By Myles Murphy @myles_physio
Sport-related concussion (SRC) has drawn a substantial level of media attention and is a significant concern for health-care professionals and athletes. While the decision to retire based on a history of multiple concussions is complex,1 as the stigma grows around concussion history and potential long-term brain health deterioration, anecdotal evidence suggests that every year more professional athletes have retired from competition due to concerns pertaining to this issue. All elite level sports have guidelines for SRC, with clear procedures in place to inform practice and assist decision making for treating clinicians.2-5 Fear and concern related to the risk of suffering head impacts, and the fear and concern related to SRC causing detriments to long-term brain health are not well supported by the current literature.6-11
Can we draw parallels from the chronic lower back pain literature?
Beliefs associated with fear are implicated in chronic lower back pain (CLBP)12 and the language used by practitioners may impact the extent to which a patient will engage in treatment.13 It is also suggested that letting go of therapist misconceptions may help management of people with CLBP.14 The current recommendations are very different to the feedback and information patients received in the past, and the treating health and medical professionals were some of the primary drivers of inaccurate and fearful beliefs. For example, while a period of rest used to be the main stay of management for CLBP, a treatment which inadvertently had negative outcomes, it is now recommended that athletes get moving as soon as possible provided the increase in load is appropriate to the athletes symptoms.15 The changes in management are remarkably similar to the recent changes in the management of SRC whereby promoting graded physical activity following SRC, as opposed to rest, is recommended.16
Decreasing the fear of head impacts in contact sport
While SRC is a result of a mechanical force to the head, the relationship between head impact frequency, impact force, and sustaining a SRC is complex.16 Previous research has shown that the number of head impacts per player in contact sport appears to be more common than SRC 17-21 These findings must be interpreted with caution as the current technology used to record head impacts has many limitations.22
Given the current research, we suggest that clinicians educate athletes that it is common for head impacts to occur in sport, particularly contact sport, and that many head impacts do not result in SRC. It is also equally important to educate athletes about the signs and symptoms of concussion and empower them to report their concerns. This changing of the current belief that all head impacts are inherently dangerous may help lessen the fear associated with participation in sport. It is also important to highlight that head impacts are a risk factor for SRC and while they should not be discouraged as a component of the sport, strategies to reduce or modify them, for example by changing technique, are likely to reduce the risk of SRC.23
Decreasing the fear of long-term brain deterioration following sport-related concussion
The current support for long-term complications from SRC resulting in degenerative neurological conditions, such as chronic traumatic encephalopathy (CTE), or depressive symptoms is based on studies of low quality and no cause and effect relationship has been established.9-11,16 While some athletes may be vulnerable to longer term brain health issues, it is not helpful to perpetuate fear by incorrectly informing athletes that SRC inevitably leads to long-term deterioration to brain health in every concussed athlete. Until high-quality, longitudinal clinicopathological studies are completed it is inaccurate to draw cause and effect relationships9,11 and this distinction between an association and a causative factor is very important.
Based on the current literature we would suggest that clinicians educate their athletes that while there may be some long-term association in low quality studies there is currently no high-quality evidence that SRC ‘causes’ long-term detriments to brain health. In fact, current evidence suggests that moderate alcohol consumption is associated with degenerative changes in the brain24 and if the athlete is serious about reducing their risk of long-term degenerative changes to the brain other modifiable lifestyle choices may be a better way to reduce their risk in the long-term.
When comparing the narrative surrounding SRC to other health conditions such as CLBP the mistakes we made in the initial management of CLBP, which are still impacting patients today, are present in our management of the athlete with SRC. We would encourage clinicians to educate their athletes using the latest evidence rather than allow the athlete, clinician or the media, which are not necessarily based on science, drive fear and decision making.
I would like to acknowledge Dr Andrew Gardner (Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, NSW, Australia; Hunter New England Local Health District Sports Concussion Program, Newcastle, NSW, Australia; Priority Research Centre for Stroke and Brain Injury, Calvary Mater Hospital, Level 5, McAuley Building, Waratah, NSW, Australia) for his assistance in developing the concept for this blog and for his assistance in proofing and approving the final submission.
Myles Murphy (@myles_physio) is a sport physiotherapist at the Western Australian Cricket Association (WACA) and a PhD candidate at The University of Notre Dame Australia.
Myles is the deputy chair for the 2019 ASICS Sports Medicine Australia (SMA) Conference in Twin Waters and a member of the scientific committee for the 2019 6th World Congress of Science and Medicine in Cricket. Myles interests include sport-related concussion, exercise rehabilitation for athletes with tendon pain and cricket related injuries. Email: firstname.lastname@example.org
- Gardner A. The Complex Clinical Issues Involved in an Athlete’s Decision to Retire from Collision Sport Due to Multiple Concussions: A Case Study of a Professional Athlete. Front Neurol2013;4:141.
- AFL Research Board, AFL Medical Officers Association. The management of concussion in Australian Football. http://www.aflcommunityclub.com.au/fileadmin/user_upload/Coach_AFL/Injury_Management/1211_AFL_Concussion_Management_2013_LowRes_1_.pdf: Australian Football League 2013 [accessed 29/12/2018]
- Football Federation Australia. FFA Concussion Guidelines. https://www.ffa.com.au/sites/ffa/files/2018-01/18-0102%20FFA%20Concussion%20Guidelines%20%28final%29.pdf: Football Federation Australia; 2018 [accessed 29/12/2018]
- Rugby Australia. Concussion Management. http://www.rugbyau.com/about/codes-and-policies/safety-and-welfare/concussion-management: Rugby Australia; 2018 [accessed 29/12/2018]
- Cricket Australia. Concussion and Head Trauma Policy. https://www.cricketaustralia.com.au/cricket/-/media/99A46A44595C482FADCB34D290B54A52.ashx: Cricket Australia; 2017 [accessed 29/12/2018]
- Gardner A, Iverson GL, McCrory P. Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med2014;48(2):84-90.
- Iverson GL, Gardner AJ, McCrory P, et al. A critical review of chronic traumatic encephalopathy. Neurosci Biobehav Rev2015;56:276-93.
- Karantzoulis S, Randolph C. Modern chronic traumatic encephalopathy in retired athletes: what is the evidence? Neuropsychol Rev2013;23(4):350-60.
- Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med2017;51(12):969-77.
- Randolph C. Is chronic traumatic encephalopathy a real disease? Curr Sports Med Rep2014;13(1):33-7.
- Randolph C. Chronic traumatic encephalopathy is not a real disease. Arch Clin Neuropsychol 2018;33(5):644-48.
- Bunzli S, Smith A, Schütze R, et al. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open2015;5(10)
- Thomson OP, Collyer K. Talking a different language: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths. Int J Osteopath Med2017;24:3-11.
- O’Keeffe M, George SZ, O’Sullivan PB, et al. Psychosocial factors in low back pain: letting go of our misconceptions can help management. Br J Sports MedPublished Online First:28 August 2018.
- O’Sullivan K, O’Sullivan PB, Gabbett TJ, et al. Advice to athletes with back pain—get active! Seriously? Br J Sports MedPublished Online First:19 September 2018.
- McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med2017;51(11):838-47.
- AFL Doctors Association, AFL Physiotherapists Association, AFL Football Operations Department. AFL Injury Survey. http://www.afl.com.au/staticfile/AFL%20Tenant/2017AFLInjuryReport.pdf, 2017:1-19. [Accessed 28/12/2018]
- Hecimovich M, King D, Dempsey A, et al. Head Impact Exposure in Junior and Adult Australian Football Players. J SportsMed (Hindawi Publ Corp)Published Online First:2018.
- Hecimovich M, King D, Dempsey AR, et al. The King-Devick test is a valid and reliable tool for assessing sport-related concussion in Australian football: A prospective cohort study. J Sci Med Sport2018 Published Online First: 4 April 2018
- King D, Hume P, Cummins C, et al. Concussion Incidence for Two Levels of Senior Amateur Rugby League in New Zealand, 2008 – 2011. Sports Med Rehab 2018;3(1):8.
- King D, Hume PA, Brughelli M, et al. Instrumented Mouthguard Acceleration Analyses for Head Impacts in Amateur Rugby Union Players Over a Season of Matches. Am J Sports Med 2015;43(3):614-24.
- Patton DA. A Review of Instrumented Equipment to Investigate Head Impacts in Sport. Appl Bionics and BiomechPublished Online First:9 August 2016.
- Sobue S, Kawasaki T, Hasegawa Y, et al. Tackler’s head position relative to the ball carrier is highly correlated with head and neck injuries in rugby. Br J Sports Med2018;52:353-358
- Welch KA. Alcohol consumption and brain health. BMJ2017;357