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Flowchart of the recruitment and follow-up of male professional rugby players.
Source publication
Objective
This study explored the association between concussion or musculoskeletal injuries, and the onset of mental health symptoms (MHS) in male professional rugby players over a 12-month period.
Methods
Observational prospective cohort study with three measurements over a follow-up period of 12 months. At baseline, 573 participants provided in...
Citations
... These behaviors may arise from similar biomechanical mechanisms as depression and anxiety [29] or through self-medication to cope with post-concussion symptoms [30]. A prospective cohort study among 573 elite rugby players by Kilic and colleagues [31] found that the number of concussions sustained over the past year was associated with a 1.5-fold increase in the odds of endorsing alcohol misuse while controlling for age and family history of psychiatric disorder. Questions have also arisen about social media addiction among athletes, with some elites struggling to balance their social media use during major sporting events [32]. ...
Background
Some studies suggest that elite athletes experience adverse mental health symptoms at rates commensurate with the general population, despite the well-established buffering effects of exercise. Within contact sports, such as ice-hockey, recurrent concussions may be a source of this discrepancy. We compared the point prevalence of various mental health outcomes with other athlete and general population samples, as well as investigated their relationship with concussive events.
Methods
We surveyed 648 active ice hockey players from the top two men’s tiers and the top women’s tier in Swedish elite ice hockey on lifetime concussive events, hazardous alcohol use, problematic social media use, depression, anxiety, and burnout.
Results
Hazardous alcohol use was more prevalent among male ice hockey players (29.5% AUDIT-C ≥ 6) compared to other athlete and general population samples, while other mental health symptoms were less common. Female ice hockey players reported higher hazardous alcohol consumption (36.4% AUDIT-C ≥ 4) than another athlete sample and more burnout (19.1%) than the general population. After adjusting for covariates, athletes with 3+ concussive events had 2.1 times the odds of elevated depressive symptoms and 3.5 times the odds of elevated burnout symptoms compared to those with no concussion history. Treating lifetime concussive events as a continuous predictor revealed positive correlations with all outcomes except for hazardous alcohol use.
Conclusions
Mental health outcome rates among active elite ice hockey athletes differ from those of other athlete and general population samples, whilst concussive events may be particularly linked to elevated symptoms of depression and burnout.
... Changes in the brain, including electrical activity, metabolic balance, oxygen consumption and irregular cerebral blood flow, continue for a prolonged period after concussion, increasing the risk of repeat concussions, psychological disorders, or musculoskeletal injuries. [18,19] It has been found that athletes who had sustained an SRC and returned to play displayed a higher incidence rate of musculoskeletal injuries compared to athletes who had not. [20] In addition, suspected dysfunction of sensorimotor integration due to disrupted neural connections and axonal shearing may lead to motor control deficits (i.e. ...
... postural instability, reduced muscle activation and force output, dizziness, peripheral neurological symptoms, modified gait patterns, and feeling of being slow etc.) that might lead to worsened performance. [19] Symptom checklists such as the Symptom Evaluation Checklist found in the SCAT6/SCOAT-6 and the ImPACT PCSS form a base of testing for athletes with SRC and persisting symptoms. [3,21] Both evaluate similar areas of interest; however, neither of them explores in detail subjective motor control signs and symptom deficits such as gait impairment and reduced muscle activation and force production (i.e. ...
Background
Persisting symptoms after concussion (PSaC) are a pathological manifestation of head injuries that present with symptoms after the acute phase of head trauma has subsided. Insufficient research about PSaC has led to gaps in knowledge and incorrect terminology being applied. Furthermore, gaps exist in standardised assessment protocols and understanding of mental health symptoms associated with sports.
Objectives
The study aimed to; 1) Determine expert consensus on appropriate terminology for symptoms lasting >4 weeks, 2) Investigate associations with mental health and postural stability symptoms, 3) Evaluate experts’ views on quantitative balance and electroencephalogram (EEG) testing.
Methods
A Delphi-like survey was designed in REDCap and sent to identified experts in the field of sports-related concussions (SRC). Expert consensus was defined as ≥75% agreement.
Results
Expert consensus identified the following mood and motor control symptoms being associated with PSaC: increases in emotional state (80%), irritability (87%), nervousness (87%), sadness (80%), balance impairment (80%), dizziness (87%) and feeling slow (80%). Numbness and tingling were not considered longer-term effects (80%). Additionally, 93% of respondents acknowledged mental health symptoms as potential longer-term effects, with 80% agreeing on inadequate current management. Respondents indicated PSaC are only somewhat adequately managed (73%) or not managed well enough (27%). The use of EEG and quantitative balance testing remains open for debate. The survey response rate was 21%.
Conclusion
Improving mental health management for athletes with PSaC and standardising terminology is crucial. Future research is required to establish effective diagnosis and treatment methods. Addressing these issues may result in better care and safer return to play for athletes.
... In contrast to our well-established understanding of concussion symptomology in the acute phase of injury (< 1 month), the long-term consequences of concussion on cognitive, physical, and psychological health are still the subject of intense debate and remain at the forefront of research [4]. Recent research, despite a lack of consensus, suggests a dose-dependent relationship between concussion, specifically sports-related concussion (SRC), and the later development of depression, emotional disturbance, sleep abnormalities, and addictive behaviors [5][6][7][8][9][10][11][12][13]. ...
... Based on previous research indicating that multiple concussions in an individual's lifetime leads to poorer mental health outcomes [5][6][7][8][9], that adolescence is a transitional period when critical development and risky behavior (i.e., illicit gambling) occur [30][31][32], and that GD is associated with poorer quality of life and suicide [21], understanding the genesis of hazardous gambling and psychological distress in adolescent populations and its relationship to concussion is essential. Thus, the purpose of the present study is to assess the impact of concussion history on psychological distress and hazardous gambling behavior in youth populations while controlling for known covariates, namely age, sex, body mass index (BMI), athlete status, sport type, current and previous parental gambling, as well as previous diagnosis of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and learning disorders (LD). ...
Background
Sustaining multiple concussions over one’s lifetime may be associated with behavioral and mood changes beyond the acute phase of injury. The present cross-sectional study examined the relationship between concussion history, the incidence of current moderate-severe psychological distress, and lifetime adolescent hazardous gambling in high school students.
Methods
Four-hundred fifty-nine high school students from southern Sweden (age: 16.81 ± 0.83, 58.2% male) completed a survey assessing concussion history (0,1,2…>8), psychological distress using the Kessler-6 scale, and lifetime hazardous gambling using the NODS-CLiP scale.
Results
Participants who self-reported three or more concussions were more likely to endorse moderate-severe symptoms of psychological distress than those with no concussion history while controlling for covariates, OR = 2.71, 95% CI [1.19, 6.18]. In contrast, concussion history was not associated with hazardous gambling after controlling for confounding variables.
Conclusions
Self-reporting three or more concussions was associated with increased current psychological distress beyond the acute phase of injury among high school students. Adolescents who have sustained multiple concussions should undergo mental health evaluations beyond the acute phase of injury to identify and treat psychological distress, but probing for hazardous gambling may not be clinically relevant in this previously concussed adolescent population.
... Other considerations that have been reported are changes to the menstrual cycle post-concussion and abnormal menstrual bleeding patterns (Snook et al., 2017) Concussions may have a mediation relationship with the mental health domain. Yet, current research has focused on short and longterm mental health implications following concussion rather than preceding or interacting with its occurrence (Decq et al., 2016;Du Preez et al., 2017;Hind et al., 2022;Kilic et al., 2019). Unfortunately, the literature is dominated by male data and a limited understanding of mental health implications during a playing career. ...
... One study has shown male rugby players who sustained more than two concussions had double the odds of depression than players reporting two or fewer (Du Preez et al., 2017). Another study has shown male rugby players are twice as likely to develop mental health symptoms after sustaining a concussion (Kilic et al., 2019). However, the current mental health state of players as they were exposed to rugby was unknown in previous research. ...
This review discusses female‐specific health considerations in injury and illness surveillance and provides rugby‐specific recommendations for future surveillance. Identifying priority injury and illness problems by determining those problems with the highest rates within women's rugby may highlight different priorities than sex comparisons between men's and women's rugby. Whilst sports exposure is the primary risk for health problems in sports injury and illness surveillance, female athletes have health domains that should also be considered. Alongside female athlete health domains, studies investigating rugby injuries and illnesses highlight the need to broaden the health problem definition typically used in rugby injury and illness surveillance. Using a non‐time‐loss health problem definition, recording female‐specific population characteristics, embedding female athlete health domains and having up‐to‐date injury and illness coding systems should be prioritized within surveillance systems to begin to shed light on potential interactions between sports exposure, health domains and, injuries and illnesses. We call for a collaborative approach across women's rugby to facilitate large injury and illness datasets to be generated and enable granular level categorization and analysis, which may be necessary for certain female athlete health domains. Applying these recommendations will ensure injury and illness surveillance systems improve risk identification and better inform injury and illness prevention strategies in women's rugby.
... 20, 21 Kilic et al prospectively observed professional rugby players over a 12-month period and found those who sustained an injury resulting in losing 28 days of play, had 1.5 odds of developing anxiety or depressive symptoms. 22 A separate longitudinal study by these authors demonstrated injury of professional soccer players resulted in a prevalence of mental health disorder symptoms that was 1.8-7 times higher than healthy players. 23 Padaki et al evaluated a cohort of student-athletes who sustained anterior cruciate ligament injuries and observed post-traumatic stress disorder symptoms, including avoidance, intrusion and hyperarousal, in 75-87.5% of participants after injury. ...
Objective
Social distancing protocols due to the COVID-19 pandemic resulted in premature ending of athletic seasons and cancellation of upcoming seasons, placing significant stress on young athletes. Inability to play or forced early retirement has significant consequences on athlete’s mental health, as demonstrated by an extensive body of injury literature. We hypothesize that premature suspension and cancellation of athletic events due to the COVID-19 pandemic leads to higher incidence of depressive symptoms among high-school and collegiate athletes. Further, athletes who strongly derive their sense of self-worth centered around athletics would have higher rates of depressive symptoms.
Methods
High school and collegiate athletes were evaluated for depressive symptoms, emotional health and athletic identity measures through validated assessment instruments from May 2020 through July 2020. The Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS-10 Depression CAT), Veterans RAND-12 (VR-12), which comprises both a physical and mental health component, and Athletic Identity Measurement Scale (AIMS) were utilized.
Results
Mental health assessments were completed by 515 athletes (52.4% male, 47.6% female; .84.5% collegiate, 15.5% high school). Female athletes scored significantly worse than males on VR-12 mental health assessments, as well as PROMIS-10 Depression scores; however, males scored significantly lower than females on VR-12 physical health assessments, irrespective of education level. Athletes who had strong associations with athletics as central to their personal identity exhibited worse psychologic impact on VR-12 mental health and PROMIS-10 Depression measures and female athletes in this cohort reported greater depressive symptoms than males.
Conclusion
Social distancing protocols due to the COVID-19 pandemic have limited athlete’s ability to participate in sports at the training and competition level. Higher rates of depressive symptoms in high school and college athletes have resulted among female athletes and those who identify strongly as an athlete.
... High training loads also increase injury risk and thus the likelihood of subsequent mental health symptoms (Palmer et al., 2021). A growing body of evidence also highlights the increased risk for athletes of experiencing distress and depression following concussion (Kilic et al., 2019). Relationships within sport, including team dynamics (Fletcher & Wagstaff, 2009), coaching expectations and climate (Pensgaard & Roberts, 2000), loneliness, and unsupportive social environments (Brownrigg et al., 2018) also contribute to the development of psychological disorders among elite athletes. ...
... This focus results in performance goals being prioritized to the detriment of well-being, with evidence linking the performance narrative with disordered eating (Busanich et al., 2016;Papathomas, 2018). Further, in a "win at all costs" environment, pressure to return to sport quickly after an injury or playing through an injury is common (Roderick et al., 2000), which is associated with longer term physical and mental health sequelae (Kilic et al., 2019). A performance focus also drives practices around athletes' bodies, which may contribute to athlete overtraining and subsequent burnout (Rice et al., 2016). ...
... Resulting brain impairments typically are less apparent (one cannot, after all, directly observe brain tissue being injured, as can be done with, for example, a bleeding wound) and they also can be hidden by not reporting symptoms. Moreover, repetitive head impacts have been associated with other health concerns, in particular the onset of chronic traumatic encephalopathy [31] and declines in mental health [32][33][34]. ...
Background
Mild traumatic brain injuries receive voluminous attention in the research literature, but this is confined almost entirely to sports and military contexts. As an occupation, performing stunts in film, television, and entertainment places the head at high risk of repetitive impact and whiplash, but stunt performers do not enjoy the same level of healthcare supervision and access as that provided to sports participants. Therefore, the aim of this study was to evaluate stunt performers’ qualitative perceptions of reporting and management of head trauma in their industry.
Methods
After giving their informed consent, 87 motion picture and television stunt performers responded to a query about their views of ways to improve how stunt performers’ occupational head trauma—specifically head impacts and head whips that could cause a concussion—are reported and managed. We analyzed their responses via content and thematic analyses. Two researchers independently marked and categorized key words, phrases, and texts to identify codes that described participants’ comments. They then revised, discussed, and resolved coding discrepancies through consensus to establish inter-coder reliability. Next, we identified thematic patterns that described participants’ understanding of the stunt performer industry and what must change to facilitate reporting of head trauma. We derived themes from data that occurred multiple times, both within and across short answer responses.
Results
We identified three primary themes cited by the stunt performers as needs in their industry: (1) Need to Reduce the Stigma of Reporting a Stunt-Related Injury, (2) Need to Eliminate the “Cowboy Culture,” and (3) Need to Improve the Quality of the Work Environment.
Conclusions
Stunt performers are crucial members of a global entertainment industry valued at approximately US$100 billion annually. A large segment of the world’s population consumes their work in motion pictures, television, and live entertainment. When they are given an anonymous opportunity to speak, stunt performers offer insight into and recommendations for industry changes—primarily cultural and educational in nature—that could improve their physical and mental health, career longevity, and employability when they are confronted with head trauma.
... In rugby, symptoms of anxiety and depression are reported above screening thresholds in about 30% of the current professional players [3,4,45]. Rugby carries a risk of concussion with its resulting impact on mental health [45][46][47], although Hunzinger et al. (2021) have found that collision sport may be associated with less depressive symptomatology, which could be the result of team sport participation [46]. ...
... In rugby, symptoms of anxiety and depression are reported above screening thresholds in about 30% of the current professional players [3,4,45]. Rugby carries a risk of concussion with its resulting impact on mental health [45][46][47], although Hunzinger et al. (2021) have found that collision sport may be associated with less depressive symptomatology, which could be the result of team sport participation [46]. However, these studies in athletes have generally used self-report tools to estimate the prevalence of CMDs [2,6], with limited data using clinicianadministered tools [5], especially from low-and middle-income countries (LMIC) [48]. ...
Objectives:
Although mental health screenings are not routinely conducted in rugby, the Sport Concussion Assessment Tool - Fifth Edition (SCAT-5) is widely performed and measures affective, cognitive, sleep, and physical symptoms. This study investigated the psychometric properties of the SCAT-5 to explore its potential as a mental health screening tool.
Methods:
During preseason for the 2021 Western Province Super League A in South Africa, clinicians conducted mental health assessments of 71 adult male rugby union players. The SCAT-5 Symptom Evaluation, Baron Depression Screener for Athletes (BDSA), Athlete Psychological Strain Questionnaire (APSQ), Center for Epidemiologic Studies-Depression (CES-D), and Generalized Anxiety Disorder-7 (GAD-7) were compared to each other and to fully structured diagnostic interviews by mental health professionals using the Mini International Neuropsychiatric Interview (MINI) 7.0.2.
Results:
Lifetime MINI-defined mental disorders were common, being identified in 33.8% (95% CI 22.79-46.17%). Only 4.29% of participants had a previous diagnosis. Exploratory Factor Analysis indicated a mental health construct of depression/anxiety being measured by the SCAT-5. The SCAT-5 had strong internal consistency (α = 0.94) and showed moderate convergent validity with the CES-D (r = 0.34; p = 0.008) and GAD-7 (r = 0.49; p < 0.0001). The area under the curve for the ability of the SCAT-5 to identify current disorders was 0.87 (p = 0.003), on par with the CES-D and GAD-7.
Conclusion:
Since the SCAT-5 has the potential to identify depression and anxiety, it may allow mental health screening without the need for additional measures. Follow-up studies should further explore its discriminative ability in larger samples.
... High impact loads in sport can result in injuries [1], along with potential reductions in health-related quality of life, post-retirement from sport [2][3][4][5]. The New Zealand Rugby-Health (NZ-RugbyHealth) project, containing four studies [6], was developed in 2012 at the request of World Rugby and conducted by New Zealand Rugby in collaboration with Auckland University of Technology researchers. ...
Background
There is limited research on associations between playing rugby union and player health post-retirement.
Objective
This study investigated differences in self-reported sport injury history and current self-reported health characteristics between former New Zealand rugby and non-contact sport players with a view to identifying issues to be further investigated with stronger epidemiological research designs.
Methods
Using a cross-sectional design, the NZ-RugbyHealth study surveyed 470 former rugby and non-contact sport players (43.8 ± 8.1 years; 127 elite rugby, 271 community rugby, 72 non-contact sport) recruited from October 2012 to April 2014. Demographic information, engagement in sport, sport injuries, medical conditions, mood, alcohol and substance use and ratings of current health status were obtained from a self-report 58-item general health e-questionnaire. We highlighted standardised differences in means of > 0.6 and differences in relative percentages of > 1.43 for variables between groups as representing at least moderate effect sizes, and of being worthy of follow-up studies.
Results
Higher percentages of the elite rugby player group had sustained injuries of a given body-site type (e.g. neck sprain/strain, thigh bruising, hamstring strain) combination than the non-contact sports players. Higher percentages of the rugby groups reported having sustained concussion (94% for elite, 82% for community, 26% for non-contact), injuries requiring hospitalisation (73%, 46%, 25%), injuries that stopped participation in sport permanently (28%, 28%, 11%) and sport-related surgery (72%, 46%, 32%) during their playing career. Both rugby groups had a higher prevalence of osteoarthritis (37%, 18%, 6%) than non-contact athletes and community rugby players had higher levels of hazardous alcohol consumption (38%, 40%, 25%) in retirement than non-contact athletes. There was little difference between rugby players and non-contact sports athletes in self-reported mood, substance use and current physical or psychological health ratings.
Conclusions
Former rugby player groups were at higher risk than the non-contact player group for most injuries during their playing careers, and in retirement had greater prevalence of osteoarthritis and hazardous alcohol consumption. The relative youth of the groups (43.8 years on average) means that health issues that typically do not emerge until later life may not have yet manifested.
... In current professional male rugby players (rugby union, rugby league and rugby sevens), 11% reported feelings of distress, 12% reported sleep disruption, 22% reported adverse alcohol use, and 28% reported feeling anxious and/or depressed [10]. In both rugby union and rugby league, players who sustained a severe musculoskeletal injury were twice as likely to develop anxiety and depression symptoms over 12 months, compared to players who had not sustained severe injuries [11]. In particular, the risk of developing adverse mental health symptoms during the season has been reported as 1.5 times greater in professional rugby union players who sustain a concussion (mild traumatic brain injury) when compared with those who do not [11]. ...
... In both rugby union and rugby league, players who sustained a severe musculoskeletal injury were twice as likely to develop anxiety and depression symptoms over 12 months, compared to players who had not sustained severe injuries [11]. In particular, the risk of developing adverse mental health symptoms during the season has been reported as 1.5 times greater in professional rugby union players who sustain a concussion (mild traumatic brain injury) when compared with those who do not [11]. Similarly, in active professional rugby league players, sustaining three or more sport-related concussions has been associated with a twofold greater risk for developing adverse mental health symptoms [12]. ...
... Gouttebarge et al. [14] reported that 25% of former professional rugby union players reported adverse alcohol use. In current rugby league players, 68% reported hazardous use of alcohol [12] and in current professional rugby union players, those who sustained two or more concussions during one season were more likely to engage in adverse alcohol use and experience symptoms of depression [11]. In contrast, we found no differences between groups for the AUDIT-C score, although former elite rugby code players reported drinking alcohol less frequently than non-contact athletes. ...
Background
Concerns have intensified over the health and wellbeing of rugby union and league players, and, in particular, about the longer-term effects of concussion. The purpose of this study was to investigate whether there were differences in mental health, sleep and alcohol use between retired elite and amateur rugby code players and non-contact athletes, and to explore associations with sports-related concussion.
Methods
189 retired elite (ER, n = 83) and amateur (AR, n = 106) rugby code players (rugby union n = 145; rugby league n = 44) and 65 former non-contact athletes (NC) were recruited to the UK Rugby Health Project between 2016 and 2018. Details on sports participation and concussion history were obtained by questionnaire, which also included questions on mental health, anger, sleep, mood, alcohol use, social connections and retirement from injury. Data were compared between sports groups (ER, AR and NC), between exposure of three or more or five or more concussions and for years in sport.
Results
ER reported more concussions than AR (5.9 ± 6.3 vs. 3.7 ± 6.3, p = 0.022) and NC (0.4 ± 1.0, p < 0.001). ER had a higher overall negative mental health score (indicating poor mental health) than AR (10.4 ± 6.3 vs. 7.4 ± 6.5, d = 0.47, p = 0.003) and NC (7.1 ± 4.8, d = 0.57, p = 0.006) and a lower overall positive score (indicating good mental health) than NC (8.9 ± 4.1 vs. 10.7 ± 3.4, d = 0.46, p = 0.021). Negative scores were highest and positive scores lowest in those reporting three or more concussions ( d = 0.36, p = 0.008; d = 0.28, p = 0.040, respectively) or five or more concussions ( d = 0.56, p < 0.001; d = 0.325, p = 0.035, respectively). Reported symptoms for sleep disruption were more prevalent in ER than NC, and in former athletes with three or more concussions ( d = 0.41–0.605, p < 0.05). There were no significant differences in alcohol score ( p = 0.733). Global anger score and covert anger expression was higher in former athletes with five or more concussions ( d = 0.32, p = 0.035; d = 0.37, p = 0.016). AR reported greater attachment to friends than NC ( d = 0.46, p = 0.033) and 20% of ER reported that they would not turn to anyone if they had a problem or felt upset about anything.
Conclusion
There was a significantly higher prevalence of adverse mental health and sleep disruption in ER and in former athletes who reported a higher number of concussions. Anger and irritability were more prevalent in former athletes with a history of five or more concussions. Strategies are needed to address mental health and sleep disturbance in elite rugby code athletes, who are also less likely to seek help should they need it. Further research is needed to elucidate causation, and the neurobiological connection between concussion, sub-concussions and longer-term psychological health and wellbeing.
