Neurogenerative disease is more common in former professional soccer players than in the general population. However, disease risk varies by player position and career length, and this pattern has remained consistent for decades. These findings can help inform strategies to reduce head impact exposure for athletes.
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Concussion is a serious concern in contact sports. A New Zealand research team of clinicians, sport scientists, and engineers is exploring the potential of soft-shell headgear and coaching programs that could make sports like rugby safer for all players, and especially youth.
Sport-Related Concussion has become recognized as a major health problem that affects millions of people around the world annually (Wang et al., 2016). In Canada, sport and recreational activities account for a large proportion of concussions, particularly amongst children, adolescents and young adults (Government of Canada 2018).
Most concussed individuals recover within 4 weeks. Typical symptoms may include headaches, nausea, dizziness and light sensitivity. However, there is a small proportion of individuals (15-30%) who continue experiencing symptoms and challenges weeks and months after a concussion (Parachute, 2017).
In this blog, I will provide information about concussion symptoms that take a longer time to improve and may impact an athlete’s cognitive and communication functioning in significant ways. I will also include information about how speech-language pathologists can play a role in recovery.
In general, concussion is a form of traumatic brain injury termed “mild traumatic brain injury.” However, even though they are labeled “mild,” this type of brain injury can have significant effects on individuals’ lives (Cleveland Clinic, 2020).
Concussion results from an impact to the head that impacts the brain. Once impacted, the brain (which is made of fragile, squishy, jelly-like tissue) stretches and bruises, damaging nerve cells and blood vessels and causing a cascade of chemical changes to occur. The damage and chemical disruption results in an acute, temporary loss of normal brain function. When this injury happens to a person participating in an athletic activity or sport, it is considered a “Sport-Related Concussion.”
According to some researchers, most children recover from concussion within 4 weeks, while adults typically recover within 2 weeks. A single concussion does not usually result in permanent brain damage. As long as another concussion does not occur shortly after the first one, most athletes do not experience ongoing clinical or cognitive symptoms (Parachute, 2017; Cleveland Clinic, 2020).
However, even after a single concussion, 15-30% of individuals do not fully recover within the expected timeframe. This is often referred to as Post-Concussion Syndrome (PCS) (McCrory, 2017), Persistent Post-Concussion Syndrome (PPCS), or, in sport, Persisting Symptoms after Sport-Related Concussion (Herring et al., 2021). Typically, by 1 to 3 months post-concussion, if concussion symptoms persist, a trained health professional will monitor the athlete more closely, make appropriate referrals for further assessment, and ultimately may diagnose the athlete with Post-Concussion Syndrome.
Of the various symptoms that may persist past the expected concussion recovery timeframe, concussed athletes may experience ongoing challenges with cognition and communication, termed “Acquired Cognitive-Communication Disorder” (ACCD) (Ontario Neurotrauma Foundation 2017).
Communication is a highly complex process that relies on the proper, intact functioning of many regions of the brain so that a person can read, write, talk, listen and socialize properly. ACCD is a communication difficulty caused by underlying deficits in cognition. In an athlete’s case, a Sport-Related Concussion may lead to ACCD.
The communication difficulties can include problems with listening, understanding spoken language, speaking, reading, writing, conversational interaction and social communication. These difficulties may occur as a result of underlying issues in areas of attention, memory, information processing, reasoning, problem solving, executive functions or self-regulation (Ontario Neurotrauma Foundation 2017). For many concussed individuals, they report feeling “dumb” long after their brain injury, when in fact they may be suffering from ACCD.
ACCD can hinder one’s ability to efficiently and effectively do activities of daily living, as well as academic and work performance. Complex, fast-paced, cognitively-heavy tasks in certain sports (for example, strategic plays in football) may also be difficult.
There are numerous examples of how ACCD issues may manifest following concussion. Often, lingering cognitive-communication challenges are only noticed after the concussed person physically feels better. They return to regular activity, but then struggle with complex, fast-paced or new cognitive-based tasks and demands. For example, a concussed football quarterback struggling with memory may experience difficulty recalling short-term or long-term information, difficulty remembering details of conversations, or difficulty learning new information to efficiently complete high-level, strategic plays on the field.
PCS and resulting ACCD may impact an athlete’s ability to perform their regular cognitive-communication related tasks of daily life, school, work or sport. So, it is important to flag ACCD early so that the appropriate supports can be put into place and training/rehabilitation can be initiated to optimize recovery.
When working with a team of professionals managing Post-Concussion Syndrome, it is crucial to involve a speech-language pathologist (Ontario Neurotrauma Foundation, 2017). Speech-language pathologists are allied health experts who have unique training in areas of cognition and communication. They work closely with physicians, neuropsychologists, occupational therapists and physiotherapists to assist athletes improve their skills for all aspects of daily life.
Given the impact of concussions globally, it is important for anyone involved in sport to be aware of the exceptions to the typical concussion experience. That is, what if an athlete is not recovering fully and fast enough in all aspects of functioning? Does the athlete struggle with ACCD and need more help?
If persistent post-concussion symptoms are suspected following a sport-related concussion, ensure ongoing proper concussion management by involving the right health professionals as early as possible, and this should include speech-language pathologists. Doing so will help to optimize the athlete’s recovery and improve the cognitive and communication skills needed for all aspects of daily life.
For racquet sports like pickleball, concussion awareness may not always be a top concern. But after one player’s fall, all it took was a trip to the emergency room and a previously undetected tumour for Pickleball Hamilton to realize how important concussion protocols are—in any sport. Read the story that shifted Pickleball Hamilton’s perspective, and what community sport organizations across the country are doing to raise concussion awareness.
Peer-led education programs, such as You-CAN, can help high-school students better understand and deal with a concussion. Because youth are strongly influenced by their social networks, peer education can shape students’ knowledge (what they know about concussion), attitudes (what they think about concussion), and intended behaviours (how they would act if they experienced a concussion or if a friend had a concussion).
For decades, rest has been prescribed for sport-related concussion symptoms. But new evidence suggests that mild to moderate aerobic exercise can be a safe and effective concussion treatment. In fact, exercise can help speed up recovery and help athletes who experience symptoms beyond the expected recovery period.
People who are into sports like soccer and rugby are familiar with yellow and red cards. When an official presents a player with a yellow card, that’s a warning that they’ve committed an offence on the playing field. A red card means the player must leave the field immediately and can no longer take part in the game.
A blue card is a new addition to rugby’s card system.
“‘That’s a Blue for you’: Referee experiences managing concussion injury risk in Canadian amateur rugby” is a SIRC Match Grant funded project. The project is spearheaded by a partnership between Rugby Canada, Rugby Ontario, and the University of Toronto. The Match Grant program is an integral part of SIRC’s mission to connect researchers and sport organizations by supporting the completion of research projects over the 2020 to 2021 year.
The “That’s a Blue for you” project studied rugby match officials’ experiences with the newly implemented Blue Card concussion risk management tool (Blue Card tool). In this blog, we introduce the research project and share findings as well as recommendations for managing concussion risk.
The Blue Card tool is for preventing and managing concussions. Its purpose is to prevent athletes and participants from returning to play without medical clearance after a suspected concussion. First introduced in New Zealand, the blue card was adopted by Australia and France afterward. World Rugby Law 3.22 and Law 3.24 established the blue card. Those laws state, “if, at any point during a match, a player is concussed or has a suspected concussion, that player must be immediately and permanently removed from the playing area.”
Like yellow and red cards, blue cards are initiated by an official. The blue cards are for when there’s a suspected concussion. “It signals to everyone what is going on, allows us to record it, and makes sure that all individuals involved are following proper return to play rules,” says David Bushell, Coordinator and Match Official Development at Rugby Ontario. In this way, the Blue Card tool acts as another way of enforcing Rowan’s Law and ensuring organizations are prioritizing athlete and participant welfare.
The Blue Card tool is now employed for all rugby activities in Ontario. Despite this, gaps still exist in our understanding of the blue carding experience for stakeholders.
Match officials play a big role in risk management. As another card is added into the mix, officials may find themselves in a tough place. “We’ve pinned the officials into, potentially, an uncomfortable space,” says Ryan Jones, Manager of Rugby Development at Rugby Canada.
Bushell adds, “Taking anyone out of the game is going to change the game, and we want to make sure that people are prepared to have those difficult conversations.”
Jones and Bushell stressed the importance of providing organizations with strategies to ensure every member’s wellbeing is considered. Part of this was making sure that officials felt supported and confident with the new system to protect their wellbeing as well as player safety.
Following their organizations’ mandates to be evidence-informed in all that they do, 19 registered rugby officials in Ontario participated in online interviews about their experiences. In particular, researchers emphasized Canadian female rugby officials’ experiences.
From interviews with officials, 6 themes surfaced:
Gendered experiences: Interviewees who identified as female officials discussed how the additional work to prove themselves as competent could have implications for game management, and as a result, injury management.From their research project and experiences, the partners provided 5 recommendations for moving forward with concussion management strategies such as the Blue Card tool:
Standard practicesWhere possible, ensure consistency between levels of competition. The Blue Card tool should be implemented across sports and especially at lower levels of competitions, university and college meets, and high school games.
Consider a standard pre-game script (particularly for novice referees) to help build their confidence with the Blue Card tool. Training and communications about the Blue Card tool should use clear language to address liability concerns for match officials.
Provide opportunities for video examples demonstrating blue carding and group learning with referees who have mixed levels of experience. Formal opportunities for mentorship will help ease the burden on novice officials.
Clarify how these new responsibilities fit into the match official role at different levels of competition. And establish support for officials from other members of the rugby community.
Give additional consideration for female officials. This could tie into extra training and the previously mentioned support from other members of the rugby community. Having female representation across all levels of rugby competition may support further recruitment.
The partnership succeeded in more ways than one. The findings from the research project served to be of significant use for Rugby Canada and Rugby Ontario in understanding the experiences of officials and making changes to improve their experiences. Additionally, the 3 partners highlighted the positive aspects of partnership research overall.
“Michael Jorgensen worked with us to figure out what our needs were… He’s been an ongoing partner and part of our task force now. [Concussion management] is an ongoing process, and he’s been a key part of that, giving us an evidence-based approach to things as opposed to us just going with what we think and how it must be,” says Bushell.
The benefits extended both ways. Jorgensen, a University of Toronto doctoral candidate and lead researcher on the project, reflected on how streamlined this type of research was compared to the years it can take to go through academic routes: “I think for me the big thing is being able to see the research have an impact a lot quicker than it might have through other formal or different types of channels. This was able to come to life right away and have an impact right away.”
By way of the partnership, we can expect to see a more colourful card system in Canadian rugby. Most importantly, this research project has helped to ensure this new Blue Card tool does its job to prevent and manage concussions by providing officials with the support and resources they need.
Learn more about the Blue Card system or SIRC’s Match Grant partnerships.
Baseline testing can help to identify when an athlete is ready to return to play following a concussion. However, it’s important that healthcare providers to be aware of the symptoms and signs that can exist in a Para athlete’s non-concussed state. For example, athletes with cognitive impairment may have difficulties with memory and concentration, and athletes with visual impairments are more likely to have pre-existing dizziness, headache and poor balance.
The Youth Concussion Awareness Network (You-CAN) is a novel, peer-led program focused on concussion education and awareness for high-school students across Canada. Findings from the use of You-CAN program in school settings show that youth with higher concussion knowledge are more likely to report a concussion to an adult and to provide social support to a peer.
With limited resources for research initiatives, partnering with external research or community groups can increase a sport organization’s capacity to conduct concussion injury prevention work. Developing initiatives with these partners, such as universities and hospitals, can help sport organizations gain access to trained staff capable of taking on some of the research burden.