What is already known on this topic

Para athletes play sports and sustain concussions; however, scientific understanding of concussion in para sport is very limited.

On baseline Sport Concussion Assessment Tool testing, para and visually impaired athletes report more concussion symptoms than footballers without disability.

Guidelines exist for para concussion assessment and management, but their effectiveness is unknown.

What this study adds

Blind footballers lack an understanding of what to experience when concussed and perceive concussion differently from a person with vision.

Postconcussion severity of symptoms and impact on daily life is more important to blind footballers than whether they sustained a concussion.

Blind footballers have impaired spatial orientation and sleep, which are important to function in daily life and are affected by concussions; however, these symptoms are not adequately included and recognised in current assessment tools or clinical guidelines for sports-related concussion.

How this study might affect research, practice or policy

Effective educational methods on concussion signs and symptoms are needed for blind footballers and their medical and support staff to improve para concussion care and diagnosis.

Different approaches may be required between footballers who have experienced concussions and those who have not, as these two groups report different perceptions, experiences and behaviours.

Symptoms and injury mechanism influence reporting behaviours, so a different approach may be needed to identify concussions that are perceived to be less concerning to blind footballers.

Introduction

“Sometimes it is the people no one can imagine anything of who do the things no one can imagine.” Alan Turing (23 June 1912–7 June 1954)

Athletes with impairments play many sports with a risk of sustaining head injuries and concussions.1 A para athlete is the international term for a sportsperson with an impairment who plays para sport.2 Within this population, a Para athlete is a person who plays sports with an impairment recognised by the International Paralympic Committee.2 Concussion carries the same important health and well-being consequences for a para athlete as an athlete with no impairments. However, there are likely to be additional considerations and adverse consequences for the para athlete because of their impairment. For example, postconcussive symptoms affecting concentration in an athlete with visual impairment may make activities of daily living, the ability to rest and movement control more difficult.

However, a thorough scientific understanding of concussions in para sport and para football is lacking. A 3-year prospective injury surveillance study suggested that injuries to the head and face are common and account for 17% of injuries in both English international blind 5-a-side football and cerebral palsy 7-a-side football.3 Injury surveillance data from the London 2012 and Rio 2016 Paralympic Games showed that blind football was the Para sport with the highest injury incidence per 1000 hours and at the London 2012 Paralympics, 13.6% of these injuries were to the head and face, also confirming blind footballers may be at risk for concussions.4 5 While head injuries have been recorded in Summer Paralympic Games, no concussions have yet been reported in surveillance studies, despite witnessed head injuries with visible signs of concussion. This suggests that concussions may have occurred but are not being diagnosed, and this needs to be understood from the perspectives of para athletes and attending medical staff. Fitzpatrick et al measured kinematic forces, using head-mounted impact sensors, on seven members of a blind football team over 6 months and demonstrated 3.29 mean low magnitude impacts per player per 50 min match, confirming regular match head impacts and therefore concussion risk.6 Lexell et al demonstrated that Swedish Para athletes with vision impairment reported a significantly higher incidence of sport-related concussion, with collisions being the most common injury mechanism.7 In different contexts, these studies demonstrate that collisions involving head and neck impacts occur commonly to blind footballers and visually impaired Swedish Para athletes report higher rates of concussions than their Para athlete counterparts with normal vision, but the risk of concussion in para sports is not known.

Blind footballers, when well, on baseline testing using the earlier version of the Sports Concussion Assessment Tool 3 (SCAT3), experienced significantly more concussion symptoms than footballers without disabilities.8 The more recent SCAT5 also includes an almost identical symptom severity score list, only differing slightly in order (and ‘trouble falling asleep’, present in both is noted only ‘if applicable’ in SCAT5). The presence of concussive symptoms when blind footballers are well, suggests that research is required to understand how this affects a blind footballer with concussion within the context of clinical practice and how a visually impaired footballer or their attending medical staff might know if they had sustained a concussion. Each phase of concussion assessment and management necessitates a concussed athlete to disclose, engage, follow clinical advice and behave as medically advised, regardless of disability or impairments.1 9

The first Concussion in Para Sport (CIPS) group position statement identified multiple knowledge gaps and called for research to better understand the intricacies of concussion care within para sport populations.1 It is essential to understand para athlete concussion perspectives and perceptions, as the athlete’s thoughts and behaviours impact the effectiveness and quality of medical care at each clinical stage (eg, disclosure, recognition, assessment, management and graduated return to play). Perhaps most importantly, para athletes are experts in their own injury context. A more effective clinical process will evolve through a thorough understanding of the injury context. It may lead to new insights into concussion care for para athletes (and possibly non-para athletes). This necessitates qualitative study designs among other study designs. To our knowledge, no qualitative studies have assessed the perceptions of para athletes on concussion.

This qualitative study explores current and retired male English blind 5-a-side footballers’ perceptions of concussion, concussion risks and concussion prevention based on their experiences in para football, in order to improve clinical care.

MethodsDesign

This is an exploratory qualitative study using semi-structured interviews. Thematic analysis was used for this study, following the Consolidated Criteria for Reporting Qualitative Research (see online supplemental appendix 1).10 Our study was pragmatic, and our methods acknowledge that people interpret reality differently. This creates a foundation for stakeholders to consider when treating para athletes, enabling future work around para concussion to be athlete-centred.11

Ethical approval

The Amsterdam UMC Ethics Committee approved the study (2021.0319), and verbal consent was obtained from all participants after they had listened to an audio recording of the study participant information sheet.

Participant selection

This study had a convenience sample of current international footballers from the men’s England blind football team and recently retired male English international blind footballers still playing club football. All subjects were over 18 years of age. The principal author (RW) previously worked with several current and retired blind footballers in the national team and had personal contact with the team’s backroom staff, through which the initial request for participation was communicated. Initial participants provided contact details for additional participants using a respondent-driven method. These additional participants were contacted by phone text messages and a follow-up phone call. All participants who were contacted agreed to participate in the study. The principal author (RW) explained the study background and purpose to the participants, after which they were sent an audio file of the participant information sheet.

Blind 5-a-side football is played on a futsal pitch with an audible ball and sideboards to avoid throw-ins. Goalkeepers are sighted and confined to a small area in front of the goal, and four outfield players are classified as completely blind. Blind footballers wear blindfolds to ensure fairness because some can have partial vision (eg, they may see light and dark, which could provide a sporting advantage). Players must shout the word ‘voy’ (in Spanish, this means “I am going”) when going in for a tackle to alert other players of their presence regarding a tackle to avoid collisions and resultant injuries. Voy infringements should be penalised by the referee, and if a player makes five voy fouls in a game, this player is disqualified from that game.12

Data collection

RW conducted all the one-to-one semi-structured interviews by phone between October and December 2021. Each interview was audio recorded. Face-to-face interviews were avoided during the COVID-19 pandemic, and given that all participants had significant visual impairment, the impact of visual cues was not considered essential to the integrity or quality of data collected. A semi-structured interview guide composed of open questions was applied to understand participants’ perceptions regarding their concussion experiences. RW developed the interview questions, which were refined through several meetings and discussions with CB, EV and OHA until agreement on the final wording of the questions was reached. Before main data collection, a pilot interview was conducted by RW with a colleague without impairment who plays amateur sport to ensure the suitability and practicality of the study methods. Once data saturation appeared to have been reached,13 one further interview was performed, from which no new concepts or ideas emerged. Data collection was subsequently stopped. The mean interview length was 27.3 min (SD 5.0), ranging from 18 to 32 min.

Data analysis

Each audio-recorded interview was transcribed verbatim by a professional medical typist who was not part of the research team. A six-stage approach to thematic analysis, described by Braun et al,14 was used to analyse the data. This approach allows for differences in qualitative research experience between researchers and enables the capture of in-depth accounts of the personal experiences and perceptions of the participants.13 The first stage involved RW familiarising himself with the transcripts through repeated reading. The second stage involved coding with basic themes. Third, these basic themes were shared and discussed with CB, enabling the development of themes and subcodes, allowing RW to refine the themes and subthemes further to reflect the footballers’ stories. The fourth stage involved sharing this data with the research team (CB, EV and OHA) to provide further feedback on the arrangement and coding. In the fifth stage, the research team developed connections between themes and subthemes and the naming of codes to be amended and agreed on by the research team. The sixth phase, which encompasses all other phases, involved writing up the data and analysis.

ResultsDemographics

Our sample consisted of nine male English blind footballers (six current and three retired blind England football team players). The three retired international blind footballers confirmed they were still playing club or cup blind football. The mean age of the players was 32 years (SD 9.9), and their mean duration of playing blind football was 12.8 years (SD 10.3). Closed questions were used to understand athletes’ backgrounds, and these questions followed those in step 1 of the office or off-field assessment of the SCAT5.15 The highest academic qualifications ranged from five participants at secondary school examinations level (one at age 16 and four at secondary school leaving exams), one participant with an undergraduate degree (BSc) and three participants with postgraduate degrees (two Masters and one PhD). Selected background information of the participants relevant to the study is shown in table 1, with all potential individual participant identifiers excluded.

Table 1

Background demographics of the study sample related to Athlete Background section of Sport Concussion Assessment Tool 5, with all potential identifiers removed

The main themes and subthemes are presented in conjunction with a short description of our findings. More detailed information and representative quotes are presented in tables 2–4 and a graphic representation of our results is presented in figure 1.

Figure 1

Concussion experiences and perceptions through the eyes of English blind footballers.

Table 2

Subthemes, codes and exemplary quotes on the theme “Do I have a concussion?”

Table 3

Subthemes, codes and exemplary quotes on the theme “Why am I concussed?”

Table 4

Subthemes, codes and exemplary quotes on the theme ‘Concussion prevention and improving concussion management?’

Theme 1: “Do I have a concussion?”“Did I have a concussion?”

No footballers could report with certainty the number of concussions they had sustained in their football careers. Several footballers perceived that it could be difficult to know if their feelings after a head injury were due to the head injury itself or to the adrenaline and fatigue felt when playing their sport. When recalling their experiences of concussion symptoms, the connection was not made with whether they may have sustained a concussion.

What is a concussion?

Footballers defined concussion based on the injury mechanism and the related symptoms. Participants were generally uncertain what a concussion is, highlighted by a wide variety of postconcussion symptoms that they mentioned to have experienced or perceived as ‘could be experienced’ following a head injury. Footballers’ perceptions of concussion varied regarding the severity of symptoms, with each participant noting only a few symptoms at best.

Would I report a concussion?

Several footballers reported an innate urge to continue playing the sport after a head injury, accepting the risks to themselves of not disclosing a suspected concussion. Several participants also recognised that as a blind footballer with a concussion, one’s performance will be adversely affected if disorientated.

Factors influencing diagnosis?

Several participants expressed that their medical teams (explicitly mentioned were physiotherapists and doctors) must decide if they have a concussion. Several participants also perceived their medical team would benefit from knowing how each footballer moves and behaves when ‘normal’ to spot if they are ‘different’ after a head injury. Footballers perceived concussions for sighted and blind people to be different experiences, suggesting that concussion assessments are designed for people with sight. Several participants felt that impaired spatial orientation may be a sensitive and important sign worth assessing after a head injury. The mental exertion and concentration required to play blind football and live as a blind person were also highlighted as challenging and were suggested as worthy of being considered by clinicians when assessing for concussion.

Theme 2: “Why am I concussed?”Game-related factors

Most participants in this study perceived that blind football is a sport involving close contact and a risk of head collisions. They suggested that this is related to the nature of the game played on a small pitch, requiring close contact and ‘battling’ for ball possession.

In contrast, several footballers perceived that because there are no aerial headers or airborne challenges in blind football, the frequency of higher force collisions is likely to be reduced compared with ‘sighted football’.

Visual impairment

Visual impairment was recognised as a key reason for collisions by participants.

Environment

Two footballers mentioned that communication between footballers is important to avoid collisions, recalling the example of collisions experienced when unable to hear in windy conditions. One footballer mentioned the importance of communication between them and their support team/sighted goalkeepers, citing an example when a player running back to defend ran into a post and examples of players running into walls and fences. These participants suggested that such collisions are avoidable if witnessed by someone sighted who communicates these movements with the footballers.

Player-related factors: experience and level

Several blind footballers stated that they had experienced more head injuries at the lower and less experienced game levels. Some participants suggested that as footballers become more experienced (as they move better and play in more experienced environments), they are less likely to have collisions and sustain fewer concussions. One footballer reflected that at the highest level, “most players on that pitch are very, very spatially aware, and they’re well coached and well guided.”

Theme 3: Concussion prevention and improving concussion management

Most participants mentioned education as important in concussion management, and education for players, coaches and medical staff were separately mentioned. Concussion ‘spotters’ (someone who witnesses head injury events live or via live video analysis, relaying their observations to side-line medical staff), equipment changes and rule changes (eg, consistency of referee ‘voy’ rule enforcement and mandatory head injury assessments by medical staff) to the game were also suggested as potential ideas for concussion prevention.

Perceptions relating to the recent introduction of 10 min temporary concussion substitutions were varied, and several blind footballers felt that 10 min was sufficient time to allow medical assessment. They acknowledged that this provision would be dependent on team resources.

Participants had mixed perceptions on enforcement of the ‘voy’ rule, suggesting that the rule is both important for safety reasons and helps the game flow. Some blind footballers perceived that the referee’s enforcement of the voy rule improves with refereeing experience. Participants also perceived that their observance of the voy rule improved with their experience.

Discussion

This qualitative study is the first to explore para athlete perceptions and experiences of concussion. This study found that blind footballers were not confident self-reporting the number of concussions they had sustained. This might be a function of their perceived lack of understanding of what to experience when concussed until the point that they may have experienced concussive symptoms that they recognise. They perceived the diagnosis and experience of a concussion to be different for a person without vision.

Diagnostic challenges

Under-reporting of concussions is common in non-para athletes.16 However, for blind footballers, also seems to be related to their visual impairment and a lack of knowledge rather than neglectful behaviours or choices where they do not report their own suspected concussions. Risk-taking and under-reporting of subsequent concussions may be apparent if an individual perceives previous concussions as ‘mild’ (regardless of visual impairment). A survey of 328 American college athletes suggested that athletes who had learnt experiences of concussions were more likely to continue playing, even while experiencing concussion symptoms.17 In our study, it seemed that blind footballers who had experienced concussions were then better able to recognise concussion symptoms, which may affect reporting, but still, these athletes were uncertain about the total number of concussions they may have experienced. These previously concussed participants also expressed a greater propensity to report future concussions due to acknowledged symptom severity and experiencing unpleasant and more severe symptoms, impacting their lives during recovery.

The participants in our study cited spatial orientation, concentration and sleep as important to blind footballers and affected when concussed. Spatial orientation is a skill that enables a person to determine their position and destination relative to objects in the environment.18 People with visual impairment know distances and directions that are observed and memorised, with an ability to commit these spatial relationships to memory when they change.19 Impaired spatial orientation from a concussion may lead to impaired football performance and impaired function in daily life activities. While many other sports injuries have definitions and classification systems based on a spectrum of findings, concussion diagnosis has evolved from a severity spectrum to a binary state (ie, you have, or you do not have a concussion).20 Despite this binary approach, blind footballers reported that symptom severity is important to them. They also recognised that spatial orientation and sleep are already impaired in people with severe visual impairment, so regular periodic baseline preparticipation examinations by medical staff may be needed to appreciate the presence and severity of these symptoms when blind footballers are well.1 21 22 One should conclude that it is clinically relevant that spatial orientation is not included in the current SCAT5 guidance for sports concussion.1 10

Our study also suggested that blind footballers are not confident in using balance tests to assess for concussion, as they perceived their balance to be generally impaired at baseline. Balance can also be improved with training and therefore balance tests may need cautious clinical interpretation in this population during suspected concussion assessments. However, Weiler et al found that blind footballers’ balance test scores on earlier SCAT3 baseline testing of blind footballers were not significantly different from sighted footballers.8 Still, low participant numbers and one testing time point limit the interpretation of this finding.

More widely, para sport clinicians should be aware that athletes with visual impairment may perceive visual bias within existing concussion assessment tools. This may affect their engagement with medical care and trust in clinical decisions, which could lead to underdiagnosis of concussions in blind footballers and poor concordance with medical treatment advice if they perceive clinical assessments (and care) not to be relevant to themselves.

van Mechelen et al reported six relevant key criteria when determining the severity of a sports injury; the duration and nature of treatment; sporting time lost; working time lost; permanent damage and cost.23 Perceived severity and previous concussion experiences are additional key criteria that are contextually important to blind footballers, which may change their concussion reporting behaviours. Aside from improving individual medical care, without improved concussion diagnosis recognising para athlete perceptions, scientific understanding of all aspects of concussion will remain non-existent because concussions will remain undiagnosed. These undiagnosed concussions will not be recorded within future injury surveillance studies preventing the injury prevention cycle from starting as the scale of the para concussion problem will remain unknown.

Reporting concussion versus risk-taking

Several participants in this study suggested that medical staff are responsible for diagnosing their concussion, as they will struggle to self-diagnose. However, none of these blind footballers made a connection that concussion diagnosis by medical staff requires them to declare their concussion symptom suspicions and seek medical advice. The exception is those blind footballers who want to continue playing when they suspect a concussion and try to conceal their symptoms, a phenomenon common in many other sports and contexts.19 Concussion assessment and subsequent diagnosis (and sports injury assessment in general) requires an honest declaration of symptoms, an interpretation of symptoms and identification of signs through clinical assessment. It is possible that blind footballers would better understand concussion if it were defined as a spectrum of severity because they can self-relate to the severity of symptoms.

Kissick and Webborn have recognised specific examples of athletes who perceived concussion not to be a ‘big problem’, comparing a brain injury with experienced major trauma or cancer as a comparator and athletes potentially being ‘risk takers’.24 Participants in our study expressed that they considered blind football a contact sport; therefore, their continued participation suggests an acceptance of perceived injury risks. Athletes who do not accept these perceived risks may choose not to participate or play perceived less risky sports. This supports the notion that some blind footballers are ‘risk takers’. Participants generally perceived differences in concussion risk between blind football and mainstream football. Some footballers perceived this concussion risk higher because blind football’ is a close contact sport. However, other footballers perceived that without high-speed aerial collisions seen in contested headers in mainstream football, concussion risk could be lower in blind football.

In wheelchair basketball athletes, Wessels et al reported in a study on 263 subjects that 6.1% reported a concussion in the current season, and 44% did not report their concussion.25 A further 67% of all wheelchair basketballers said they did not want to be removed from physical activity because of concussion, while 50% thought concussion was not serious and 50% did not know it was a concussion. In the only other qualitative study of general para sports injuries, Fagher et al reported that Swedish Para athletes (with 25 participants, of whom 8 had visual impairments) who were aware of their sports-related injuries often chose to continue training, despite considering elite sport to be risky.26 Within the context of these two studies in para sport, the behaviours reported by some blind footballers related to concealing a suspected concussion, accepting the long-term risks, and choosing to continue to play are not unique. Fagher et al have also shown that Swedish Para athletes with visual impairment perceived their injuries as mainly related to collisions and falls, which all carry a risk of head injury and concussion. This finding was mirrored in our study on the general perceptions of concussion among blind footballers.

Clinical assessment and visual bias

We found blind footballers relied on others (including attending medical staff) to witness and confirm their concussions. They also perceived that assessments and tests for concussions are ‘visually biased’ (ie, they implied assessments include tests they cannot do because of visual impairment), and medical staff may not always be present to witness the mechanism or know the athletes. These factors present challenges to the diagnosis of concussion, and this perceived lack of confidence in ‘visually biased’ assessments may also drive under-reporting of concussions in this cohort. The CIPS group position statement1 recognised specific limitations in SCAT5 assessment tools for concussion-related visual signs and symptoms, which medical staff must consider when attending to visually impaired athletes.

Blind footballers rely on their attending medical staff being present and able to tell them if they have a concussion. While no studies have been undertaken on the knowledge of clinicians working in blind football, a survey of clinicians working with teams participating in the 2015 Cerebral Palsy Football World Championships showed that 29% had received no general concussion education. Only 28.6% used an assessment tool to support concussion diagnosis, and 50% used a cognitive assessment.27 These apparent gaps in concussion knowledge at a recent para football World Championships suggests blind footballers’ reliance on their attending medical staff to tell them if they have a concussion may be misguided. The ability and reliability of attending para sport medical staff undertaking concussion assessment and management are likely to depend on both resources (ie, medical staff present) and the training, experience and knowledge of these clinicians. These factors will be variable in different countries and at different levels of blind football, thus highlighting the broad need for improved clinician para concussion education and awareness.

Prevention and improved management opportunities

The footballers in our study expressed that they neither know the risk of concussion in their sport, nor the risk compared with mainstream football, meaning that issues with quantifying risk will remain if recognition and diagnosis remain challenging. Suppose athletes cannot recognise, or choose not to reveal a suspected concussion, and clinicians are neither present nor trained to make a diagnosis or struggle to apply visually biased assessment tools. In that case, concussion rates will remain under-reported. These clinical challenges confirm that complexity and context matter for the injury prevention being considered, as described by Bolling et al.28 Therefore, even when context and complexity are recognised and considered, the concussion injury prevention cycle cannot be commenced as the true extent of the problem will remain unknown.

Blind footballers in our study perceived that padded blindfolds worn during play might offer some protection during collisions. Conversely, it was also suggested that these padded blindfolds might present a visual barrier to full clinical assessment by clinicians as they prevent the clinician from seeing and assessing clinical concussion signs on the face of a footballer. Several participants perceived that temporary concussion substitutions reduce the time pressure on clinicians allowing them more time to remove blindfolds or head protection for a complete assessment. This was generally perceived to be a beneficial step.

Blind footballers stated the rules of blind football to be important, with the ‘voy’ rule being especially important to prevent collisions and allow the game to flow. Opinions varied regarding whether the voy rule is enforced appropriately, and several participants suggested that collisions (and subsequently concussions) increase when referees and athletes are less experienced. The inference was, therefore, that concussions are less likely in elite-level or international-level blind football compared with the lower levels of the sport. One blind footballer in this study highlighted that coaches could help to train athlete movement to reduce the risk of collisions, which presents a further education opportunity.

Asked, the footballers expressed perceptions and ideas on initiatives they think could be considered for injury prevention. Blind footballers in our study perceived that concussion education would raise awareness and recognition, and would improve reporting and clinical assessment. They suggest this education should be for athletes, coaches, referees and medical staff. Medical staff perceptions need to be studied to understand clinical perceptions and diagnostic issues. Future research would need to determine the purpose, content, delivery and effectiveness of such education programmes within the blind football community.

Practical implications

Our study found a perceived lack of understanding of what to experience when concussed, because visually impaired footballers also experience a high number of concussive symptoms when well. This suggests that effective education methods are needed to provide more concussion information to blind footballers, and perhaps to their medical and support staff, on how they can be aware of the signs and symptoms of concussion to improve concussion reporting. Given the reported different perceptions and beliefs observed in our study in footballers who thought they had been concussed and those who had not, different approaches may be required between these two groups as they report different perceptions, experiences and behaviours. Blind footballers perceived concussion symptom severity and mechanism of injury to be of greater relevance to them than whether they sustained a concussion, so we may require different approaches that acknowledge these perceptions to help identify less symptomatic concussions.

Methodological considerations

The study findings are limited to the unique environment of English blind 5-a-side football and, as such, may not be transferrable to other para sport impairment groups. To better understand clinical implications, the voices of para athlete medical staff and other support staff are needed as our study was limited to blind footballers. Our approach allowed us to sample participants of various ages and experiences who play blind football at amateur and elite levels. RW had a previous professional relationship with five participants, which could have impacted how the participants responded during these interviews.

Conclusion

Participants stated that the quality and accuracy of concussion diagnosis is impacted by lack of concussion experience, knowledge and concomitant impairment. The study suggests that blind footballers’ experiences and perceptions must be considered by clinicians and researchers as they provide insights to help tailor clinical approaches and to determine whether blind footballers have sustained a concussion. This study highlights many contextual factors influencing concussion diagnosis, symptom reporting and prevention within blind football that should be considered clinically by governing bodies.

Future studies should listen to para athletes’ concussion experiences and perceptions from other countries and levels, and explore contextual differences across sports and impairments. To improve clinical concussion care, the perceptions of medical staff also need to be determined. This will support improvements in concussion reporting by para athletes and their subsequent assessment.

Data availability statement

Data are available on reasonable request; however, key data are anonymously shared in the results and no data with potential to identify participants, such as audio files, can be shared.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

The Amsterdam UMC Ethics Committee approved the study (2021.0319), and verbal consent was obtained from all participants after they had listened to an audio recording of the study participant information sheet.

Acknowledgments

The authors would like to sincerely thank the athletes who gave their time to share their experiences and stories.