Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-044199 on 9 April 2021. Downloaded from Investigating correlates of athletic identity and sport- related injury outcomes: a scoping review Tian Renton ,1,2 Brian Petersen,3 Sidney Kennedy1,2,4 To cite: Renton T, Petersen B, ABSTRACT Strengths and limitations of this study Kennedy S. Investigating Objectives To conduct a scoping review that (1) describes correlates of athletic identity and what is known about the relationship between athletic ► The search strategy was constructed in consultation sport- related injury outcomes: identity and sport- related injury outcomes and (2) a scoping review. BMJ Open with a University of Toronto librarian. describes the relationship that an injury (as an exposure) 2021;11:e044199. doi:10.1136/ ► Citation management (EndNote) and systematic re- has on athletic identity (as an outcome) in athletes. bmjopen-2020-044199 view citation screening software (Covidence) were Design Scoping review. used to allow reviewers to independently screen ► Prepublication history for Participants A total of n=1852 athletes from various citations and extract data. this paper is available online. To sport backgrounds and levels of competition. ► Data extraction variables thoroughly described the view these files, please visit the Primary and secondary outcome measures The journal online (). study sample, injuries sustained, theoretical models primary measure used within the studies identified was referenced, athletic identity scores and timeline of the Athletic Identity Measurement Scale. Secondary Received 26 August 2020 administration, significant key findings as well as outcome measures assessed demographic, psychosocial, Revised 16 January 2021 study strengths and limitations. Accepted 03 March 2021 behavioural, physical function and pain- related constructs. ► A quality assessment was not conducted, and level Results Twenty- two studies were identified for inclusion. of evidence ratings were not assigned to studies. Samples were dominated by male, Caucasian athletes. The majority of studies captured musculoskeletal injuries, while only three studies included sport- related concussion. Athletic identity was significantly and positively associated anxiety symptoms8) and cognitive benefits with depressive symptom severity, sport performance (eg, improved academic performance9 and traits (eg, ego- orientation and mastery- orientation), social 10 memory recall ) associated with physical http://bmjopen.bmj.com/ network size, physical self- worth, motivation, rehabilitation overadherence, mental toughness and playing through activity in general. Despite these benefits, pain, as well as injury severity and functional recovery negative outcomes should also be considered, outcomes. Findings pertaining to the association that an namely risk of injury. However, not all athletes injury (as an exposure) had on athletic identity (as an are created equal, nor are their respective © Author(s) (or their outcome) were inconsistent and limited. risks of sport injury. This is illustrated by employer(s)) 2021. Re- use Conclusions Athletic identity was most frequently several large- scale epidemiological studies permitted under CC BY- NC. No associated with psychosocial, behavioural and injury- describing marked differences in injury inci- commercial re- use. See rights 11–16 specific outcomes. Future research should seek to include dence when stratified by sport. Internal on September 27, 2021 by guest. Protected copyright. and permissions. Published by diverse athlete samples (eg, women, athletes of different BMJ. risk factors, such as an athlete’s biological and races, para-a thletes) and should continue to reference 1 physical characteristics (eg, age, sex, anthro- Rehabilitation Sciences theoretical injury models to inform study methodologies pometry, skill level and physical fitness) as Institute, University of Toronto and to specify variables of interest for further exploration. Faculty of Medicine, Toronto, well as their psychological predisposition Ontario, Canada 2 (eg, personality, history of stressors and avail- Centre for Depression and INTRODUCTION ability of coping resources) are also posited to Suicide Studies, St Michael's 17–19 Hospital, Toronto, Ontario, Participation in sport, be it in a formal (eg, modify injury risk. External factors, such Canada registered league) or informal (eg, pick- up, as level of competition and playing surface, 3Faculty of Kinesiology and drop- in) setting, is a popular pastime for have also been implicated.18 19 Physical Education, University individuals the world over. Positive benefits Despite individual athlete (eg, physicality, of Toronto, Toronto, Ontario, associated with sport participation include disposition) and sport- specific differences Canada 1 1 2 4Department of Psychiatry, increased mental toughness, perseverance (eg, type, level, frequency of involvement, 2–4 University of Toronto Faculty and positive self-esteem, as well as the devel- injury risk), all athletes are thought to of Medicine, Toronto, Ontario, opment of fine and gross motor skills, team embody an ‘athletic identity’ (AI). Initially Canada work and problem- solving abilities.5 These defined by Brewer et al in 1993, AI is defined Correspondence to benefits are aside from the countless physical as ‘the exclusivity and strength with which an 6 Tian Renton; (eg, maintenance of a healthy body weight ), individual identifies with the athlete role, and tian. renton@ mail. utoronto. ca mental (eg, reduction in depression7 and looks to others for confirmation of that role’.20 Renton T, et al. BMJ Open 2021;11:e044199. doi:10.1136/bmjopen-2020-044199 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-044199 on 9 April 2021. Downloaded from To some extent, an athlete’s self- perception of their AI METHOD can provide an important measure of their longevity in Search strategy and study identification sport.21 Stronger AIs have been associated with positive Search strategies and terms were developed in consulta- health outcomes, increased sport engagement, enhanced tion with a University of Toronto health science librarian athletic performance, improved global self-esteem and (EN; 20 January 2020). The following databases were confidence, as well as improved social relationships.20 22–25 searched in March and April 2020 by one reviewer Conversely, following a sport-related injury, stronger AIs (TR): MEDLINE, EMBASE, SPORTDiscus, CINAHL, have been associated with depressive symptoms.26 It has APA PsycInfo, and Sport Medicine & Education Index also been suggested that athletes who hold a stronger AI (Proquest). The number of citations identified were may neglect other identities and role responsibilities to recorded in table 1. 37 maintain the athlete role.20 Therefore, a strong AI may Search results were exported to EndNote and dupli- be helpful in some cases and harmful in others, especially cates were discarded (n=334). Thereafter, article titles and 38 within a sport injury context. abstracts (n=1122) were exported to Covidence. Covi- Athletes will continue to sustain injuries so long as sport dence collates each reviewer’s decision to accept or reject exists, thus illustrating the need to understand factors a citation and identifies screening conflicts for resolution. associated with recovery. To inform stakeholders’ (eg, The programme also populates a Preferred Reporting clinicians, coaches, athletes) understanding and expec- Items for Systematic Reviews and Meta- Analyses (PRISMA) tations, many theoretical injury recovery models have flow chart to reflect the number of citations included been developed, several of which are presented here: The or excluded at each screening stage (see online supple- Biopsychosocial Model27 28 ; Biopsychosocial Model of Stress and mental appendix 1). Reasons for exclusion were cited at Athletic Injury29 ; Integrated Model of Psychological Response the full- text screening stage only. Studies identified for to the Sport Injury and Rehabilitation Process30 ; and Cogni- inclusion at full- text screening also had their reference tive Appraisal Model of Psychological Adjustment to Athletic lists reviewed for additional studies. ClinicalTrials. gov was Injury.31 Although not specific to sport, some models have also searched using the following terms: “athlete”, “iden- been developed to explain and predict outcomes associ- tity”, “injury” and “sport”, but did not identify any addi- ated with a specific injury, such as concussion (Neurobiopsy- tional studies. TR and BP independently performed each 32 stage of the screening process (titles, abstracts and full- chosocial Model of Concussion ). Others have been adapted 33 text screening) as well as full- text data extraction. After from existing models (Transactional Stress Model ) to suit completing each stage, reviewers met virtually (via Zoom) a sport injury context (Injury Response Model34 35). For a to discuss and resolve conflicts. Progression to the next more comprehensive review of select models, please see 36 screening stage occurred only after 100% agreement was the following article. Despite variation in the labelling http://bmjopen.bmj.com/ achieved. The same process was applied throughout the used within the models cited above, constructs can be data extraction phase. For quality assurance, this scoping categorised as modifiable (ie, flexible, subject to inter- review was structured according to the PRISMA extension vention) or non-