Concussion in sport: The Home Straight?

The Digital Media Culture and Sport Select Committee’s (DMCSSC) fourth formal meeting took place on 18 May to address concussion in sport, the recording of which can be accessed here.

There remains no confirmed date for publication of the Committee’s report, nor any hint that further oral hearings will take place; in fact, the inquiry’s web page still refers to it being heard over two sessions. This fourth session adopted a more relaxed approach than we have previously seen, with a reduced panel of witnesses and a shorter session concluded by evidence from another inquiry. Overall, it gives the impression that the evidence gathering phase is slowing to a stop.

In two panels, the Committee heard from

  • Professor Alistair Burns CBE, National Clinical Director for Dementia and Older People’s Mental Health at NHS England

And from

  • Dr Niall Elliott. Head of Sports Medicine at Sport Scotland
  • Dr Rod Jaques OBE. Director of Medical Services at English Institute of Sport
  • Sally Munday. Chief Executive at UK Sport
  • Phil Smith, Director of Sport at Sport England

Both panels were data and statistic heavy.

NHS policies and statistics on concussion injuries

Prof. Burns offered some context to the NHS policy on concussion and brain injury;

  • About 1m people every year attend A&E with a head injury, of which about 900,000 have no or only brief loss of consciousness.
  • Of those, about 85% recover after one week with no lingering symptoms, rising to about 97% after one month.
  • The Primary care provider for head injury is the A&E department, whereas those with symptoms of concussion are more likely to attend their GP.
  • Between April 2017 and February 2021, hospital administration systems recorded 7,536 admissions with concussion, of which only 8.5% were sports related; figures which have remained consistent over the years, albeit with a drop in the 2020, put down to COVID
  • 98.6% of those admissions had no specific intervention.  13 died, but not relating to sports injuries.
  • The data identified a spike in 11-16 year olds (although no detail was offered as to what that spike identified, or when it occurred).

A breakdown of which sports were involved in the sports-related admissions could not be immediately provided; the treatment of head injury was not determined by whether it was caused in sport or not; “head injuries are treated as head injuries”.

Whilst beyond the Committee’s terms of reference but potentially of interest in a wider claims context, reference was made to an unidentified study where 40% of the male prison population were said to have suffered head trauma, and that the homeless were more likely than the general population to present with head injury to the NHS.

The committee risked straying into territory which it has intended to avoid, when Kevin Brennan MP (Cardiff West) recounted fondly his memories of Wales’ triumph over England at Twickenham in 2008; a match in which Alix Popham, one of the named claimants in the ongoing litigation, participated but which he cannot remember at all.  Accepting that Prof. Burns could not provide a formal diagnosis, he was nevertheless asked by Mr Brennan “Why can’t he remember?”

Somewhat contrary to evidence from earlier sessions, Prof. Burns identified that there were 27 Major Trauma Centres and 122 Trauma Units across the country, with a full range of specialists able to support someone with the correct treatment, and considered that to be sufficient.

Identifying what might lie ahead in the Committee’s conclusion, Public Health England were considered potentially to be better placed than the NHS in terms of education and information around prevention.

The reference to national organisations and who might hold the key to improvement in concussion protocols segued to the second panel of witnesses.

Data and grass roots sport

Dr Elliott identified there was no central repository in the UK for collating data on the incidence and extent of trauma in grass roots sport, whether in relation to child or adult participation.  He cited examples in South Africa and the USA of agencies where data regarding head injury and catastrophic (brain, spinal and fatal) injuries is collated from which it is possible to determine “threatening environments”.

The issue of education was also a key point of discussion. Mr Smith observed that the advice relating to grass roots sport had improved in recent years and was largely very good, looking at prevention, treatment and the return to play.

Having looked at “pretty much every national governing body’s (NGB) guidance” in preparation for giving evidence, Mr Smith considered there was comprehensive information available to all grass roots sports, and which shared common characteristics and common themes.  There was some surprise that information on concussion was not considered as a fundamental / core issue for coaches; where stage 1 coaching certificates required basic first aid principles, concussion was not addressed by some sports until stage 2 or 3.

He added that any improvement would not be resolved by a single solution; there would need to be greater awareness, greater education and information made more widely and more easily available. 

It was a point with which Dr Jaques agreed with and developed, on the back of more statistics:

  • The Institute of Sport considered data from their doctors and physiotherapists from the last five years and determined that 28,400 different physical and mental injuries from sport had been identified, of which 382 were concussions, indicating it is a rare event.
  • One athlete has a 4% chance of concussion in any one year.
  • The median duration of symptoms from concussion for male athletes was recorded as 10 days, with female athletes recorded at 14 days.
  • 73% of concussions resolve completely in 30 days.

And whilst concussion awareness was improving, there was a recognised importance to educate, to “get across to athletes that it is OK to talk about concussion, to come forward with symptoms.”

As the session wound down, John Nicholson MP queried whether there had been enough emphasis in the inquiry on sub-concussive injuries, which he suggested were quite common, and “can lead to early onset dementia.”

It was an observation met by a final flurry of statistics from Dr Elliott; a lifetime prevalence of a concussive episode / minor  brain injury is 1 in 5 in the general population – so over a lifetime, 20% of us will have some form of minor brain injury.  And perhaps obviously, anyone who undertakes an active lifestyle increases the risk of any injury, including minor brain injury from sub-concussive and concussive brain injury.

Diplomatically correcting Mr Nicholson’s understanding on causality, Dr Elliott observed that the cumulative effect of concussion and sub-concussion and its long term effect is something we are only now starting to learn, with the work of Professor Willie Stewart, amongst others.

Shared responsibility

There was brief exploration of the role that government might have in the development of this area and again, positive examples from Scotland, the USA, Canada and South Africa were referenced.

The view of Phil Smith was government involvement may have led to a difference in approach, but not necessarily a difference in outcome. There was a shared responsibility between organisers of sport and NGBs to look at the rules of their sport and the safety of its participants, and responsibility on the individual, whether participant or coach.  It should not be down to a single body or organisation to hold all of the responsibility.

Should causation be the focus?

The final observations were left to Dr Jaques; that if there was one single thing to go into the committee’s report, what should it be?

In a measured response, which he identified he had given some thought to in advance of the hearing, his view was that we are all interested in causation and to do that, we have to look carefully at training habits and rules in sports and the only way to make informed decisions is to carefully audit the circumstances around concussions at the point they happen.  He referred to an ambition to have a code of sport governance, contained in which is the intention to have a board member of each NGB to look at safety and welfare of staff and athletes.  If concussion can be included in that, it would drive at board level a closer inspection around causation of concussion in each NGB.

As those representing some of the national and international governing bodies have appeared before the committee in earlier sessions, we don’t anticipate that they will be invited back for, in the language of the courtroom, re-examination.

If the intention had been to mark the difference between professional and grass roots sport in identifying and treating concussion, I am not confident that was achieved.  What the latest evidence session did highlight was commonality; the welfare of those participating in sport was paramount, and whilst education, information, prevention and rehabilitation existed, it needed to be improved.  To do so will be require a multi-layered and likely multi-agency approach.

With four sessions having been held and with the pool of possible witnesses diminishing with each of those, it seems that the Committee is probably reaching the end of its evidence-gathering phase.

We might anticipate that some significant time will need to be spent poring over the evidence (oral and written) and then more time spent constructing a report.

There was nothing from this latest session to add to what, based on the earlier hearings, the probable outcomes might be: a single consistent and comprehensive concussion protocol across all UK sport, a significant improvement in the education of participants, parents, coaches, clinicians, clubs and NGBs, and some form of welfare fund for those impacted by neurodegenerative decline determined to be as a consequence of sports participation.

None of these are likely to be informed by litigation, but in common with the ongoing and anticipated claims in this area, the financial implications could well be significant.

David Spencer, Partner and Head of Sports

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