10.Most people who play sport do so at the mass participation (or grassroots) level. Therefore, it is likely that the majority of injuries (including concussions) will also occur at this level. The key problem here is the relatively unstructured fashion in which grassroots sport takes place, often organised by insufficiently trained volunteers with no dedicated medical oversight. Dr Richard of the Institute of Sport, Exercise and Health said:
I am exceptionally concerned, more concerned about grassroots than in the professional game. […] I see adolescents who cannot do their A-levels because of a head injury playing rugby at school. I uniformly do not see people being managed well after head injury still in the NHS. I think the governing bodies clearly have a responsibility, they have a duty of care. The clubs and the PFA do. This is a wider public health issue and in Scotland there has been involvement from public health but in England there has been a silence from that.
11.The numbers are large. In football alone there are “13.5 million players of all ages, approximately 400,000 volunteers, over 200,000 coaches and over 27,000 qualified referees”. There is also a lack of information about the scale of the problem: neither sportscotland nor Sport England collected data on incidence of concussion for participants in grassroots sport and the NHS did not systematically record this information on medical records. Professor Burns, NHS England’s National Clinical Director for Dementia and Older People’s Mental Health, told us:
I don’t think we have one central repository of knowledge from general practice about the exact level of incidents within grassroots sport at any level, from children to adult.
12.Sportsmen and women told us about a lack of awareness among participants and those facilitating sport about the problem of concussion or, more specifically, the potential long-term consequences of suffering this kind of injury. Phil Smith, Director of Sport at Sport England, told us that:
Having looked at pretty much every national governing body’s guidance in preparation for this discussion, the guidance is not only comprehensive but it shares a number of common characteristics.
The challenge we have in grassroots sport is how we make that advice more widely known to those who, like me, spend their evenings and weekends helping others to enjoy sport.
13.Scotland appears to be further advanced in this area than other parts of the UK. Dr Elliott of sportscotland outlined the approach being taken there:
From the outset we have had a multi-agency engagement in trying to get people around the table to improve grassroots education and knowledge of concussion.
The heart of this is a recognise and remove process. We ensure that everyone at the football game or at a sports session understands what concussion might look like and on the back of that are able to remove that individual. […] We then ensure the continuation from there is that they get the right access to the healthcare system, how to rehabilitate the person, how to rehabilitate the brain. […] The process looks predominantly at the next stages for us, which is education, looking at parents, looking at PE teachers, looking at students at university level, looking at coaches, and we are facilitating that through these guidances. This is filtered down to grassroots and is engaged by all sports.
This encouraging approach was slightly tarnished by the admission that research by Stirling University identified that the information had not been reaching coaches at grassroots level. The Scottish protocol only covers organised sport and if coaches are not as aware as they should be it is likely that participants and spectators are even less informed.
14.We were concerned that even in organised sport a lack of awareness could put sportsmen and women in danger through failure to observe widely known return to play protocols. Monica Petrosino, a retired TeamGB ice hockey player, told us of the injury that effectively ended her career:
My head over the years probably took a number of knocks but nothing like the hit that I had in 2015. That was very different and I felt very different. I knew that something was very wrong.
I think I blacked out for a minute as I cannot remember what happened. I remember getting back up off the ice with my coach helping me get off, and I can remember having this headache. It is a very specific headache. It feels like your head is crushing. I remember not being able to speak properly or anything. It was like my brain was not working right.
I didn’t play the rest of that game, but unfortunately the thing that I was not aware of, and neither were my coaches or my parent, was that I played a game the next day.
15.One aspect of every protocol that has been highlighted to us is the need to limit return to play. There is no way to know if playing the following day exacerbated the injury suffered by Monica, but in her own words:
I wish someone had stopped me before it might have been too late. Yes, that would be the most important thing. It does affect you for the rest of your life.
16.Peter McCabe, Chief Executive of the Headway charity, made the important point that, for many participating in grassroots and youth sports, the example set by their heroes around head injury needs to change:
Elite sports have a responsibility to set a good example to youth and grassroots sports. If concussion is not taken seriously in elite sport, that is going to be happening on a Saturday morning when youngsters are playing, where there aren’t ambulances waiting at the side of the pitch. Concussion must be taken seriously and if somebody sustains a bang on the head they need to be withdrawn from the field of play and you need to adopt a precautionary approach.
There is a tendency for the press to laud athletes who sustain injuries and drag themselves back onto the field of play, even swathed in bandages. Several of the families who wrote to us spoke of how their fathers were stitched up, bandaged and sent back out to play. This happens despite the cautionary experience of Benjamin Robinson and his father’s campaign to raise awareness about second impact syndrome.
17.The reality is that, for most people playing sport, there is no one to stop them except themselves, their friends, teammates, and family. That is how far down the knowledge and awareness of concussion and how to respond to it must reach to ensure people seek the necessary help and treatment rather than returning to the field to the detriment of their long-term health.
18.There is no end of advice and protocols on concussion in sporting arenas; we had evidence from football, rugby, boxing, cricket and horseracing among others, all of which provided extensive evidence of their protocols for those participating in their sport. It is also easy to find lots of advice and comment online. What is not clear is what the best advice might be for someone who has recently suffered an impact to the head. There is no obvious single source to reference. While there is some collaboration among sports on research, and the community of chief medical officers seems to be reasonably tight, there is no minimum standard. Sport England told us that it was for each sport to develop its own advice, even though some sports might not be able to afford a full-time chief medical officer or have access to the necessary expertise.
19.It is encouraging that groups are being established, such as Sport United against Dementia launched by the Alzheimer’s Society in December 2020 and Love of the Game, but none of these groups will have the profile or power to be the single source of authoritative advice for all sports across the whole of the UK. Throughout this inquiry, discussions have led back to sportscotland’s concussion guidance: ‘If in doubt, sit them out’. This guidance, first produced in 2015 and since updated, was a collaboration between sport, academia, NHS Scotland and the Scottish Government aimed squarely at grassroots sport and the general public. Both Wales and Northern Ireland have similar guidance but there is no equivalent in England.
20.Another message that we repeatedly received was that the NHS is not properly equipped to deal with this issue. In our first evidence session, Professors Willie Stewart and Craig Ritchie spoke of the need to promote brain health and move away from the long-held belief that nothing can be done once brain injury is received. Professor Ritchie was concerned that “we have players now, ex-players now, who are terrified about their own brain health and what is going to happen to them in the future”. Campaigning groups wanted to see better facilities and improved continuing professional development courses for GPs and Accident and Emergency specialists. Dr Grey, of the UK Acquired Brain Injury Forum, highlighted the need for better information on those who present with head trauma:
In the east of England we have the Concussion Action Programme and we have recently looked at this issue and produced a report. With respect to the NHS, we found that there is a large variation in the content and quality of discharge information that people are given if they attend A&E with a mild traumatic brain injury. That information is typically these red flag issues but there is nothing given typically on return to play, return to learn or return to work issues.
21.We contacted both NHS England and Public Health England to give oral evidence but Public Health England, to the surprise of Dr Etherington, of the Faculty of Exercise and Sport Medicine, indicated that it had no contribution to make to the inquiry. Dr Etherington commented that:
That is because, as far as I am aware, there is no concussion protocol or concussion group looking at managing brain injury in presenting to A&E or in the sporting environment, and there probably should be. For the vast majority of people, it is going to be transient and can be managed quite simply, but we need to pick up those people in which it is recurrent or who have serious consequences.
22.Professor Burns, National Clinical Director for Dementia and Older People’s Mental Health for NHS England, was reasonably confident that NHS England was properly resourced and sought to provide some context to the extent of the issue:
Every year, about 1 million people attend A&E in England with a head injury. Of that 1 million people, about 900,000 have no or a very brief loss of consciousness. The vast majority, about 85%, recover after a week with no lingering symptoms and that rises to 97% after about a month.
In the hospital system, between April 2017 and February this year, there were 7,536 admissions with concussion. Only 8.5% were sports-related, and that is fairly consistent over the years. There has been a significant drop in the last year with much less sport taking place. In the vast majority of cases, 98.6%, there was no specific intervention. People were in hospital perhaps one or two days. There was a peak with monitoring in children because of the concentration of children 11 to 16. Thirteen people were recorded over that period as having died, but none of those deaths were related to sports injuries. The data and the information for the hospital system is there.
Those numbers, however, need to be considered alongside those presented by Dr Etherington:
If you look at very severe brain injury and the services commissioned by NHS England, there are 950 beds commissioned for the whole of England, and of those just under 200 are probably used for trauma. Neurological rehabilitation for trauma is about 200 beds in England, but in context I used to have that many beds with complex trauma in the military in one site, Headley Court, in England.
Professor Burns was also confident about the knowledge and awareness of medics in Accident and Emergency wards and that GPs would be able to refer patients presenting with symptoms of concussion to a wide range of specialist services. He was however unwilling to address a comment from Dr Sylvester, of the Institute of Sport, Exercise and Health, who suggested that:
The management of post-concussion syndrome in most non-specialists’ minds is: it will get better over time or it will not. It is clinical nihilism.
Dr Elliott of sportscotland also suggested that non-specialist doctors working in the NHS were unlikely to have picked up the necessary knowledge to properly treat those suffering from this kind of traumatic brain injury:
But we have colleagues who see the weekend warriors on a Monday or a Tuesday in general practice. While they have a degree of understanding of how to manage major concussion issues, they might not be aware of the subtle returning to work or learning bit before returning to sport. For us it is also educating our medical colleagues. That could be nurses, physiotherapists, doctors. Anyone who has a point-of-care touch with a patient should know about concussion. That is an area that we feel we need to improve on, and we have colleagues already working with the Royal College of Emergency Medicine and the Royal College of GPs to provide e-learning modules and platforms to give our colleagues upskilling.
23.We also heard some concerns about the collection of data. It has been pointed out that the oft-quoted FIELD study was only possible due to Scotland’s record keeping of footballers who had experienced neurological disease in later life. Professor Burns was unclear on the availability of structured data relating to those who present at hospitals with concussion-related injuries, specifically sports related injuries. The importance of collecting structured data that could be referenced by clinicians (as well as data scientists) is highlighted by Dr Sylvester:
Also, kids do not just play one sport. They play rugby, they play football, they play basketball, and they play cricket. I have loads of kids who had a concussion playing rugby but then are in the basketball game three days later, because it is a different coach and there are no guidelines on concussion in basketball. I am not sure if there are or not. This transcends individual sports as well.
24.Doctors may not be able to rely on patients to remember previous concussions or head traumas, especially if these happened at different times playing different sports. They must instead be able to rely on robust information that should be collated on a patient’s records.
25.We recommend that NHS England reviews the way in which it collates data about concussion and concussion-related brain injury and ensures that doctors have a full history available to better inform patient treatments.
26.We are also concerned that the relative infrequency with which clinicians encounter this kind of condition suggests that many of them are likely to be out of date with regard to the best possible practice in treating these patients and getting them the necessary specialist treatments.
27.We recommend that NHS England, in collaboration with the Faculty of Exercise and Sport Medicine, within the next twelve months, prepares a learning module on the best practice for treating and advising those who present with concussive trauma and ensure that all General Practice and Accident & Emergency practitioners take this module within the next 2 years. The module, and the updating of practitioners, should be repeated every 2 years thereafter.
12 The Football Association ()
18 For example, The Football Association ()
21 “”, Daily Telegraph, 19 October 2017
22 For example, Lauren Pender (); Mrs Dana Saul ()
23 Mr Peter Robinson ()
24 For example, British Horseracing Authority (); England Boxing, British Boxing Board of Control, Boxing Scotland, Welsh Boxing, GB Boxing ()
26 For example,
27 Alzheimer’s Society ()
28 Love of the Game ()
29 “”, sportscotland, 15 November 2016 (updated 2018)