A qualitative analysis of existing concussion return to play protocols and psychological recovery management in Gaelic games

Transcription and categorisation

The recordings from Microsoft Teams (Microsoft, USA) were used to generate transcripts of the interviews. The lead researcher initially reviewed and transcribed these transcripts, in turn each transcript was compared against the original Microsoft Teams video recordings and a secondary audio recording to identify and correct any discrepancies. This iterative process ensured the accuracy and reliability of the final transcripts for all participants (n = 22).

The decontextualization process of each interview allowed the lead researcher (ED) to fully familiarize themselves with the content of each transcript. This process involved repeatedly listening to the audio recordings while simultaneously reading the corresponding transcripts to ensure that the questions and responses accurately matched the audio files. This verification was performed approximately 4–5 times per transcript, depending on the level of editing required for each interview.

The lead researcher identified thematic categories and subcategories from the twenty-two-athlete interview transcripts, ³⁰ during the recontextualization process, the initial list of identified themes were reviewed and consolidated into subcategories to reduce the overall number of themes. ³¹ Table 1 presents the athletes’ perceptions of concussion recognition and management within this group of Gaelic games athletes.

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Table 1.

Sample results of thematic analysis of interviews with Gaelic games athletes (n = 22).

Themes	Categories	Subcategories	Sample Quote
Lack of psychological recovery management for concussion in Gaelic games athletes	Acknowledgement of concussion as a prevalent injury in Gaelic games	Psychological recovery, fears, and anxiety as part of the concussion recovery process Perceived psychological pressure from peers and coaching staff.	“I feel like a bit of a fraud being injured with a concussion because if it was a cruciate (ligament), if it was a broken bone, the lads are training the way, they're looking over going, saying he's grand” (P9) “I'd be afraid of getting hit again…. I don't know, what if (her eye) stops working or something….I don't know anything about concussions or anything. So, I only know what they tell me” (P16) “It's frustrating for the player as well because you're nearly saying to yourself is this is it? Is it actually just in my head like? Nearly feel like ‘cause, you can't physically see it. You can feel it in your head, but you're like, am I nearly over thinking it (being asked to return to play)” (P22)
Non-standardised concussion protocols and concussion education within Gaelic games	Awareness and promotion of concussion education programs within the GAA	Non standardised procedures and consistent access to resources to assist recovery. Knowledge of RTP and differences in adult male and female return to play protocols	“Even though I'm aware of it now because I've suffered one, I still haven't seen like every county, every club in every county should be offering a talk to know….. just to even give, especially even underage players who think they're invincible” (P11) “Some people will deliberately score worse (on baseline testing)” (P1) “I think that's a bit crazy to have only a week return to play after getting that significant of a hit like that (to cause concussion)” (P2)

Psychological recovery as part of the concussion recovery process

Most of the focus in concussion recovery research is focused on the physical recovery or the negation of concussion symptoms by symptom provocation and symptom monitoring. A common manifestation of non-physical recovery which presented during the interviews were the number of athletes who expressed concerns regarding psychological issues during return to activity or return to play. These concerns were amplified after they experienced post-concussion syndrome or if they experienced a number of diagnosed or undiagnosed concussions. Interestingly, this ‘psychological recovery’ is oftentimes neglected in large swathes of academic research with respect to concussion in sport. Perhaps this amplification is more overtly observed in elite amateur athletes where the perceived pressures of returning to competition are more publicly known when compared to amateur levels. A subsequent point which emerged was that this type of recovery only became obvious once they began to discuss the complications they experienced during recovery. It was imminently obvious this psychological recovery went unnoticed or unrecognised by most of the cohort involved in this research, “It was actually the next game that I got hit, but I was so afraid, I was so afraid. I had not got over the actual concussion, even though physically I was fine” (P5) supported by “I can get past this stuff (anxiety caused by concussion symptoms) and it wasn't a new occurrence to me” (P6).

All participants expressed frustrations and internal anxieties about being injured, whether this was a physical injury involving a musculoskeletal injury, or where the injury involved concussion. They were generally of the opinion, if the injury was ‘physical’, this category of injury was more manageable. The rationale behind this manageability was that physical injuries had defined timelines and/or, physiotherapists or medical staff had better knowledge of these injuries and were able to get athletes back on track quicker. The less overt frustrations emerged with concussion as athletes felt ““Really lonely, and especially as well, I was meant to be captain, you nearly feel like a failure letting them down because like, I couldn't lead myself, never mind them”. (P10) or “When can I do that (exercise) again? Then you start to, even though you know you shouldn't, you feel I won't use the word depressed, but definitely really down”. (P11).

These types of stresses and anxieties were heightened because in the athlete's opinion, their concussion did not have a defined recovery period. Many of the athletes had added stress because they did not know if they had recovered or not, due to poorly managed recovery timescales, most of the athletes self-managed their RTP, or went back to activity when they felt they had recovered. However, this was generally ill advised, as many discovered to their detriment that they were not fully recovered, which in turn had a negative cascade effect “I was crying and stuff. I wasn't in pain. It was like my body was like, ‘oh, God, don't let this happen again’…. or if my body was just kind of like gone into shock because it didn't want to get hit again” (P16)

These categories of ‘anxious experiences’ were common across many of the athletes’ recovery trajectories, whereby they would make some progress, and in many instances, this apparent progress was accompanied by periods of regressions. For example, with one athlete who was self-managing their recovery, they went through bouts of nausea while attempting to return to activity “I was really sick….and it just started to hit my system as if we need to, we need to go quick because I don't feel well, and so, I was like, get dressed quick and we'll get out of here.” (P16). Another athlete had a similar experience while they were receiving specialist concussion care, “Doing all these tests and she (physiotherapist) kept failing me for about three or four weeks in a row” (P15).

It is notable to observe the number of athletes who are having to manage long term post-concussion symptoms. With some of these athletes, the long-term symptoms such as ‘headaches’ or ‘migraines’ share a common trait which is that these symptoms are part of their ‘daily lives’, “I remember being so annoyed (long term symptoms) with the whole situation because when it was affecting my day-to-day life, it was really annoying me” (P18). Other long-term issues which are perceived to be connected to their concussion histories come in form of panic attacks and heightened emotions, “I kind of get panic attacks too…… I just don't feel right, they just come out of the blue like, you know, just like a freight train” (P8) or “I just had, like a bit of an episode (panic attack)….I kind of felt nauseous and again and dizzy and frustrated and was kind of was crying….I don't know what's wrong with me” (P16). One athlete who has struggled with severe side effects of concussions, attempted to seek multiple medical sources to ‘fix’ how they were feeling commented “I was kind of dealing with it, and that's what she (clinical psychologist) was saying (I) was kind of presenting as someone with a mild traumatic kind of background or PTSD” (P5).

Different athletes have developed different coping mechanisms to disguise these long-term effects, “I'd be halfway through a sentence like nearly forget what I was saying, and I'd be like all, oh, never mind” (P14). Even though some athletes may use dismissive language or other types of behaviour to not disclose how they are feeling, other athletes are focused on the potential long term effects of multiple concussions, “(It) was hard enough to remember them, like, how many (concussions)….you'd like to look into more and see what's the damage doing to your head” (P15) supported by “worries, because I experienced them, but I still don't know if I understood the seriousness of it (multiple concussions)” (P18).

Perceived psychological pressure from peers and coaching staff

During the interview process, there was a generic admission by many of the athletes during the recovery process that they felt various pressures from a variety of sources, including self-imposed pressure to RTP. Many of these pressures were latent, or a combination of latent and direct, particularly in relation to pressure to RTP from the management of squads. The consensus was that concussion was not ‘taken as seriously’ as other injuries such as musculoskeletal injuries. By extension, when athletes were forced to retire because of concussions, these were viewed with scepticism, “fellas that had to stop playing because of multiple concussions….I know for fact they're viewed differently, are perceived differently than those who had the stop playing because of a serious knee injury and that's the sad reality” (P4).

Concerns discussed during the interviews highlighted a relatively well managed RTP process for most categories of injuries in Gaelic games. These processes became less defined for athletes once they were managing a concussion and the associated steps to recovery. The complexities involved in these procedures became additionally muddied when the processes were ill defined “I wanted to get back as fast as I could, and the doctor doesn't want you back at all. Like, the management keep checking out. ‘When will you be back?’ So, everyone's kind of pulling out of you, and then when you're not training, you kind of don't feel like you're a part of the team” (P15). Regardless of whether athletes were coming from an amateur or elite amateur background, many of them expressed points of view where management were attempting to influence an earlier RTP. It was a widely held belief, that if the athletes had a visible injury, or were obviously injured such as having a broken limb, then the pressure to return would not have been present. It appears that some athletes felt a level of distrust by their management or coaches, some thought the coaches believed they were just ‘trying to get out of training’. “they're all like ‘Are you going to be back tonight?’ nobody knows what or how to deal with your situation….you're probably worse off than if you tore your hamstring. “ (P10)

Other comments from the athletes suggested that the main reason for the ‘pressures’ had a more concise explanation. It was clear from the interviews that concussion is a largely unrecognised injury in Gaelic games. The participants believed there is an education and knowledge gap in the implementation of suitable processes to manage RTP, this is one of the reasons why concussion is not widely discussed in Gaelic games. An athlete commented that his conversation with a manager was “You're fine, you're alright, like you know, but obviously they didn't know that much about it (concussion) either” (P8) and supported by “ They (management and coaches) just don't know….I think it could be a lack of education around the issues that could happen as a result (long term effects)” (P13)

The lack of knowledge about the subtleties of concussion recovery are compounded by factors such as the limited time they (managers and athletes) physically meet “I think they (team management) don't see. They only see you for an hour of the day. But they don't see the symptoms for the rest of the day or they don't feel the headaches” (P17). Intentionally or unintentionally, these types of comments from management exert a form of pressure on athletes to consider returning to play while symptomatic or remaining unwell due to the myriad of long-term effects of concussion. “And the managers were always asking ‘how are you’, but at the same time, they want you back. and every time you say ‘no’, you feel like you're putting a dagger in their heart”. (P10). It's well established that athletes will continue to play while injured for various reasons, such as loyalty to a team, determination to play due to being competitive individuals or the perceived magnitude of the games being played.

Non standardised procedures and consistent access to resources to assist recovery

There are many ways to view the current concussion protocols in Gaelic sports, it is possible to view RTP through the prism of whether athletes are informed that protocols exist. Another lens may examine if there are sufficient measures to create awareness regarding brain injury as a consequence of participating in Gaelic sports. Another viewpoint may critique if there is a sufficient depth of specific concussion knowledge within the medical and physiotherapy practitioners servicing Gaelic sports at amateur or elite amateur levels. Reviewing the remarks from the cohort of athletes in this research, all these observable viewpoints came under scrutiny.

For instance, one athlete commented “there wasn't as much awareness around it. The amount of players that probably played through (while symptomatic)….and yeah, didn't give it the healing process” (P4). As has been established, all of this cohort had experienced at least one medically diagnosed concussion, however the vast majority of athletes, either did not recognise concussion as an injury or the processes in place were simply not adequate “Like, nobody knows how long the recovery process takes, no one really cares how long it takes. All they want to know is when you're back that like there's no, there's no kind of procedure in place for concussion” (P12). It was notable that athletes who had retired due to multiple concussions, or those who had experienced a number of concussions believed that the current RTP system and Gaelic games concussion protocols were “not fit for purpose….seven days is a cop out” (P9).

One point on which there was universal agreement was the need to officially standardise the process and more importantly, make the process as objective as is possible. These ‘objective’ comments were prominent across the cohort of participants, “I could look at someone and think something (concussion assessment) and you could look at someone and think something else. So, it probably would need an objective measurement which could reduce the risk of people lying about their symptoms” (P17). The principles regarding an objective test centred around two distinct point; taking the decision out of the athletes’ hands as to whether they were concussed or not, and secondly, an objective measure may reduce the incidence of athletes not disclosing their symptoms.

During the interviews, many athletes suggested that the GAA give serious consideration to introducing a head injury assessment (HIA) similar to other field sports, “I think it would definitely be very easily put in place the HIA, just like that's in the rugby. I don't see how that would slow down the game or have any effect on it, and I think that would definitely be a huge benefit if they (GAA) could” (P12). These sentiments were shared and added to by other athletes, particularly in relation to the use of helmets in hurling and camogie, “If you get a belt to the head, I think you should be going off for a HIA just like the rugby…… I don't think there's any of that in GAA….the helmet doesn't really save you” (P15). Gradually during the interviews, a range of tangential comments were expressed by the athletes, as for many it was their first-time discussing concussion and the wider concerns they held about head injury. Some of these comments led to a broader concern for concussion management across other sports, as some of these athletes were currently, or former multisport athletes, “And the one thing I would say that really bothers me is that everyone, like the IRFU, the GAA they all seem to have different protocols and like should it not be a one size fits all?” (P10). This was an interesting point to note as in many countries, concussion is growing public health concern, and this is an area where the governance of sport in Ireland needs to take a unified approach.

Deficits in concussion management for many participants originated from the initial level of care and subsequent follow-on levels of care received in amateur and elite amateur settings. This very common standpoint reflected the opinions of many athletes “I probably don't think it's treated equally….the biggest problem is probably the practitioners working with the teams aren't in a position to deal with it (concussion) at the same as they deal with hamstrings, quads, calves”. (P10). The widely stated issue in which practitioners were not able to fully assist was stated in a number of ways “I definitely think a lot of physios are, I would say probably don't know the proper symptoms of concussion” (P20) or “I didn't go to any physio because I didn't see the point of going to physio, I don't know what physios do in terms of concussion” (P14) supported by “There's not enough requirements for people to who are involved to know what the best path…and I find a lot of people who get concussed now don't go to the physio” (P10) and more explicitly as “things (recovery)were really difficult, but there was no return to play and there was no real (player) welfare in it, you know, and I felt that pressure” (P3). As mentioned, all athletes had or have played amateur and a large percentage had or have played at elite amateur level, this parallel career reflected some commentary around better treatment outcomes for athletes at all levels, “At club level, there's no charter to ensure that all those medical professionals are there. They need to start putting structures in place to be able for clubs to be able to facilitate the protocols” (P17). Even where changes may be implemented regarding concussion management, some feared that meaningful changes may still be remote “I think people are more aware of it (concussion), whether practice changes, I'm not 100% sure” (P13).

Even though the athletes openly acknowledged a lack of standardised care from their concussion experiences, they felt that there were a series of relatively implementable steps which may improve the outcomes for athletes who experience concussion “I think the biggest thing that needs to be done is just training the people that are going to be on the sidelines to be able to respond effectively” (P10) and “I suppose to have information on what professional to see if you suspect a concussion or how they might help you” (P14). In parallel, with medical staff and allied health practitioners, the athletes acknowledged that it goes beyond the medical dimension. Whereby they believed that the responsibility for concussion identification and management should be within the remit of other officials and administrators associated with Gaelic sports. “I think physios and managers, need to have more power…..it's not up to the player; referees as well that if they suspect a concussion, it's non-negotiable, you're off the pitch for a proper assessment” (P14) along with a greater focus on stricter implementation of the rules of the game “I think it's more referees getting strict and if you get a hurl in the head….. I didn't even get a free when I got hit in the head” (P16).

Being cognisant of the fact that many athletes purported there may be potential for long term effects of repeated concussions over the course of a Gaelic games career. These short- and long-term effects were discussed by the athletes, particularly considering historic and recent litigation in other organised field sports “I would follow, obviously other sports and you see the fallout from those sports where players were exposed…… it wasn't really given the respect it needed, you see the fallout down the line that those players encounter, and that scares you” (P4).

Knowledge of RTP and differences in adult male and female return to play protocols

Based on discussions and remarks from the participants, there was no ongoing education and awareness regarding concussion during any part of their Gaelic games’ careers. The principal reason the athletes began to recognise concussion as an injury was when they experienced it directly for themselves. Other than physically going through the range of signs and symptoms, they would not have viewed concussion as an injury which would have made them stop competing. As a peripheral consequence of possessing a low level of concussion knowledge, even while they suspected themselves of being in a concussed state, they chose not to disclose their condition for a variety of reasons, “You have other players who are fiercely competitive and will not show anything, and we've had one other girl who I don't know if she was concussed, I think potentially was, and again played on, this was a training session and (she) continued to train through it (being concussed)” (P13).

Playing through symptoms, either acute or chronic, was a common occurrence within the cohort of athletes interviewed. There were many reasons for continuing to play, two in particular stand out from the others. These were that (a) nobody in a management position consistently checked their health status, or (b) they managed to ‘hold things together’ and hide the true effects of concussion. For example one athlete stated that “where you get those effects, you get the stares in your eyes and especially where you're kind of mentally exhausted, your just drained (trying to hide symptoms)” (P8) and “maybe one of the selectors said ‘are you alright’ and I was probably like, ‘yeah, I'm grand’ cause I was still standing, moving and walking around, so I was still all right” (P16).

There was a diversity of responses to what the current Gaelic games RTP might include or the duration of a standard RTP is in the GAA. Some respondents had categorised their concussion symptoms as ‘delayed concussion’ where they believed these symptoms were not ‘as bad’ as being knocked unconscious, hence they could continue to play their sport “I suppose my first concussion was in 2018 or 19. I think it was, I get a ‘delayed concussion’, so I haven't been fully knocked out” (P15). There were a number of comments regarding the volume of concussions which could be experienced “If you pick up a number of them in a year, you have to be very worried about (them) but that was my understanding” (P5) and conversely a number of athletes questioned if they had returned to play too quickly, particularly if they had an amount of both diagnosed and undiagnosed concussions, “(I) do wonder if going back too early was half the reason why mine (symptoms) kept returning and the first two times I got back before or the first time I was back well before I should” (P18), and supported by “I don't know if it was a coincidence that the two that I had were probably in the space of twelve months of each other…..you probably do hear people who have had two-three, maybe even four concussions…..if you look at the stats if you've had one maybe you are more inclined to get a second or even a third”. (P21). For those athletes who had progressed through an RTP process, they felt there was either outdated or obscure information received from people who were helping them to recover “it's completely changed now because, I was told to go into a dark room. No screen time, no nothing. And then last year, the protocol has changed completely, now it's you have to be more active, so I actually stayed working and everything” (P15).

On first inquiry, knowledge of RTP in Gaelic sports was superficial and generally poor across amateur and elite amateur levels. There was evidence of vague recollections of structured attempts to create awareness of the complexity and dangers of undiagnosed concussions by player welfare groups. Others simply had no knowledge of what the RTP processes were “I can assume that they (RTP protocols) may be similar to what to do in the rugby practices….I'd only be guessing really if I told you what like what the steps were or what they did” (P7) and “the GPA (Gaelic Players Association) would have ran a campaign a couple of years ago….so there's been some effort to try and like raise awareness of it.” (P5).

A final area of contention for RTP was the anomaly of differing durations for female and male athletes. For the majority of the cohort, they were unaware that for female athletes, the recommended RTP, once formally diagnosed was fifteen days. For male Gaelic sports athletes, this duration was seven days. Examining this incongruity in Gaelic games, it was not apparent for the justification of this rationale, the GAA do not overtly provide reasons for these differences in duration for RTP.

It may be concisely summarised in the following statements “If you're a male or female, why would they be different to one another. The thing that's jumps out in me, and why would they not merge them, and form one return (to play) protocol? Obviously, they both have to go through the same steps, same procedures” (P11) and supported by “I mean a head trauma is a head trauma, a head injury is a head injury…… so, I don't understand why there would be a difference in that (difference in RTP durations in GAA)” (P13). Once participants in the research understood that there were differences, people began to view the reality of RTP in terms of “Surely the recovery rate is the same, and it's putting more pressure on men…. It's giving them (male GAA players) less of a chance to actually see if they have symptoms” (P14). The pertinent issue of full symptomology resolution in male athletes was strongly expressed, particularly where symptoms may not be fully dissipated in seven days. “you're putting that player back into a scenario where they could very much get crushed.” (P11)

These differences in RTP duration either in an overt or covert manner, add to the pressure under which male athletes operate in Gaelic games, it was summed up effectively in one comment “but if the game was on the eight (day), I could play that. See the problem is as well, like if a big game is coming up, no one wants to miss it.” (P22). From a male athlete perspective, they felt that the seven-day RTP was an inadequate timeframe to be for to play at a high level due to wide range of concussion symptomology . “ If you get a leg injury, take fourteen days and come back, well, did you strain your hamstring or did you have like a leg break? Do you know it's just; it just makes no sense” (P5) and “There's still underlying things going on that are just kind of invisible until you actually test and have a look at them….. but I don't think it should be seven days after my experience with it.” (P16).