On the 27th November 2019, we had the pleasure of attending the 4th Annual UK Sports Concussion Research Symposium at Twickenham Stadium (London, UK). The Symposium, this year jointly hosted by The Drake Foundation, Rugby Football Union, Football Association, England and Wales Cricket Board and British Horseracing Authority, featured updates in concussion research from a range of different sports and highlighted potential future directions.
In this report, I’ll share my highlights from the day and summarize some of the main key takeaways.
Football focus – where are we now?
In the first morning session, chaired by Charlotte Cowie (Head of Performance Medicine at the FA), speakers provided updates on their football-focused concussion research and provided insight on what the future direction for this field should be.
The FIELD study: neurodegenerative disease in former professional footballers and mental health outcomes
The first talk of the day was from Willie Stewart (University of Glasgow, UK), who presented findings from the recent initial publication from the FIELD study, which revealed that former professional footballers have an increased mortality from neurodegenerative disease. Learn more about FIELD’s findings here. So far from the FIELD study data, only a history of heading the ball has been identified as a risk factor for the development of neurodegenerative disease in footballers. Therefore, Stewart concluded that there is a need to reduce the risk of head injuries and better manage head injuries when they do occur. The FIELD study aims to further these initial findings by comparing all-cause and disease-specific mortality in former professional footballers to a matched general population comparison group.
During his talk Stewart emphasized the importance of remembering the positive outcomes a career in football can have. Though the findings from his study show an increased risk of developing a neurodegenerative disease, the risk of developing other diseases, such as lung cancer and ischemic heart disease, is significantly reduced. This became a recurring theme through the day: while evidence is mounting that links a history of repetitive head impacts with cognitive and pathological impacts later in life, the other health benefits of taking part in sport can be huge and should not be forgotten.
Further soon-to-be-published work from the FIELD study was presented by Emma Russell (University of Glasgow, UK), who focused on the growing concern surrounding players mental health.
PREVENT:FC and PREVENT:RFC
Natalie Jenkins (University of Edinburgh, UK) presented updates on the PREVENT dementia studies, which aim to identify the earliest signs of neurodegenerative disease in order to increase disease prevention by risk detection. In particular, Jenkins talked through the PREVENT:FC and PREVENT:RFC arms of the study that plan to use imagining techniques to assess the brains of footballers and rugby players, respectively.
HEADING study update
Both Damien McElvenny and Ioannis Basinas (both Institute of Occupational Medicine, UK) mentioned heading exposure again during their talk, as they provided an overview of The Drake Foundation-funded HEADING study, which aims to find out if there are any associations between history of concussion and/or heading the ball with the development of neurodegenerative disease. In the HEADING study – for which assessment has now started – former elite footballers will undergo series of tests evaluating their physical and cognitive capabilities, as well as neurological clinical examinations. The study will also seek to assess and categorize heading exposure in these former players.
The study is now actively recruiting participants: if you are a retired football player and have received an invitation to participate, please use the contact details provided in your invite to reply to the study investigators.
For any other queries on the HEADING study, you can contact the research team via [email protected].
Heading exposure and direction in EuRope (HEADER)
Again, following in the theme of heading exposure in football, Katy Stewart (Hampden Sports Clinic) explained that the aims of the current HEADER study are to establish current youth football protocols in heading and concussion management across Europe and assess children’s and youth football coaches’ current knowledge of the protocols.
Panel discussion: where next in football?
The first panel discussion of the day featured Mark Batt (University of Nottingham, UK), Damien McElvenny, Willie Stewart and Charlotte Cowie. Whilst the panel discussed the future direction football-focused concussion research should take, similar to Stewarts’s earlier comment, Batt highlighted the importance of remembering the beneficial effects of sport in order to keep a balanced view in research. Cowie supported this by saying we must be careful with the signals we give, as it may stop young people from playing any sport at all. Further, Cowie explained how the FA are already taking steps to minimize head injuries in younger players with the introduction of ‘mini soccer’, which uses smaller balls and encourages ball play on the ground.
Overall, the research presented in this session has shown that there is still a need to better understand, prevent and manage head injuries in football. As research in this field advances, possible changes to the Laws of the Game, such as concussion substitutions, should be considered by FIFA and IFAB. Further, increasing concussion protocol knowledge among players and their coaches is required for a shift in attitude towards head impacts.
Research updates from horseracing, cricket and rugby
In the second morning session, speakers with backgrounds in a range of different sports presented their research. Whilst the findings from many of the studies could have useful applications across various sports, it was interesting to learn about the unique challenges each sport faces.
James Murray (British Horseracing Authority, UK) commented on the importance of each sport having their own concussion research studies, as different sports will have different patterns of injury. Horseracing injuries are quite infrequent, but are extremely violent.
During Antonia Trotta’s (University College Dublin, Ireland) talk on concussion prevention in horseracing, Trotta mentioned the fact that amateur jockeys are 2.5-times more likely to sustain a concussion after a fall when compared with professionals, highlighting the importance of fall training in horseracing.
Moving the conversation over to cricket, Nick Peirce (England and Wales Cricket Board, UK) noted how there has been little change in the Laws of the Game. Despite the introduction of concussion replacements being a step in the right direction, this has not altered the number of concussions sustained. A unique challenge that cricket has to face is that it is not just the players who are at risk of concussion: there have been cases of both the umpire and spectators sustaining injuries and in a small number of extreme cases, these injuries have led to death. Therefore, should changing the ball be considered?
Focusing on reconstructions of head impacts in cricket and beyond, Andy Harland (Loughborough University, UK) presented some of the methods used to model head impacts in hope to develop a better understanding of injuries in an ethical, repeatable manner. Development of head and neck forms allow specific impacts in sport to be reconstructed. Though current models of helmets do not prevent concussion completely, Harland emphasized that they should not be dismissed as useless.
Simon Kemp (Rugby Football Union, UK) started the discussion on concussion in rugby. He mentioned that the tacklers in the game are the most at risk, as 80% of all rugby concussions occur during the tackle. In order to protect these players law changes and education is required. Recently, at the 2019 Rugby World Cup, we have seen success of the new high tackle sanction reducing concussion rates.
Following this, Gus Zimmerman (Imperial College London, UK) discussed the imaging and psychometric measurements currently being used to investigate head injury in elite active rugby players across different points in the season in an ongoing study working with London rugby clubs. Most of the presented data is yet to be published, however, more background on the study can be found here.
Technology and future outlook
The final session of the day was extremely insightful, as it featured talks on the anticipated outcomes from new studies and the potential of technology, such as sensors, in sport.
The first talk in this session was from Naomi Deakin (University of Cambridge, UK), who gave an update on the RESCUE-RACER’s first year. This program aims to investigate concussed motorsport participants by using brain imaging and saliva analysis, as well as vision and memory tests. Participants are tested both at baseline and as soon as possible after their injury. Though the study is not scheduled to finish until December 2020, there have already been some immediate outputs. The main outcome discussed has been a culture change, as drivers are being much more honest about their injuries, demonstrating a step towards the correct direction.
The Drake Football Study
As we hear more about the long-term impacts of a career in sport on neurocognitive capabilities, attention has also mounted around the overall health of players both in their careers and through retirement. Vincent Gouttebarge (FIFPRO and Amsterdam UMC, The Netherlands) discussed the trends we are already beginning to see in cardiovascular, musculoskeletal, cognitive and mental health, and the need for longitudinal research in this area. He went on to outline the recently launched Drake Football Study, co-funded by The Drake Foundation, FIFPRO and several collaborators, which will track and provide valuable insight over at least 10 years on professional footballers’ overall health and wellbeing. Learn more about The Drake Football Study here.
Have instrumented mouthguards come of age?
Sensors have developed a lot over the years, and now we are able to accurately measure events in real time, plus multiple users can be tracked at the same time. During their talk on using sensors in mouthguards, Chris Turner (Sports and Wellbeing Analytics, UK) and Mike Loosemore (Institute of Sport, Exercise and Health, UK) discussed some of the unexpected issues they discovered – such as the need to compensate for amplification of forces in sports where players are shouting, such as hockey – and how the technology can be applied to many different sports.
Inertial and neurophysiological measures of concussion
Mo Mahmud (Imperial College London, UK) talked through the inertial and neurophysiological measures used to assess concussion. Mahmud noted that balance is impaired following TBI and can be linked to injury severity, however, subjective symptoms, such as dizziness, do not predict TBI severity.
Panel discussion: opportunities and challenges in sensor concussion research – where are we now?
The second panel, featuring Mazdak Ghajari (Imperial College London, UK), Mike Loosemore, Chris Turner and hosted by Keith Stokes (Rugby Football Union and Bath University), debated the validation of sensors currently being designed. Ghajari commented on the need for a standard testing method for mouthguards. However, interestingly Turner commented: “When is good enough, good enough?”: Turner questioned whether it is impossible to produce the perfect test model and when there may be a need to draw a link in order to gather meaningful data as early as possible.
Before the day came to the end, Simon Kemp closed the symposium with his personal key takeaways. He mentioned that one of the main challenges faced in this field of research is that many of the effects we would like to measure do not present until much later in life, such as cognitive effects, and therefore, researchers must be mindful with how they frame their studies. Finally, he highlighted the importance of taking discussions, similar to those had during the symposium, beyond the science audience to reach coaches and players.
A recurring question that came up during the day was over the lack of female participants in many ongoing studies in this area. Most researchers cited funding as a major contributing factor to this shortfall in female study participation, as well as a lack of historical data. However, it is certainly on the agendas of both researchers and sporting bodies alike to include female participants. Indeed, studies such as RESCUE-RACER are setting a precedent with the inclusion of female drivers in the study.
Another key takeaway from the day centered on the overall benefit of sports and the communication of this message. Though sharing information about the potential risks associated with head impacts is key to promote the necessary changes in attitude and protocol in order to ensure safe play, researchers should be mindful with how new knowledge is communicated to prevent discouragement of sport participation overall.
Lauren Pulling, Programme Manager at The Drake Foundation and co-organizer of the Symposium, commented on the day: “This year’s Symposium has marked a significant year in the concussion field, with media attention and public interest in the long-term effects of sports concussions continuing to grow, particularly around the publication of the first results from the FIELD study. It has been fantastic to hear progress from speakers in concussion research, sporting bodies and technology development today, as well as discussions and debates that will hopefully facilitate new collaborations to further advance our knowledge. Plus, with the recent launch of several new studies, and the anticipated publication of results from ongoing research, 2020 looks set to be another busy year.”
Reflecting on the day, co-host Charlotte Cowie said that is has been “great to see the progression over time of the projects as we move from year to year”, with Simon Kemp adding: “The areas of research focus have remained pretty constant over the 4 years that we’ve been running the event – diagnostic/recognition tools, understanding of recovery, and medium and long term consequences. It’s encouraging to hear results coming out of studies that we were first aware of at the study design stage and see good positive collaborations between sport and academia. There is a need to upscale the scope and scale of studies, but to do this we will need to access new funding streams.”
Overall, the 4th Annual UK Sports Concussion Research Symposium was packed with many insightful talks, with a lot of progress set to continue into 2020. We look forward to attending the symposium again in 2020!