The Lived Experiences of NCAA Athletes with One or Multiple Concussions

Abstract

Background/Objectives: Concussions, their physical presentation, and patients’ recovery have been researched and documented numerous times, but the experiences of surviving and recovering from a concussion need to be explored further. The purpose of this study was to examine the lived experiences of NCAA Division I, II, and III student athletes who had suffered from one or more concussions. Methods: The consensual qualitative research (CQR) methodology was employed, guiding the formation of the interview questions and the analysis of the responses. The participants completed a free-response questionnaire as well as a semi-structured virtual interview that utilized a blend of idiographic, inductive, hermeneutic, and interpretive phenomenological approaches. Through their questionnaire and interview responses, they discussed their experience being concussed at a collegiate level. Results: Ten NCAA student athletes described their various physical, cognitive, emotional, and sleep-related symptoms due to receiving their concussion(s). Many of these student athletes reported feelings of loneliness, being misunderstood, or even not feeling “normal or at baseline” during and after their concussion recovery. One primary finding was the key role the athletic trainers played in the student athletes’ recovery process from initially receiving the concussion to their return to play. Conclusions: These findings will help contribute to the knowledge of what it is like to experience one or multiple concussions, the recovery process, and how that process can be improved.

1. Introduction

Sports are a favorite national pastime and a universal element in many cultures. While people of all ages participate in sports either actively or passively, there is evidence to show that at a young age, amongst various cultures, they participate in sports for enjoyment, personal achievement, and the experiential euphoria of winning. As children reach high school and continue playing their chosen sport through college, it is unlikely that coaches, athletic trainers, athletic departments, and clinicians will anticipate the need to educate their players on the signs, symptoms, effects, and potentially life-altering consequences of sustaining a sport-related concussion. Concussions account for approximately 80% of traumatic brain injury (TBI)-related visits to the emergency room each year [1,2]. This equates to an estimated 1.6 million to 3.8 million sport-related concussions occurring annually in the United States, representing epidemic levels [3,4,5].

A national study indicated that 20% of all TBIs accompanied by loss of consciousness were the result of sports and recreational activities [1,6]. Within the sport-related sample (N = 300,000 total TBIs), 34% did not seek medical attention, and 55% received only outpatient care, including emergency room visits [1]. The 34% who did not receive medical attention may have not done so due to socioeconomic, structural, or cultural differences or disparities amongst those who incurred a TBI [1,7]. The statistics compiled from the 2009–2010 and 2013–2014 National Collegiate Athletic Association (NCAA) seasons revealed that sport-related concussions encompassed about 6.2% of injuries and that nearly one of every eleven reported concussions were recurrent [8]. Research also recognizes that college student athletes (CSAs) tend to under-report (and/or undiagnosed) their concussion symptoms and falsely inflate their level of recovery, either because of competing messages from stakeholders or in the hope of a rapid return to competition [9,10,11]. The culture of collegiate athletics to work hard and continue playing despite discomfort is often delivered explicitly from multiple sources, including teammates, coaches, parents, and fans [10,12], with more sources of pressure leading to an increased likelihood of continued play after a concussion [13]. In addition, CSAs may fear losing play time and ruining their chances that they may be able to become a professional after college [14]. For athletes playing on a scholarship, the risk of losing their scholarship presents a threat to not only their athletic career, but their ability to continue attending their academic institution. Kerr and colleagues [13] conducted a study of formerly concussed athletes and found that 39.6% of those athletes believed that they had sustained at least one undiagnosed concussion either due to the failure to report because their symptoms “were not that bad” and/or they feared ridicule from teammates [8,14]. It is estimated that approximately 50% of all sport-related concussions go unreported [15]. Some reasons why CSAs often under-report concussive symptoms are they believe they need a variety of signs and symptoms to be present to report, concern about the immediate reactions to receiving a concussion, and influential factors that mitigate the short-term (e.g., unable to physically support their team and not wanting to complete the full concussion recovery protocol) and long-term consequences (e.g., negative health outcomes such as cognitive deficiencies hinder the longevity of a sports career) [14].

Across college sports, female CSAs sustain more concussions during practices and games than their male counterparts “due in part to a lower biomechanical threshold tolerance for head impacts” [16,17]. There are numerous ways and opportunities for an athlete to sustain this injury, and with them comes a cascade of possible symptoms they may experience when recovering. This makes concussion management in sports remain one of the largest challenges for those caring for CSAs to confront [18,19]. A concussion occurs when trauma shifts the brain by accelerating, decelerating, or rotating within the skull, and it causes injury below the point of trauma or directly opposite [20,21,22]. This injury is still a challenge for those within the CSA care system as concussions are difficult to identify because they do not cause any externally visible changes in the brain [23].

Another challenge within the realm of concussion injuries is having a consistent definition of what a concussion is and what the injury consists of symptomatology-wise. In 2012, during the fourth International Conference on Concussion in Sport (ICCS), a concussion was defined as an injury triggered by trauma, typically accompanied by the following clinical, pathological, and biomechanical features: any type of impact to the face, head, or neck; the short-term impairment of neurological functioning; possible neuropathology that is mostly exemplified in declining changes in daily functioning rather than anatomical changes; and the possible loss of consciousness at the time of injury. Neuroimaging scans are beneficial in diagnosing brain swelling and bleeding, but do not reveal any abnormalities in a concussed brain. These injuries are often characterized as inconsequential or minor and many individuals reporting improvements in symptoms within a week of sustaining the injury [24].

Of these clinical, pathological, and biomechanical features of a concussion, its respective symptoms can be broken down into four domains: physical, cognitive, emotional, and sleep-related [25,26]. The post-concussion-specific symptoms experienced by a given individual may vary, but typically the most reported symptoms include a headache, dizziness, feeling “slowed down”, being dazed, and fatigue. The athlete may experience nausea, vomiting, impaired balance, visual problems, photosensitivity, and phonosensitivity. The athlete may also experience cognitive impairment, including mental fogginess, slow information processing, slowed speech, a slow reaction time, impaired concentration, amnesia, and memory deficits. There may also be emotional changes, such as irritability, lability, anxiety, and sadness. The athlete’s sleep patterns may also be affected due to insomnia or drowsiness [20,27]. Following a forceful collision to the head, if any of these symptoms are present, it is sufficient to diagnose a concussion [1,28].

These post-concussion symptoms can have an immediate impact on an athlete’s quality of life, but the long-term effects may be limited in some cases [29]. The variety of impairments and functional limitations that negatively impact one or more quality-of-life domains include headaches, interference with cognitive function (difficulty focusing and mental drain) and engagement in social relationships (withdrawing and feeling more emotional than usual), and inhibited physical functioning [29,30]. These impairments and limitations take away from their ability to perform as a CSA and substantially alter their life experiences, whether it be practicing and competing in their sport, finishing mentally demanding tasks (e.g., completing their degree), or other activities of daily living [30,31,32].

Although these limitations can create strains on different aspects of life, the impairments and the limitations of having a concussion can create significant psychological stress for an individual. Being unable to perform in academics or athletics due to a concussion can prove a major setback, potentially affecting the CSAs’ livelihood and leading to feelings of identity loss. Their confidence and self-concept may be threatened, leading to fear, anxiety, and lower self-confidence [33,34]. The focus during concussion recovery is reducing the physical symptoms, such as headaches and dizziness, but healthcare providers should also consider reducing the psychological and emotional symptoms as well [35,36]. CSAs who have experienced concussions report feeling embarrassment, anger, frustration, anxiety, irritability, depression, and even suicidal ideation after suffering a concussion [37,38]. Thus, it is important to prioritize social support during concussion recovery, whether it is informational, emotional, esteem, network, or tangible support [37,38]. In contrast, social support may be minimal for CSAs, such as being pressured to return to play before making a full recovery by their coaches and/or teammates [30,37,39]. This not only has an impact on the CSA in terms of physical symptoms but also intensifies the psychological and emotional symptoms they may be experiencing during their retirement (e.g., guilt that the concussed CSA is unable to support their team) [37].

Educating CSAs about the risks, signs, and symptoms of concussions can play a role in minimizing the recovery burden by modifying individual risk-related behaviors. The knowledge and administration of educational material concerning concussions are incomplete at the collegiate level. Currently, in the United States, collegiate sport delivery and the content of concussion education are left up to individual institutions, potentially resulting in high variability in what educational materials CSAs receive. There also is no requirement for institutions to incorporate a psychological readiness portion into their educational concussion material, and very little research investigates the psychological effects of concussions on these CSAs [40].

As of 2022, the NCAA Concussion Safety Protocol Review Process updated the Division I legislation and policy requirements for concussion management practices in NCAA Division I institutions [41]. Although the updated concussion safety protocol checklist and template do incorporate psychologists into the recovery protocol, it is solely to determine if a CSA is eligible to return to learning, a program to assist CSAs in gradually returning to class after a concussion or extended absence via cognitive tests, followed by light thinking activity if the CSA remains symptom-free [41,42]. Psychologists and neurologists are often not involved in pre-participation assessment, recognition and diagnosis, initial suspected concussion evaluation, post-concussion management, or the return-to-play protocol, a program parallel to return to learning, where CSAs are assisted in gradually returning to physical activity [41,42]. Given the possible severe consequences of secondary impact syndrome, including the potential onset of chronic traumatic encephalopathy (CTE), a lack of clinical assessment by a trained neurologist can lead to the mismanagement of the concussion and risks devastating consequences for the CSA [43,44]. In addition, institutions are not required to use the template in formulating their concussion protocol, which creates inconsistencies in concussion protocols throughout the NCAA Divisions and universities [38]. This is potentially problematic, as few concussion education programs have demonstrated efficacy or consistency in information distribution [45]. Uninformed CSAs who continue to play while symptomatic present a health threat as they are at risk of developing magnified and potentially catastrophic neurologic sequelae [45,46,47]. Thus, the lack of education about concussive symptoms and the regulation of post-concussion management make recovering from concussions particularly challenging for CSAs.

The literature surrounding sport-related concussions highlights significant gaps in education, reporting, and management practices that affect college student athletes (CSAs). Despite the established prevalence of concussions, with some studies indicating that 34% of athletes do not seek medical attention and that nearly half of all concussions go unreported [1,15], the systemic barriers to effective management remain largely unaddressed. The inconsistency in concussion definitions and symptom recognition complicates diagnosis and treatment [24]. Furthermore, the pressures CSAs face from coaches and peers to return to play before full recovery exacerbate the psychological and emotional challenges associated with concussions [37,39]. This literature underscores the urgent need for standardized educational protocols and comprehensive support systems to facilitate better recovery outcomes and enhance the overall understanding of concussion impacts on student athletes.

More qualitative research is crucial to learn directly about CSAs’ experiences during concussion recovery. This research can improve the livelihood of concussed CSAs and provide a better understanding of their experiences, ultimately creating a better recovery process. Qualitative research specifically allows researchers to ask questions of their participants that are not easily quantifiable, deepening the understanding of the human experience [48]. The current study explores the lived experiences of NCAA CSAs who sustained one or multiple concussions during their collegiate athletic career using consensual qualitative research (CQR). Although entrenched in a basis of being, existence, and the study of how people know things, CQR is also characterized by its notes of post-positivism, or that the truth is objective, and individuals’ experiences of such truths are imperfect as they are influenced by their values and experiences [49,50,51]. The current study aims to gain a better understanding of what CSAs experienced when they sustained their concussion, what their recovery process was like, and what and how they experienced their concussive symptoms. This study will help contribute to the knowledge of what is currently known about CSAs who have sustained one or multiple concussions, the physical and psychological recovery process, and provide a framework on how to better support CSAs during concussion recovery.

2. Materials and Methods

In order to gain the experiences of CSAs who have had concussions, we used CQR due to its support of the qualitative ontology of treasuring the multiple experiences of reality held by each participant [50]. CQR notes that each experience of reality is a valid and socially constructed version of “the truth”, unique to each individual [50]. During the process of gaining the CSA recovery experiences, we knew that we needed to be aware of the notion that engaging in an interview includes the reciprocal influence between participant and interviewer [50].

2.1. Participants

To participate in the study, the CSAs were required to be a student athlete currently competing in an NCAA sanctioned sport (Division I, II, or III) or had competed within the last five years of participating in this study. The collegiate student athletes who desired to participate were also required to have a history of sustaining one or multiple concussions during their career as NCAA student athletes. The recruitment process began by contacting the CSAs through personal networks, numerous NCAA college athletic departments, and various forms of media (e.g., Instagram posts and flyers posted throughout campus). All the CSAs provided written informed consent prior to enrollment in this study.

The participants were ten NCAA CSAs (9 female and 1 male) skilled in a range of NCAA sports (cheer, women’s water polo, women’s basketball, soccer, lacrosse, and softball) in differing Divisions (9 DI and 1 DII) and universities. They ranged between the ages 20 and 26 (M = 22.8; SD = 5.23). The participants suffered either one (N = 4) or multiple (two or more; N = 6) concussions during their time as a CSA. The concussions were sustained in a variety of ways, including having a ball kicked or thrown at their head, being kicked in the head, and falling against a weight bar while doing banded squats. Recovery varied from unremarkable, with few symptoms, to intense, with severe headaches, emotional disturbance, and cognitive deficits. The persistence of concussive symptoms varied, corresponding to the frequency of concussions. The CSAs with one concussion experience recovery relatively quickly (1–2 weeks), while the CSAs with multiple concussions experienced concussive symptoms for several months to years after the incident. Two of the CSAs reported that the concussive symptoms never fully went away.

2.2. Data Collection

This study deployed a convenience sampling method as a means to gather the participants. The researchers posted flyers with information about their study around the various athletic facilities, as well as emailing various NCAA coaches. Once the participants were gathered, there was a dual-part data collection process where the CSAs completed a free-response questionnaire through a Google Doc, and then once finished, set up a date and time to complete a semi-structured virtual interview to facilitate the CSAs sharing their own experiences related to their concussion recovery [51,52]. The free-response questionnaire was utilized as an introduction to this study and the screener to determine whether the participants were eligible. The free-response questionnaire and the interview guide were based on the review of higher-education literature and were developed by one of the authors [53,54,55]. The researchers additionally consulted with multiple qualitative researchers to determine how to create the study’s interview guide. From there, questions were developed to gain perception of the CSAs recovery experiences (e.g., “What was your social support system comprised of during your concussion recovery?”, “Did you experience any socioeconomic pressure during your recovery?”, and “If you had the opportunity, would you be open to seeking mental health treatment during or post-concussion to assist with the recovery process?”). The interviewers utilized probing and clarifying questions throughout the semi-structured interview in order to gain more thorough responses from the participants (e.g., “How did you receive your concussion(s)?” and “What did you experience after you were hit?”). A pilot study was deployed, utilizing one of the researcher’s athletic teams as the population. However, the pilot yielded only one participant.

There were pre-existing relationships present between Authors 1, 2, and some of the participants. This was due to Authors 1 and 2 having previous experience as CSAs and having played on the same teams as the participants during their CSA careers. The previous interactions and shared CSA background and terminology promoted conversation. Both Authors 1 and 2 interviewed the participants they had pre-existing relationships with. However, all the interviews conducted possessed a conversation-like approach, which, in turn, produced rich and detailed responses from the participants. The interviews were digitally recorded through Zoom (2021 Zoom Video Communications), and then transcribed verbatim. Engaging in Zoom interviews allowed us to interview the CSAs from a variety of locations without the expense of travel. It also allowed Author 1 to conduct interviews during the COVID-19 pandemic, while complying with all protocols, mandates, and procedures at the time of the interviews. It should be noted that due to the pandemic, Author 1 was unable to access the interview guide that Authors 2, 3, and 4 utilized for their interviews and used an earlier draft of the guide.

2.3. Data Analysis

Utilizing CQR includes a highly structured data analysis process where researchers are required to reach a general concord in all analytical products. This system was used as the aim of this study to understand the lived experiences by the CSAs’ accounts, while attempting to also understand them within a foundation forged from the existing higher-education literature. CQR includes four structured steps: (1) domain identification, (2) establishing core ideas, (3) cross-analysis, and (4) assessing category representativeness [56].

The process of CQR began initially through (1) domain identification, listing “meaningful and unique topic areas” from the participant responses [56,57]. The research team would read the transcripts independently and identify the main topics (domains) in the CSAs’ responses for within-participant analysis. For each domain, the research team developed a summary of the keywords to summarize into (2) core ideas that illustrate the domains and capture the essence of the participants’ responses [51,56].

As a team, we then took part in a review to finalize the list of domains and core ideas until consensus was reached over the course of multiple meetings. Once within-participant analysis was completed, (3) cross-analysis began and consisted of the creation of categories (domains and subthemes), which was conducted individually, and then reviewed as a team over the course of multiple meetings until majority agreement was reached [51,58,59]. Finally, the research team (4) assessed for category representativeness to identify “the common presence of an idea in the data” [56]. Category frequency labels are determined by CQR and are as follows: general, the category is represented in all or all but one case; typical, occurs between half and less than all; and variant, equals less than half, but more than three cases [57]. The list of domains and subthemes, their definitions, and frequency labels are reported in

Table 1. Summary of domains and frequency. General: category is represented in all or all but one case. Typical: occurs between half and less than all. Variant: equals less than half, but more than three cases.

Domains/Categories	Frequencies
Domain 1: Social support system
Family	Typical
Friends and Significant Others	Typical
Team	Typical
Athletic Trainers	Variant
Domain 2: Initial diagnosis by a professional
Athletic trainer	General
Other	Typical
Follow up with a separate professional	Typical
Domain 3: Symptoms presented
Physical	General
Cognitive	Typical
Emotional	Variant
Sleep	Variant
Domain 4: Symptom management
Removed from play immediately	Typical
Continued to play	Typical
Stop activity (physical and cognitive) altogether	General
Take medications	Variant
Return to play timing	Typical
Stop playing sport altogether	Variant

.

2.4. Authenticity and Rigor

With CQR, it is imperative that researchers are aware that their subjectivities contribute to the investigation of data and that personal biases are unavoidable and need to be discussed [51,60]. For example, Authors 1 and 2 both have experiences as CSAs themselves in the past, which could have influence over how they conduct research. Although a critical friend was not deployed, each research team member from different backgrounds and expertise areas read, evaluated, and coded the transcripts. Having team members from various backgrounds assisted in facilitating critical discussions when the research team came together to discuss individual interpretations. This diversity helped the team address any biases that might have occurred in interpretation. In addition, the supervising professor on the study facilitated discussions between the reviewers on how their biases may influence their perception of the narratives.

2.5. Transparency and Openness

In accordance with the transparency and openness promotion (TOP) guidelines [61], the study design, data collection, and analytic methods are described and cited above for transparency, with the original interview guide available in Appendix A. The raw data and interview transcripts are unavailable for confidentiality reasons as stipulated within the ethical approval for this study and information conveyed to the participants. This study was not preregistered. The information presented in this article is compliant with the APA Style Journal Article Reporting Standards.

3. Results

As a result of the CQR procedures, four domains and 17 categories were constructed. The four of domains were as follows: (a) a social support system; (b) initial diagnosis by a professional; (c) the symptoms presented; and (d) symptom management (see Table 1). The CSAs highlighted the importance of social support systems during concussion recovery and had both positive and negative experiences with their support systems (Domain 1). Then, the CSAs underscored the pivotal role their diagnosing professional played and the importance of ATs in the concussion recovery process (Domain 2). The CSAs then described the symptoms that presented during their recovery and how it impacted the physical, cognitive, emotional, and sleep-related areas of functioning (Domain 3). Finally, the CSAs discussed the various methods in which their concussion symptoms were managed, such as being removed from play immediately, working with professionals while in recovery, and return-to-play timelines (Domain 4). In the description of each domain, all the names associated with the participant’s own words are removed.

3.1. Domain 1: Social Support System

The first domain addresses the different methods of social support received by the concussed CSAs during their recovery time. The domain is composed of friends, family, significant others, teammates, coaches, and athletic trainers, which is consistent with the current literature [38]. Overall, the levels of social support varied between the participants in terms of distance from their support system, the frequency of check-ins, and the quality of support.

3.1.1. Family

Many interviewees reported communicating with family members about their concussion(s), its symptoms, and the support they received from their family. One participant stated, “I told my mom and my dad what was going on” and kept them up to date on their recovery process. While another participant reported that “My parents were in and out consistently making sure I was okay”. Other participants expressed how even though they were distant from their family, the CSAs still experienced quality support from their families. For example, one participant noted, “My family was—they were—I was at college so it was mainly phone calls but it was checking in and everything”. Regardless of distance, the participants noted consistency and support from their family members throughout their concussion recovery.

3.1.2. Friends and Significant Others

Friends and significant others also played a crucial role in the recovery journey. One athlete shared that their boyfriend “lived with [her]” throughout the recovery period, underscoring the importance of having someone close by for emotional and physical support. This consistent presence helped mitigate feelings of isolation that can accompany recovery from a concussion. Additionally, one CSA recounted a positive and unique experience where her and her roommate endured concussions at the same time, being able to go through the concussion recovery process together. This participant shared, “My roommate and I both had concussions at the same time”, which highlighted the mutual support during their recovery, highlighting the importance of shared experiences in managing the concussion symptoms.

3.1.3. Team

When it came to the support of their team, the CSAs’ responses varied in terms of positive or negative experiences of support and overall quality. For instance, one CSA experienced a team telling her “Suck it up and get back out there because we need you”, but when she transferred, her second team was “very loving, supportive, very concerned and worried, they cared more about my health than they did about the games and me playing”. Additionally, another CSA reported feeling isolated, misunderstood, and even had issues with renewing their scholarship post-injury. They reported “a little bit of a divide… it was very like lonesome a little bit. Plus, no one really had concussions like I had, so truly no one knew what I was going through or what I needed” and “a possible issue with not renewing my scholarship… So I had to fight for my scholarship”. These CSA reports of experiencing isolation, lonesomeness, and stress about maintaining their athletic scholarship can put strain on the CSA’s relationship with their teammates and/or coaches.

However, some CSAs in the study experienced positive and consistent support from their team. The teammates contributed to the support system as well; one participant mentioned that their coach regularly checked in on them, stating, “My coach called about—you know just kind of checked on me a couple times”. Another CSA stated, “My teammates would always like how I’m doing and if I need anything”. The CSAs in this study also reported the ease of support from their team due to living on campus close to the team or even living directly with teammates. This demonstrated a culture of care within the sports team environment, which is essential for athletes dealing with injuries.

3.1.4. Athletic Trainers

The CSAs highlighted the significant influence of athletic trainers in feeling supported throughout their recovery process. For example, one CSA reported having professors who were also athletic trainers and the unique and supportive experience that came of that:

“My professor was really, like, supportive. I mean the professors are always supportive… They are like, ‘Yeah we’ll schedule this for another day…’ So my professors understood because they’re all athletic trainers…”

Another CSA in this study reported their athletic trainers “walked [them] through the steps”, helping the CSA feel less alone and lost in what to do during recovery. Additionally, the consistency of checking in with athletic trainers was a theme found across a majority of the CSAs in this study. One CSA stated, “I went to the athletic trainer every day” in order to mitigate their symptoms and recovery quickly and efficiently.

3.2. Domain 2: Initial Diagnosis by a Professional

The second domain examined which professionals initially diagnosed the CSAs with their concussions and also reflected on whether or not further professional consultation was sought out during the concussion recovery process.

3.2.1. Athletic Trainer

All ten participants reported seeking treatment from their athletic trainers during the recovery process, with nine being initially diagnosed by athletic trainers. One participant received their initial concussion diagnosis from a medical doctor, and five sought out further treatment from other health professionals (e.g., neurologists and primary care providers).

The initial diagnosis of the concussions was primarily conducted by athletic trainers, who were often the first point of contact for athletes following an injury. One participant noted, “I went to the athletic trainer and got checked out” and emphasized the role of athletic trainers in the immediate assessment of concussion symptoms. Many athletes expressed trust in the care provided by these professionals, often forgoing further medical evaluations unless recommended.

3.2.2. Others (e.g., Physicians, Hospital Staff, and Neurologists)

While all ten CSAs had athletic trainers readily available, some were diagnosed by or sought out further treatment by other professionals trained to treat concussions. One participant who was initially diagnosed by a doctor, noted that their coach suggested they “should see a doctor”, and was then treated by an athletic trainer for the remainder of recovery. Four sought additional care from a primary care provider (PCP), a neurologist, and/or a physical therapist (PT). This indicates a gap that can exist in the understanding of concussion severity and appropriate follow-up care.

3.2.3. Follow up with a Separate Professional

Four sought additional care from a primary care provider (PCP), a neurologist, and/or a physical therapist (PT). A CSA who suffered two concussions during her athletic career stated during the recovery of her first concussion, they were diagnosed by an athletic trainer, but during their second, they were diagnosed by an athletic trainer, and a doctor was brought in for further assessment and treatment. The CSA stated that they “didn’t see a doctor at all. It was just through the athletic trainer just because I think they just didn’t have as much access as they do—This year, they have a doctor that comes pretty much every day… So before, they didn’t. And so, I just went to the athletic trainer. And maybe my athletic trainer didn’t think it [the concussion] was as bad”.

Another CSA reported after receiving a ball straight to the head during softball practice, her coach took her “to the physical therapy section at our school, and they just assessed me right away… I had my athletic trainers. They kind of assessed me. And because my face was swollen and like couldn’t really remember things, they took me to the hospital”.

3.3. Domain 3: Symptoms Presented

The concussion symptoms are most commonly broken down into four main categories: physical, cognitive, emotional, and sleep-related [24,25].

3.3.1. Physical

Within the physical category, the CSAs experienced symptoms, such as a headache or migraine, dizziness, balance issues, sensitivity to light, inflammation of the area directly concussed, and nausea, among many others. Seven out of the ten CSAs who participated in this study reported having headaches during the entirety of their recovery, and one reported pain that was similar to a “sharp kind of chisel going into my eye”. One CSA stated experiencing cognitive difficulties in which they did not “register things like I used to”, while another stated “feeling like in a fog and just slowed down”. An additional CSA remarked, “I had a headache every single day”, reflecting the debilitating nature of such injuries. The CSAs noticed a decrease in their physical performance, with one CSA stating “during practice my reaction time, you know, to the shots or whatever was a little slower”.

3.3.2. Cognitive

Cognitive symptoms were also prominent; one participant described experiencing confusion and memory loss, stating, “ In class, my attention span was less, like, I couldn’t really focus that much…I felt super in a fog”, and another stating “It was tough to be in class and try and do any of the reading or any of the homework”. One CSA stated experiencing cognitive difficulties in which they did not “register things like I used to”, while another stated “feeling like in a fog and just slowed down”. Four of the ten CSAs described some experience or level of confusion and/or memory loss post-concussion as well. These cognitive symptoms led to a poorer academic performance, with one participant stating, “I got like 60 or 70 on it (final exam), which is not normal. And yeah, and it dropped me down to a beat”.

3.3.3. Emotional

For emotional symptomology, two CSAs reported experiencing emotional and even personality changes during their recovery processes. During her second concussion, the first CSA experienced mood changes, where she “was either really happy or I was, like, crying hysterically”. The second CSA experienced mood changes due to the inability to play her sport, while also battling the challenges of her athletic career coming to an end because her concussion symptoms were so severe and persistent over the span of a year. In addition, the second CSA reported that they still experience mood changes as well as personality changes such as being more irritable over a year post-concussion. The symptomology represented by the CSAs are consistent with the findings of multiple research studies, as investigated by Langdon and colleagues [26].

3.3.4. Sleep

In regard to sleep, the CSAs stated either sleeping too much, too little, or having difficulty falling or staying asleep. All the symptoms discussed by the CSAs were representative and consistent with the current literature [16,29,30]. In terms of sleep, one CSA communicated that since suffering and recovering from her concussions, her sleeping patterns and overall quality have gotten progressively worse.

3.4. Domain 4: Symptom Management

In concussion management, there are many methods deployed by athletic trainers and medical professionals to help negate a CSA’s symptoms. Some are more established and stricter, such as removing a CSA from play to assess for concussion symptoms after a hit to the head. This also includes the halt of physical and cognitive activities altogether to allow the brain to heal for a certain period of time. Other symptom management methods may be not managing the symptoms at all. This could include the CSA continuing to play despite displaying concussion symptoms after a hit to the head, being cleared too early from the recovery process, or those within their world (e.g., coaches) pushing for their return to play before they are ready [30,39].

3.4.1. Removed from Play Immediately

A common approach was immediate removal from play, as many participants described being taken out of practice or competition upon displaying symptoms. One athlete shared, “They assessed me right away”, which highlights the importance of prompt medical attention in reducing the risk of further injury.

3.4.2. Continued to Play

In some cases, the athletes expressed the desire to return to play quickly, indicating a conflict between their eagerness to compete and the necessity of recovery. An example of poor symptom management was described by one CSA who was allowed to play in important games despite lying about the severity of her symptoms. She reported that “…I definitely lied a couple of times about my symptoms so that I could play again…”

3.4.3. Stopped Activity (Physical and Cognitive) Altogether

All ten participants stopped physical activity in some capacity. Resting and avoiding physical and cognitive strain were emphasized as the crucial components of recovery. One participant explained, “I stayed in just a dark room for a couple of days” (Interviewee, Interview P4), highlighting the need for a controlled environment during the initial recovery phase.

3.4.4. Take Medications

Seven of the ten participants also reported using medication(s) during their recovery, such as Tylenol, Advil, and Gabapentin to manage pain; Topamax for headaches; and Ambien for sleep. One CSA noted, “I was on gabapentin; I was on Topamax for headaches”. However, some CSAs reported their concussion recovery process forewent the medication route, as indicated by one CSA who mentioned that their athletic trainer “would not let me take anything”, emphasizing a desire for clarity about their symptoms without the influence of medication.

3.4.5. Return-to-Play Timing

An example of return-to-play timing was described by one CSA who experienced her coaches pushing her to return to play too early, before all of her concussion symptoms had subsided. They stated “if there was a big game involved and I was concussed, they would actually allow me [to play]… my coaches mainly like ‘Suck it up and get back out there because we need you.’”

3.4.6. Stopped Playing Sport Altogether

There are some examples of more established management plans, such as the very strict protocol of this CSA, who also had to adjust and plan for the long-term symptoms that lingered post-concussions:

“So, basically, for both [concussions], it was, “Take it easy. Rest”. With all the lights symptoms, obviously, they’re like, “Stay off of your phone”, all that good stuff. And just, “We’ll reassess”, and they kept reassessing. And for the first one, I was back, and then, the other one, I wasn’t. So, that was what their protocol was like. “We’ll do what we got to do”. They [Athletic trainer] were the best, of course. They did daily neck massages and stuff for me. But yeah, it was mainly just like, “Rest. Monitor symptoms. See where we’re at”. And then, yeah, and then, once we got past a month, and I came back, and all that good stuff, they’re like, “Okay, we’re in this for the long haul”, kind of thing”.

4. Discussion

The purpose of this study was to examine the lived recovery experiences of NCAA student athletes that experienced one or multiple concussions. The aim was to understand the main stressors and struggles these CSAs faced during their recovery to provide others involved in their lives with a better understanding of their experience of recovering from a concussion. The five main themes found within the CSAs’ responses were about their social support system, their initial concussion diagnosis by a professional, the symptoms presented during recovery, the steps they took for symptom management, and whether they would be interested in seeking mental health treatment to assist with their recovery.

Social support appeared to be a frequent theme within the participants’ interviews. Social support encompassed family, friends, teammates, coaches, church groups, professors, and athletic trainers. Although the level of social support varied among the participants, the theme revealed the significance of social support in recovering from concussions and how each of the various types of social support groups provided unique support to the CSAs. The role of social support may have a significant impact on the CSAs’ perceived symptomology and recovery [62]. The significance of social support indicated within the interviews offers insight into the power perceived social support may have on a CSAs’ ability to recover efficiently. Due to the emotional impact concussions can have on CSAs, such as lability, anxiety, and sadness, social support may assist them as they attempt to reach full recovery [20].

Although social support can assist CSAs in recovery, negative social support may produce the opposite effect [63,64]. Some participants stated that their perceived social supports applied pressure to return to their sport despite the symptoms. The fear of losing athletic scholarships was also mentioned due to their absence from the team. The pressure to ignore symptomology and participate in their sport for the team’s good may negatively impact CSAs attempting to recover from concussions. This pressure, along with the lack of support from their coaches and teammates, inspired one of the participants to transfer to a different university.

While the NCAA has established concussion protocols and templates [41], this research indicates the absence of a standardized protocol used within NCAA athletic programs to diagnose a concussion. After the onset of injury, almost all the participants were first assessed and diagnosed by an athletic trainer. Less than half of the participants sought further treatment from another professional, such as a neurologist or a primary care provider. Seeking additional care from a medical professional seemed to be influenced by the severity of the injury, the severity of symptoms, and the recommendations of an athletic trainer. A few CSAs reported severe symptoms and required specialized care from a neurologist or physical therapist, mainly due to symptoms that were out of an athletic trainer’s professional scope. Most of the CSAs relied solely on education and instruction from the athletic trainer during the duration of their recovery and to determine when the CSA could return to learning and play.

Despite their limited scope, the current study highlighted the pivotal role athletic trainers played in the CSA’s concussion recovery. In recovery from any injury, not just concussions, the rehabilitation process has a meaningful impact on a CSA’s psychosocial response to injuries and their recovery outcomes [65]. These professionals are a consistent point of contact during recovery that CSAs rely on to help them handle the emotional distress that comes with injuries and provide more social support than coaches, teammates, and even family [65]. As highlighted in many of the interviews, these CSAs reported having the most contact during their concussion recovery with their athletic trainer. These professionals, for many of the CSAs, were the ones to diagnose their concussion, provide them with guidance for recovery and support, assist in alleviating many of their symptoms, as well as authorize clearance for the CSAs to return to play and learning. Although athletic trainers can help CSAs recover from a myriad of concussion symptoms, some of the ranging symptoms fall out of their scope of practice.

The symptoms reported by the participants appeared to be multifaceted and diverse. The interviews revealed physical, cognitive, emotional, and sleep disturbances following the concussions. The symptomology ranged in severity within the participants, but most of the interviews indicated shared physical and cognitive experiences from the concussions. The physical symptoms included common concussion symptomologies, such as headaches, nausea, and sensitivity to light or sound. The recurrent cognitive symptoms amongst the participants included confusion, memory loss, and slurred speech. The symptoms reported during the interviews were not unique to previous research and reports concerning side effects following an injury to the head [1].

However, two participants reported experiencing symptoms that are still present to this day. Of those symptoms, these CSAs experienced mood and personality changes, migraines, as well as feelings as though they never returned to normal post-concussion. Both the CSAs endured multiple concussions during their collegiate athletic careers, and even before entering college athletics. These mood and personality changes the CSAs continue to experience could better be explained by the anatomy of the brain and how the central nervous system regions and circuits involved in emotional and behavioral regulation, as well as high-order cognitive operations, can be greatly affected by one or multiple concussions [66]. These unique symptoms, as well as those CSAs who experienced common concussion symptoms, lead to numerous methods of symptom management during their recovery.

Symptom management ranged from removing the CSA from play immediately, continuing to play despite the symptoms, reducing physical and cognitive activity, medication usage, and ceasing playing their sport for the remainder of the season. Many CSAs in this study reported daily visits to their athletic trainer to assess the severity of their concussion symptoms during the course of recovery. The athletic trainer typically was the professional to make the call as to whether the CSA could return to play, or if they should be removed from the practice or competition which they sustained their concussion during. These trainers typically advised the CSAs to decrease physical and cognitive activities, such as attending practices and classes, as well as stay in a dark room to avoid light irritation and possible medication (e.g., Tylenol) for headaches.

Some of the CSA participants did not have an athletic trainer present when they suffered their concussion and continued to practice or compete, regardless of experiencing concussive symptoms. However, those CSAs reported to their athletic trainer once the practice or competition was over. Only a few of the CSAs who participated in this study obtained treatment from a professional besides their athletic trainer (e.g., a primary care provider and a neurologist), mainly due to symptoms that were out of the scope of an athletic trainer’s profession. The only symptoms that were not necessarily managed during these CSAs’ recovery processes were the emotional symptoms that came from being concussed, such as feeling isolated and misunderstood and experiencing emotional dysregulation.

Of the ten participants interviewed for this study, eight reported they would be willing to seek out mental health treatment to assist in their recovery. Being required to isolate and completely halt all physical and mental activities can be an extremely trying time for a CSA. Not being able to socialize with teammates or classmates and not being able to attend practices or compete or even sometimes move without experiencing symptoms such as a debilitating headache can be a grueling experience. The remaining two participants simply were not asked this question regarding willingness to seek mental health treatment during the interview portion of their participation due to the interviewer not having access to the interview guide used for the initial interviews during the COVID-19 pandemic. The NCAA institutions that are able to deploy mental health services specifically geared toward CSAs and notify and offer these services to those CSAs experiencing any sort of injury may improve the recovery process for not just the concussed students, but other injured CSAs as well.

As mentioned previously, this research indicates the absence of a standardized protocol used within NCAA athletic programs to diagnose a concussion. In discussing the recovery experiences of these CSAs from various universities and NCAA Divisions, it would be highly encouraged that the NCAA adopt a uniform protocol for concussion recovery across the Divisions. Although the NCAA does provide concussion fact sheets, a concussion protocol template, and other educational resources, institutions that compete under the NCAA are not required to adhere closely to the examples and resources provided. In 2020, all three NCAA Divisions passed legislation requiring active member institutions to create a reporting process through which they would report concussions that have been sustained from 18 May 2020, onward [67]. This furthers the need for uniformity within the NCAA’s concussion protocol as they allow each institution to create their own protocol for reporting concussions.

While the NCAA has available concussion protocol templates and policies [41], these do not ensure standardization amongst NCAA institutions. Along with a call for a more uniform concussion protocol, allowing CSAs to speak about their concussion recovery experience could be extremely beneficial in forming a more informed and understanding action plan. Additionally, this information could encourage NCAA institutions that do not have athlete-specific mental health services to incorporate them into their counseling and psychological service centers. The experiences of the participants in this study can be informative to coaches and teammates as to what their CSAs and teammates are experiencing during their concussion recovery. Learning about their recovery experience could elicit more understanding and empathy for what the concussed CSA is going through. These concussion recovery experiences could contribute to general injury recovery and assist in making those involved in the process more competent and empathetic overall, thus possibly forming a healthier recovery experience for the injured CSA.

Although athletic trainers are trained to recognize and refer CSAs presenting with psychological concerns, their training and education does not equip them with the proper skills to address the psychological concerns [68]. The CSAs that participated in the current study reported that their athletic trainer was a large part of their concussion recovery process. It is also important to bolster the training of athletic trainers to help them identify the different psychological issues and warning signs specific to concussions. Athletic trainers are often the first person and line of defense when CSAs suffer a concussion [69]. Along with the myriads of services they provide, being consistent and frequent points of contact, athletic trainers also establish rapport that can have “far-reaching effects” on CSAs [69].

Athletic trainers serve a very pivotal role in the recovery process for a CSA; the psychological effect they can have on the recovery process also has the possibility of putting athletic trainers in a position where they may feel as though they are practicing out of their scope. Therefore, it is important to have an interdisciplinary team that includes mental health professionals, such as a Certified Mental Performance Consultant (CMPC) or a Sport and Performance Psychologist, to address the psychological side effects of injury. With concussions especially, it is paramount to have an interdisciplinary team as well as individuals involved in the CSAs life to have a well-rounded understanding of what a concussion and its recovery consists of.

This research has added to the understanding of what CSAs experience when recovering from a concussion and how that experience can be for them. A limitation of this study was the potential experiences of the researchers and the various interview styles that were deployed by each. For example, two interviewers had prior experiences as CSAs and recovered from concussions themselves. With their backgrounds, they were able to establish rapport with the participants more quickly compared to their counterparts that were not CSAs or had background or experiences with concussions. Future studies may benefit from having a research team with similar backgrounds to conduct interviews in a similar fashion and elicit richer responses from participants due to building rapport with the participants based on shared experiences. Additionally, Authors 1 and 2 had pre-existing relationships with some of the participants and still interviewed them regardless. It would be best practice for future studies to have their authors interview participants they do not have pre-existing relationships with to limit bias.

Another limitation of this study is that the interviews were conducted from one to four years post-recovery, which may affect memory recall [70,71]. Future research on concussion recovery should consider gathering data closer to the end of the recovery process for more accurate recollections. Additionally, the structure of questions in the semi-structured interview guide. The phrasing of our questions may not have warranted deeper, more qualitative responses from the participants. Researchers attempting to replicate and expound upon the current study should be sure to format their questions in an open-ended format to allow participants to provide richer, more detailed responses. It is recommended to review the formatting suggestions of Valovich McLeod and colleagues [72] to better phrase and structure interview guides for future studies to minimize repetitiveness. In addition, Author 1 was conducting interviews during the COVID-19 pandemic and was unable to access the interview guide utilized by Authors 2, 3, and 4, thus using an earlier draft of the guide. To minimize errors such as this, it would be best practice for a research team to have a professional messaging application to allow for the virtual sharing of documents such as a semi-structured interview guide. For items such as participant data, an HIPAA compliant application would be preferred.

Although concussions have been systematically studied, increased public consciousness of the lived experiences of concussed CSAs and athletes at any level is necessary. In building conscientiousness of what the injury of a concussion is and what it entails in regard to symptomatology and recovery, it will also build a greater understanding of what CSAs are experiencing. This greater understanding may then assist those involved in the CSAs’ life and athletic career (e.g., family, friends, professors, coaches, and athletic trainers) in fostering a more positive and supportive recovery process to those healing from a concussion. Further explorations into the impact of positive and negative social support during CSA concussion recovery should be conducted. How to cultivate a successful positive social support system for a CSA recovering from a concussion should also be explored. A better insight as to CSAs’ reasoning for reporting or not reporting their concussion(s) is needed as well. Oddo and colleagues [73] began the journey of studying this behavioral phenomenon, and their work serves as a excellent starting point for those interested in continuing to study this important topic.

Another area for future research could be determining how to better educate CSAs and those involved in their lives (e.g., coaches, teammates, athletic trainers, family, and friends) on how concussion and traumatic brain injury survivors have a greater chance of developing a psychiatric disorder due to their injury than the general population that has never experienced a diagnosable impact to the head [66]. Exploring new methods of educating and informing CSAs and those in their lives about this neuropsychiatric disorder after receiving a concussion and how a concussed CSA begins to experience this post-concussion would be greatly beneficial to not just the collegiate athletic community, but athletic communities of all ages and levels of experience.

5. Conclusions

The literature calls for a better understanding of what CSAs experience when recovering from a concussion to better support them in their recovery experience. This study contributes to facilitating this understanding by listening to CSAs who had experienced one or multiple concussions during their collegiate athletic career. The CSAs who participated in this study discussed the ways they sustained their concussion(s), the symptoms they experienced, their social support system, who diagnosed their concussion(s), and what treatment methods were deployed for recovery. Developing an understanding of these CSA recovery processes may aid in our understanding of what is experienced during concussion recovery for student athletes. This understanding can then inform mental health service offerings for CSAs. Being able to provide CSAs with proper mental health support once cleared from recovery may assist the CSAs in coping with the lingering symptoms from their concussion, returning to play, and improving concussion recovery as a whole.

The paramount finding of this study was the major importance of athletic trainers in the CSA concussion recovery process. Although athletic trainers are a primary point of contact for CSAs in their recovery process and provide numerous supportive services, athletic trainers can be put into a position that extends outside of their professional scope. These professionals, while treating the physical symptoms of a concussion, also have an impact on the psychological effects and symptoms a CSA can experience as well. Therefore, it is important to have an interdisciplinary team that includes mental health professionals, such as a Certified Mental Performance Consultant (CMPC) or a Sport and Performance Psychologist, to address the psychological side effects of injury. With concussions especially, it is crucial to have an interdisciplinary team as well as individuals involved in the CSAs’ life to have a well-rounded understanding of what a concussion and its recovery consists of. Providing CSAs with an interdisciplinary team that can tackle both the physical and psychological symptoms of their concussion could drastically improve the recovery process and encourage CSAs to seek out physical and mental health treatment beyond recovery.

This study makes significant contributions to the field of sports psychology and concussion management by providing a nuanced understanding of the lived experiences of collegiate student athletes (CSAs) recovering from concussions. By employing qualitative research methods, this study captures the complex interplay between the physical and psychological aspects of concussion recovery, emphasizing the critical role of social support systems. The findings reveal how varying levels of support from family, friends, and teammates impact CSAs’ perceptions of their symptoms and overall recovery journey. Moreover, this study highlights the necessity of incorporating mental health professionals into the concussion management framework, advocating for interdisciplinary teams to address both the psychological and physical challenges athletes face post-injury. This dual focus on education and comprehensive support not only advances our knowledge of the field, but also offers practical solutions aimed at improving recovery outcomes and promoting athlete well-being. By identifying the gaps in the current educational practices and concussion protocols within NCAA institutions, this research suggests pathways for standardizing concussion management practices, thereby enhancing the quality of care for CSAs across various athletic programs.