Literature Review
Overview of Athletic Injuries
Researchers define a reportable injury as: (1) occurred as a result of participation in an organized athletic practice or competition, (2) required the attention of an athletic trainer or physician, and (3) resulted in the restriction of an athlete’s participation in their sport (Kerr et al., 2015). According to the National Collegiate Athletic Association (NCAA, 2020), there are over 480,000 collegiate athletes. Out of those student-athletes, over 40% will experience an injury every year (Kerr et al., 2015). Due to the high rate of injuries, it is important student-athletes, athletic trainers, and coaches are aware of common, effective coping mechanisms (Vann et al., 2018).
Seeking social support is the most common response when a student-athlete is injured (Clement et al., 2015). Clement et al. (2015) found evidence supporting a shift during the rehabilitation process concerning who the student-athlete turns to for support. In response to the injury, student-athletes mostly seemed to turn to their family and significant others for support, but once the rehabilitation began, the source of support shifted to their athletic trainer. Both previous and current research support the role social feedback plays in the rehabilitation process of an injured student-athlete (Johnston & Carroll, 1998; Vann et al., 2018).
Common misconceptions may assume an injured student-athlete has the full support of their teammates, coaches, and athletic trainers, but previous research shows this is far from accurate (Groot et al., 2018). Groot et al. (2018) found “people tend to forget that the injured student-athlete may still need social support from their social network even though it has been months since their injury” (p. 178), and that many student-athletes report once the physical component such as a brace or crutches is removed, teammates, coaches, and athletic trainers no longer view it as a “real” injury. Abgarov et al. (2012) also found coaches and teammates being in denial of a student-athlete’s injury, making it difficult for the student-athlete to seek support from them.
Social support can be a critical coping resource for injured student-athletes and aid in the recovery process. Bianco (2001) focused on the role of social support in adult skiers who recently recovered from injury. The study found reduced distress and improved motivation during recovery exhibited by the athletes that reported satisfied social support. Other studies demonstrated social support can reduce feelings of isolation and fears concerning reinjury (Podlog & Eklund, 2010). Injury can provoke many other stressors, such as increased depression, anxiety, and suicidal ideation (Koren et al., 2005; Sheinbein, 2016). To reduce the psychological effects of an injury, many student-athletes will turn to others that are also injured or experienced a similar injury (Johnston & Carroll, 1998). They also rely heavily on members of their athletic training staff (Yang et al., 2014).
Roles of the Athletic Trainer
The National Athletic Trainers’ Association (NATA, 2014) defined athletic trainers as “health care professionals who collaborate with physicians” (p. 1), and provide services such as prevention, emergency treatment, diagnosing, and rehabilitation of injuries. Athletic trainers can have beneficial or damaging effects on the rehabilitation process (Arvinen-Barrow et al., 2014; Putukian, 2016). Putukian (2016) concluded responsibilities of athletic trainers during the rehabilitation process is to recognize signs and symptoms of different mental illnesses, broadcast different resources available to their student-athletes, address the stigma of mental health, and assist student-athletes in understanding mental health is as important as physical health. Putukian (2016) also found the athletic trainer to be an important role in encouraging student-athletes to “seek help instead of ‘tough it out’” (p. 147). Robbins and Rosenfield (2001) found many injured student-athletes feel more satisfied with the support provided by their athletic trainers compared to their coaches.
In order for athletic trainers to establish a successful rehabilitation program, injury evaluation must be the foundation (Padua & Frank, 2020). Athletic trainers must also reevaluate the injury continuously to appropriately adjust the rehabilitation plan (Padua & Frank, 2020). Rehabilitation programs should have an end goal in mind, particularly aiming for preinjury physical and emotional levels, so utilizing baseline measures are important (Dhillon et al., 2017). In order to restore function and performance, routine screening and comparing to the baseline data is vital, as well as utilizing functional testing to determine rehabilitation progression compared to time-based progression (Dhillon et. al, 2017).
Bishop et al. (2015) demonstrated the benefits and effectiveness of manual, or hands-on, rehabilitation techniques. Massage is widely used and offers benefits such as swelling control, increase of blood flow, and pain relief (Goats, 1994). Bang and Deyle (2000) conducted a study analyzing effects of exercise and manual therapy on those with shoulder injuries. The study found the manual therapy group had significantly more improvement compared to the exercise group, supporting later research that also shows the effectiveness of manual therapy (Almeida et al. 2011; Bergman et al., 2010). Athletic trainers also utilize exercise equipment to assist rehabilitation. Some equipment includes elastic bands, stretching machines, weights, and BOSU stability balls (Brumitt et al., 2010).
Sport injury rehabilitation programs are starting to include psychological interventions (Clement & Shannon, 2009; Cupal, 1998), such as relaxation, mindfulness, imagery, goal setting, and stress management (Johnson, 2000). Mahoney and Hanrahan (2011) found these interventions are effective in providing student-athletes coping skills, reducing fear and anxiety over re-injury, and reducing other negative psychological effects such as depression. Combined, these physical, social, and psychological factors impact a student-athlete’s identity.
Impacts of Injuries on Identity
Social identity theory explains that one views themself based on the groups they belong to (Tajfel & Turner, 1979). Studies shown that an athletic identity may be the dominant identity for a college student-athlete (Adler & Adler, 1991; Horton & Mack, 2000; Tasiemski et al., 2004). An individual’s athletic identity reflects “the degree of importance, strength, and exclusivity attributed to one’s role as an athlete” (Cabrita et al., 2014, p. 472). When a student-athlete becomes injured, their main identity may be threatened (Heird & Steinfedt, 2013). A disruption in this identity can lead to negative emotional and psychological reactions as the student-athlete scrambles to find a sense of belonging (Brewer et al., 2010; Green & Weinberg, 2001).
In 2006, The American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine released a consensus statement. In that statement, the organizations concluded identity loss was one of the most common emotional issues that arises from injury (2006). Groot et al. (2018) found many injured student-athletes are faced with the challenge of finding a new way to stay connected to the team. Some student-athletes saw their reduced role as an insult on top of their injury, and others reported feelings of stripped identity and the need to redefine who they. Lack of social support may increase feelings of isolation from both their teammates and their sport, possibly contributing to a loss of identity (Brewer et al., 2010; Green & Weinberg, 2001; Mainwaring, 1999).
Lockhart (2010) found student-athletes with a self-acceptance self-esteem, compared to an achievement self-esteem, plus a lower athletic identity are less likely to experience psychological trauma due to their injury since the student-athlete will not experience a perceived loss of identity. Achievement self-esteem is based on an individual having a healthy sense of self based on what they achieve, while self-acceptance self-esteem is based on a healthy sense of self regardless of achievement. The two paths contradict based on internal and external sources of self-esteem, and Lockhart (2010) argued the athletic identity is fixated around achievement self-esteem. Student-athletes who have a strong athletic identity potentially view their injury as a personal failure (Heinrich et al., 2012), and may experience feelings of blame, shame, and guilt (Timpka et al., 2015).
When student-athletes are isolated from their teammates and can no longer participate in their sports activities, they may suffer a feeling of loss to their identity as a student-athlete (Graupensperger et al., 2020). The COVID-19 pandemic forced universities to close down, mandating student-athletes to return home and become isolated from their teammates (Graupensperger et al., 2020). Student-athletes follow strict training and competition schedules with interpersonal interactions (Heidari et al., 2019), and the sudden disruption from COVID-19 can negatively affect mental health and disband the sense of connectedness (Williams et al., 2018).
Overview of COVID-19
COVID-19, commonly referred to as the coronavirus, emerged in Wuhan, China, in December of 2019. The virus spread globally, resulting in a pandemic. As of March of 2021, the World Health Organization (WHO) reported 122,524,424 confirmed cases of COVID-19, with 2,703,620 deaths. According to Zhang and colleagues (2020), the nervous system, immune system, reproductive system, and digestive system may all be impacted, potentially resulting in fatal infections. Elabiyi (2020) concluded the three major routes of transmission for COVID-19 are through respiratory droplets, contact, and aerosol.
COVID-19 is a threat to the physical health of people around the world, but it also made significant psychosocial threats. Instability spread globally as well, resulting in fear of a confirmed case, stigmatization, higher death rate, increased stress and anxiety, and psychological issues among those in quarantine or isolation (Elabiyi, 2020). Some countries instilled nationwide lockdowns and/or statewide stay-at-home orders, increasing the prevalence of depression and anxiety symptoms (Gualano et al., 2020). The intense media coverage also had a huge impact on worsening individuals’ mental health (Rubin & Wessely, 2020).
The Pfizer vaccine became the first COVID-19 vaccine approved by the FDA for emergency use in December of 2020 (Katella, 2021). Trials of the vaccine reported a 95% efficacy rate in preventing COVID-19 after two doses (Badiani et al., 2020). The second approved vaccine, Moderna, reported a 94.1% efficacy rate also requiring two doses (Centers for Disease Control and Prevention, CDC, 2021a). The latest approved vaccination, the Johnson & Johnson vaccine, only requires one dose, but reduces the efficacy rate to 66% in preventing moderate to severe COVID-19 (Livingston et al., 2021). However, the Johnson & Johnson vaccine is 100% effective in preventing COVID-19-related hospitalizations and deaths (Livingston, Malani, & Creech, 2021).
COVID-19 disrupted routine life based on the social role and risk factor an individual presents (Klaiber et al., 2020). In order to slow the spread of the virus, leaders implemented nationwide public health orders (e.g., stay-at-home orders, business closures, and prohibitions against social gatherings), leading to many social events being cancelled (Czeisler et al., 2020). Ebrahim and Memish (2020) found cancellation or suspensions of mass gatherings are critical to pandemic mitigation, leading to many popular, daily activities being restricted. Mark Emmert, the NCAA President, cancelled the remainder of NCAA winter and spring championships in March of 2020 to slow the spread of the pandemic, leaving many student-athletes heartbroken. The cancellation of the 2020 NCAA Division I Men’s Basketball Tournament, referred to as “March Madness”, caused millions of dollars to be lost in the tourism industry (Cooper & Alderman, 2020).
Impact of COVID-19 on Athletic Injuries
Collegiate athletes are typically younger and present less comorbidities (Yanguas et al., 2020). Nevertheless, collegiate athletes are still responsible for following the same preventative strategies to limit the spread of COVID-19 to protect healthcare systems from collapsing (Mann et al., 2020). Due to long lockdown and stay-at-home periods, individuals should be assessed thoroughly for a higher risk of injury (Yanguas et al., 2020). Yanguas et al. (2020) recommends daily monitoring and symptom control in regard to this assessment.
COVID-19 impacted surgical practices significantly, sparking issues with sufficient staff, prioritizing essential procedures, and increased risk of transmission (Al-Jabir et al., 2020). Medical professionals tried to avoid unneeded face-to-face appointments, causing long and delayed wait-times to be seen due to preventative policies (Al-Jabir et al., 2020). Because of COVID-19 policies to limit the spread, telehealth appointments became very common (Monaghesh & Hajizadeh, 2020).
With the cancellations of season and college/university restrictions, student-athletes experienced disruption in athletic training services (Jagim et al., 2020). Many student-athletes did at-home training and rehabilitation, predominately on their own without professional supervision (Sarto et al., 2020). COVID-19’s home-confinement increased levels of detraining, the loss of progress, consequently from inadequate or inappropriate training stimuli (Mujika & Padilla, 2000). Many student-athletes reported a lack of resources, such as not having access to rehabilitation services or hands-on treatment for their injuries (Bullard, 2020). Bullard (2020) found the lack of access can cause feelings of disappointment, anger, frustration, and sadness.