The Concussion Crisis in Sport

Dominic Malcolm

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367262914
• eBook ISBN: 9781000103885
• Edition: 1
• Topic: Medicine
• Subtopic: Sports Medicine

Concussion has become one of the most significant issues in contemporary sport. The life-changing impact of head injury and the possible threat that chronic traumatic encephalopathy poses to children and young athletes in particular is calling into question the long-term future of some of our most well-established sports. But what are the real issues behind the headlines and the public outcry, and what can and should be done to save sport from itself? This concise, provocative introduction draws on perspectives from sociology, medicine, ethics, psychology, and public health to answer these questions and more.

The book explores the context in which the current cultural crisis has emerged. It assesses the current state of biomedical knowledge; the ethics of regulating for brain injury; the contribution of the social sciences to understanding the behaviour of sports participants; and the impact of public health interventions and campaigns. Drawing on the latest research evidence, the book explores the social roots of sport's concussion crisis and assesses potential future solutions that might resolve this crisis.

This is essential reading for anybody with an interest in sport, from students and researchers to athletes, coaches, teachers, parents, policy-makers, and clinicians.

1

INTRODUCTION

Ash lay on the pitch gradually coming to. There were voices all around giving contradictory advice. ‘You’ll be fine, see how you feel in 5 minutes’. Others were more cautious: ‘take a break, it’s not worth the risk’. Ash had been concussed before but now the voices were coming from all directions and getting louder and louder. Perhaps it was time to retire. ‘Game over?’

Crisis is a big word. Consider the 2008–2009 financial crisis that saw the near collapse of the global banking system, the humanitarian crisis in Yemen in 2018 where an estimated 22 million people were in need of aid, or the Ebola health crisis which affected over 28,000 people across ten countries in 2014. But crisis is also a widely used word. On the day of writing this introduction, the British media used the word ‘crisis’ in relation to Brexit, recycling, the penal system, a bank’s IT system, murder rates in Latin America, and the number of players injured at one football (soccer) club. Crisis is often used as a rhetorical device to generate interest. So, is The Concussion Crisis in Sport simply hype or does it refer to something more tangible?

Concussion is defined as ‘a traumatic brain injury induced by biomechanical forces’ which typically: 1) results from a direct blow to the body; 2) leads to ‘the rapid onset of short-lived impairment of neurological function that resolves spontaneously’; and 3) entails ‘functional disturbance rather than a structural injury’ (McCrory et al. 2017: 1). But the concussion crisis is a rather broader phenomenon. Partly this is due to the imprecision of what is meant by concussion such that even the very appropriateness of the term ‘concussion’ is debated. Should we talk specifically about sport-related concussion (SRC) or are these simply part of the broader spectrum of ‘brain injury’ (Sharp and Jenkins 2015)? Some make the case for supplanting concussion with the term ‘mild traumatic brain injury’ (mTBI), while others argue that labelling such conditions as ‘mild’ provides a highly misleading message (Fry 2017). Further fuelling the crisis is uncertainty about the underlying pathology of concussion. To what extent does head injury lead to either immediate or briefly delayed fatalities and/or longer-term neurocognitive conditions? Specifically, the concussion crisis includes issues such as Second Impact Syndrome (SIS), post-concussion syndrome (where symptoms are experienced for a prolonged period after the initial injury), and a form of dementia called Chronic Traumatic Encephalopathy (CTE) that might develop over half a century and is only diagnosable post-mortem. The Concussion Crisis in Sport therefore considers a broad definition of concussion and related conditions.

The use of the term sport – defined as structured, goal-oriented, competitive forms of play (McPherson et al. 1989) – also requires clarification, for concussion is not (currently) a crisis for all sports. As we will see (Chapter 2), these issues primarily started within fighting or combat sports (e.g. boxing) and subsequently spread into collision sports (e.g. ice hockey), and latterly contact sports (e.g. soccer). They have also begun to influence non-contact sports such as cricket, baseball, and volleyball (Greenhow and Gowthorp 2017; Cantu and Hyman 2012). Indeed, concussion is also now a significant concern in cheerleading, an activity which sits on the boundary of ‘sport’ and artistic display. Moreover, what at first appeared to be evidence of the dangers faced by elite sport participants has increasingly expanded into concerns about the health of all sport participants and particularly the young. The notion of sport used here, therefore, includes all aspects of physical cultures and various levels of organizational complexity and competitiveness.

And what do we mean by crisis? An important initial distinction should be made between crises which are ‘natural’ or ‘cultural’. Both tend to be large in scale and entail some kind of ‘spill-over’, enveloping people beyond those immediately affected. But while a natural crisis is often seen as largely out of human control and consequently tends to unite people, a cultural crisis tends to divide. Specifically, although a cultural crisis can unite populations around the ideas that the current issue/period represents abnormal practice that should not continue, cultural crises centre on phenomena that human action ‘should’ be able to ‘fix’. Cultural crises inevitably draw different responses to the question of how, in what ways, and when.

These essential features of action (how?) and timing (when?) mean that a cultural crisis frequently entails the transition to a new cultural form. Thus, typically a cultural crisis will involve either an existential question – can a particular group, activity, or ideology continue to exist – or an axiological question – where is the boundary between a tolerable and intolerable existence (Holton 1987)? In such cases a crisis may involve the reassessment of what was previously taken for granted or thought to be unquestionable. It will lead to uneven or uncoordinated development, where one constituency or population changes while another does not. Imbalance is therefore the key: ‘The prime mark of a crisis is neither widespread misery nor rapid change, either of which may exist when no crisis is present, but a great discrepancy between potentialities and accomplishments’ (Rader 1947: 278).

In combining the terms ‘concussion’, ‘sport’, and ‘crisis’ we begin to see that current concerns exhibit the fundamental characteristics of a cultural crisis.

1. We see evidence of a spill-over effect as the number of people affected by SRC has steadily expanded. Indicatively the content of this book will primarily focus on the various forms of football – American football, association football (referred to throughout the text as soccer), Australian rules football, and rugby football (both union and league) – and to a lesser extent field and ice hockey, lacrosse, and combat sports. While the issues discussed also have implications for those who take part in horse-riding, motorsport, cycling, etc., these are less well-documented and therefore largely beyond the scope of this book.
2. This spill-over effect now extends beyond sporting populations, as previously discrete groups of expertise have been sucked into the crisis. Currently politicians, journalists, sports administrators, physical education teachers, and parents are all active in the debate about concussion. Equally, researchers from medicine, biomechanics, engineering, law, psychological, sociology, and ethics variously feel that they ‘should’ have a say on the issue. As others have noted, concussion in sport is far more than simply a medical issue (e.g. McNamee 2014).
3. While few dispute that ‘something’ needs to be done, there is considerable division over specifically what. Concussion has led to disequilibrium in many sports for while the issues have led to a range of changes (see Chapter 3), self-evidently the degree of change has not been sufficient to balance opinions and ‘resolve’ the crisis. Indeed, views appear to be increasingly polarized as some contend that the problems of concussion have been exaggerated by media over-reaction and speculation and others express dismay at the lack of effective change. It remains to be seen what new cultural form will emerge to provide a resolution (see Chapter 9).
4. For a few, the concussion crisis takes an essentially existential character: in other words, ultimately there are groups for whom the issue threatens their very being. For instance, will the National Football League (NFL) in particular, or American football in general, continue as part of the cultural landscape once this crisis is resolved? These questions have been raised partly because surveys suggest that high school football is bucking the trend of increasing youth sport participation and experiencing a significant decline in popularity (Hruby 2019), and because of reports that both the NFL and amateur football leagues are faced with ‘an evaporating insurance market’ due to the uncertainty over future payouts (Fainaru and Fainaru-Wada 2019). For most sports, however, SRC has largely axiological implications, leading to a debate between the acceptable limits of physical harm versus the degree to which pacification would strip certain sports of all their essential value and make them redundant or worthless.
5. The concussion crisis entails us asking questions about pastimes and activities which we had not only taken for granted but thought were positively good for us. This introspection has led groups that were previously united in their support of sport to become divided. The fundamental discrepancy between expectations and achievements relates to whether the sport-health ideology – sport seen as fundamentally good for our physical and mental health, an essential part of avoiding a range or illnesses, and providing a unique contribution to building ‘character’ (Waddington 2000) – holds good, or whether participation ultimately destroys our cognitive abilities and thus the defining qualities of being human.

On these grounds, the title ‘concussion crisis’ seems warranted. We are clearly experiencing more than just an abnormal period in the development of sport, more than just a questioning of the status quo, and more than just the reassessment of certain value judgements about sport. We need to ask some wide-ranging and deeply probing questions if we are to better understand this acute social conflict that defines the crisis.

In addressing SRC as a crisis, I have explicitly rejected the idea that we are witnessing ‘a public health epidemic’ (Zemek et al. 2016: 1015; emphasis added. See also Marshall and Spencer 2001 and Carroll and Rosner 2011 for scientific and populist examples of this representation of concussion as an epidemic). I do so for three reasons. First, use of the term ‘epidemic’ suggests that concussion is rife or especially prevalent and, as we will see, there remains a debate about the degree to which the recorded increase in the incidence of concussion is attributable to changes in awareness, measurement, and investigation (see Chapter 4). Second, ‘epidemic’ can imply that a condition is catching, a position which is clearly false. In this respect, the use of the term ‘epidemic’ is part of the hype which positions the ‘crisis’ as out of human control and, therefore, like a natural disaster, compelling a united response. Third, ‘epidemic’ is essentially a biomedical term and as such is inappropriate for what – as I argue throughout the book – needs to be understood as a cultural phenomenon.

But as a cultural phenomenon, the study of crisis tells us something more broadly about the world in which we live. For instance, some have argued that the term crisis is such a widely used word today because our degree of interconnectedness as a global population, and the speed and variety of conventional and social media communications, ‘creates’ the perception that crisis is a more-or-less ever-present state of affairs (Bauman 2000; Beck 2008). While The Concussion Crisis in Sport does not centrally address this question, it does inevitably tell us something beyond the crisis itself, and poses fundamental questions about the societies we form. In what kind of society do questions about the consequences of head injuries incurred while playing sport become so especially significant that a cultural crisis develops?

The aims of The Concussion Crisis in Sport are therefore to explore the various dimensions of SRC as an issue and to identify the distinct features of certain contemporary societies that have led these concerns to come to the fore. The first of these aims requires a distinctly multidisciplinary approach, and the book explores a wide range of evidence and interrogates a number of different perspectives. In Chapter 4 we look at the biomedical evidence in relation to concussion (and related conditions), providing a state-of-the-art review and reflecting on what and how much is currently known. Subsequently, in Chapter 5, we consider the distinct ethical considerations in relation to regulating head injuries in sport, before exploring in Chapter 6 what behavioural science has shown us about the lived experience of concussion. Chapter 7 begins our synthesis of divergent bodies of knowledge as we look at the convergence of biomedical evidence, ethical implications and the realities of human behaviour. These intersect in public health debates and interventions in relation to concussion. This provides the ideal segue to Chapter 8, which provides a more concentrated focus on the second aim of The Concussion Crisis in Sport. Here we develop our understanding of concussion in relation to a set of wider social processes, looking at the relationship between medicine, health, risk, ageing, commercialization, nationalism, celebrity, and violence (amongst others) in contemporary societies, attempting to understand the social roots of concerns over SRC. In Chapter 9 we consider the future of sport’s concussion crisis and the potential for resolution.

Before embarking on that analysis though, we need to look in more detail about what the concussion crisis entails and how it came to be. Therefore, in the next two chapters we look at how head injury in sport became a social issue and the multiple ways in which the issue now permeates various spheres of social life. The aim here is to demonstrate how tangible is the crisis related to concussion in contemporary sport.

References

Bauman, Z. (2000) Liquid Modernity. Cambridge: Polity Press.

Beck, U. (2008) World at Risk. Cambridge: Polity Press(2nd Edition).

Cantu, R. and Hyman, M. (2012) Concussions and Our Kids. Boston, MA: Mariner Books.

Carroll, L. and Rosner, D. (2011) The Concussion Crisis: Anatomy of a Silent Epidemic. New York: Simon and Schuster.

Fairnaru, S. and Fainaru-Wada, M. (2019) ‘For the NFL and all of football, a new threat: an evaporating insurance market’, 17 January, www.espn.co.uk/espn/story/_/id/25776964/insurance-market-football-evaporating-causing-major-threat-nfl-pop-warner-colleges-espn

Fraas, M. and Burchiel, J. (2016) ‘A systematic review of education programmes to prevent concussion in rugby union’, European Journal of Sport Science, 16(8): 1212–1218.

Fry, J. (2017) ‘Two kinds of brain injury in sport’, Sport, Ethics and Philosophy, 11(3): 294–306.

Greenhow, A. and Gowthorp, L. (2017) ‘Head injuries and concussion issues’, in N. Shulenkorf and S. Frawley (eds.), Critical Issues in Global Sports Management, Abingdon, UK: Routledge, 93–112.

Holton, R. (1987) ‘The idea of crisis in modern society’, The British Journal of Sociology, 38(4): 502–520.

Hruby, P. (2019) ‘As the SuperBowl approaches, is high school football dying a slow death?’, The Guardian, 30 January, www.theguardian.com/sport/2019/jan/30/high-school-football-numbers-drop-brain-trauma

Marshall, S. and Spencer, R. (2001) ‘Concussion in rugby: the hidden epidemic’, Journal of Athletic Training, 36(3): 334–338.

McCrory, P., Meeuwisse, W., Dvorak, J. et al. (2017) ‘Consensus statement on concussion in sport: the 5th international conference on concussion...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of tables
• Abbreviations
• 1. Introduction
• 2. Concussion as a social issue
• 3. Concussion as a cultural phenomenon
• 4. Concussion and medicine
• 5. Concussion and ethics
• 6. Concussion and behavioural science
• 7. Concussion and public health
• 8. The social roots of sport’s concussion crisis
• 9. The future
• Index