Sports concussion: time for a culture change.

Abstract

INTRODUCTION The “concussion problem” in sport can no longer be ignored. Concussion has long been perceived as a benign condition part and parcel of sporting activity. However, emerging scientific reports suggesting long-term cognitive, psychiatric, and neurobehavioral problems associated with concussion have raised public concern and resulted in intense recent media focus. There is now sound science to implicate concussion (and repeated concussive episodes) with significant chronic morbidity. This expanding evidence base has also indicated that many of these potential sequelae can be prevented through timely recognition and appropriate management. Much is being done to improve the prevention, recognition, and management of concussion by sporting authorities. However, these are unlikely to have considerable impact without a fundamental cultural change in the perception of this condition by all those involved in sport. HIGH RATES OF CONCUSSION IN SPORT There are an estimated 3.8 million concussions per annum in the United States alone.1 These estimates are likely to be conservative given that sport-related concussion is underdiagnosed and underreported.1 Sports associated with increased risk of concussion include those involving collisions or contact, such as American football, rugby, boxing, ice hockey, and soccer, and high-velocity sports, such as cycling, skiing, and the equestrian sports.2,3 However, participation in any sport carries a risk of experiencing a brain injury. This rising trends seen in rugby union reflect a pattern seen in many contact sports. Rugby union is enjoying unprecedented growth and popularity, being played by more than 5.5 million worldwide.4 Modern rugby players are heavier and faster, and involved in more contact events per match than their predecessors.5 This has been reflected in an increase in concussions, now the third most common match injury in amateur and professional rugby.6,7 The incidence of concussion in rugby is now comparable with that of American football and ice hockey,7,8 with reported incidences of up to 9 concussions per 1000 player-games.8 Almost half of rugby players aged younger than 20 years have sustained a concussion.9 Attempts to stem this epidemic, including the wearing of headgear in rugby7,10 and face shields in ice hockey,11 have made no difference to the incidence. The key problem is that, until now, concussion has not always been taken seriously enough by players, coaches, and medical staff. The severity of potential sequelae (both acute and long term) is no longer questioned, as illustrated by the National (American) Football League's eagerness to settle a lawsuit with former players for $765 million for failing to inform and protect players of the risks.12 CONCUSSION In recent years, there has been a growing understanding of the pathophysiology of concussion and an appreciation of its short- and long-term sequelae. Concussion is induced by traumatic biomechanical forces affecting the brain, typically resulting in a rapid onset of short-lived neurological impairments.13–15 It presents clinically with cognitive, physical, and behavioral signs and symptoms.16 Headache, dizziness, and memory impairment are the most frequent clinical symptoms. Contrary to popular belief, loss of consciousness is not a requirement for diagnosis.16 Concussions tend to resolve spontaneously within 7 to 14 days in adults,17–19 although the recovery period can be longer in younger athletes14 and in females.20,21 Diagnosis relies on clinical evaluation with standard structural neurological imaging outcomes typically normal. A temporal window of brain vulnerability to further injury exists during the recovery period,22 and it is therefore imperative that the player be immediately removed from the field of play.13–15 A period of cognitive and physical rest is essential until the athlete becomes asymptomatic. Once an athlete is asymptomatic and no longer receiving medications to treat or modify the symptoms of concussion, a gradual stepwise return to competition should be implemented.15 Mismanagement can lead to acute problems, including second impact syndrome or diffuse cerebral swelling, as well as persistent and chronic post-concussion syndrome.16 The potential for long-term sequelae in those suffering even mild concussion has been highlighted by evidence of residual cortical changes evident long after resolution of clinical symptoms and signs.23 CHALLENGES TO EFFECTIVE MANAGEMENT Key obstacles to effective management of concussion in sport include underreporting by players, underrecognition by those observing, and mismanagement of recognized concussions. Underreporting of concussive injuries is substantial with up to 50% of athletes not reporting concussions.24 Reasons cited by players include not being aware they were concussed or not believing that the condition was sufficiently serious to warrant reporting.24 A “culture of resistance” makes young athletes less likely to report symptoms so that they can keep playing.25 Even without underreporting, the on-field assessment of concussion in the young and adult players is challenging, particularly given the elusiveness of the injury, its occurrence in contact sites often obscured to touchline observers, the poor sensitivity and specificity of touchline assessment tools, and the evolving nature of concussive injury. High-profile examples have shown that we are not recognizing concussion consistently enough. Players featuring in the most recent Rugby World Cup Final, test match cricket, and the English Premier League football have been allowed to play on despite a possible concussion. There are also reports of players being permitted to continue despite recognition of concussion by coaches and medical staff. A recent study found that only 42% of rugby players were removed from the field of play following concussion.7 This is contrary to current best practice and is clearly unacceptable. For well over a decade, the opinion that the diagnosis and treatment of sports concussions (including providing clearance for return to play) is a medical issue has been articulated in national and international concussion consensus statements.13–15,26,27 It is clear from recent incidents in English Premier League football that this is not an attitude accepted by all coaching staff. In relation to the decision to return his goalkeeper Hugo Lloris to the field of play following a clear concussive episode, the manager Andre Villas-Boas stated “The call always belongs to me.”28 Such comments serve to highlight the need for a radical change in attitudes around sports concussion. In recreational sport, it has also been demonstrated in that even where concussion guidelines and policies have been introduced, their implementation and effectiveness is often entirely based on an individual administrator's or coach's desires and input.25 MUCH IS BEING DONE Scientific and Health organizations together with international and national sporting bodies have been quick to recognize this emerging epidemic and have implemented strategies to improve the prevention, recognition, and management of concussion.27 These include the establishment of evidence-based tools for objective assessment, such as the Sport Concussion Assessment Tools. Evidence-based summary principles for the management of concussion in sport are published regularly.28 In rugby, a player welfare web site (www.irbplayerwelfare.com) was launched in 2010 that provides resources on concussion for players, coaches, officials, and medical staff.29 Similar initiatives have been launched in American football30 and ice hockey31 among others. Concussion is now a core topic at immediate care courses, including those run by the sporting national bodies. Laws and sanctions in rugby have even been adapted to discourage dangerous play,5 while studies have been commissioned to explore the long-term sequelae of concussion in rugby players. A comprehensive report from the US Institute of Medicine argues for renewed attention to concussions and their sequelae and calls for a detailed national surveillance system to enable better understanding of concussion and factors related to its occurrence.27,32 Importantly, sporting organizations have been quick to emphasize the severity of concussion and condemn that the health and safety of players be left to coaches, trainers, or even the players themselves. As such, the Professional Footballers Association (PFA), the World Players Union (FIFpro), and FIFA were publically united in their criticism of the decision to return Hugo Lloris to play.33 WE NEED A CULTURAL CHANGE IN OUR ATTITUDES TO CONCUSSION These important steps represent considerable progress to keep evolving sports safe. However, they are all contingent on a common appreciation that concussions are brain injuries that can potentially result in life-altering consequences, particularly if ignored or mismanaged. This has historically not been the case and remains a problem. Concussion has long been viewed as a benign occurrence, “part and parcel” of sport, and for some even considered as a “badge of honor.” Convincing society of the importance of recognizing concussion is particularly challenging because most athletes who experience concussion seem to recover without readily apparent consequence. The recent media focus on the long-term effects of concussion should not deter people from participating in sport, where the positive health benefits of participation are considerable. Rather, it should serve as a stimulus for a cultural change in our attitudes toward concussion and its management. CONCLUSIONS It is now clear that prompt recognition and appropriate management of concussion improves the short- and long-term health outcomes for players. Although considerable steps have been taken to improve management and educate all involved, a fundamental cultural change in the perception of this condition is needed.