1.1 Concussion in sport – And the need to study people ‘in the round’

Christopher R. Matthews, Senior Lecturer, Nottingham Trent University

While there’s evidence that points to concussion and other traumatic and chronic brain injuries as having a long association with various sports, the last decade has seen a sharp increase in the attention directed at the topic by the media, players, fans, sports officials and governing bodies. This has led to educational programs and awareness campaigns, various changes in practice and policy, and the proliferation of research in a variety of scholarly disciplines. Such work proceeds from a position of seeking to tackle the various personal and social problems that flow from sporting brain injuries. However, these problems, with their complex biological, physiological and sociological origins, often require equally complex ‘solutions’ and to work in that direction requires academic colleagues, who might often exist in disciplinary ‘silos’, to value each other’s various contributions and engage with the people, communities and policies that are directly affected.

My PhD supervisor referred to such a need to consider the problems associated with sport as studying people ‘in the round’ (Maguire, 1991). Such a way of working resists the temptation to see research participants as ‘atomized’ and isolated units of analysis, and instead seeks to situate them within ongoing cultural and historical processes. This means, as Malcolm rightly points out, that alongside biotechnological and game/rule-based solutions, we must also seek to understand the cultural roots of the concussion ‘crisis’ (Malcolm, 2019). And for such work to have impactful change, academics must seek out, engage and partner with the various public entities who will be central to delivering and benefiting from it. With that in mind, Nottingham, with its two universities, Queens Medical Centre and associated medical school, various professional sporting clubs, numerous sporting venues and central location in the English Midlands provides an opportunity to work in that direction. And specifically at Nottingham Trent University, within our Sport, Health, Activity, Performance and Exercise (SHAPE) research center, we are motivated to deliver community orientated research in partnership with local residents.

So, in late 2022 I organized a one day symposium titled Concussion in sport - What do we know, and what’s next? There were two broad aims of the day. Firstly, to help inform people who would like to know more about the risks of concussion and repeated blows to the head, and to detail what is currently being done to support athletes, coaches and medical personnel to reduce the damaging effects of brain injuries. Secondly, to consider what problems still need further understanding and to develop ideas to shape the future directions of work in the area. In this regard, I invited a diverse set of speakers, and we advertised the event widely with a view to attracting attendees with a variety of interests and from various backgrounds in relation to sport and brain health. This included people who play various sports and have suffered concussions themselves, coaches, physiotherapists, trainee sports practitioners in various fields, teachers, representatives from sport’s governing bodies, campaigners, and scholars working across all levels of academia. This group enabled the aims of the day to be achieved in that there was a great opportunity for those from sporting communities to enhance their knowledge of concussion - which will hopefully lead to some important social changes at the ‘coalface’. And, there was time for free flowing chats between speakers and attendees which would not have been possible if we had followed the structure of a usual academic conference - I return to some takeaways from these discussions in the concluding section.

In what follows, we outline key elements from presentations and discussions from the day. It is important to note that this is neither an exhaustive account or overview of what is known about this topic, nor should it be understood as a definitive statement. Rather, these are the well-considered and empirically informed arguments developed by certain speakers with expertise in the area. One clear gap in this regard is that due to the speakers’ expertise the focus is largely on adult populations throughout. All the authors are based in the UK, and largely focus on this context, also, soccer is referred to as football throughout. Each author details their take on ‘what we know, and what’s next?’ and has aimed to write, as they presented, with a wide audience in mind. While we all share connections around wanting to understand brain health in more detail, we also come to this topic via various routes which means there is a diversity to the writing style and approach. I have edited the work to try and help it flow together while also maintaining the authors’ distinctive voices - a challenging task.

I have chosen to start with Penny Watson’s powerful piece. This is to show the importance that was placed by attendees in hearing the stories of those who have been personally affected by brain injuries - a topic which has recently received some media attention but is largely absent in academic research connected to sport. Following this I group three discussions that broadly draw on bio-medical approaches and three that proceed from a social scientific position. As these proceedings are necessarily short, I suggest reaching out to the individual scholars if you would like further information about their work and the arguments they present. I conclude by discussing some observations from the day and outlining a broad way of working that colleagues may wish to pursue.

2.1 Living with Neurodegenerative Diseases

Penny Watson, brain health campaigner and activist

My husband Dave was an international footballer, known primarily as a centre half and a great header of the ball. He played professionally for 19 years until he was almost 39, playing over 700 matches including representing England. Dave sustained many head injuries and most likely thousands of sub-concussive injuries especially during training sessions. He was admitted to hospital with one particularly severe concussion. After football he became a successful businessman. His business acumen and ideas were astounding, he even did a talk at the University of Sheffield on sponsorship. He did lots of charity work, raising money for the survivors of Hillsborough and the Boxing Day Tsunami. He was an excellent organizer, with great intellect. However, now he is a different man.

People ask “when did you notice things?” and “is it just his memory?”. Well, dementia can be so insidious. About 10/11 years ago, I noticed signs. Yes, short-term memory at first but so much more. This continued for a couple of years or so and eventually the family noticed too. After changes became increasingly obvious we persuaded Dave to go to the doctor. After a scan ruled out a brain tumor he was diagnosed with probable Alzheimer’s, we were handed leaflets and left with little else advice wise. It is at this point that many given a dementia diagnosis feel bereft, abandoned.

The Watson family became active, researching big time. We found out more about the connection between football and former players developing neurodegenerative diseases (NDD) – often given the label Alzheimer’s. We learnt more about CTE and other forms of dementia. Meanwhile Dave continued attending matches particularly England games at Wembley. It was there in November 2019 when it became apparent that we needed to let the fans know his diagnosis because being asked to sign autographs was presenting issues. We discussed it and agreed that it would not only help Dave still be able to go to games but also hopefully give other former players the courage to “come out” about their diagnoses. 14th February 2020 a statement was released through The Press Association. The reaction from the football community and fans, was so supportive and moving.

By early November 2020 we were ready to do an interview. A full-page article headlined The Forgotten England Captain turned out to be the spark to light the fire to commence the campaigning to help former players. Dave’s thousands of fans were outraged that The Professional Footballers Association (PFA) were doing very little to help (after all they are the union for players, current and former). Let’s be clear: we never really wanted the publicity but we realized we could use Dave’s profile and all this attention to help others. Lots followed, including advising the PFA and Head Injury Policy Oversight group in an independent capacity, which included discussing strategic planning and offering advice on the set up of a new dedicated Department.

The following year Dave won a landmark ruling to have some of the brain injuries he’d sustained during his playing career recognized as ‘industrial injuries’ paving the way for footballers with dementia to receive industrial injuries disablement benefit. We compiled evidence of 10 serious head injuries. We hope more than anything that this has set a precedent for others to seek help.

Dave’s scans show cavuum spetum pellucidum – a potential cavity in a part of the brain which has been associated with dementia in former boxers – which is being recognised in UK now. This is ground-breaking news (we pursued this for almost two years). UK researchers have been woefully behind the USA but the UK scientists have finally taken notice. Concussion Legacy Foundation (CLF) have a UK arm now which assisted greatly in acceptance that UK is behind the USA, specifically Boston University and San Fran. There is much work to be done, but I am quite optimistic about some things: Soon there will be an industry wide fund which the Premier League, English Football League and The FA should contribute to as the success of modern football was built on the legacy of former players. On a more personal note — I set up a self-help group on Zoom for former WAGS (Yes, I was an original WAG I guess). We carry the burden of being the ones who make decisions that before would have been made together with our partners. We are the ones who have lost our husbands, our soul mates and even though physically they resemble our guys they are not the men we have lived with and loved for decades. We have become their mothers. None of us envisaged our lives together ending like this – on a journey we would not have taken by choice. It is truly heart-breaking.

This is where some of you come in. Knowledge is powerful – informed decisions will prevent heartache for others in the future. Educate and spread the word. Sport can do so much good but concussion in sport can ultimately take away so much.

5.1 Sport Concussion and Dementia Risk

Angus Hunter, Professor of Neuromuscular Physiology and Head of Department of Sport Science, Nottingham Trent University

The field of sport concussion and associated dementia risk has evolved rapidly over the past few years with: i) growing concern about the risk of long term neurological complications secondary to participation in sports; ii) in particular the development of chronic traumatic encephalopathy (CTE); iii) while initially the focus on this condition was within boxing this has now expanded to other contact sports, in particular, American Football, rugby and soccer and; iv) sport concussion is now described as a public health issue. Although concussion guidance describes symptoms to enable recognition, they are still notoriously difficult to diagnose as concussion understanding is still in its early stages. Nevertheless, this guidance provides an important step forward in helping to prevent second impact syndrome in the short term and help reduce dementia risk in the longer term. What is perceived as a related, but in many ways a greater challenge, is management of sub-concussion as there may be no obvious symptoms to act on. To meet this challenge there are studies being performed using sensors for real time monitoring to establish acceptable limits of head impacts that athletes may receive. However, much work is needed to quantify acceptable limits in relation to neurodegenerative risk.

Now sport concussion has been recognised as a public health issue and with impending law suits from former rugby union players the UK Government decided to act in July 2021 by launching an enquiry through its Department for Culture Media and Sport (DCMS). The key findings of the report were concerning as they were unsatisfied that sporting governing bodies were adequately safeguard their players and were “allowed to mark its own homework” when it came to reducing brain injury risk. Following these findings, the DCMS notably recommended that the government needs to establish a UK-wide minimum standard definition for concussion which, while achievable, is a long way off given existing knowledge. Subsequently, and probably consequently, respective sporting governing bodies have recommended that a maximum of ten high force ‘headers’ are carried out in a training week (Scotland ban heading before and after game), rugby contact in training limited to 15 minutes and children 12 years and younger are not allowed to head footballs in both training and competition.

Any sport modification introduced to protect athlete health and wellbeing are welcome, however, compliance to concussion guidance has been mixed at grass root levels. In particular, this seems to be a problem in the reluctance of some people to adhere to what is perceived to be lengthy post-concussion rest/graded return to play periods in youth sport (McArdle et al., 2021). It may be that traditional attitudes take time to change, but when considering how attitudes towards drink driving shifted, it is reasonable to expect greater social responsibility surrounding concussion to occur too. Whilst improving awareness and understanding of concussion are positive, a potential downside is increased levels of anxiety, in particular with former players and parents of young players, which might be exacerbated by media sensationalism. This anxiety, particularly amongst parents, can reduce sport participation in youth players (Findler, 2015) which may then increase sedentary behavior and increased risk of lifestyle disease later in life. Also, with former players anxiety can cause cognitive deficit, and as cognitive testing is a core component of dementia assessment, this could conceivably contribute to a diagnosis of early onset of dementia (Roberts et al., 2020). To help prevent this issue the Scotland Rugby Union has launched the Brain Health Clinic targeting, initially, former international players where they are advised on how to reduce their anxiety and dementia risk factors through lifestyle modifications.

Concussion is often classified as mild traumatic brain injury (mTBI), however there is nothing ‘mild’ about this condition as 15% of individuals with concussion go on to experience persisting neurodegenerative conditions (Smith and Stewart, 2020). Currently, concussion is difficult to truly diagnose as we don’t yet understand the underlying pathological processes (Smith & Stewart, 2020). However, our understanding of the causes of CTE is increasing, thanks to (Bieniek et al., 2021) advanced MRI techniques (Shenton et al., 2012). However, as yet, no advance neuroimaging have been included as routine assessment for patients with suspected concussion which is likely due to time needed, cost, accessibility and calibration between MRI scanners (Smith & Stewart, 2020). Additionally, blood biomarkers for detecting concussion are also showing promise although they are yet to be proven to be sufficiently sensitive at an individual level (Johnson et al., 2015; Siman et al., 2013).

In conclusion, concussion is recognized as a public health issue with the UK Government acting to prevent neurodegenerative diseases in contact sport athletes. Sporting governing bodies have responded to this by imposing guidance to limit head impacts but there is still work to be done in terms of tailoring this for different ages and sexes. Concussion research has come a long way in recent years although we are still to understand the pathology behind it to diagnose correctly. However, although the definitive link between head impacts and early onset of dementia is still to be established evidence to date suggests an association does exist. Concussion recognition is likely to come in the form of blood biomarkers although there is still work to be done in establishing acceptable sensitivity. Finally, it is important that the ongoing work on concussion underpins the need to reduce player risk not sport participation.

7.1 Women, sport, and some potential problems for brain health

Debi Forbes, PhD researcher, Nottingham Trent University

While conducting the literature review for my PhD research it became apparent that there might be something of a ‘perfect storm’ brewing in women’s sport. This idea provides the empirical, theoretical and political justification for the studies I’m currently in the middle of conducting. Firstly, women have historically been excluded from sport in significant ways, but more recently have increased their participation at various levels. Secondly, athletes regularly damage their bodies in the pursuit of success and the medical support they receive has not only been found to be deficient in numerous ways but can also function to reinforce risk taking, pain and injury. And, thirdly, there is an established history of women being treated poorly by, and excluded from, the medical profession. Of course, there are details and counterpoints within each of these three propositions which can focus attention towards important complications to the broad social processes I’ll be researching. However, I think that when taken together, the research which supports these broad claims highlights something of a ‘perfect storm’ faced by sportswomen.

Research demonstrates that sportswomen often exist in the culture of risk that is prevalent in traditionally dominated male sporting spaces. As such, they frequently prescribe to the same performance oriented and health compromising ideas as their male counterparts (Charlesworth & Young, 2004; Pike, 2005). Despite this, women remain significantly underrepresented in sports and exercise science research (Cowley et al., 2021; Elliott-Sale et al., 2021). The contemporary legacy of their historical and cultural exclusion from sport and medicine is then felt by women in the gendering of their sporting environments which appears to contribute to difference in injury types and rate, the medical care they receive and the ideas for treatment often proposed and taken up by women (Cowley et al., 2021; Parsons et al., 2021; Pike, 2005).

When considered together all these points lead to the continuation of issues faced by women athletes, many of these problems are deep rooted in the historic and symbolic aspects of sport. What is more, there seem to be a range of specific biological problems faced by sportswomen. For example, a systematic review conducted by McGroarty et al. (2020) suggested that “female athletes may be more susceptible to concussion, have prolonged symptoms after a concussion, and are more likely to report a concussion than their male counterparts” suggesting - although, I would argue, certainly not proving in any simplistic sense - that female athletes are at higher risk due to “biomechanical differences and hormonal differences” (McGroarty et al., 2020).

In terms of the biomechanical risk of concussion, neck girth and strength, and head/neck dimensions have been highlighted as possible causes of sex differences, as well as differences in reporting and recovery compared to male athletes. And there is an increasing body of research regarding, concussions in women athletes as related to the phase of the menstrual cycle and the fluctuation of associated hormones. This includes possible differences between hormonal contraceptive users and non-users. When taken together, this means that concussions may present in differing ways, including the severity of symptoms and length of recovery when compared to male athletes.

Chaychi et al. (2022) suggests that employing a lens of sex and gender to understanding “concussion/mild traumatic brain injury is imperative for discovery of its pathophysiology and moving closer to treatments”. While important work is focusing on how the biology of sex might be involved in this process, fewer scholars are looking at the topic through the social scientific lens of gender. To that end, in my first study I have shown how amateur sports women appear to rely on medical care though a DIY approach whereby teammates often treat and advise each other. So, while the research described above points towards biological issues which effect women’s experiences and recovery from concussion, I would argue these issues may well also revolve around their lack of access to professional medical care. And if it is indeed the case that sportswomen find themselves in a unique position at the center of the perfect storm produced by their traditional exclusion from sport and medicine, their chances for protecting and preserving health will be undermined.

9.1 Some takeaways and ideas for what’s next

Christopher R. Matthews, Senior Lecturer, Nottingham Trent University

There were several take aways from the symposium. Many of these, and the ones discussed here, are connected to comments, questions and discussions that followed on from the talks above. I’ll discuss them in turn and then attempt to pull them together. The first of these comes from the realization that none of the expert speakers in attendance were comfortable providing a definitive statement on what a concussion was. Such definition hesitations, and associated debates and wranglings, are commonplace within academia, but it became apparent that some of those in attendance assumed a more solid core sat at the foundation of the science that was being discussed. Of course, something of such a foundation does exist in relation to the disciplinary and methodological standards upon which most good science proceeds. But clearly there is more work to be done by those of us who seek to communicate our science to a wider audience to capture some of the caveats, doubts and the ‘known unknowns’ that are central to our work. The associated problem here, is that such intellectual ‘honesty’, could, in the hands of bad faith actors, undermine some of the important but tentative conclusions we are able to make with our research. In this regard, the epistemological doubt that is central to the scientific method has, in part, enabled sports’ governing bodies and those with various vested interests to do exactly that: cast doubt over the concussion debate (for important discussions around this point please see Malcolm, 2021; Piggin et al., 2022).

Secondly, while it is possible to speak about any academic research in rather cold and stilted ways, it was quite clear that the speakers and attendees were all personally and emotionally invested in the topic. Some had seen the neurological consequence that flowed from extended careers in sport, and others had personally felt such outcomes. And while it is important that academic research attempts to present rationalized analysis, we must not fool ourselves into thinking that we are emotionless beings. And, in reality, many of us are drawn to explore such topics exactly because they matter to us in deeply personal ways. It is these emotional connections that provide the (axiological) foundation upon which I believe much of the best science is conducted.

A further dimension of this emotionality is that many people have powerful emotional connections to ‘sport’, and particularly ‘their sport’. Such emotional significance should not be overlooked in how it might present a barrier to more critical and rational thinking about the empirical reality of the damage sport can, and does, do to bodies (see Matthews & Maguire, 2019). Methodological and theoretical approaches that allow the epistemological space for understanding how such emotional connections shape the way people think about and act in relation to brain injuries in sport are important. It is also crucial to consider such ideas when examining the wider cultural response to concussion in sport, which, I argue, would be very different if those who own and govern sport were not so emotionally (and financially) invested in maintaining its status quo.

Such approaches should also be employed to explore the emotional experiences associated with sustaining brain injuries. And, in connection to those experiences, the lives of those who caring for people who suffer the prolonged consequences of brain injuries connected to sport, deserve to be more clearly articulated within academic research. Such a focus would help document important parts of the lives of current and former athletes and help draw much needed attention to the reality of living with neurological disorders. The importance of this was most clear in Penny’s talk and when those who lived with neurological damage discussed their experiences.

Thirdly, there was a sense from the day that everyone left having learned something important. This, I think, is a distinctive characteristic of organising an event which seeks to draw people together from across academic disciplines and communities more broadly. And, this is one of the ways that those interested in significantly tackling the problem of brain injuries in sport can follow Maguire’s (1991) call to study people ‘in the round’ and Malcolm’s (2019) call for a multidisciplinary approach to the concussion ‘crisis’. Of course, there have been calls for this sort of scholarly ‘border crossing’ for almost as long as academics have separated themselves into different disciplinary groups. But what is a more recent addition to such ideas is the central role funding agencies are now placing on the participation of communities in the development, design and delivery of academic research. Public and patient involvement (PPI) and the co-production of research have reached the level of ‘buzz words’ within academia, and while some researchers will see this as simply another box to be ticked or a ‘trendy’ word to be used, others rightly see the positives that come from bringing communities of practice into the core of what we do.

Here, then, we have the communication of scientific ideas, emotion in framing scholarship and as a topic of focus, and the place of multi-disciplinary and community engaged and engaging research. I think there is much to be gained from academics understanding the importance of these ideas especially in relation to increasing the impact of their work on concussion and brain injuries. You see, by working across disciplinary boundaries on an emotive topic such as this, scholars are more likely to overcome the different philosophical start points, methods and academic language, that might usually serve as obstacles to working together. Further to this, the emotional connections that sit at the foundation of such work provide a clear motivation for academics to work closely with communities of practice and center PPI to help develop impactful research with a view to changing the lives of people for the better. And, by bringing communities and various public entities into the core of our attempts to better understand and change the lives of people, we will also be better placed to communicate some of the parameters and limitations of research, and also the tentative conclusions we make along the way. This would represent a genuine shift to doing research and developing science with people and should be a future direction for scholars working in this field.

An example of such work flowed from this symposium as several of the attendees formed a research steering group to help develop a project on former athletes who live with neurological disorders. The idea here is to tell the stories of these people and their families using a co-produced methodology which centers the needs and voices of patients’ carers and communities of practice within the conception, design and delivery of the work. It is also expected that the new forms of knowledge that are developed from this research will help future athletes be far more informed about the reality of living with the neurological consequences of their involvement in sport. While ever such experiences remain largely absent from discussions about the long-term outcomes of involvement in certain sports, it is tempting to argue that almost all athletes involved in regular heavy contact are doing so in an uninformed, if still, consenting manner. This statement and focus builds on recent research on consent in sport Channon & Matthews (2021). One of the goals here is to develop our knowledge of how consent is asked for, given and received in sport, so we can help move past the now repetitive calls for athletes to be educated about the consequences of brain injuries. We argue that focusing on consent has a much more practical intention than is the case with calls for more and more education. This is because working to ensuring someone has an active ‘informedness’, which means they can easily withdraw their consent to actions that might harm them, has a radically different focus to the passive receiving of knowledge.

And, although this research is in its initial stages, I am confident from the work that has already been undertaken, to make a firm recommendation – within sporting spaces where physical contact is a regular and normalized ‘part of the game’, coaches, managers, parents, teammates, captains, fans and anyone else with an interest in the future of those playing sport, and therefore, the sport more broadly, should be openly discussing the long-term consequences of sport in terms of brain health, and health more broadly. These conversations should not engage in scaremongering but should approach the very real threats that flow from taking repeated blows to the head. And it is incumbent on those who are in a position of power in such settings to actively create a culture where withdrawing consent to take part in physical contact is normalized. This is especially the case where children and young people are involved – consent in minors is a complicated phenomenon and should certainly not be left to parents to decide in some unitary fashion. In this regard, rather than valorizing those athletes that sacrifice themselves for ‘the game’, we should be creating sporting cultures where individual sovereignty, and the personal right to say “no” to being involved in injurious and damaging behaviors, is held as a central feature of how athletes are taught to play their sports.

In summary, it is hoped this communication piece based on a cross-disciplinary and cross-community symposium has highlighted the following:

• Some important knowledge about concussion and brain injuries in sport from a diverse field from experts.
• An articulation of areas in need of greater understanding and further research.
• Some direction and perhaps inspiration for scholars who are interested in developing contributions in the field.
• And the value of holding events like this which integrate the underlying ethos of co-production and community involvement into work on concussion in sport moving forward.

10.1 Contact Information

1. dr.christopher.r.matthews@gmail.com
2. tom.dening@nottingham.ac.uk
3. ian.varley@ntu.ac.uk
4. angus.hunter@ntu.ac.uk
5. d.e.malcolm@lboro.ac.uk
6. debraforbes013@gmail.com
7. reem.alsayed.alhashmi@gmail.com

10.2 Data Accessibility

Not applicable

10.3 Author Contributions

Each author contributed to their own section of this manuscript.

10.4 Conflict of Interest

The authors have no conflict of interest to declare.

10.5 Funding

Nottingham Trent University’s SHAPE research centre.

10.6 Acknowledgments

The authors would like to thank the attendees of the symposium at Nottingham Trent University for their engaging questions and personal accounts in relation to brain injuries in sport. The corresponding author would like to thank the reviewers for appreciating the specific nature of this project and providing important opportunities for developing the piece. He would also like to thank Jack Hardwicke for his help in redeveloping the final section of the paper.