Opinion: the rise of sports-related brain injuries raises issues about the widespread culture of playing while hurt 

Have you experienced a sports-related brain injury? Known in everyday vernacular as concussion, it includes immediate and temporary symptoms associated with a mild traumatic brain injury. It also includes a clinical state of brain functioning and the events that generated it - i.e. brain shaking, a jarring sensation from sudden acceleration/deceleration that does not have to involve direct contact with the head.

Concussion is similar to and different from other sports injuries in a number of important ways. It is more challenging to diagnose with delayed and often hidden symptoms across a range of domains including balance, memory, vision and cognition. Loss of consciousness does not occur in the majority of cases. It is potentially life threatening as a one-off or recurrent event, the death of Co. Antrim schoolboy, Ben Robinson, being a case in point.

From RTÉ Radio 1's Today with Sean O'Rourke show, a discussion on concussion in the GAA with former Tyrone star Sean Cavanagh and Donegal GAA Team Doctor and Member of hte GAA's Medical, Scientific and Welfare Committee, Dr Kevin Moran

It is more heavily regulated and unique in now having discrete and often lengthy codes of practice written into the regulations of many sports, requiring specialist clinical oversight and an individualised graduated return to training and competition. Importantly, the social relations of concussion reflect the same sanctioning and support of injury more generally and the pressure to "play on", as well as the associated burden on sports medics and healthcare professionals to declare players fit to train, play or return to the game. Critically, the complex presentation means that the relationship with pain is less straightforward than for most other injuries.

For these reasons, concussion generates more debate than all other sports injuries combined. Most view the injury in largely bio-medical terms, drawing, understandably, from the expertise of neurologists, sports medics, epidemiologists and the like. Yet this is a skewed approach that generates a dangerously incomplete picture. Crucial questions pertain to this injury that simply cannot be answered by those wearing white laboratory coats.

From RTÉ 2fm's Game On, sports-related concussion expert Dr Michael Collins on sports injuries

For instance, why do sportspeople continue to reject diagnosis protocols despite greater awareness surrounding the injury? The admissions of Brian O’Driscoll and Sean Kavanagh are local examples of this. How, and why do sportspeople frame the injury in ways that are unique to the culture of sport - that is, in terms of minimal time loss and return to play - and not in medical terms? What are the implications of this for trying to prevent the injury? Why are players’ incentives to seek medical consultation so weak?

Medical insights are important. But when considered superior to and/or in isolation from the socio-economic and cultural processes that shape our attitudes, values, behaviours and motivation for sport, we restrict the potential effectiveness of educational initiatives. Make no mistake, this is as challenging as the Enigma code: how do we move away from a culture of risk and towards a culture of precaution in sport?

From RTÉ Radio 1's Morning Ireland, Kieran Loughran, CEO Headway and Dr David Connolly, Dundalk FC Team Doctor discuss new research from a national survey on concussion and the launch of a campaign to raise awareness among schools and clubs

The starting point has to involve relations between players, coaches, managers, sports medics and institutions. Put simply, playing sport is a shared practice. It is not something that can be reduced to things that individuals do and think in isolation from others. Sport exists above and beyond the individuals who partake in it.

The norm of "playing hurt" is deeply engrained in the cultural DNA of competitive sport at all levels. This is a culture that fosters achievement values and ideologies. Think of the numerous times that well-intentioned coaches and parents have said to their players, sons and daughters: "you’re fine, up you get", which is a benign message at face value of "the pain will ease". In more competitive scenarios, it's "we need you, your team needs you" or "we’ll take a look afterwards, play on". More explicit social pressure is exerted. This normative practice is inculcated from a young age to the point of becoming second nature. It's so pervasive by our adult years that the very process of naming and exposing this practice seems almost anachronistic.

Katie Liston's presentation at the GAA National Games Development Conference 2019

We need to be willing to examine the sports ethic and to change it. In saying this, we should neither apologise nor are we "soft" for desiring greater levels of safety in sport, especially when it comes to brain injury. Taking fewer risks requires much more than an appeal to common sense. If changing concussion behaviours were simply about common sense and better choices, then sportspeople would be able to make whatever changes they wanted whenever they wanted, but they do not.  

Changing attitudes regarding concussion is also more than a matter of getting this message "out there" in forms that people can identify with and understand. Concussion awareness campaigns have an important role, but they are one part of a much wider strategy. Just like anti-smoking campaigns, changing the sports ethic will not be a one-off event triggered by more information involving health threats. This is because sport helps people to define who they are. Their sense of self is deeply intertwined in its’ habits and habitat: involving the willingness to make sacrifices by showing unwavering commitment; striving for sporting distinction; the acceptance of risk and the probability of participation while enduring pain; and, a tacit acceptance of pushing limits in the pursuit of performance.

READ: Taking one for the team: why playing hurt is a bad move

Understanding this social practice will require more research from a socio-cultural perspective into the sports ethic and the associated norm of playing hurt. If we understand these, and the particular attitudes exhibited by sportspeople towards concussion, we are better able to support them to change. Ultimately, when sports injury ceases to be glamorised and is therefore less socially desirable, we will break the links between the sports talk around concussion, the norms that drive athletes to avoid diagnosis and the networks around it. In short, we need to reframe concussion in equal cultural and medical terms. Well begun is half done in order to crack the concussion code.

The views expressed here are those of the author and do not represent or reflect the views of RTÉ