Sports Injury - the Increasing Concern of Concussion in Professional Sport

With an ongoing legal settlement by retired athletes for concussion-related injuries whilst playing American Football reaching over £520M, the issue of sport-related concussion (SRC) has received increasing interest and attention from the media, sports governing bodies and medical professionals. Playing sport carries an inherent risk of injury and by their very nature, collision and contact sports such as Rugby Union carry a greater risk when compared to other sports. A concussion is a head injury, resulting from a forceful blow to the head and in extreme circumstances can be catastrophic. Symptoms of a concussion can vary from immediate unconsciousness to headaches and dizziness, and also have longer-term impacts around negative cognitive impairment, forgetfulness, and confusion (BMA, 2019). Focusing on research mostly carried out on professional athletes playing collision and contact sports, this review considers the reasons for the increased interest, as well as how SRC is being researched and how sports are evolving their approach to the prevention of concussion injuries.

The Increasing Concern Surrounding Concussion

Over recent years there has been an increasing number of televised games and sporting events. The increasing strength and size of athletes (table 1) have led to several high-profile cases of concussion across different sports.

Table1. Average weight and height of male England Rugby Union players (adapted from Fordyce 2012) David Denton who played Rugby Union for Scotland (BBC, 2019), Liam Picken who played Australian Rules Football (Australian Associated Press, 2019) and Rick Nash who played Ice Hockey (Reuters, 2019) all retired due to ongoing concussion concerns. Whilst a multi-sport issue, the concussion concern is also impacting younger players, with 24-year-old Joshua Perry retiring from playing American Football in 2018, only two years after beginning his professional career (Reyes, 2018).

Whilst greater visibility through television is one factor, the concern is increasing as more research is undertaken. Lincoln et al (2011) researched multiple sports and found that incidence rates increased by 16% annually (table 2) over their study period in all sports. In addition to increasing incidence, recent research also raises concerns around multiple concussions and the potentially catastrophic outcomes as well as on-going impacts on an athlete’s post-career quality of life. Tator et al. (2019) explain how multiple concussions were the cause of death for a 17-year-old Rugby Union player. With this background of statistics, the concern surrounding concussion crosses sporting codes and geographical borders and is a focus for academics and sporting governing bodies to proactively address.

Table 2: Concussion data for school years 1997/1998 - 2007/2008 (Lincoln, A. E. et al. 2011)

Concussion Research

The growing interest in SRC has resulted in more studies and greater data surrounding concussion being collected. This naturally raises the number of cases identified, even though historically it may be at the same level (Lincoln et al. 2011). Hoskins et al. (2006) state that there is a need for consistency of definition and assessment of concussion, and that a more coordinated effort across sporting codes is required. This is supported by (Davis et al. 2019) who note that there is “little consistency across sporting codes” Subsequently, there is a need to check the veracity of conclusions when pooling multiple research findings, especially across sporting codes.

One specific area of research around gender and concussion shows women who participate in these sports have nearly twice the concussion risk as males (Lincoln et al. 2011). This is consistent with earlier research that finds females were cognitively impaired approximately 1. 7 times more frequently than males following concussions (Broshek et al. 2005). Broshek et al. (2005) also identify that there are no specific gender-related return-to-play protocols, or that any other individual differences into account (Broshek et al. 2005). These findings prompt the question for further research as to why this is the case. Is it physiological, technique, coaching or another reason? Without understanding this issue further, any prevention measures may be sub-optimal when put in place.

Prevention of Concussion

Prevention of concussion is a key aim for sporting bodies (e. g. World Rugby), and the importance of prevention was highlighted in research that concluded “since treatment options in chronic traumatic brain injury (CBTI) are relatively limited, the prevention of CTBI is of paramount importance” (Rabadi and Jordan, 2001).

Equipment is one method for helping prevent concussion, and there is a range of sports specific equipment available tailored for the specific sport (e. g. Head guards, helmets, and mouthguards). Research and analysis into the usefulness in preventing concussion is inconclusive, where Connor et al. (2019) finds that helmets “reduce the severity of head injury”, yet Bailly et al. (2018) when researching skiing helmets found that whilst the helmet reduced head injuries (scratches, cuts), there were still concerns about their effectiveness at preventing concussion. Equipment aimed at reducing concussion is not the only solution, and should not solely be relied on by the athlete as the panacea to prevent injury.

The athletes themselves are in part responsible for the reduction in risk of concussion, and Burger et al. (2017) found that incorrect tackling techniques in rugby union increased the risk of concussion. Furthermore with an increase in susceptibility towards the end of the match suggesting either fatigue-related technique reduction or the introduction of less experienced players, an athlete’s fitness, attitude, control, and technique are all contributors to risks of concussion.

Changing sporting laws and practices is a further prevention method and Kemp et al. (2008) identified a clinical challenge when assessing a potentially concussed player during a game is compounded by the current regulations regarding the permanent replacement of injured players. In 2015 World Rugby introduced temporary substitutions into governing laws, and in 2014 English Rugby Football Union introduced a training module for all coaches and players around the issue of concussion. Other sports have also changed their laws in response to the concussion issue with Westermann, Wehr and Amendola, (2016) noting that the National Collegiate Athletic Association introduced rule changes aimed at halving the increasing rates of CTBIs in 2008. These law changes are evidence of how governing bodies are reacting to concussion concerns and research findings to try to reduce concussion injuries.