Concussion in Sport. The injury issue that will not go away

Cross Fertilising Injury Prevention (IP) and the British Journal of Sports Medicine (BJSM)

Few types  of sports injury have received as much attention as concussion . It’s an issue that has witnessed increasing attention in the public media, dominating several social media discussions, and also has been the subject of previous IP Blogs. So important is it, that the British Journal of Sports Medicine (BJSM) Volume 48, Issue 2 is devoted to the topic.

As a paper by Williams et al. shows, the public is increasingly accessing information about concussion from sources such as YouTube, but the majority of this is just depictions of injury events, not preventive advice. But this lack of preventive detail is not limited to information exchange aimed at the masses. There is also now strong evidence from Australia (White et al.) that the professionals who most need the information about how to prevent and recognise concussion, namely coaches and those that provide on-field injury assessment, have poor levels of knowledge. In a study (Cusimano et al.) of the effectiveness of an educational video to inform ice hockey players about concussion, immediate knowledge gains were observed, but had disappeared again two months later. The challenge, as with much injury prevention advice, remains how to address poor knowledge and its retention. This is the classic problem of knowledge transfer and research dissemination – a problem that injury prevention professionals should prioritise addressing.

This lack of knowledge transfer is perhaps not surprising in the light of another paper in this BJSM issue by second paper by White et al. There has been considerable effort given to the development of international consensus guidelines for the management and diagnosis of concussion (as reported in the 2013 47(5) issue of BJSM). But independent appraiser assessment of these guidelines highlights major gaps in knowledge about, and guidance, for actually implementing them and ensuring appropriate action follows from their use. It never ceases to amaze me that there is still an implicit assumption that just having guidelines/published resources is enough for action.

A good example of how such limitations have been recognised and addressed is a paper by Davis and Purcell. These authors recognised that earlier iterations of the international consensus statements were developed from literature relating to adults, that was then expected to be applied to children. Their work has led to the refinement of concussion evaluation guidelines into a form that is specifically suitable for children – in that it includes testing procedures that can actually be completed by children and it addresses the manifestations of concussion and its management that are particular to young people.

It is a sad fact that almost all of the concussion in sport research literature focusses only on the diagnosis and management of concussion, with very little attention given to its primary prevention. Perhaps we are seeing this trend start to reverse a bit, as this issue of BJSM also includes two paper describing different aspects of implementation of head/neck injury prevention measures. The paper by Crowley and Crowley gives an overview of the actions taken by the Gaelic Athletic Associations’ 27-year programme leading to the mandating of helmets in Gaelic football. Donaldson and Poulos describe how they engaged directly with coaches to plan how a neck-injury prevention program should be delivered in rugby union. It will be interesting to read the final preventive outcomes of their work, when the results of their implementation are reported.

In the popular press, concussion has been most commonly linked to participation in the football codes – which code depends on the country of origin of the reports.  Regular readers of Injury Prevention, will be very aware that concussion is also common amongst among other popular activities participated in for sport and recreation such as cycling, motorcycling and horse riding. My own research shows that the football codes (collectively) only account for about one-third of all sport-related hospitalisations for concussion. Notwithstanding this, it is certainly the concussion rates in the football codes that have attracted most public attention over the recent couple of years. There is a clear need for peak football bodies, and those of other sports with particular high concussion rates such as ice hockey, to develop and implement strategies to prevent concussions and to reduce their adverse impacts when they do occur. It is fitting, therefore, that this issue of the BJSM describes some of the identified priorities and actions to date from the International Rugby Board and the (Canadian) National Hockey League.

Finally, the concussion debate has been fuelled by increasing reports of potential long-term adverse effects of sports–related concussion. This evidence should surely help to provide added priority status to the prevention of this injury type, especially if it can be demonstrated to have very significant, adverse health outcomes, even if they do not lead directly to death. Several papers in this BJSM issue describe the topic of chronic traumatic encephalopathy (or CTE), secondary to initial concussive episodes in sport, but highlight the current lack of good scientific evidence in this important area. I am expecting there to be increased research attention given to this area over the next few years.

Caroline Finch is an injury prevention researcher and Head of the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Federation University Australia located in Ballarat, Victoria, Australia. She specialises in two areas: (1) sports injury surveillance and research methodologies and (2) implementation and dissemination science applications for sports injury prevention. She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and the Statistical Editor for Injury Prevention; both journals are published by the BMJ Group. Caroline can be followed on Twitter @CarolineFinch.

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