UF study finds retired NFL players’ thoughts about pain may be more significant than the pain itself

NFL retirees who worry excessively about their pain or believe it will never get better, also known as pain catastrophizing, are more likely to have moderate to severe depressive symptoms and poor physical and mental health-related quality of life, according to a University of Florida study.

Since more than 90% of retired NFL players report pain due to muscle overuse and musculoskeletal injuries and head trauma accumulated over an athletic career, coping with chronic pain is no small matter for this group. Yet, the UF researchers found that retirees’ thoughts about their pain may actually have a bigger impact on their lives than the intensity of the pain.

“This study shows that how NFL retirees think about their physical pain may be more salient in explaining mood symptoms and quality of life than the intensity of the pain itself,” said the study’s lead author, Zachary Mannes, a doctoral student in clinical psychology in the UF College of Public Health and Health Professions, part of UF Health.

The UF study is the first to examine former players’ thoughts and moods in relation to their health. Depression is common among retired NFL players, but scientists haven’t had a good understanding of why, Mannes said. While the effects of concussions on NFL retirees’ health has received considerable attention and study, surprisingly, concussions weren’t associated with depressive symptoms in the UF study.

“This result is contrary to much of the published literature that shows a significant relationship between concussions and depression such that the more concussions an NFL athlete experiences during their career, the higher the likelihood of reporting depression in retirement,” Mannes said. “We did not find this, as pain catastrophizing was the only significant predictor of moderate to severe depressive symptoms.”

For the study, which appears in the journal Health Psychology, researchers conducted phone interviews with 90 former NFL athletes who played professional football between 1967 and 2004. They responded to questions about their NFL careers, substance use, pain factors, current depressive symptoms and health-related quality of life.

A third of the participants reported moderate to severe depressive symptoms. Those participants were also more likely to report lower physical and mental health-related quality of life, pain interfering with their activities of daily life and greater pain catastrophizing.

Though the study has important clinical implications for NFL athletes, several limitations should be considered while interpreting the results, Mannes said, such as the relatively modest sample size, the cross-sectional study design and the possibility of self-report bias given the sensitive nature of the information collected.

Effective treatments exist to help retired NFL players, veterans and others with chronic pain change their beliefs about pain, Mannes said. Cognitive behavioral therapies have been shown to effectively treat both pain catastrophizing and related consequences of depression, anxiety and substance misuse.

In May 2019, the NFL and NFL Players Association passed a mandate that each NFL team employ a behavioral health team clinician, an important step toward optimizing the mental and emotional well-being of NFL players, Mannes said.

“On the basis of our study results, pain catastrophizing should be assessed among current and retired NFL athletes, and players reporting elevated symptoms should be referred to a behavioral health provider for treatment,” Mannes said. “Reducing pain catastrophizing would likely improve mental health among retired NFL athletes and may improve the performance and emotional well-being of current players.”

In addition to Mannes, the study team included Erin Ferguson, a UF graduate student in clinical psychology; William Perlstein, Ph.D., an associate professor in the UF Department of Clinical and Health Psychology; Lori Waxenberg, Ph.D., a clinical professor in the UF Department of Clinical and Health Psychology; Linda B. Cottler, Ph.D., M.P.H., a dean’s professor in the UF Department of Epidemiology and PHHP’s associate dean for research; and Nicole Ennis, Ph.D., an associate professor at the Florida State University College of Medicine.