Spinal cord injuries and concussions

Because of their career-ending and life-altering potential, injuries affecting the central nervous system (i.e., brain and spinal cord) are among those with the greatest implications for athletes’ psychosocial health. Because so little research has examined the psychosocial health consequences of sport-based SCI and concussions in athletes of any kind (whether high-level or recreational), I include studies with athletes at any level of participation to illustrate the psychosocial impact of these injuries.

According to the National Spinal Cord Injury Statistical Center (NSCISC, 2016), of the approximately 282,000 Americans who suffered a spinal cord injury (SCI) in 2016, more than 25,000 occurred in the act of a sport or recreational activity. In countries such as Russia and Canada, sport participation accounts for more than 13% of SCIs. Whereas SCIs affecting the cervical vertebrae are the most common type in collision sports such as American football and speed sports such as downhill skiing, thoracic and lumbosacral injuries are more common in horseback riding and snowboarding (Chan, Eng, Tator, & Krassioukov, 2016). Depending on the severity, symptoms of SCIs range from numbness, to loss of muscle function, to paralysis. Whereas incomplete injuries result in partial loss of motor function below the injury site, complete injuries result in total loss of function. In the most extreme case, a complete SCI occurring to the upper cervical vertebrae results in loss of autonomous ventilatory function, and the end of an athlete’s career (Sabharwal, 2013). Although such injuries are rare, former Rutgers University American football player Eric LeGrand fractured his C3 and C4 vertebrae during a collision during a 2010 game. Although LeGrand has since regained some use of his upper body, he still requires a wheelchair (Politi, 2018).

In one of the earlier studies on SCI in sport, Smith and Sparkes (2005) engaged in in-depth narrative analysis of interviews with 14 men who sustained injuries leading to paralysis while playing rugby. The authors were specifically interested in how these men talked about hope, and it was found that the men conceptualized hope in one of three ways: (a) concrete hope (e.g., hope of finding a cure), (b) transcendent hope (e.g., hope of gaining something valuable from the SCI experience), and (c) despair (e.g., things will never get better). Later, Smith (2013) used a storytelling approach to represent the views of 20 men in rehabilitation from an SCI sustained while playing sport. The central finding of Smith’s novel study was how the psychosocial consequences of sport-based SCI were neither solely dependent on athletes’ social environment (e.g., social structures, views of others) nor their personal attributes, but rather they were the product of dynamic interactions between people with SCI and their social environment (i.e., social relations). That is, past and anticipated future social interactions shape how people with an SCI think, feel, and act.

Much more common than SCI in sport are traumatic brain injuries (TBI) due to sport-related concussions (SRCs). As compared to SCIs, the damage caused by SR.Cs is often invisible, and may not truly be revealed until years after the initial injury. The Centers for Disease Control and Prevention define concussions as:

a type of traumatic brain injury ... caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.

(Centers for Disease Control and Prevention, 2017, para. 1)

According to a five-year epidemiologic study sponsored by the NCAA, there were 1,670 SRCs in NCAA athletes between 2009 and 2014, corresponding to a rate of 4.47 SRCs per 10,000 athlete-practices or competitions (Zuckerman, Kerr, Yengo-Kahn, Wasserman, Covassin, & Solomon, 2015). SRCs are particularly common in collision sports such as American football, boxing, and ice hockey, but also often occur in soccer, lacrosse, and water polo (Blumenfeld, Winsell, Hicks, & Small, 2016; Forstl, Haass, Hemmer, Meyer, & Halle, 2010; Zuckerman et al., 2015). Although boxing is by far the deadliest sport—an average of 10 deaths per year since 1890 (Forstl et al., 2010)—the extreme popularity of American football in the U.S. means that it has been the subject of most media attention and scholarly research on SRCs.

Once treated as a natural part of contact sports (e.g., “He’s ok, he just had his bell rung a bit.”), a rash of reported cognitive impairments to and suicides of former American football players in the last ten years has raised awareness of the potential danger of high-impact collisions, as well as accumulated low-impact blows to the head (Breedlove et al., 2012). Of all the threats to athletes’ psychosocial health discussed in this text, SRCs undoubtedly pose the largest threat to the cognitive domain. Breedlove et al. (2012) reported the findings of a two-year study of high-school American football players, in which concussions were found to occur because of repeated low-impact blows to the head rather than a single high-impact blow. Further, debilitative changes to the brain were found in several players who did not sustain an SRC over the two seasons. Such changes to athletes’ brains may trigger emotional health issues such as anxiety, depression, and suicidal behavior (Covassin, Elbin, Beidler, LaFevor, & Kontos, 2017).

Of greatest concern for the cognitive health of athletes who have sustained one or more SRCs in their career is the potential development of chronic traumatic encephalopathy (CTE)—a neurodegenerative condition characterized by the buildup of protein which disables neuropathways in the brain (Emanuel, 2017). The brain damage caused by CTE can manifest in a variety of negative cognitive and emotional symptoms, including memory loss, confusion, impaired judgment, aggression, depression, anxiety, impulse control, and suicidal behavior (McKee et al., 2009). Research conducted by faculty of Boston University’s CTE Center reveals the pervasive nature of CTE for American football players. Of the 202 brains of deceased pre-high-school, high-school, collegiate, and professional American football players examined, 87% showed signs of CTE, including 99% of former NFL players (Mez et al., 2017).

Despite compelling research findings, efforts to prevent serious head injuries and long-term health consequences are hindered by the aforementioned sport ethic, which compels athletes to withhold concussion symptoms for fear that they may lose playing time, or worse, be viewed as lacking toughness. Indeed, many high-level athletes from both high- and low-contact sports continue to subscribe to the notion that concussions are part of what they agreed to when they chose to play their sport, and report intentionally withholding concussion symptoms to preserve their spot on the team (Beverly et al., 2018). Additionally, athletes in low-contact sports such as tennis and swimming may fail to report concussion symptoms out of embarrassment for their “clumsy” actions (Beverly et al., 2018).

Although the risk of TBI associated with contact sports has been acknowledged for several years, it was not until recently that the psychosocial elements of these injuries were examined. Of note is a 2017 special issue of the journal Sport, Exercise, and Performance Psychology (SEPP) focused on the psychology of SRCs, in which both pre- and post-psychosocial aspects of SRCs were the subject of investigation. One of the studies in the special issue detailed the predictive utility of several psychosocial variables (e.g., athletic identity, performance anxiety, and motivation) on self-reported symptomatology from 7 to 28 days post-concussion in youth athletes (O’Rourke, Smith, Punt, Coppel, & Breiger, 2017). In brief, lower motivation, higher athletic identity, and higher performance anxiety predicted slower declines in self-reported symptomatology. The authors proposed several underlying mechanisms to explain these findings, including less productive cognitive appraisals of injury from athletes with high athletic identity, less incentive to minimize symptoms for amotivated athletes, and heightened symptom sensitivity in athletes with more performance anxiety.

Several other studies in the special issue of SEPP focused on the psychosocial aftermath of SRCs. Of note is a piece by André-Morin, Caron, & Bloom (2017), which addresses a gap in SRC research by exploring the experiences of collegiate female athletes with protracted concussion symptoms. The authors argue that because contact sports such as American football, in which most participants are men, have been the focus of most SRC research, the experiences of female athletes with SRC have been ignored. The athletes in their study spoke about a number of psychosocial ramifications of their SRC, including depression, mood swings, and social isolation (André-Morin et al.). One athlete said,

“All the things that I knew would usually make me happy and put a smile on my face didn’t work” (Andre-Morin et al., p. 296). One athlete in the study even reported that she attempted suicide. Clearly, male athletes are not alone in dealing with the harmful psychosocial effects of SRCs. And because female athletes may actually experience concussions at a higher rate than male athletes (Covassin, Moran, & Elbin, 2016), further discussion on the potential long-term effects of these injuries for women is warranted.

A final study from the special issue warrants consideration, as it addresses the question of whether the psychosocial responses associated with SRCs are unique in comparison to other common sport injuries. Prompted by previous studies suggesting differences in the psychological responses of athletes with musculoskeletal versus athletes with an SRC (e.g., Mainwaring, Hutchison, Bisschop, Comper, & Richards, 2010), Turner, Langdon, Shaver, Graham, Naugle, & Buckley, 2017) compared changes in mood and anxiety from up to 72 hours post-injury to return to play in two matched groups of athletes diagnosed with either an SRC (и = 15) or a minor musculoskeletal injury (n = 15). In contrast to the findings of Mainwaring et al. (2010), the authors found no significant difference between the two groups across time in mood or anxiety. Because past studies failed to control for time loss and duration of rehabilitation, the authors concluded that it may be these factors that accounted for disparate psychological responses rather than any physiological changes associated with SRCs.

Summary

SCIs and SRCs are serious injuries to the central nervous system that can end athletes’ careers and result in permanent cognitive and/or motor impairments. As such, these injuries may have a particularly profound effect on athletes’ cognitive, emotional, social, and spiritual health. Research by Smith on sport-related SCIs shows the variety of ways that athletes negotiate their new reality and possible future, and how their disability experience is the product of dynamic social relations. The more extensive research on SRCs highlights psychosocial influences that may prevent athletes from reporting symptoms, how psychosocial factors influence the cessation of symptomatology, and the wide-ranging cognitive, emotional, and social health implications of SRCs.