especially as it relates to an injury such as SRC.

Athletic identity can be assessed using the Athletic Identity Measurement Scale (AIMS).²³ The AIMS is a 7-item questionnaire developed by Brewer et al²³ that assesses the extent to which the athlete role is a stable and central part of one’s self-identity. We consider athletic identity to be a relatively stable personality trait, yet results on the AIMS indicate it can change with situational disturbances (eg, poor sporting season, injury)^26,29 and over time (eg, retirement from sport).³² The AIMS could be used to understand how athletic identity influences outcomes after SRC.

To better inform stakeholders (eg, health care providers) who often treat athletes about the consequences of maladaptive psychological responses post–SRC and further elucidate the effect of these responses on SRC recovery, it is beneficial to use and apply theory to understand the sequalae of poor outcomes (eg, failure to disclose symptoms, lack of rehabilitation adherence) associated with these psychological responses. One such model is the integrated model of response to sport injury.³³ In this model, athletic identity is listed as a personal factor to consider as part of an athlete’s psychological response to injury. Further exploration of athletic identity in the integrated model of response to sport injury is important to inform health care providers on ways to address an overlooked factor that could influence SRC recovery. Therefore, the purpose of our paper was to use current literature to characterize the negative consequences of a stronger athletic identity in individuals after SRC. More specifically, the evidence we discuss will help inform health care providers on (1) the negative consequences of athletic identity on health-related outcomes after SRC and (2) how to effectively assess athletic identity in order to enhance patient management strategies for athletes with stronger athletic identities. Additionally, recommendations for theory-driven research to further characterize how athletic identity affects the recovery process of SRC will be offered.

INTEGRATED MODEL OF RESPONSE TO SPORT INJURY

Among the many cognitive appraisal models, the integrated model of response to sport injury has received the most empirical support to date.^34–36 The integrated model of response to sport injury was developed from existing conceptual models to illustrate the dynamic process of psychological responses that occur after sport injury.³³ More specifically, this model posits that personal and situational factors influence a psychological response that can dynamically change over time to affect recovery. Personal factors may include psychological, demographic, and injury characteristics and biological differences, whereas situational factors may include sport characteristics and social and environmental influences, among others.³³

These factors directly influence a patient’s cognitive appraisal of the injury, which influences his or her emotional and behavioral responses. A cognitive appraisal is a personal interpretation of a situation and possible reactions to it.³⁷ An injured athlete appraises both the nature of the injury (primary appraisal) as either stressful or not stressful and his or her perceived ability to cope with the stress associated with the injury (secondary appraisal). These appraisals then determine the subsequent emotional responses an athlete might have and the behavioral responses that could influence recovery outcomes. Thus, a dynamic process exists in which primary and secondary appraisals of an injury play central roles in determining the ever-changing cognitive, emotional, and behavioral responses the athlete might experience during the recovery process.³⁷ A positive appraisal of the injury would likely move an athlete toward a positive recovery experience; a negative cognitive appraisal may put an athlete at risk for a negative recovery outcome.³⁸

An example of the negative outcomes using the integrated model of response to sport injury can be seen in Figure 1. An injured athlete who has a stronger athletic identity may appraise the injury as a direct threat to his or her self-concept, causing emotional responses such as fear, helplessness, frustration, sadness, apathy, and irritability.³⁹ This may cause a variety of behavioral responses, including the athlete choosing to overadhere or underadhere to rehabilitation, minimizing symptoms, hyperfocusing on symptom expression, or isolating from important social support networks. Unfortunately, this could affect recovery outcomes, as it can either prolong recovery after SRC or result in a too early return to sport. Both options put an athlete at risk for negative health outcomes.⁴

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ATHLETIC IDENTITY AFTER SRC

Qualitative methods have typically been applied to explore how athletic identity influences the recovery process and life afterward when an athlete retires because of SRC.^40–43 Former professional National Hockey League players described loss of athletic identity.⁴⁰ This had a negative effect on their recovery process, as they continued to experience symptoms long after the event, resulting in frustration and depression about the situation (ie, emotional response). Additionally, these retired athletes encountered difficulty transitioning to and embracing another career.⁴⁰ Results were similar in another sample of former ice hockey players who retired from sport due to SRC.⁴¹ Previous researchers have indicated that 47% of former female collegiate soccer players had identity struggles after their collegiate careers ended, with 40% of those individuals commenting that it was hard to find a new identity.⁴⁴ Those with stronger athletic identities were more likely to have negative career transitions, especially when they were unplanned, after an injury such as SRC.^32,45,46 Using the integrated model of response to sport injury to understand these observed outcomes, an athlete with a stronger athletic identity who ends sport participation due to SRC may stop identifying with the athletic role and have difficulty adjusting to a new identity.⁴⁴ This may produce negative emotional responses including depression and apathy. Furthermore, it may result in behavioral responses such as underadherence to treatment and isolation from their support system.³⁹ This could negatively influence recovery outcomes for the athlete and affect long-term quality of life, with outcomes including decreased motor fitness (eg, speed, agility, power, and balance)⁴⁷ and dissatisfaction with activity levels in retirement⁴⁸ (Figure 1).

In an autoethnography, Dean⁴² focused on his personal experiences of SRC, particularly related to the change in athletic identity that occurred due to sustaining an SRC. The author described the change in athletic identity as a “(re)negotiation of identity” to convince his doctor to allow him to return to play and to convince himself he was still a normal, healthy athlete. When an injury can be hidden, as is possible in patients after SRC, an incongruency in perception exists between the individual and others, as they may not perceive the individual to be injured. This makes it more challenging for the individual to construct an identity that is grounded in reality.⁴² This threat to identity may also cause athletes to minimize symptoms or choose not to disclose their injury. Failure to disclose an SRC ultimately puts athletes at risk for further injury and prevents timely, appropriate, and effective treatment.⁴³ This idea has been supported by the findings of 2 other studies. Among National Collegiate Athletic Association Division I men’s hockey players, athletes with stronger athletic identities who viewed SRC as a threat to their athletic status were less likely to report a concussion.⁴⁹ Also, among Division I football players, a stronger athletic identity was associated with less intention to report symptoms of a concussion during a game or 24 hours after a game.⁵⁰

Reasons athletes give for not reporting symptoms of an SRC include not wanting to lose playing time⁵¹ and not wanting to lose their starting position on their team.⁵² These reasons are associated with an athlete’s athletic identity and further indicate the importance of this psychological construct in understanding a behavioral response such as nondisclosure of symptoms.⁵⁰ According to the model, an athlete may experience frustration and irritability about the possible consequences of being removed from sport, which could influence the individual to minimize symptoms after SRC or not report symptoms at all. An athlete may do this to return to sport as soon as possible. However, as noted by the authors of a recent systematic review, minimizing symptoms can ultimately prolong recovery.⁵³ Athletes who did not immediately report symptoms of their concussions added about 5 days to their recovery time compared with athletes who did not delay reporting.⁴ Other researchers have shown that a stronger athletic identity has been associated with a higher level of rehabilitation overadherence.⁵⁴ Overadherence to rehabilitation for a person with concussion might present as attempting additional rehabilitation activities or failing to indicate the presence of or an increase in SRC symptoms during the stepwise return-to-play protocol. This could drastically increase the risk of prolonged recovery after SRC^4,53 (Figure 1).

To the best of our knowledge, only O’Rourke et al²⁰ have used the integrated model of response to sport injury to identify potential self-reported factors that may predict recovery in SRC.²⁰ They compared personal (eg, athletic identity) and situational (eg, quality of social support) factors with concussion symptoms experienced by youth athletes and demonstrated that stronger athletic identity was related to more intense symptoms and slower recovery after SRC. The authors theorized that athletes with stronger athletic identities interpreted their concussions more catastrophically and had difficulty adjusting to their injuries and recoveries given the threat to their identities.²⁰ This negative appraisal of their injuries affected athletes’ use of psychological coping skills and made them hypervigilant regarding ongoing SRC symptoms. The possible emotional and behavioral responses associated with the negative cognitive appraisal of youth athletes with stronger athletic identities may have exacerbated symptom expression and contributed to a slower recovery²⁰ (see Figure 1). O’Rourke et al²⁰ also discussed that a slower recovery occurred, as athletes may have distanced themselves from sport as a coping mechanism after injury.

A reduction in athletic identity after injury has been primarily observed with injuries that required extensive time away from sport (ie, months).²⁹ Brewer and Cornelius²⁹ found that athletic identity decreased during the rehabilitation process after anterior cruciate ligament surgery, particularly between 6 and 12 months postoperatively. This reduction in athletic identity has been seen as a protective measure to preserve self-esteem in response to the injury.²⁹ After SRC, the recovery period is usually 1 to 3 weeks,³ which may not give athletes enough time to distance themselves from sport. However, those with persisting symptoms after SRC might reduce their athletic identities as a protective measure similar to athletes with injuries that require long-term rehabilitation (eg, anterior cruciate ligament reconstruction). This is concerning, as a decrease in athletic identity has been associated with a reduction in physical activity levels once athletes stop participating in sport^55,56 (Figure 1). Therefore, a critical need exists to assess and address athletic identity in patients after SRC, especially those who exhibit persisting symptoms after concussion. These individuals may be at particular risk for declines in physical activity engagement with longer-term negative health outcomes.^55,56

IMPLICATIONS FOR CLINICAL PRACTICE AND FUTURE RESEARCH

Health care providers play an important role in evaluating and managing athletes after SRC. They may be able to identify athletes who exhibit strong athletic identities because of their day-to-day interactions with athletes, patients, and teams. Health care providers must be aware of how to effectively assess athletic identity and implement patient management strategies for athletes with stronger athletic identities. To assess athletic identity, health care providers could use the AIMS to detect those who exhibit stronger athletic identities and assess changes in athletic identity across recovery. Information from the 3 subscales of the AIMS—social identity, exclusivity, and negative affectivity—can be used to better inform intervention selection for athletes. Social identity is defined as the extent to which individuals view themselves as occupying the athlete role, exclusivity is the extent to which an individual’s self-worth is determined only by performance in the corresponding athlete role, and negative affectivity is the extent to which an individual experiences negative affect in response to undesirable outcomes in athletic domains. For example, an athlete who is stronger in exclusivity might work to identify and develop other important identity roles. Another athlete who is stronger in negative affectivity might benefit from self-talk to reframe the negative feelings associated with undesirable outcomes of sport, such as being injured and away from sport. Although the AIMS is an appropriate starting point for assessing athletic identity after SRC,²⁰ future researchers should validate the use of the AIMS in specific populations, including youth and professional athletes. Additionally, updated normative data from these populations are needed.

Athletic identity concerns can also lead to the opportunity for interprofessional collaboration. If an athlete with a strong athletic identity is injured, the health care provider can work with coaches to help keep that person involved with the team during the recovery process. This may be especially important for those struggling with persisting symptoms after SRC or who may have ended sport participation because of SRC. Athletes could work as managers or assistant coaches or by simply serving as supportive teammates on the bench. Furthermore, health care providers should be able to effectively refer individuals to appropriate licensed mental health providers when the athletic identity concern is beyond the scope of their clinical practice.^57,58 Appropriate licensed professionals include sport psychologists, counselors, social workers, and clinical or counseling psychologists.^39,46,59 These mental health providers can help an athlete explore identities outside of the sports domain and encourage exposure to other social environments to secure identities. An athlete may choose to focus on his or her role as a student, spend time with family or friends who are not athletes, or explore nonsport hobbies such as cooking, exercising, or reading.^44,46

It is also important to consider that a stronger athletic identity after SRC may be beneficial. An athlete may positively interpret the injury as something he or she can handle, perhaps viewing the rehabilitation process as a new sport, with the stronger athletic identity acting as a Hercules’ muscle.²² In response to this cognitive appraisal, the athlete has a positive outlook and behaviorally decides to adhere to rehabilitation and use psychological coping skills. This can lead to a healthy return to sport and maintenance of a physically active lifestyle after SRC. We have shown how positive responses may influence recovery through the lens of the integrated model of response to sport injury (Figure 2). However, currently, no available evidence supports the role of the Hercules’ muscle in recovery outcomes after injury. Future investigators should examine the potential positive outcomes associated with a stronger athletic identity after SRC.

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Theory-based research is necessary to further understand the role of athletic identity after SRC and its potential effect on recovery. We have used the integrated model of response to sport injury to present potential negative outcomes in individuals who sustain SRCs and exhibit stronger athletic identities. Authors of future studies should apply the integrated model of response to sport injury to examine the relationships among athletic identity and emotional and behavioral responses post–SRC to provide additional evidence to support our theoretical claims. Lastly, future theory-driven intervention randomized controlled trials are needed to determine the best strategies to maintain or reduce athletic identity for athletes after SRC to enhance health outcomes.

LIMITATIONS

This paper is not without limitations. First, the integrated model of response to sport injury is restricted to the psychological response after injury and is not intended to explain the biological aspects of recovery. Second, we did not include literature related to SRC and management strategies not pertaining to athletic identity. The literature was selected to help characterize our understanding of athletic identity and to provide tangible strategies for health care providers to aid patients after SRC who may exhibit stronger athletic identities. Finally, as previously noted, few authors have examined the influence of athletic identity on outcomes after SRC, and this work primarily involved athletes in only 2 sports (ie, hockey and football). Therefore, these results may not be applicable to other sport populations.

CONCLUSIONS

In this review, we applied the integrated model of response to sport injury to help characterize how a stronger athletic identity may lead to negative consequences on health outcomes after SRC. Further examining athletic identity is necessary to understand an athlete’s psychological response to sport injury and ultimately improve outcomes for individuals after SRC. Health care providers may tailor treatment plans for athletes who more strongly identify with the athletic role. Future theory-driven research is needed to explore how stronger athletic identity affects recovery outcomes after SRC and identify the effectiveness of interventions to promote adaptive athletic identity in patients post–SRC.