Denial culture hides extent of concussion
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 centred on the loss of training or playing time, or a combination of both. Progressively more sports medics and coaches also do so.
In North American, British and, increasingly, Irish studies of competitive sport at all levels, athletes continue to train and compete when in pain and injured. Actually, they are expected to do so by their coaches, managers, peers and physios. No pain no gain.
As a result, their tolerance levels adapt to these demands. They typically deny the existence of pain and even develop an irreverent attitude to it. Those who are not prepared to tolerate pain and injury are often stigmatised or shamed as not having 'the right attitude'. Athletes conceal pain and injury and they receive recognition and enhancement of their social status for doing so. This culture of risk is to be found not only in sports played by men, but also by women. It is identifiable in team and in individual sports (rowing, running, cycling and boxing for instance) and, crucially, it is inculcated from a young age.
Concussion is not just a neurological issue or the sole domain of bio-medics and the national governing bodies. Doctors, medics and sports administrators are appropriately placed to treat the symptoms of this injury and enforce changes to tackle laws, substitution regulations and the like. However, left to their areas of important (but not sacrosanct) expertise, they underestimate the social epidemiology of concussion and the all-encompassing confounding variable: that of identity and its links to culture.
Reflect on the following insights from amateur rugby players who, having undergone concussion education in the past two years, confided to us that they continued to apply their own lay understandings of the injury and they reverted to playing "in a primal state" in the face of a diminishing cognitive function. Some went so far as to express a preference for this injury diagnosis because "you can get back sooner" than other injuries.
Being a sports person - embodying the values of sacrifice, risk and 'playing hurt' - is intensely salient to the identities of those involved. Consider what a player or athlete in any sports code, but especially in competitive team sports, is likely to do in the heat of the moment when he or she knows there are limited substitutions, owing either to a regulation by the governing body or to the size of the team. "It's very easy to bluff your way through a test" and, in big games, players "would probably work the system because they know what to do and what to say about concussion".
These self-exempting beliefs are neither surprising, shameful nor infrequent. They are a product of the deeply embedded set of values in competitive sport that foster the reproduction of some health compromising beliefs and behaviours. Such beliefs act as a shield, giving false reassurance and allowing sports people to avoid thinking too deeply about the seriousness of injury. This is especially evident in 'worth it' accounts routinely promoted by the very same sporting codes who advise that 'if in doubt, sit it out'.
The real crisis then lies in the normative clash between performance or sports-related criteria and those of health, the former typically elevated in competitive sports at the expense of the latter. There is even ideological resistance to the acknowledgement of this clash, evidence for which can be seen in the different responses to concussion proposed by public health experts compared with those heavily invested in the sports industry (players, administrators, former players turned journalists, sponsors and so on). This paradox lies deep in the cultural DNA of our society.
Lest you conclude that I must be a sports heretic intent on disrupting everything that you hold dear, let me assure you that I, too, have been socialised into this culture and know it intimately. However, this immersion should not hold us back from asking the hard questions in the interests of players, especially about the claim that education is the answer to the 'problem' of concussion.
Why, for instance, do athletes continue to view concussion in functional terms, even when they have completed education programmes with their clubs, counties and provinces? How, and in what ways, do they continue to give meaning to this injury, leading to continued denial or concealment of it? What of the weak player incentives to seek medical consultation? And, ultimately, what constitutes sensible risk-taking in sport?
Left unanswered, the paradox is that in encouraging people to take part in competitive sport from a young age, their active socialisation into a culture of risk buffers the effect of education about injury and concussion. Put a spoonful of sugar in that cup of tea because you're going to need it.
- Dr Katie Liston works at Ulster University. She is author of 'On being "head strong": The pain zone and concussion in non-elite rugby union', published as a research article in 2016; she is a former international soccer and rugby player, and an All-Ireland medal winner and All Star holder for Kerry (@kliston14).
Sunday Indo Sport