On Saturday, I tackle the question of whether there is a concussion crisis in sport at Trinity’s Sport and Ethics conference. The easiest response is either yes or no – an alluring simplicity and a quiet Sunday read. In that scenario, you pour a cup of tea, recline the armchair and rely on the paper for the answer.
Do so at your peril, however, for your full undivided attention is required. Some of the neurological experts who spoke at the second National Concussion Symposium at Croke Park last month would have us believe that the answer to any crisis is education. This, they claim, will ensure that hysteria does not prevail in the face of increasing awareness about brain injury in sport.
The take-home message delivered by UPMC’s sports medicine experts was that brain trauma is like any other sports injury. Ergo, it can be diagnosed and managed – not through rest, whose inclusion in the Berlin Consensus statement they questioned, but through individualised graduated physical, psychological and cognitive tests and return protocols – to ‘get kids back in the game’ as they put it.
For this simple message we pay a potentially heavy price in terms of understanding the injury. Why? Because it is symptomatic of a potentially much greater crisis, an existential one. This is one of too much information and not enough knowledge.
Coaches, physios and players can feel inundated by the abundance of workshops, apps, protocols and posters about concussion. There are the added challenges of varied symptoms and their complex manifestations. We see regular updates to the latest on- and off-field tests and the quest for the silver bullet of biomarkers (saliva, blood tests, the build-up of blood proteins and the role of immunotherapies, for instance).
Recommendations vary on how to manage such sports-related brain trauma. There is the question for physios of whether and how informed consent is given, freely or not, in a return-to-play scenario, especially where the denial of pain and injury is validated. In addition, there are the potentially life-threatening consequences of missing this injury that open a Pandora’s Box in socio-legal terms.
But as long as we position concussion solely in bio-medical terms, we omit half of the picture. Concussion has a social epidemiology and its manifestation, diagnosis and management are heavily mediated by its cultural context.
Even the very meaning of the injury is different for sports people compared with the general population. This is because of the influence of culture (defined as attitudes, values and beliefs) in understanding the routine normalisation and romanticisation of pain and injury in competitive sport. Social scientists like me have termed this an ethos of training or ‘playing hurt’, something that lies deep in the cultural DNA of elite and amateur sport.
Accordingly, players do not necessarily define the seriousness of injury in pure clinical or health terms, but rather in terms of sports-related criteria…