From Social Isolation to Becoming an Advocate: Exploring Athletes’ Grief Discourse About Lived Concussion Experiences in Online Forums

Abstract

Athletes who sustain concussions endure a variety of physical, mental, emotional, and social isolation effects as they rehabilitate. Accordingly, concussion recovery can induce grieving processes as athletes navigate the loss of athletic participation, social networks, and daily routine disruption. This research sought to gain a richer understanding of athletes’ lived experiences with concussions through grief discourse shared in online narratives. Through an analysis of athletes’ experiences shared via 58 blog posts on three concussion websites, the data reveal how athletes frame the losses that concussions bring into their lives, the subsequent feelings and expressions that result, along with how they eventually cope. The information disclosed in these online spaces can benefit parents, friends, coaches, and others to better understand concussion recovery, thereby enhancing their supportive communication and behaviors towards athletes as they rehabilitate from concussions.

Keywords

athletes and concussions grief online forums online support groups sport and health

Sport and recreational activities are a significant cause of traumatic brain injuries (TBIs), with 1.6–3.8 million sports-related TBIs occurring each year (Langlois, Rutland-Brown, & Wald, 2006). Some scholars suggest that these numbers are underrepresented, as many TBIs go unreported (Langlois, Rutland-Brown, & Wald, 2006). TBIs are also considered a disabling injury as they can induce long-term and in some cases, lifelong physical, cognitive, and behavioral effects that can impact a person’s ability to work and resume daily activities (Langlois, Rutland-Brown, & Wald, 2006). Researchers also have noted that TBIs sustained in childhood and adolescence can impact learning and functioning later in life (Sariaslan, Sharp, D’Onofrio, Larsson, & Fazel, 2016) and are associated with increased risk of dementia (Fann et al., 2018). This information correlates with elevated public concern regarding TBIs in sport, such as concussions,¹ particularly in high contact sports such as football and soccer (Preidt, 2017; Rapaport, 2018).

Athletes who sustain concussions often experience physical, psychological, and emotional effects (Kroshus, Kubzansky, Goldman, & Austin, 2015; Weinberg, Vernau, & Horn, 2013). These outcomes are further exaggerated by challenges related to their inability to participate in sport, which for some athletes, functions as a significant identity mechanism (Colon, Smith, & Fucillo, 2017; Hilliard, Blom, Hankemeier, & Bolin, 2017; Weinberg et al., 2013). Thus, the concussion recovery process can be frustrating for athletes due to the physical symptoms (e.g., inability to tolerate light), daily routine disruption (e.g., ability to attend school), social isolation from peers, and identity loss (Covassin, Elbin, Beidler, LaFevor, & Kontos, 2017).

Athletes also can struggle with feelings of inadequacy that arise from sport cultural norms, such as perceptions that by reporting a concussion, thereby being held out of competition, they are disappointing their teammates and coaches (Anderson & White, 2017; Sanderson, Weathers, Snedaker, & Gramlich, 2017). Concussions can be challenging and complex to endure, and as a result, athletes may exhibit symptoms associated with grief. Grief is an emotional response people feel when loss occurs (Jakoby, 2012; Neimeyer, Klass, & Dennis, 2014), that is influenced by social and cultural norms (Jakoby, 2012). Accordingly, when athletes sustain a concussion, it may be difficult for them to express their true feelings, particularly if they perceive that their experiences may contrast with social norms (Varga & Paulus, 2014). These feelings can be further compounded by the lack of empathy and skepticism athletes can encounter when reporting a concussion (Sanderson et al., 2017).

Consequently, athletes may benefit from spaces where they can discuss their concussion experiences in ways that are personally meaningful and in which social norms are mitigated (Varga & Paulus, 2014). Accordingly, this research examines how online forums enable athletes to share personal narratives around concussion recovery, including grief discourse. For those working with athletes who are recovering from concussions, these narratives can be used to better understand athletes’ lived experiences. This knowledge can then prompt more empathy and supportive communication (Cohen & Samp, 2017) towards athletes as they recover from concussions.

Review of Literature

Athletes and Concussions

A concussion occurs when a person sustains a direct or indirect impact to their head, neck, or face (McCrory et al., 2017). Concussion effects can be pervasive and include physical, behavioral, cognitive, sleep-related, and emotional symptoms (McCrory et al., 2017); social consequences such as isolation (Covassin et al., 2017); and mental health issues such as decreased self-esteem (Brewer, 1993; Hilliard et al., 2017). Concussions can be difficult to diagnose and may be improperly attributed to other ailments (Daneshvar, Nowinski, McKee, & Cantu, 2011). Athletes’ reticence to report concussions also complicates this issue (Register-Mihalik et al., 2013; Sanderson et al., 2017). Researchers have noted that athletes' nonreporting results from the pressures they face to conform to sport cultural norms such as playing through pain (Weinberg et al., 2013) and their fear of consequences such as losing playing time (Sanderson et al., 2017).

Although there is significant literature on concussion symptoms (King, Crawford, Wenden, Moss, & Wade, 1995; McCrory et al., 2017), and how to treat concussions (Kinnaman, Mannix, Comstock, & Meehan, 2013; Moser, Glatts, & Schatz, 2012), less attention has focused on providing support for athletes during concussion recovery (see Covassin et al., 2014; Horton, Bloom, & Johnston, 2002, for some exceptions). Whereas athletes' duration of concussion symptoms varies, the identity fulfillment some athletes derive from their athletic participation (Podlog et al., 2013), compounded with other impacts can make concussion rehabilitation difficult to endure.

Athlete Identity and Injuries

For many athletes, athletic participation is a significant identity component (Hilliard et al., 2017; Podlog et al., 2013). These individuals tend to define themselves via their athletic accomplishments and place great importance on their athletic performance (Weinberg et al., 2013). A person’s connection to the athletic role (Brewer, Van Raalte, & Linder, 1993) can influence his or her sport participation, and people who value their athletic roles tend to behave in ways that they perceive to be consistent with an athlete identity (Wiechman & Williams, 1997). Such conformance also influences their decision-making, particularly when health is involved (Kroshus, Kubzansky, Goldman, & Austin, 2015; Weinberg et al., 2013).

For instance, people with high athletic identity levels tend to be more willing to play through pain (Sabo, 2004; Weinberg et al., 2013) and to engage in risk-taking and other behaviors that are traditionally associated with masculinity (Steinfeldt & Steinfeldt, 2012). Kroshus, Kubzansky, Goldman, and Austin (2015) observed that “an athlete who believes that not reporting concussions is consistent with the athletic role and who identifies strongly with that role may be less likely to report concussive symptoms to medical or coaching personnel” (p. 96; emphasis in original). Indeed, many athletes are influenced by the “sport ethic” (Weinberg et al., 2013, p. 42), a construct which suggests that sport participation is valued above all other considerations. Those who subscribe to the sport ethic must accept and play through injury and mask any side effects resulting from injury (Hughes & Coakley, 1991; Nixon, 1996).

The desire to conform to perceived athlete identity and sport cultural norms can also influence how athletes manage concussions. The disruption that concussions can cause athletes in both their sport participation and daily routine is significant (Hilliard et al., 2017), and athletes may risk their health to minimize these effects. Podlog et al. (2013) observed that some athletes engaged in overadherence to rehabilitation recommendations so they could hurriedly return to athletic competition to achieve goals and maintain athletic excellence. They also found that athletes who possessed high self-presentation needs hastened returning from injury to obtain approval from coaches, teammates, and fans. These social factors are important to many athletes (Stephan & Brewer, 2007), and the desire for approval is particularly salient in young athletes, who may not report athletic injuries or ignore practitioner recommendations to avoid looking bad in front of their peers (Podlog & Eklund, 2005). The social aspects of sport participation are so pervasive that some researchers argue that concussion risk should be understood as a desire for social interaction rather than an uninformed health risk (Colon et al., 2017).

Given the serious health effects that athletes can experience from not reporting injuries or expediting their rehabilitation, social support can help athletes counteract the pressure to return from injury early or to not report them at all (Iadevaia, Roiger, & Zwart, 2015; Podlog et al., 2013). Whereas an athlete may benefit from local support resources, such as empathetic coaches and teammates, supportive parents, family members, and friends who can help them in coping with a concussion, online support groups extend the sphere of support for athletes.

Online Health Support Groups

Support groups allow participants to receive social support from other members who share a similar condition or experience (Arntson & Droge, 1987). While many support groups have and still do meet in physical spaces, advancements in digital technology have shifted them into online settings as well (Rains & Young, 2009). Online support groups enable people to access their group on demand, overcoming geographical and time constraints (Rains & Young, 2009). Online forums tend to focus on a unifying theme (e.g., breast cancer) and serve as a digital meeting place for discussions on that topic (Tanis, 2008). Online support groups can help members manage stress and uncertainty, while also often contributing to positive health outcomes (Albrecht & Goldsmith, 2003).

Tanis (2008) also observed three characteristics of online forums that make them attractive to users: (a) text-based; (b) anonymity; and (c) extending social networks. Considering the concussion effects that many athletes experience, online forums provide spaces for athletes to disclose their feelings and experiences in ways that give them control over their concussion narrative and may prompt them to divulge information that they may not disclose offline. For example, researchers have observed that more active use in online forums resulted in more emotional relief (Barak & Dolev-Cohen, 2006) and that online forum participation can reduce social isolation and loneliness (Letourneau et al., 2012). Horton, Bloom, and Johnston (2002) looked at the effect of offline support groups on athletes who had sustained concussions and determined that those involved in the support group improved their mood state. Keating (2013) observed that online support groups are useful for people suffering from depression, a symptom commonly associated with concussion. Being able to draw on these resources may help athletes mitigate concussion effects such as social isolation (Covassin et al., 2017), lower self-esteem, and other issues such as irritability and mental fatigue (McCrory et al., 2017).

Additionally, via online forums, athletes are empowered to discuss their concussion recovery feelings and experiences by sharing which aspects of recovery are most pertinent to them, and in so doing, they connect with others with whom they can share similarity. Thus, by disclosing their feelings in a space populated by others who have also sustained sport-related concussions, athletes may derive the social and emotional benefits that can manifest within online forums (Barak & Doley-Cohen, 2006; Letourneau et al., 2012).

Online domains also provide athletes with opportunities to share their concussion recovery experiences and manage grief associated with the temporary or permanent loss of their athletic participation (MacAlearney, Hefner, Sieck, & Huerta, 2015). Varga and Paulus (2014) observed that grief may be constructed differently online than offline and that people may turn to online support forums to fulfill validation needs. Online forums also may enhance empathy as online support group members may be more willing to share their experiences with those whom they perceive similarly (Guise, McVittie, & McKinlay, 2010). Moreover, as grief can be experienced in ways that diverge from cultural norms, online forums provide a platform for individuals to construct and share their grief experiences in ways that they may have difficulty expressing offline (Varga & Paulus, 2014).

Grief

Grief is an emotion (Jakoby, 2012) that individuals feel in response to loss as they seek, “reaffirmation or reconstruction of a world of meaning that has been challenged by loss, at social as well as individual levels” (Neimeyer et al., 2014, p. 486). Grief can manifest as normal grief or complicated (pathological) grief, which are distinguished by the duration and prevalence of symptoms (Penman, Breen, Hewitt, & Prigerson, 2014). The duration and intensity of grief that people experience differs based on several factors. Researchers have noted that those who can come to terms with their loss reported fewer symptoms of complicated grief (Currier, Holland, & Neimeyer, 2006) and that integrating the grief experience into one’s meaning system (e.g., religious beliefs) leads to fewer reported symptoms of complicated grief (Holland, Currier, Coleman, & Neimeyer, 2010). Other scholars have noted that grief can be a lifelong process, as reminders of the loss occur over time (Kim et al., 2017), and that grief duration also is impacted by social isolation (Bruinsma, Tiemeier, Verkoost-van Heemst, van der Heide, & Rietjens, 2015) and what a person is grieving over (e.g., pet, spouse; Tzivian, Friger, & Kushnir, 2014).

Grief is an interpretive and communicative act (Neimeyer et al., 2014), that is influenced by social norms (Averill & Nunley, 2006; Neimeyer et al., 2014), and is socially and discursively produced (Varga & Paulus, 2014). Jakoby (2012) posited that while a person’s interpretation and definition of the loss shape grief, it is also influenced by one’s social interactions, relationships, and culture. Jakoby (2012), drawing on Hochschild (1979, 1983), also observed that grief expressions are managed by feeling rules that dictate the duration and intensity of grief and display rules that govern grief expression. Thus, it is common for people to manage grief by restraining it and pretending to feel good (Jakoby, 2012). Grief, then, is a social process that is influenced by multiple of internal and external factors (Jakoby, 2012).

People can choose a variety of options as they seek to manage grief. While there are diverse strategies a person can select from to manage grief, narratives can be a meaningful method to cope, as they initiate processes of reaffirmation (Neimeyer et al., 2014). Neimeyer, Klass, and Dennis (2014) noted that this narrative process includes (a) event stories—processing of the loss, its importance in one’s life, and what it means going forward and (b) back stories—relational processing and attempting to reestablish a link between one’s life before and after the loss.

Given the social and cultural forces that influence grief along with the social effects of concussion recovery, such as isolation from friends and teammates (Covassin et al., 2017), we apply Jakoby’s (2012) cognitive structural model to examine athletes’ grief discourse in athletes’ online narratives around their lived experiences with concussions. Jakoby’s (2012) model conceptualizes grief as a three-stage process: (a) framing the loss, (b) feelings and expressions, and (c) coping. Framing the loss helps to provide understanding for the person going through the loss, including reactions of the person’s social network. Feeling and expressions are influenced by social and cultural norms of feeling and display rules, whereas coping is a function of one’s personal resources, such as self-esteem, and social resources, such as one’s access to social and economic capital. Jakoby’s (2012) framework will help illuminate how athletes perceive their concussion experiences, along with the feelings they manage as they deal with recovery, including loss of athletic participation, as they cope and move forward from their loss.

Method

Data Collection

Data were obtained from postings on public online support group websites focused on concussions and head injuries. While the people who shared stories in these online forums are not representative, the publicly available data were necessary for the researchers’ aim to understand athletes’ grief discourses associated with concussions. Three online sites were included in study: (a) ConcussionConnection.com, (b) TheKnockoutProject.org, and (c) TalkConcussions.com. Media coverage about online concussion support groups directed the researchers to these sites, and these three sites were specifically chosen as they included first-person accounts of people experiencing and living with concussion symptoms.

On ConcussionConnection.com, such postings were found under the “Connect” tab, which led to a section of athlete “Stories.” Also under the Connect tab is a section called “Share Your Story,” where users are asked to provide their concussion experience, as well as their name and e-mail address. For TheKnockoutProject.org, researchers went through the archives of every post on the website to determine relevance. For TalkConcussions.com,relevant postings were located under a tab entitled “Concussion Talk.” The researchers examined the postings on each site to determine relevance to the study. Posts that included an athlete’s first-person narrative concussion story were included. Posts that were excluded were those written in secondhand accounts (e.g., by parents) or those which were news oriented (e.g., information/opinion on concussions in National Football League). There were seven posts excluded from ConcussionConnection.com, and 22 excluded from TheKnockoutProject.org. All posts from TalkConcussions.com were included in the sample. Not all posts included a date of publication, but those that did ranged from February 2013 to May 2016. There were 58 posts included in the sample: ConcussionConnection.com (n = 26), TheKnockoutProject.org (n = 23), and TalkConcussions.com (n = 9). Of the 58 posts included in the sample, the researchers could determine gender (e.g., profile pictures) in 56 of them, resulting in a breakdown of 45 females and 11 males. Exact ages were unclear but based on the narratives, the researchers ascertained that individuals ranged from high school students to middle-aged adults at the time of their concussion. The 58 users indicated 16 sports in which their concussion occurred, with soccer (n = 16) being the most prevalent.

We recognize that online data collection brings some privacy and ethical challenges. The data included in our sample were publicly available and thus, we considered it to be in the public domain. Walther (2002) observed that the Code of Federal Regulations Title 45, Part 46, Protection of Human Subjects protects communication privacy in personal spaces such as a physician’s office, but publicly available Internet archives have human subjects’ exemption as they are similar to newspaper or Congressional Record archives. Although the blog posts are considered public domain, we do not disclose names or any other personally identifiable information contained in blog posts (e.g., names of parents, doctors).

Data Analysis

To identify grief discourse in the athletes’ posts, the researchers used a theory-driven deductive approach for qualitative analysis (Cho & Lee, 2014), in which an a priori template of codes was established (Crabtree & Miller, 1999). This method allows researchers to analyze manifest and latent meaning of communication and was deemed appropriate to examine athletes’ narratives about their concussion experiences. The blog post served as the unit of analysis. Consistent with deductive procedures (Cho & Lee, 2014), analysis was guided by Jakoby’s (2012) three-stage grief processing model, with each stage serving as a theoretical-based coding category (Cho & Lee, 2014). Each of the two researchers coded half the sample, which was split using probability sampling techniques with each half including postings from all three sources in the sample. The posts were initially read and the researchers identified meaning and patterns in the data (Braun & Clarke, 2006) by making notes to indicate how participants’ grief discourse aligned with the stages of Jakoby’s (2012) model. Due to the interpretive nature of the analysis, the researchers allowed for each stage to be present in a post, reflecting the individualized nature of grieving (Messing, Mohr, & Durfee, 2015). After making notes of the grief stages in each post, each researcher returned to the sample to reread each post to verify the existence the grief stages in the discourse. The authors then discussed the stage examples in each data set and reached consensus on the a priori categories fitting the data and although revision of categories can be done in this method (Cho & Lee, 2014), the researchers agreed that Jakoby’s model captured athletes’ grief discourse and that additional categories were unnecessary.

Results

The number following each exemplar reflects where the post fell in the data set. For example, a comment with the designation (10) after it indicates the 10th post in the data set.

Framing the Loss

Athletes shared how their concussion had resulted in significant life alteration and disruption, “I didn’t think something could be so serious and change my life forever” (17); “This concussion has changed my life—and it is so hard” (3); “Everything I knew—school, friends, and sports—had been taken from me because of this injury” (45); and, “If I had never suffered that life-threatening injury, my life would be immensely different” (30). Some athletes discussed how their concussion had resulted in social isolation. For instance, “I missed more and more school and couldn’t see my friends anymore” (11); “I no longer went out with friends, I could barely attend class and it hurt to even eat. I rarely left my room” (12); “I am systematically isolating myself from everyone who was ever important to me” (6); and, “I became very depressed because I felt like no one believed me after the first two months. My friends started to forget about me because I was never at school” (35). In addition to social isolation, some athletes experienced the loss of people in their social networks. Comments here included sentiments such as, “I’m losing friends who don’t understand why I am the way I am” (25); “Some friends who I was once close with are now just faces in the hall” (48); “It has taken away any social life, my job for the time being, hampered my relationship with my husband” (14); and:

My best friend of 12 years did not call or text for two whole months after she found out I got a concussion. I had a little bit of an easier time understanding why my friends at school didn’t reach out to me, but I was so hurt and baffled by the lack of care from someone I considered best friend (32).

Still others framed loss around their athletic identity. For example, “I am still not cleared for gym or sports. I am now 13 years old and can’t play hockey again and am really not supposed to do any contact sports ever again” (29); “The hardest part of not being able to play is watching everyone play a sport you love” (27); “Soccer was my life, it defined me as a person. Losing soccer was one of the hardest things I have ever had to go through” (11); “I soon came to the conclusion that this was the end for me. As I unlaced my shoes and ankle braces for the last time ever, tears ran down my face” (22); and:

I was done with my life of soccer as well as my new life of lacrosse. It was the worst news I have ever gotten. The thought of never being able to play soccer again after playing for 11 to 12 years broke my heart (17).

Feelings and Expressions

Athletes conveyed a variety of emotions and feelings they experienced from their concussions, including the inability to stay composed and project happiness to outward audiences. For example, “I remember my anger as I laid there and bawled” (46); “It’s hard to keep your emotions in check and stay positive while going through this” (11); and, “The healing process was slow, frustrating, and wrought with emotion” (4). For others, they shared feelings of depression and frustration, which they attributed to a lack of empathy and understanding from others, perhaps reflecting educational deficits around concussions. Comments here included, “I became very depressed because I felt like no one believed me after the first two months. My friends started to forget about me because I was never at school” (36) and, “These challenges seem minimal to many outsiders as they can’t necessarily see your injury that still lingers. That can make a person really feel alone in their battle leading to anxiety and depression” (51). Here, athletes also talked about perceived lack of empathy from school personnel due to accommodations they were seeking as part of their rehabilitation. For instance, “After several fights with the school, I finally got the tutors I needed” (31) and, “I am able to have accommodations at school. There has been some backlash from professors because of this. They don’t understand concussions and believe that I am faking this so that I don’t have to study” (34).

Perhaps because of the lack of empathy and understanding, athletes described experiencing depression and their difficulty in overcoming it, “I lost more than 20 pounds and sank into a severe depression” (12); “As time went on, I felt myself feeling lower and lower, and just slipping. I got depressed and hated everything about myself” (46); and, “I’m depressed. I’m hopeless. I have lost any desire to do anything” (15). For some athletes, this depression became so severe that they contemplated suicide, “There wasn’t one day for a span of months that I didn’t contemplate disappearing and ending my life” (22); “At night, I would sit there and wonder if I would wake back up. Why am I even alive? I would rather be dead than deal with this. Who wants to live this way?” (5); and:

All I ever wanted was to play collegiate soccer and now that dream was stripped away from me. At this point I was at an all time low and several days contemplated suicide. I just couldn’t imagine my life without soccer there was just no way (58).

Coping

Jakoby (2012) posited that coping is a function of one's personal and social resources and athletes conveyed how these sources helped them cope with their concussion, enabling them to turn a negative situation into a positive one. For instance, athletes disclosed how they had become resilient through their experiences including channeling the effort they previously put into athletics into concussion education. For instance, “The same drive, passion and work ethic I had on the football field was then translated to my new goal of making football, and all sports for that matter, safer for athletes of all ages” (30) and, “But I would like to think I tackle things with the same determination and competitive spirit that made me such a great athlete” (23). Some athletes shared how self-discovery had helped them in their coping. Examples here included, “I have learned so much about myself through this recovery. I have grown as a person and am so much stronger and more mature than I was before” (32) and, “I’ve learned to be proud of myself and the issues I have” (5).

Other athletes conveyed how they were coping through sharing their stories with others, providing the empathy they had not received. Sentiments here included comments such as “I try to share my story with anyone who will listen in order to prevent them from suffering like I did” (7); “I want to help others who have suffered injuries like mine. I want to help them recover and live the lives they could only dream about” (22); and:

My experience is the catalyst for speaking out and trying to warn others about inadvertently following in my footsteps. There are a number of us who speak out vociferously about concussion because so many people have the ultimate choice to treat healing from them the right way (21).

Other shared they were drawing on resources available to them to engage in advocacy. For example, “While undergoing vestibular therapy this summer to help decrease my dizziness, I decided to create a foundation and raise money through a trail race” (33); “I also presented a speech to my dad’s athletic training students at [school] to show how much athletes can be affected by their injuries” (28); and, “I began telling my story and educating other athletes on the importance of concussion awareness. I did this through guest lectures at [school], speaking at local high schools and even being interviewed on national television” (30).

Discussion

Concussion recovery is a complex and emotionally intensive process (Covassin et al., 2017; Kroshus et al., 2015). As participants in the data illustrated, their concussion rehabilitation was typified by grief discourse resulting from both their individual challenges and the actions of those in their social networks. The information these athletes shared, however, can be useful in helping parents, coaches, teachers, administrators, physicians, friends, and others work with athletes who experience concussions. In understanding concussion recovery as being associated with grief discourse and symptoms, these stakeholders can better understand how to enact supportive communication. Rossetto (2015) found that for individuals experiencing grief, supportive communication included participation in activities and creating feelings of togetherness. Considering that athletes reported social isolation and indifference from people in their social networks, those who live and work with athletes recovering from concussions can devise activities that will help athletes experience togetherness. For instance, a parent could arrange for an athlete to participate in activities with family and friends. Additionally, coaches could look for ways to involve athletes in team activities, although individual adaptation is necessary as being around the team and the sport may enhance grief.

Toller (2011) found that being present and honoring ongoing connections with the loss were forms of supportive communication to enact with those grieving. With athletes, a correlation here with athletic identity can be seen. That is, athletes shared how difficult it was for them to give up their sport. Those who live and work with athletes can find ways to help athletes remember their enjoyment with sport, such as having the athlete talk about what their memories. Another option here is looking for ways to keep athletes involved in the sport. Some athletes in the data reported that they had gotten into coaching or officiating to stay engaged with the sport, and these opportunities could be presented as viable options for athletes as they manage concussion recovery. Wilder (2016) observed that people could enact supportive communication by listening and responding with empathy to those who are grieving. This recommendation represents arguably one of the most salient points athletes shared in their narratives—that people did not understand what they were going through and expressed skepticism about their symptoms. For instance, some athletes shared the difficulties they experienced with teachers accommodating their learning restrictions, and training school and other administrative personnel to be more empathetic with athletes managing concussions is an important educational direction to pursue.

Additionally, Messing, Mohr, and Durfee (2015), in their examination of grief with women who experienced intimate partner violence (IPV), argued that understanding could promote positive outcomes, specifically, that responses to IPV could help social workers, “increase their patience and empathy, as well as provide a framework for encouraging a survivor to move through the stages of grief towards acceptance” (p. 36). They also observed that it was important for individuals to help victims learn coping strategies, allow them to process grief, and to normalize grief experiences. We advocate for similar behaviors to be adopted by those working with athletes recovering from concussions.

Researchers have noted that grieving may function differently online than offline (Varga & Paulus, 2014), and a second implication from the current study is that online forums empower athletes to talk about and share their experiences in personally meaningful ways. Researchers have noted that online forums can prevent individuals from engaging in behaviors such as suicide, due to accessible and helpful information being provided, and that they also promote communication from people willing to share their experiences (Owens et al., 2012). Athletes shared feelings in their narratives that may be difficult to express in off-line venues, yet which nonetheless represented their concussion reality. Understanding the depth of emotions and feelings that athletes encounter as they manage concussions can be used to foster more education and awareness on this topic. For example, many concussion education programs are centered on awareness and recognition (Chrisman, Schiff, Chung, Herring, & Rivara, 2014) and reporting behavior (Kroshus, Baugh, Daneshvar, Nowinski, & Cantu, 2015). While these are important elements, understanding the range of emotions and feelings athletes experience also would be beneficial in concussion education.

Researchers also have found that people who disclose in online health support groups report feeling more emotional well-being and decreased negative mood (Shaw, Hawkins, McTavish, Pingree, & Gustafson, 2006), and with athletes managing concussions, similar outcomes may emerge, particularly as they read about how others have turned this adversity into a positive life direction. For instance, consider the athletes who shared that their concussion experience had prompted them to become an advocate. In many cases, this transition did not come without turbulence, and even depression, yet these adversities were eventually overcome. Exposing athletes managing concussions to such messages may help them navigate through their negative emotions more constructively, while also exposing them to community members who are empathetic (McKiernan, Ryan, McMahon, & Butler, 2017) and who can help buffer the social isolation that often accompanies concussion rehabilitation. Whereas there appear to be positive benefits to athletes sharing in online forums, communication in these domains may subject athletes to violating care recommendations such as managing their light sensitivity. However, athletes may feel the benefits outweigh the risks, and technological innovations such as apps continue to be pursued to manage concussion symptoms (Worthen-Chaudhari et al., 2017).

Finally, better understanding athletes’ experiences as they recover also may help change cultural norms around concussion reporting, if peers, coaches, family, and others understand how their communication and behavior are perceived by athletes managing concussion rehabilitation. For instance, Kroshus, Garnett, Hawrilenko, Baugh, and Calzo (2015) found that athletes who received pressure from sources such as coaches, teammates, parents, and fans were more likely to continue playing through a head injury than those who only received pressure from some of these sources, or only from coaches and teammates. Rivara et al. (2014) observed that legislation alone was likely to be insufficient to encourage athletes to more frequently report concussions. Consequently, if peers, parents, coaches, and others are made aware of the internal struggles athletes face in recovering from a concussion, they can be more proactive in offering encouragement and support rather than pressuring athletes to play through this injury and questioning the severity of symptoms.

Limitations and Directions for Future Research

This research was subject to several limitations. First, our sample was skewed to women. While some research has looked at gender differences in concussion reporting (Sanderson et al., 2017), it would be worthwhile to look at how men and women process concussion recovery and similarities and differences in their use of grief discourse. Second, our data were cross-sectional and consisted of athletes’ disclosures at one moment. It would be helpful to know how athletes write about their concussion experiences across time. For instance, some athletes may provide a “summary” of their concussion recovery in one post, others may write about it multiple times, and it would be fruitful to examine how athletes’ messages reflect grief stages over time, including the time spent in the various grief stages.

Additionally, the sample was limited to those who chose to disclose online, and not all athletes will choose this option to talk about concussion experiences. Thus, future work could examine grief management processes by comparing athletes who post online versus those who might keep a journal or other written record of their thoughts. For example, researchers could examine athletes’ concussion recovery shared via blogs or social media and compare that to other athletes who journal their feelings. Researchers also could examine difference by sport to ascertain similarity and differences in how athletes manage concussion recovery. Another direction for future research to explore would be to examine the role of social support in concussion recovery. Many athletes attributed parts of their grieving to the lack of empathy from others, such as friends no longer talking to them and teachers not being accommodating of learning restrictions. Future work could explore the community process or dialogic exchanges between athletes and other community members within online forums to ascertain whether appropriate support is being received in these forums.

Conclusion

Concussions continue to be a prominent talking point within both sport and public health. Whereas programmatic, policy, and educational programs are important components in addressing this topic, so too are the feelings and experiences that athletes encounter as they manage concussion effects. Understanding that athletes can experience grief-related symptoms as they recover can aid both in supporting athletes as they navigate through this process and in fostering cultural change that will encourage more athletes to report concussions, as they will receive empathy and support, rather than pressure and isolation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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Note

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