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Each circle has different recovery trajectories and treatments. We have made great strides in learning how to rehabilitate these areas of dysfunction. We have learned, for example, how to retrain the vestibular system to interpret dynamic movement, and how to exercise the eyes to reestablish normal, healthy vision. Athletes with car sickness are more likely to get vestibular problems after a concussion, those with learning disabilities are more likely to develop cognitive problems, those with anxiety are more likely to have anxiety and mood issues.

I believe the truth is somewhere in between — having a concussion is worse than what we used to think it was and not as bad as it is being made out to be. While we certainly need more research and randomized controlled trials, I believe that concussion is now a fully manageable, treatable condition. If an athlete responds to rehabilitation in a robust, predictable way, and we fully treat that problem, I have no problem with him or her returning to play and, in fact, encourage it.

By William Meehan: The number of concussions an athlete has sustained is an important data point to consider when deciding whether or not he or she should return to play. But evaluation goes far beyond the number of concussions. We consider the severity of the symptoms and the cognitive difficulties a player experiences after injury. We evaluate whether successive concussions are being caused by less and less force, and whether the athlete is taking longer and longer to recover from successive concussions. An athlete who is playing at a high level, has a contract lined up with a professional team, and is planning to build a future career around a sport might choose to play longer and accept a greater risk than someone who wants to become a veterinarian and is playing just for fun.

The decision is often straightforward. Over a series of meetings, we discuss with such an athlete the medical studies that point to the risks of continuing to play. He or she must then weigh the risks against the benefits. Most of the time, the athlete makes a reasonable, well-informed decision. These athletes were, of course, free to get a second opinion. Many found a physician who then determined it was safe to return to play and cleared them to do so.

I have also worked with some athletes for whom I thought the risks of returning to play were minimal, but they decided that the risks were too great and stepped away from the sport. You have to give him or her time to heal. The second step was axial coding, to group specific codes that were related to each other. Codes were grouped if they belonged to a certain phenomenon, conditions of a phenomenon, actions related to a phenomenon, or consequences of a phenomenon.

The final stage was selective coding, wherein the primary codes were selected. The purpose of selective coding is to identify the primary driving code or theme that carries the selected narrative. NVIVO 10, a qualitative computer software package, was used to store and organize the various codes derived from the data. To ensure the rigor and trustworthiness of our analysis, we relied on theoretical saturation, wherein the data was analyzed until all the concepts in the theory were well developed and no new data arose.

In addition, negative cases were identified and incorporated into the theory [ 40 ]. Throughout this process, the individuals who were actively coding looked for commonalities, differences, behaviours, attitudes and perspectives, and connected these concepts and the relationship among them into a theory of experience of concussion among hockey players and other stakeholders.

Table 2 provides an example of how three interview segments were coded. Through the grounded theory process, we discovered that participants described their experience of concussion in hockey by discussing the biographical significance that hockey had in their lives. Below, we describe how hockey players and other stakeholders construct, disrupt and reconstruct their biographies through the experience of concussion within a Canadian hockey culture.


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The importance of hockey in the lives and upbringing of the Canadians interviewed was unmistakable. Of course, this concept is not unique to young Canadian athletes, and is similar to young Irish boys dreaming of playing professional football [ 41 ], or a young American child wanting to play professional basketball [ 42 ]. The participants in this research defined an interesting transformative process through which a hockey player is created. This process begins early in the lives of young players, is often all encompassing in their development, and includes multiple ritualistic steps.

One participant, a concussion specialist who also has played hockey for thirty years, noted the cultural learning process that he experienced from a young age:. The culture of hockey is, you have it at the beginning of school, you have it at the end of school, you spend winters doing it. So as you hang around it enough I think the next thing that I learnt is the traditions of hockey. All of the minor, professional, and retired professional hockey players interviewed integrated hockey culture into most aspects of their everyday life, and incorporated its cultural teachings into their identity.

One great example of this is from a retired professional hockey player, who when asked to reflect on the role of hockey in his life stated:. An important theme throughout the analysis was the mental strength needed to be a successful hockey player. It was clear, that individuals were taught by coaches and parents from a young age that mental toughness was crucial to the core identity of the hockey player. One participant who was a hockey coach for the previous fifteen years, and who also played high-level hockey, noted that mental strength was more important than physical strength:.

Mental strength seemed to be most associated with resilience through hardship, maintaining motivation, and remaining calm through anxiety-provoking situations. The majority of participants stated that although physical strength in hockey is important, only those with mental strength succeeded in hockey. According to this participant, who was a hockey coach:.

Multiple hockey players noted that their mental strength was an important part of their hockey identity, and crucial to their success in the game. One coach, who previously played high-level hockey, illustrated the concept of mental strength and hockey identity when asked about the pressure of playing hockey, by replying:. This ideal is often encompassing the identity and the personhood of the individual. A significant portion of the cultural teachings of hockey is the need to possess mental strength. Players integrated the idea of mental strength into their personhood, took pride in it, and felt it was crucial to their identity as a hockey player.

These participants gave well-rounded and explicit explanations of the acute and chronic symptoms of concussion. This group, all with some involvement in the game of hockey, each had personally experienced a concussion, or knew an intimate story of someone who had. Each individual highlighted the increasing prevalence of concussion in the game of hockey. The resounding narrative of these interviews was the multi-faceted difficulty and resultant isolation these individuals faced post-concussion.

When asked about the worst experiences of his concussion recovery, one former player illustrated this by saying:. The participants in this study who were minor, professional, or retired professional hockey players who had suffered concussions eloquently described the psychological state in which an athlete becomes socially reclusive because of concussive symptoms. This minor hockey player, who had suffered a concussion, was asked about their worst experience with concussion and noted:.

The minor, professional, and retired professional hockey players who had suffered a concussion described a social isolation process that was concerning and provoked many depressive symptoms. When asked to provide a deeper description of the isolation process that occurred after a concussion, this particular retired professional hockey player elaborated:.

I mean, and I could sit there. One of the primary difficulties of the concussion recovery process is that concussion is an injury without physical demarcation. As noted by this professional hockey player:. When you break your arm, you go get a cast on it. All of the minor, professional, and retired professional hockey players in this study mentioned that there is more understanding and acceptance of injuries that are visible in the hockey world.

This particular concept was highlighted by a retired professional hockey player talking about the frustrations of coping with a concussive injury:.


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With concussion you got no signs at all, you look as normal as everyone else. This lack of understanding compounded the isolation these players experienced. A minor hockey player described a process of feeling unheard and invalidated, and when asked to provide a specific example shared this episode:.

Five of the hockey players who had also suffered concussions noted that the hockey concussion, the invisible injury, and the isolation that ensued created a change in self-image and in how they imagined their life to be. When asked about the process of change after a concussion, this retired professional hockey player described it as distressing to the point of suicidal thoughts and actions:. That was like rock bottom…you feel like you have nothing. Participants who had a concussion, described how they were at times able to conquer the physical symptoms of concussion, but then had to deal with post-concussion depression, anxiety, and post-traumatic stress disorder.

The onset of mental illness with these individuals created a new set of challenges, and struggles with their personhood. All of the participants identified that they knew individuals in the hockey world who had mental illness, and many had stories revolving around isolating depressions, suicide, and post-concussive illness. There was a firm recognition that mental illness exists with hockey players.

An interesting narrative that arose was that of mental illness as weakness; however, this theme was typically voiced as an external other. One participant, who was also a member of the hockey media, noted:. And people are still trying hard to hide it. This binary of mental strength and mental weakness was a common theme throughout the analysis. Individuals reflected that mental toughness was a large part of success in the game of hockey, and that individuals who were able to recover from a concussion had an element of mental strength.

The binary system that has been created puts hockey players with mental illness in a difficult circumstance, and puts them in a corner of being distinctively non-hockey like. In addition, the most complicated and difficult hurdle for concussed athletes to overcome were the symptoms associated with depression, anxiety, and PTSD. Large swaths of interview transcripts were dedicated to these difficult and lonely narratives.

There was a general recognition that mental illness does exist in the hockey world; however, it is typically covered up and avoided. This was understood as a greater cultural stigma toward mental illness, and also the notion of mental illness as mental weakness.

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The notion that concussion is an invisible injury was important for our participants to verbalize. Because it is an injury without physical demarcation, many concussion sufferers noted times of invalidation and misunderstanding from peers and health care providers. Some individuals noted frustration when health care providers assured them that their symptoms would improve in the short term.

This set up an expectation that was not met, followed by intense disappointment and guilt. In turn, they felt most comfortable and taken care of by those care providers who validated their suffering and normalized their concussion recovery process. This minor hockey player who suffered a concussion wanted to discuss the healing process, and what was helpful, saying:.

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The individuals in this group who had struggled with post-concussive symptoms, were able to, with some difficulty, begin to change their activity patterns and their way of perceiving themselves. Those individuals who were able to garner the support to complete a life transition noted they were able to learn important life lessons and perceived themselves to be stronger for having experienced it.

When asked about transitioning to life without hockey and contact sport, this minor hockey player wanted to discuss ways in which she had grown as an individual, through the process of concussion recovery:. This qualitative study provides a perspective of hockey stakeholders around concussion, and the experience of the concussed hockey player.

The results of this analysis elicited three selective codes that drove the narrative of these interviews: The biographical construction of the hockey player, the biographical disruption and deconstruction of the hockey player, and the biographical reconstruction of the individual. The concept of biographical disruption was originally described by Bury in [ 44 ]. Their biography that they had created was being disrupted. We build on the concept of biographical disruption by introducing the concept of the biographical deconstruction wherein players are forced to re-imagine their identity and the constructs that create this identity.

Understanding this psychological trajectory of the concussed hockey player may help health care providers give appropriate support and treatment to these athletes who are suffering with the effects of concussion injuries. Using grounded theory, we have identified the concepts of biographical construction, disruption and deconstruction, and reconstruction which have emerged from the data.

Perhaps the most important finding of this analysis, wherein care-providers can intervene most effectively, is the understanding of this process of construction, disruption and deconstruction, and reconstruction. Through this process we saw a natural developmental trajectory of hockey players and the process they undertake when they have a concussion. This process can be reasonably applied to all athletes with other types of season- and career-jeopardizing injuries.

A primary learning was the importance of identity. When treating athletes with mental illness, it is ever important to understand the identity that has been formed around the sport that they play. Health care providers must remember the potency in this identity, and that it often endures above all other identities.

Athletes with high levels of athletic identity typically expect others to see themselves as only athletes and personally exclude other personal identities outside of sport [ 47 ], putting them at greater risk of difficulty transitioning out of sport. Understanding the psychological trajectory of concussion in hockey players can prime health care providers to recognize and address these identity issues in addition to the physical symptoms of concussion.

Biographical disruption has been examined in other neurologic illnesses such as stroke [ 48 ] and multiple sclerosis [ 49 ], complementing our current work with concussion. These biographical disruptions can lead to change in self-identity and relationship dynamics [ 50 ]. Many participants in this study discussed needing to accept new life circumstances and expectations as part of their recovery.

In particular, we explored the dynamics between coaches, caregivers, and concussed athletes, identifying instances where a concussion can cause social isolation and strain relationships if not properly understood. Our interview participants also touched on the role played by hockey culture, as well as the wider Canadian culture. The notion of the hockey player being mentally strong runs in direct opposition to what the hockey world perpetuates about mental illness, which is that it is rooted in mental weakness.

Herein lies the crux of the biographical deconstruction of the hockey player. The latent speech surrounding mental health being caused or perpetuated by weakness, and abated by strength is damaging because it perpetuates the notion that mental illness is volitional. This creates a barrier for athletes seeking help, but also presents an opportunity for intervention with psychoeducation on mental illness. Importantly, individuals who had validation, proper medical care, and support were able to describe a process of reconstruction of their identity.

Health care providers are well positioned to provide an objective and therapeutic lens for patients in stewarding a biographical reconstruction towards self-understanding and acceptance of their life after concussion. This qualitative work was able to show that caregivers can help concussion sufferers with their new identity, by highlighting their strengths and personhood outside of the game of hockey. However, as highlighted by Gordon and Lavallee [ 52 ], athletes whom undertake these transitions in sport can experience intense stress and anxiety and require resources to cope effectively.

This work was also able to point out the value of empathy and validation. Caregivers, as individuals intimately involved in the trajectory of the concussion process, are well positioned to provide validation of pain and suffering. This process can be effectively facilitated by health care providers as well. One therapeutic modality that aligns well with these methods is interpersonal psychotherapy or IPT [ 53 ].

This psychotherapy modality is time limited, structured, and can have a particular focus on grief, interpersonal disputes, role transitions, or interpersonal deficits [ 54 , 55 ], which may all be encountered in the context of biographical deconstruction following hockey concussion. Initially developed for depression, interpersonal psychotherapy has proven flexible and efficacious in improving outcomes in contexts where dysfunctional interpersonal relationships play a role [ 56 ]. IPT has also been effectively adapted to incorporate caregivers, for example among aged patients with cognitive impairment [ 57 ].

This form of IPT may be especially relevant when applied to hockey concussions, as it recognizes the dual role transitions that both the patient and caregiver must navigate, while focusing on resolving role conflicts and facilitating biographical reconstruction at the new cognitive baseline. Those who were able to successfully navigate the life transition were able to reconsolidate their personhood, reconstruct ideals of who they are, who they want to be, and redefine their notion of self. In this process of biographical reconstruction, gaining support from peers, family, and health care providers was key to success.

The primary limitation of this research study was the inability to member check with all participants. Our team was only able to member check with five of the participants. The main reason for this was geographical because our participants lived in many different parts of the continent, creating a financial and logistical barrier to member check.

To improve validity, triangulation of sources [ 58 ] was used see Methods. Triangulation was achieved by having participants along various trajectories of concussion recovery. Although there was a broad number of perspectives covered, it would have been helpful to recruit more coaches and hockey parents because they are largely the decision makers for young hockey players. We were unable to talk to individuals who refused medical care after a concussion, or were still dysfunctional because of persistent concussion symptoms; this would have provided an interesting perspective.

Kendall Lee, a professor of neurosurgery and biomedical engineer at the Mayo Clinic in Rochester, Minn. He has called it "a pacemaker for the brain. Meanwhile, John Walsh is sold on his new brain-health regimen.

This Is Your Brain on Multiple Concussions

He checks in every six months with a neurologist and has even cut back on his polo playing — though his first granddaughter may play a role in that behavioral change. The man who growls that he has "brought 1, dirtbags to justice" over 27 years is now content to slow down a step or two: "I'm learning to listen. And Tony Dorsett stays active by chasing Hawke, his year-old grandson. How does your brain score? Find out at Staying Sharp. This tool helps you identify your pills by color, shape and markings.

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Experts debate: How many concussions are too many for an athlete?

Share using email. Not just jocks "This problem is not unique to athletes," says Robert Cantu, a clinical professor in Boston University's Department of Neurosurgery and a senior adviser to the National Football League on head and neck injuries. Long-term effects When she was 10, Melanie Werth fell off a horse, hit her head on pavement and was unconscious for about 20 minutes. Deep brain stimulation Americans over 50 who suffered what doctors call a "single uncomplicated" concussion earlier in life usually don't have to worry about cognitive impairment later, says Amy Jak, associate professor in residence in the Department of Psychiatry at the University of California in San Diego.

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