Authors: Wahid Hamidi1, Yusuf Hamidi2, and George Karlis1
1Department of Human Kinetics, University of Ottawa, 125 University pvt., Ottawa, ON, Canada, K1N 1A2
2Department of Nursing, University of Ottawa 125, University pvt., Ottawa, ON, Canada, K1N 1A2
Wahid Hamidi, Ph.D. Candidate
125 University pvt.
Ottawa, ON, Canada
Wahid Hamidi is a Ph.D. candidate in the School of Human Kinetics at the University of Ottawa, Canada. His area or research focuses on initiating and maintaining physical activity and exercise behavior, and injury prevention and concussion management in the academic and athletic settings for varsity student-athletes. He is a recipient of the University of Ottawa Admission Scholarship.
Yusuf Hamidi is a Master of Science student in the School of Nursing at the University of Ottawa, Canada. His area of research focuses on problem-solving approaches to learning barriers for undergraduate students using simulated-based learning. He is a recipient of the Undergraduate Research Opportunity Program award.
George Karlis is a Full Professor in the School of Human Kinetics at the University of Ottawa, Canada. His area of research focuses on leisure, society, recreation, sport, and community development.
A phenomenological exploration of constraints for varsity football student-athletes with a sport-related concussion
Sports-related concussions are an emergent public health concern due to an increase in mortality and morbidity incident rates. The purpose of this study is to identify constraints in academic and athletic settings for varsity football student-athletes with a sport-related concussion. Twelve varsity football student-athletes from one institution who were diagnosed with a sport-related concussion took part in semi-structured interviews. This study used the social ecological model to identify intrapersonal, interpersonal, and environmental factors. Results suggested that varsity football student-athletes with a sport-related concussion experienced several constraining social ecological factors in the academic and athletic settings. Intrapersonal constraints related to loss of motivation, loss of social identification, stress, anxiety and depression, injury-specific issues, and internal pressure to return. Interpersonal constraints related to insufficient social support, lack of awareness and guidance on concussion knowledge, external pressure to return, and lack of academic support post-concussion. Environmental constraints related to return-to-play and return-to-learn protocols. Findings suggested that there remains a need to address constraining factors in the academic and athletic settings for varsity football student-athletes with a sport-related concussion.
Key Words: sport-related concussion, football, high school, student-athlete, academic, athletic, constraints, qualitative, phenomenology
Participation in sports has been associated with benefits to overall quality of life, cognitive development, physical, social, and psychological health (4). Although participating in sports provides numerous benefits, it also carries the risk of injury. The risk of injury stems from the nature of the sport and the specific activities of the participant. When a student-athlete sustains a concussion, what are the academic and athletic impacts?
Concussion is an injury typically associated with sports and is often associated with football (10). Due to the combination of high speeds and full contact, football players are susceptible to a variety of injuries during games and practice. Common injuries football players suffer are head injuries and ligament injuries (10). These types of injuries have the potential to negatively affect a student-athlete’s involvement in the classroom, and on the playing field (17).
According to the Centers for Disease Control and the Brain Injury Research Institute, about 1.6 to 3.8 million individuals suffer from a sport-related concussion in the United States (20). In addition, according to Brain Injury Canada (2), brain injuries currently impact 1.5 million Canadians, and another 160,000 Canadians experiencing a brain injury every year. Specifically, sport-related concussion in the sport of football has gained significant attention largely due to several professional athletes who have died from chronic traumatic encephalopathy (CTE) (22).
Further, due to the rigorous schedule of a varsity football student-athlete, students can miss classes due to team travel obligations, late nights as a result of game and practice schedule, and inconsistent eating and sleeping patterns (10). This schedule becomes more challenging to manage for student-athletes who are suffering and recovering from a sport-related concussion. It is thus essential for coaches and educators to recognize the potential constraints an injury can pose on regular academic and athletic activities (10). To better understand the potential that an injury can pose on student-athletes, the purpose of this study is to identify constraints in academic and athletic settings for varsity football student-athletes with a sport-related concussion.
Sport-Related Injury Constraints
Injuries, according to Margot Putukian (16) pose a major constraint that could potentially lead to significant challenges. Performing and succeeding academically and athletically becomes more challenging and difficult if an athlete is injured (16). Stress poses a major constraint in the response to, rehabilitation and return to learning and playing after injury. In addition, there are constraints to mental health treatment in student-athletes following an injury. For instance, Putukian (16) mentioned how student-athletes see requesting help as a sign of weakness because they should be able to overcome psychological issues as they do physical issues.
Pre-injury constraints include biological, physical, psychological, and sociocultural that could increase a student-athlete’s risk of injury and poor recovery. Stress, according to Putukian (16) could cause attention changes, distraction and heightened self-consciousness that could hinder a student-athlete’s overall performance and predispose a student-athlete to injury. Putukian (16) noted that stress played a major role as a constraint for student-athletes, which led to increased muscle tension and coordination that increased the risk for injury.
In a study conducted by Brewer and Petrie (3) physical injury caused 33% of Division 1 football players in the United States as having high levels of depressive symptoms, compared with 27% of non-injured student-athletes. Intrapersonal constraints, such as depression, and stress increase the risk of injury, and impact academic and athletic performance for a student-athlete (19). For instance, when an athlete is injured, common emotional responses are the following: sadness, isolation, irritation, lack of motivation, anger, frustration, changes in appetite, sleep disturbance, and disengagement (3). However, student-athletes differ in their response to injury (16).
Concussion can pose a major challenge for student-athletes to recover physically and emotionally, and is usually associated with significant time loss or retirement from sport (9). Putukian (16) mentioned how not being able to exercise following initial diagnoses of a concussion, and given emotional and cognitive symptoms associated with concussion, student-athletes may struggle with academics as well as the emotional response from a concussion. As well, with the recent rise in literature of CTE, student-athletes are concerned that they may develop CTE following a concussion (9).
According to Gulliver et al. (9) student-athletes are less likely to seek out assistance for mental health issues than non-athletes. Student-athletes may be more susceptible to be at a higher risk for mental health issues because they are less likely to seek services that provide assistance due in large part to potentially being afraid to disclose symptoms, seeking counseling as a sign of weakness, sense of entitlement or may not have developed healthy coping mechanisms to deal with failure (9). Gulliver et al. (9) also noted that many athletes may not have developed a sense of identity outside of that as an athlete, and as a result, if their role as an athlete is threatened by injury, they may be more susceptible to a loss of identity, which could lead to a heightened risk in mental health issues. Furthermore, stigma surrounding mental health services for a student-athlete remains one of the biggest constraints to seeking help following an injury (9). For example, in a study conducted by Gulliver et al. (9) of elite athletes aged 16-23, focus group discussions revealed that stigma was the dominant perceived constraint for student-athletes requesting assistance. Other constraints to help seeking for student-athletes following an injury included: lack of problem awareness, difficulty in expressing emotion, lack of time, denial of problem, not sure who to ask for help, fear of what might happen, worried about affecting ability to play, and belief that seeking assistance would not help (15).
For this research, purposeful and convenience sampling techniques were employed to access varsity football student-athletes who have sustained a sport-related concussion. A purposeful sampling technique is justified because it involves recruiting knowledgeable individuals who perceived the phenomenon under investigation (6). A convenience sampling technique is justified since the target population in this study meets practical criteria, such as accessibility, and geographical proximity (8). Therefore, since the ultimate goal of this study was focused on the perceptions of a particular population in relation to identifying constraints and facilitators in the academic and athletic settings for varsity football student-athletes with a sport-related concussion, purpose and convenience sampling technique enabled the researcher to elicit valuable information to address the purpose of this study.
Purposeful sampling is not a probability sample that will lead to the development of statistical inferences to a population, rather; it involves making a deliberate choice of specific individuals and sites that can provide necessary information to answer the research questions that cannot be obtained using other sampling choices (12). Small sample sizes preserve the individuality of participants during analyses, instead of collecting a large amount of data from greater samples and generalizing the data for all participants (5). Thus, participants in this study met the practical criterion for convenience sampling.
Participants were recruited from the University of Ottawa football program where the researcher has been a previous member and is well acquainted and familiar with the coaching staff, players, and football culture. Recruitment was conducted through a recruitment letter posted around the football training facility, social media, and email. Recruitment efforts included an accurate description of the purpose of the study, name and contact information of the researcher, eligibility criteria, time commitments required, and location of the research. Additionally, recruitment efforts stated that the participants would remain anonymous.
For this study, twelve participants took part in single semi-structured interviews. Participants consisted of 12 males between 19 and 23 years of age. Additionally, participants were selected to participate on a first-come, first-serve basis. Participants also met the criteria outlined by Leedy and Ormrod (11) by being knowledgeable about the investigated area, willing to discuss it, and sharing their perspectives and points of view.
This study had specific inclusion criteria. To be eligible to participate in this study, (a) participants had to speak English, (b) be on the official roster of the University of Ottawa varsity football team, (c) registered as full-time students, (d) diagnosed with a sport-related concussion by a medical professional, (e) and compete in U Sports at the time of the study (13).
Prior to data collection, the researcher obtained ethical approval through the Research Ethics Board (REB) at the University of Ottawa. Data was collected through semi-structured interviews (14), which allowed participants to share personal narratives on their perception of suffering and recovering from a sport-related concussion.
A semi-structured interview guide was developed for this study. The interview guide consisted of the following sections: (a) demographic questions, (b) past and present sport experiences, (c) past and present sport injuries, (d) facilitators to academic and athletic settings following a sport-related concussion for university football student-athletes, and (e) constraints to academic and athletic settings following a sport-related concussion for university football student-athletes.
During the audio-recorded interviews, participants were given the opportunity to reflect on their academic and athletic experiences in the context of a sport-related concussion through open-ended questions. To ensure the questions were pertinent to the purpose of the study, an interview guide has been designed to identify the constraints and facilitators in academic and athletic settings for varsity football student-athletes with a sport-related concussion.
Interviews were transcribed verbatim and examined using the thematic analysis steps suggested by Braun, Clarke, and Weate (1). Every transcript encompassed different layers of interpretation constructed by the researcher. For this study, analysis was guided by the descriptions of the three main types of factors within the social ecological model (18). Thematic analysis steps, as outlined by Braun et al. (1), included six steps: familiarization, coding, theme development, theme refinement, theme defining and naming, and writing the report. Thematic analysis, according to Braun et al. (1) is a method for identifying, analyzing, and finding patterns within the data set. Thematic analysis offers a specific set of techniques to collect and analyze textual description that are not bound to any theoretical framework, making thematic analysis a flexible method in which it can be combined with phenomenology to create meaning and examine factors that underlie a phenomenon under investigation (1). According to Crotty (7) a methodology is a comprehensive strategy that outlines choice and use of methods relating to the outcome. Therefore, a phenomenological research design was utilized to gain a better understanding of the study under investigation. Phenomenology, according to Leedy and Ormrod (11) refers to “a person’s perception of the meaning of an event, as opposed to the event as it exists external to the person”. The combination of thematic analysis and phenomenology was appropriate for this study as every transcript encompassed different layers of interpretation and the analysis was guided by the phenomena described by the participants through three main types of factors within the social ecological model (i.e., intrapersonal, interpersonal, and environmental). In addition, the researchers emphasized key sections of the transcripts by highlighting and underlining what was deemed to be significant to the study’s topic. As well, descriptive comments were documented for additional reference associated with the key sections to produce ideas for new relevant themes based on the phenomena under investigation. Subsequently, key sections were paired with other relevant sections and organized into groups of similar quotes deriving of related ideas and concepts. During the process of creating subthemes, overarching labels were grouped and then identified with broader groups to form overarching themes. Next, final themes were originated to provide a deep understanding of the topic being studied. Throughout the entire process, analysis occurred concurrently during the data collection process to notify how data collection would progress and to decide when a sufficient amount of data was gathered to address the purpose of the research (21).
The 12 participants discussed their thoughts, feelings, and overall perception of their individual sport-related concussion. Following data collection, threemajor themes surfaced which addressed the purpose of this study. Through Braun et al. (1) steps for thematic analysis, three main categories were identified with each containing their own set of sub-groups, of themes. The first category is intrapersonal constraining factors. This category of themes explained the participants’ intrapersonal constraining difficulties factors encountered following a sport-related concussion. Identifying five sub-themes created this category: (a) loss of motivation; (b) loss of social identification; (c) stress, depression, and anxiety; (d) internal pressure to return; and (e) injury-specific issues. The second category of themes discussed the participants’ interpersonal constraining factors encountered following a sport-related concussion. Identifying four sub-themes created this category: (a) insufficient social support; (b) lack of awareness and guidance; (c) external pressure to return; and (d) lack of academic support post-concussion. The third category of themes described the participants’ environmental constraining factors encountered following a sport-related concussion. Identifying two sub-themes created this category: (a) return-to-play and return-to-learn protocols, and (b) online access to resources for concussion management. For each of the themes, descriptions and quotations were provided to highlight the context.
Intrapersonal Factors – Constraints
Loss of motivation.
In a competitive sporting environment, especially a contact sport such as football, injuries are likely to occur. As identified by participants in this study, maintaining and finding motivation in the classroom and on the playing field following a sport-related concussion is something student-athletes found challenging. All participants in this study explained how they felt a loss of motivation following a sport-related concussion in their academic and/or athletic settings.
One participant explained how a lack of motivation in the academic and athletic settings was evident after suffering a sport-related concussion. He shared:
It’s tough when you’re so used to a regular routine of working out and studying almost every day of the week, to sitting in a dark room doing absolutely nothing but resting. At times I questioned if I ever wanted to play football again but realized that playing football made studying and attending class easier because I knew there was something to look forward to, whether that be going to practice or working out with my teammates.
In addition, another participant mentioned how he felt a loss of motivation following a sport-related concussion because:
A concussion is a lot different than a lot of injuries. You’re advised to stay away from any athletic or academic things in order to rest and heal as quickly as possible. So I did that, and when I did it was de-motivating because I felt I was no longer involved within the team. I wasn’t able to attend practice, film review, meetings, or gym sessions.
Furthermore, he discussed how being removed from the playing field made him lose a feeling of social acceptance within the team. He recalled, “Not being able to attend social events with the team made me feel like an outsider. I didn’t want to go back and have my coaches and teammates feel bad for my injury.”
It was mentioned, “When I got hurt, I started falling behind in class, and honestly, I lost motivation in wanting to achieve my academic goals I set out for the year.” He suggested his motivation to play football directly impacted his motivation to attend classes. Additionally, other participants reiterated accepting physical rest had resulted in losing motivation to return to the classroom and the playing field. For instance, not being able to practice, run, tackle, catch, throw, weight lift, attend class, and study were common thoughts suggested by the participants.
Loss of social identification.
Sport involvement, especially at the U Sports level, can play a significant role in a student-athlete’s social identification as expressed by the participants in this study. Several participants shared how they felt a loss of social identification following a sport-related concussion.
All participants in this study agreed that their friends and family would be surprised if they had stopped being involved in athletics. In contrast, more than half of the participants agreed with friends and family thinking of them as a member of the athletics community. The strongest commonality between the participants who voiced a loss of social identification was the difficulty of no longer associating and identifying themselves as student-athletes following the sport-related concussion.
For instance, one participant recalled:
Since I was 10 years old all I did was eat, sleep, and play football. When you devote so many hours per day for the majority of your life, doing something that you’re passionate about, the feeling of being stripped away from your passion is huge. I started to identify myself as an athlete-student instead of student-athlete. My recovery process took over many months to fully recover, and during that time, I felt like a phony telling people that I’m a football player, because at the time, I wasn’t playing obviously. I’d say it was an important time in my life because I learned to re-evaluate my values and priorities, and try to develop interests and find other passionate things in my life that I had been neglecting since I mainly focused on football.
Another participant reiterated:
I definitely went through a period of having an identity crisis when I was recovering from my concussion. When you’re taken away from the game for so long, you start to question whether you’re still a student-athlete. For as long as I could remember I would associate myself with being a student-athlete, when in reality, I was just a student recovering from a concussion. The fact that I was struggling with associating myself as a student or student-athlete bothered me for many days during recovery.” Moreover, another participant made it important to highlight to be more than the “uniform” to any current or future student-athlete going through a similar situation. He suggested, represent the “uniform” with honour, and play your “heart out”, but do your best to not solely associate and identity yourself with that. The reason being, “there will be a time when the uniform comes off for good, make sure you know who you are outside the uniform so that you don’t have to go through an identity crisis like I went through.
Although participants struggled with social identification following sport-related concussion, when asked how they identified themselves today, participants primarily identified themselves as student-athletes. It is also important to note, they all stressed the importance of being students first before athletes. It was mentioned, “Football will always be a part of my life that’s for sure.”
Stress, anxiety, and depression.
A sport-related concussion has the potential to disrupt student-athletes’ day-to-day academic and athletic activities and can impact their mental health as expressed by the participants. Several participants described stress, anxiety, and depression as common mental health symptoms following a sport-related concussion.
Participants who dealt with mental health symptoms following a sport-related concussion expressed how their symptoms affected their academic activities. It was explained:
I definitely felt stressed. Basically, I just kind of felt anxious all the time. I would sleep for 6 hours, and wake up feeling a little down and depressed. Like even trying to read and do homework was tough, so I was told not to do anything school related, but I didn’t want to fall behind, so I tried my best to keep up. But even then, it was really hard, and I didn’t want to do homework for the next couple of weeks. I guess I was just down and stressed”. Additionally, a few other participants expressed the feeling of not wanting to fall behind academically and decided against the advice of their medical professionals to push themselves to keep up with their academic requirements; however, this only resulted in symptoms worsening, and feeling “stressed all the time.
Several participants voiced their feelings on how they rely on exercise as a means of coping with stress. For example:
Working out is huge for me, it’s what keeps me calm when I’m stressed and I just enjoy it and of course when you’re concussed, the first thing you’re told is to rest, rest, and rest. And so, when your means of dealing with stress is stripped away from you, it can take its toll. So at times when I felt stressed, I couldn’t rely on working out to get my mind off things, and this only lead to more built up stress. It just wasn’t a good situation for me.
Further, another participant discussed how he dealt with depression when he saw his roster positioning beginning to slip away. He recalled, “Football’s a next man up type of game. I went from being a starter to third string player after my concussion and I’m not ashamed to admit that I felt depressed seeing my starting spot slip away from me.” One participant discussed how he went through depression after his doctor diagnosed his injury as a severe concussion; however, he noted that his depression symptoms lasted until he came to terms with accepting, he would be out of the classroom and playing field for a prolonged period of time. Additionally, some participants experienced depression immediately following the sport-related concussion, while others developed depression months after initial concussion diagnoses.
Three participants mentioned experiencing anxiety in relation to re-injury following a sport-related concussion. For instance, “Even when I would think about going back to practice, I had negative thoughts running through my head worried that I would get concussed again, and I wasn’t mentally ready to go through another rehab process.”
For intrapersonal constraints, participants mentioned how various injury-specific issues associated with a sport-related concussion limited their overall ability in the academic and athletic settings. For instance, individuals cited difficulty thinking clearly, focusing, remembering, drowsiness, and headache all made their engagement in academic and athletic activities difficult.
For participants that felt that injury-specific symptoms constrained their academic and athletic activities, it was mentioned that:
Academically, the biggest challenge for me was staying focused because I had constant headaches throughout the day and saw my GPA drop because of it”. Another participant stated, “The biggest athletic challenge for me was the physical side of things. While I was out, I physically was not cleared to practice so I tried making up for it by watching practice and game film. I found it almost impossible to focus. I ended up falling behind on the playbook and saw my roster position slip.
Participants were also constrained in their ability to recover quickly from a sport-related concussion and get back to their academic and athletic activities through limited knowledge on the benefits of rest. One participant stated, “I didn’t know at the time rest meant physical and cognitive. I took time off the gym, doing chores, but I didn’t rest my brain from cognitive things like looking over the playbook, or reviewing game films.” The participant continued to discuss how his limited knowledge on the benefits of rest only prolonged his injury unknowingly. In addition to physical and cognitive rest, one participant discussed how one of the key aspects of recovering from a concussion included mental rest, such as, avoiding social media, video games and computers.
Furthermore, for some participants, rest was hard to come by as they struggled with sleeping at night. One participant stated:
It was hard keeping the same bedtime schedule with the concussion. My sleeping habits were all over the place, I was sleeping and waking up at different times throughout the week. I even tried setting up an alarm to get my sleep habits back to normal but that still didn’t work.
This led to extreme daytime fatigue, which only created additional stress. In addition, other participants mentioned keeping cellphone out of bedroom to avoid screen time temptation and using earplugs, white noise machine, or a fan as a strategy to create better sleep environment.
Internal pressure to return.
Another intrapersonal constraint consisted of internal pressure to return to football. Several participants intrinsically felt self-pressure to return to football following a sport-related concussion. The term “competitive” served as a commonality into wanting to return to football while recovering from a sport-related concussion. For example, one participant mentioned “just having that competitive spirit in me I wanted to come back the next day, but obviously with my concussion circumstance it wasn’t a reality.”
It was described:
At the time, you’re so focused on your sport and it’s all that you know in life and you want to return even if that means opening up the gate for re-injury, you don’t think about things like ‘I will have a life outside of football once I hang up the cleats’ because in that moment, you’re a competitor and that’s all you can think about.
Another participant mentioned how he felt high levels of internal pressure to return in order to make it into the Canadian Football League. He stated:
My goal is to take my play to the next level and play for the CFL. When I was hurt man, all I could think about were ways to return as quickly as possible because the scouts aren’t going to wait on me, I need to pump out as much game film as I can to get my name out there. I’m trying to turn this sport into my fulltime career, I don’t want to let the people who believe in me down either, so many sacrifices were made for me to be in this position.
Additionally, another participant described how his internal pressure to return to football stemmed from not wanting to let his coaches and teammates down. For instance, he recalled:
We were playing (arch rival) and we got beat on a deep ball for a touchdown, and I kept beating myself up for it because that should’ve been me covering that receiver, not a 2nd year defensive back who has no experience playing in a game. My coaches and teammates rely on me to be healthy to go out and make those kind of plays for the team”. He went on to say how he felt a sense of internal pressure and urgency to play, , “you only get a few opportunities in life to play in front of 25,000 screaming fans. I wanted to get out there so bad, there was a point leading up to that week where I was like I don’t care how I’m feeling I want to suit up for this game and play with my brothers.
Another participant described how he was not being truthful behind disclosing his concussion symptoms to the athletic staff in an effort to “escape concussion protocol” because he felt the process to return to competition would be long and he did not want to let his teammates down. He recalled, “The last thing I want to do is let my teammates hanging over an injury, it’s crazy to say but that’s how I felt”.
Interestingly, it was mentioned that the idea of being “weak” played into internal pressure to return to football. For instance, one participant described how he essentially got knocked out while participating in a tackling drill during practice and to avoid looking weak in front of his teammates he wanted to prove he was strong and tough enough, so he got back in line ready to go again; however, a coach pulled him from the drill to seek medical attention.
Interpersonal Factors – Constraints
Insufficient social support.
Participants encountered various interpersonal constraints. A lack of social support following a sport-related concussion were among the notable constraints. As outlined by some participants, social support following an injury can play an integral role as a coping resource in the recovery process for student-athletes. In particular, one participant mentioned:
The support from your family, friends, school, medical team, teammates and coaches can go a long way in helping you recover mentally and physically. Knowing that you have people in your corner supporting you not only from the start, but throughout the process definitely helps.
However, several participants voiced insufficient social support.
In addition, it was reported that some participants lacked emotional social support at the beginning of the recovery process from people outside of their immediate family. One participant said:
Of course your family is going to be there for you, it just would have been nice if my friends and teammates could have reciprocated the same support. I only had one teammate send me a direct message over Instagram, and he basically wanted to know when I would be ready to come back and play.
Additionally, it was mentioned that support throughout the entirety of the recovery process from the coaches would have been beneficial. He said, “obviously the coaches are busy, and this may not be a reality but I would have appreciated just a quick weekly check-up. It makes you feel like you haven’t been forgotten.” Otherwise, the participant mentioned, “without the consistent support from my coaches, it almost made me feel like I needed to return to football almost prematurely to be a part of the squad again.”
As well, one participant identified a lack of social support from a professor. He mentioned that:
Most of my profs really understood and gave me enough time to recover and write make-up midterms and assignments as a later date, but I had this one prof, and he didn’t really understand. I needed someone in the class who was willing to share their notes with me since I couldn’t go to class, and typically, the prof would either mention if someone would voluntarily do this in class or by email, but this prof refused to accommodate.
The participant noted the lack of social support from the professor as “insufficient” and discussed how this negatively impacted academic activities.
Lack of awareness and guidance.
According to several participants, a lack of awarenessand guidance among the athletic staff regarding concussion management served as an interpersonal constraint according to several participants. Although acknowledging these athletes expressed a lack of self-awareness regarding concussion management despite numerous concussion injury headlines in professional sport, they were surprised by the lack of awareness and guidance from the athletic staff (e.g., coaches, interns, and athletic trainers).
Due to a lack of prior concussion management education, the student-athletes expressed difficulty assessing the level of risk their concussion posed and so they relied heavily on the information provided by the athletic staff. However, the student-athletes were surprised by the lack of awareness and guidance. For example, one participant mentioned:
“I asked one of the trainers if they could explain to me the concussion protocol and in return, I just got a blank stare. I was a little worried because I only had basic concussion knowledge at the time.” Afterwards, the participant discussed how he tried to find concussion protocols on the University of Ottawa website but fell short of finding any protocol. He stated:
So, after my conversation with the intern, I told myself I would just take matters into my own hands and do some self-research and look for the uOttawa’s concussion protocols online. After looking online for about 10 minutes, I gave up. I couldn’t find any protocol endorsed by the university online.
Interestingly, some participants discussed how they did not receive a returning-to-learn protocol from the athletic staff following a sport-related concussion. For example:
Once I got concussed, I entered a stepwise progression protocol, basically consisted of passing each stage without getting any symptoms, and if you were to experience symptoms then they’d make you go back to the previous stage and try again. Each stage is 24 hours minimum. But I never got a returning-to-learn protocol. You would think as student-athletes they would prioritize school first, but I never got one.
As a strategy, some of the participants mentioned implementing concussion education seminars before the season, in-season and after the season in an effort to educate the varsity football athletes due to the nature of head impacts sustained in the sport of football. By doing so, student-athletes would be able to know where to find concussion management information, such as, concussion protocols. One participant stated, “I think having year-round concussion education presentations would only be beneficial for us. We would be able to know who to contact and what to do if any of us were to get concussed.”
External pressure to return.
Furthermore, some participants voiced external pressure to return to football following sport-related concussion. Pressure to return to football came from coaches, teammates, and family members. Participants mentioned how they felt pressure to return to play while recovering from injury. Participants described pressure to return to football from coaches as either direct or indirect. For instance, one participant discussed how he suffered a sport-related concussion right before playoffs, and as one of the key players on the offensive side of the ball, he felt direct pressure to return from the coaching staff. He mentioned how a positional coach approached him with urgency for him to return for playoffs because if they were to lose that game, some coaches and assistants’ jobs may be on the line. He stated:
It took me by surprise. I told myself I do not want to be the reason why people lose their jobs, but at the same time I have to look out for my best interests”. The participant ended up not returning to play prematurely for the sake of his own health and stated “I don’t want to be a vegetable with all these hits to the head when I’m older.
Additionally, another participant discussed how there were not many backups for his position, especially since the backups were inexperienced, he felt pressure to return from his teammates. For example:
It almost felt like peer pressure to come back and play immediately because if I didn’t, I would be letting the team down. I swear some of my teammates were guilt tripping me into returning prematurely. Any time I would see my teammates, they would say things like ‘it isn’t the same without you bro, if we want to win we need you back on the field now’.
The participant mentioned how he did not want to be seen as another player, but instead wanted to be considered a friend by his teammates who genuinely were concerned about his health first and foremost. The participant ended up returning once he was medically cleared by his doctor.
Participants expressed pressure to return to football from their coaches and teammates, one participant expressed pressure to return from his siblings. For instance, he said:
I come from a very athletic background, my brothers all play or played at a really high level of sport, and sometimes I felt pressure from them to return. They would jokingly tell me things like ‘man up, I’ve played through way worse and turned out okay” or ‘you don’t have the luxury of missing games, the season is so short’.
He explained and reiterated how they were joking but felt there was some truth to it and expressed that they were disappointed he was sidelined and not playing. The participant returned to football after receiving medical clearance from his doctor.
Lack of academic support post-concussion.
The effects of sport-related concussion can impact student-athletes’ academic activities in various ways as experienced by the participants. After being diagnosed with a sport-related concussion, the participants required absence from academic activities. In doing so, participants had to make arrangements with their respective professors accordingly.
There were various commonalities between the participants, such as, difficulty paying attention, problems remembering, frustration, fatigue, and various physical symptoms. One participant explained:
When I got concussed, I had trouble thinking clearly and remembering things. It wasn’t until my mom called me out on not remembering my brother’s birthday. And even after I got back to school, in class group discussions, I always felt foggy and had a tough time trying to remember recapping the reading from the night before. And my marks took a hit because of it, I wasn’t getting full participation marks on group discussions because I seriously couldn’t think clearly and contribute to the class discussion and I tried explaining that to the prof but I still lost marks because of it.
Additionally, another participant stated, “My concussion injury required me to take a few weeks off school, and I had this one prof that straight up told me to drop his course because I wouldn’t succeed with the time I was missing.” Furthermore, as a strategy one participant mentioned creating an individualized academic plan in conjunction with the student-athletes respective professors to aid in the recovery process and successfully allow the student-athlete to return to the classroom healthy. He said:
I think if there was a plan in place where the student-athlete and professor could come up with an academic plan to help in terms of providing all the necessary academic accommodations related to a concussion, like having someone take notes while you’re away, preferred classroom seating and postpone exams or assignments at a later date would make sense in my opinion because like I said before, at the end of the day we’re paying tuition to hopefully get a degree.
Environmental Factors – Constraints
Return-to-play and return-to-learn protocols.
An environmental constraint that participants suggested was the return-to-play and/or return-to-learn protocols. All 12 participants recalled not receiving a returning-to-learn-protocol; however, it was discussed that some were given a returning-to-play protocol. For instance:
It wasn’t until the day I officially was diagnosed with a concussion by the doctor that I got the stepwise progression protocol to return to play, but I don’t remember ever getting a returning-to-learn protocol”. While other participants believed there was no concussion protocol in place. For example, “at first I didn’t think there was any sort of concussion policy or plan in place. I thought it was just baseline testing and return whenever you tell the doctor you’re symptom free.
Furthermore, another participant discussed remembering one athletic trainer mentioned the existence of a returning-to-play protocol during pre-season baseline testing; however, having access in finding the protocol proved to be difficult. He stated, “One of the ATs told us that we have a returning-to-play protocol, but it was never shared with the team and they never told us how we could find it online or just have a hard copy of it”. Additionally, another participant mentioned:
You would think you’d be able to find it online very easily. I looked through the website, had my sister look through the website and we came up with nothing. But eventually, after a couple of hours my sister found some concussion guidelines through the OUA website, but that’s it. There was no returning-to-learn protocol though.
Since all the sport-related concussions between the participants varied between occurring during the past three football seasons, participants offered different responses in their belief that a concussion protocol was in place for the University of Ottawa. One participant noted “even if we did have a protocol in place, there’s a gap in terms of awareness with the student-athletes and sports services in getting that information out there”.
These findings have important implications for healthcare professionals who develop and implement interventions designed to bolster concussion management for this population. For instance, healthcare professionals can provide important information about concussion trends, education, resources and outcomes of health interventions that can lead to new insight regarding concussion-based research in research and contribute to improvements in health care for individuals in this population. In addition, this study can be practical for coaches, educators, student-athletes and researchers to understand, and address the potential constraints a concussion can pose on academic and athletic activities.
As only one sport was examined in this study, future research may want to incorporate a variety of sports to be able to draw conclusions about student-athletes from their respective sport. In addition, since male student-athletes were only interviewed, future research may include female student-athletes as results may differ and for inclusivity purposes. As well, the current study only sampled student-athletes from one university. Results collected from different universities has the potential to provide new insight into concussion management. Furthermore, it may be of interest to compare concussion management from different conferences around U Sports (i.e., Ontario University Athletics, Réseau du sport étudiant du Québec, and Atlantic Universities Sport).
During the data collection phase of this research, all participants’ interviews were conducted subsequent the football season. It may be of interest to conduct interviews at different points during the season (i.e., pre-season, in-season, and post-season) to see how participants would respond to similar concussion management questions throughout the year to compare constraining factors. Additionally, future research may want to include interviews not only with the student-athletes but with coaches, athletic staff, educators, teammates, and family members as well.
Since the study used a phenomenological approach, supported with semi-structured interviews, future research may want to incorporate different sources of data collection to analyze constraining factors for varsity football student-athletes following a concussion. For example, collecting the student-athletes’ grade point average (pre-concussion and post-concussion) may reveal insight into the negative effects a sport-related concussion can pose on academic success.
Sports-related concussions are a significant health concern for numerous varsity football student-athletes. The findings of this study derived from the thematic analysis of semi-structured interviews from the 12 participants and presented understandings on intrapersonal, interpersonal, and environmental constraining factors in the academic and athletic settings for varsity football student-athletes with a sport-related concussion.
The application of the social ecological model (18) helps us with classifying factors in the academic and athletic settings for varsity football student-athletes as well as identifying what types of factors are perceived the most. The constraints identified in each level of the social ecological model (i.e., intrapersonal, interpersonal, and environmental) have important implications for understanding the academic and athletic factors for varsity football student-athletes with a sport-related concussion.
Finally, this study will further enhance knowledge by increasing awareness on constraints in academic and athletic activities for varsity football student-athletes with a sport-related concussion. The findings of this study have the potential to benefit society considering that concussion-based research is gaining significant momentum following recent insight into the severe detriments a concussion can pose. The study may thus be practical for coaches, educators, student-athletes, and researchers to understand, and address the potential impacts a concussion can pose on academic and athletic activities.
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