Nutritional Considerations of Irish Performance Dietitians and Nutritionists in Concussion Injury Management

In the context of concussion awareness, participants who cited having prior personal experience diagnosing or reporting concussions exhibited a higher awareness of their impact on athletes. In comparison, those without such experience demonstrated a lower awareness. The participants reporting concussion as common, casual occurrence amongst their athletes showed higher awareness of injury incidence without prompting or hesitation.

In 2014, World Rugby introduced the Head Injury Assessment (HIA) concussion management system into an injury policy []. One participant mentioned that head injury such as concussion “” [PN 3]. Before this, PDs/PNs involved in rugby were not part of the conversation or made aware of concussion incidence compared to 2022, when HIA was protocol and actively used to assist and improve reporting practices. However, in PDs/PNs working with hockey, soccer, combat, Gaelic football, and some individual athletes, reporting was not evident as they showed no awareness of concussion occurrence as an injury subset. In this instance, PDs/PNs reported that they were fortunate to have no recorded cases of concussion among their athletes: ⁵⁶ wasn’t really like a… like a thing… before HIAs

Alternatively, it is possible that they may be unfortunate, and that in reality, underreporting is going unnoticed. Another participant highlighted the prevalence of injuries among high-level combat athletes and pointed out that “” [PN 12]. Meanwhile, a PN with a background as a hockey player shared insight into their injury experience, having had “” [PN 11], highlighting differing levels of cognitive decline experienced and their subsequent need for nutrition to fuel their healing and extra rest. However, the PN was unaware of concussion incidences within their own hockey or soccer athletes (see). …you never even hear of like concussions reported back to you, but God knows, even though it’s probably likely you’ll never hear back! …three concussions at one point in 18 months Table 2

The interviews generated patterns linking PDs’/PNs’ experiences and awareness of concussion to the level of communication that existed between back-team members and their athletes in the incident of injury. Delving deeper, the data highlighted incidences of poor communication where the PDs/PNs were overlooked and, as result, did not know athletes had sustained an impact or SRC. PDs/PNs admitted feeling the need to be present at training and matches to be aware and in the know regarding SRC events. They felt the onus was on them as practitioners; otherwise, their involvement/awareness of injury events would be easily overlooked, especially if they were not present.

Having an awareness and understanding of an athlete’s health and injury status, specifically after concussion, is a multifaceted task that requires collaboration across the entire back team. It is not the sole responsibility of one professional (i.e., doctor or the physio) in isolation to provide support, as highlighted by PN 4:

PDs/PNs know that differing communication and collaboration levels are present within a sport setting and are aware of their impact on forming “” [PN 4]. A well-coordinated backroom team characterised by shared values, mutual respect, and effective communication collaborating on members’ expertise would guarantee the successful implementation of essential measures following an SRC. a decent backroom team

While the ideal scenario involves strong collaboration within the back-team setup, it is not always common practice, as expressed by PN 4 sharing the impact of limited collaboration situations where they felt it had not “” [PN 4]. In addition, PN 13 commented on the value placed on the PDs’/PNs’ discipline and noted that at …been as strong, you know, and I think that makes a big difference in terms of catching the acute phase

This highlighted the potential dangers of scenarios where the back-team setup is not valued, is fragmented, and has poor communication channels. In contrast, when communication channels are open, PDs/PNs have injury awareness. PDs/PNs can effectively prepare and tailor their support and work with back-team members to ensure athletes’ best recovery interests are met, emphasising the importance of a cohesive relationship and collaborative approach. Furthermore, providing more insight into the dynamics of the back team, PN 5 stated:

For some participants, their first protocol following a suspected SRC impact is a diagnosis and medical sign-off; they know this is a crucial step before any other back-team member implements support: “” [PN 1]. However, PDs/PNs seemingly underestimate the significance of their role in acute recovery support compared to other back-team members. on the day I would be leaving it to the medic, really

Awareness of concussion incidence amongst PDs/PNs appears to be influenced by a seemingly ‘blasé’ attitude toward the injury. This may influence an athlete or backroom team member’s reaction and subsequent reporting behaviour if a suspected concussive impact occurs. PDs/PNs working with athletes in contact collision-based sports, like rugby, expect injuries due to the nature of the sport and perceive athletes to often be in a heightened recovery state, especially after matches. For example, PN 8 commented:

However, could this better awareness be creating a more casual attitude toward concussion, as some participants comment and perceive it as “” [PN 8]? just another like…injury

Athletes in collision sports may have a casual attitude due to the subjective nature of concussions. For instance, they may believe that they can quickly RTP, as stated in an example of an athlete persona by PN 8: “” [PN 8]. The frequency of SRC in a collision sport and its subjective presentation (i.e., symptoms) may feed behaviours of poor compliance to recovery support programs. As stated by one PN, speaking specifically about professional rugby athletes, …ahhh no I’ll be fine, I’ll be back in a week

Athletes tend to disregard subjective and invisible injuries, especially when they are eager to RTP. As noted by PN 7, athletes can be “” [PN 7] due to physical symptoms such as limping or bruising. This behaviour is commonly observed among younger rugby and Gaelic athletes, who may be more inclined to take risks to get back on the field, as mentioned both by PN 7 and PN 8. …very quick to dismiss…injuries, especially when, I suppose, there’s no, not that there’s no obvious symptoms of it…you know, they’re not carrying their leg

In elite-level combat sports, where concussions are frequently reported, some PDs/PNs proactively implement objective tests and diagnostic protocols to help athletes better understand the impact of SRC on their brains. One such protocol involved using the ’Sport Concussion Assessment Tool 5 (SCAT5)’ [,] to assess brain function and provide athletes with objective evidence (subjective) of injury and concussion. In addition, PN 14 explains that SCAT5 results help demonstrate the significance of proper hydration to an athlete on their brain function and may support concussion prevention, given that “” [PN 14]. ^{57 58} if they’re dehydrated, their response to the SCAT5 is actually a lot less

Several participants showed awareness and knowledge of the acute metabolic and physiological changes that occur in the brain tissue following a concussion, which reduces energy availability, mentioning the following statements:

Additionally, in the period following the concussion,

These statements reflect PDs’/PNs’ genuine understanding and knowledge of the manifestation of concussion as an injury and the associated metabolic and functional changes in the brain tissues’ physiology.

Participants’ consideration of nutritional strategies to support their athletes with SRC was linked closely to their awareness and understanding of nutrition for its role in healing the brain tissue during recovery. This was evidently reflected through PDs’/PNs’ implementation of nutritional support protocols for athletes with SRC.

However, participants had mixed levels of awareness and knowledge; some presented uncertainty around SRC as an injury and its subsequent need for nutrition, impacting their knowledge of strategies to support and manage recovery. PDs’/PNs’ lack of awareness and nutrition knowledge was a concern as they were not well informed about its role following SRC. As a result, they did not see or consider the benefits of using nutritional support to promote brain tissue healing, which could pose a risk to their athletes.

A link was identified between participants who were unaware of concussion incidence within their team setup and/or athletes. These participants did not consider and were unaware of any physiological and metabolic changes that happen in the brain after impact, providing vague responses revealing a limited understanding. In addition, they had poor knowledge of the significance of adjusting athletes’ nutritional intake (for perceived ‘invisible injury’) to meet altered requirements to facilitate healing and recovery post-SRC.

For example, PN 15 commented,

A number of PDs/PNs were aware of concussion events and the role of nutrition in brain health as they actively kept up to date with scientific research. However, informed participants were not confident or certain on nutrition protocols and considered strategies based on their acquired knowledge influenced by limited scientific evidence.

Participants who demonstrated a more certain type of knowledge actively kept informed by scientific research related to concussions/brain injuries and the role of nutrition in brain health and function. However, they were unsure of protocols as they, too, were influenced and limited by “” [PN 9]. no real hard and fast evidence on it

PDs’/PNs’ personal experiences with concussion and head injuries provided them with experiential knowledge on the importance of a nutritious dietary intake and regular eating habits for brain recovery. This experience led them to logically consider implementing nutrition strategies to support their athletes’ recovery following SRC prospectively.

Some participants who lacked knowledge of potential SRC management protocols were not negatively limited as they had access to a network of expert nutritionists. This network helped bridge their knowledge gap and supported them implement necessary nutrition protocols with their athletes in the event of an acute injury.

This evidence presents an opportunity for PD/PN professionals who can often work independently to have an open network to share expertise and support the expansion of nutrition knowledge. The PDs/PNs who mentioned being able to refer to a niche network of nutrition experts with experience in SRC, as a result, had the support they needed to implement safe nutritional protocols to manage their athletes’ recovery. Interestingly, PN 9, despite having extensive knowledge on concussion and the sequel metabolic brain changes that occur, mentioned only implementing nutritional strategies at an individual level with athletes, unlike with other protocols formulated into their injury (rugby) management guidelines and policy. Experts expressed hesitancy and discomfort in recommending nutritional protocols following a concussive impact (invisible brain injury). This reluctance stemmed from the variability in research, such as the lack of human-specific studies and numerous unanswered questions and knowledge gaps.

PN 9 highlighted these concerns:

This led the nutrition focus to remain on physical or visible type injuries, which may cause other sports (outside of rugby) to follow suit and, as a result, neglect nutrition as a strategy (or PDs/PNs role) for brain healing following SRC due to the subjective and non-physical presentation of the injuries (creating a potential implementation barrier).

Participants who did mention attempts to implement or actively trial specific nutritional strategies to facilitate athlete recovery following SRC did so with an element of uncertainty. Following a known SRC, some PDs/PNs took a comprehensive approach aiming to minimise athletes’ mental load and any potential challenges faced by athletes during their injury recovery. They addressed athletes’ nutrition requirements, overseeing fuel selection (i.e., carbohydrates and fats), quality (i.e., protein), and nutrient variety (i.e., micronutrients) and implementing specific supplements for optimal performance and to facilitate SRC recovery.

In the event of injury, an athlete’s focus needs to shift from performing at their very best to healing and recovery to support their return to sport (RTS) []. During this period, the athlete’s mood may fluctuate between motivated and capable to depleted, depressed, and unmotivated, which may impact their nutritional habits. For example, suppose athletes’ habits fall by the wayside. In that case, their level of engagement with the PD/PN may become disjointed, which may/will impact the level of nutrition support they receive, and subsequently their recovery will suffer. ¹

Some PDs/PNs were mindful of this shift and took practical steps to implement nutrition strategies specific to their athlete’s needs that would minimise their mental load. These strategies focused on ensuring athletes ate enough food to fuel and nourish brain tissue healing and support them in feeling better overall.

Strategies to facilitate acute energy requirements post-SRC need to be tailored and consider the varying (subjective) symptoms experienced by athletes, such as being “” and unable “” (i.e., nausea), through implementing “” [PN 7] to help simplify and support adherence. PNs/PDs focus on and manage athletes’ dietary changes to nourish and support brain tissue healing by encouraging and supporting athletes’ intake of “” [PN 11] and promoting their intake of poly-unsaturated dietary fats via omega-3 rich foods and supplements. Dietary fat plays a significant role in providing fuel and nutrient support for the brain. However, following injury, specific types become exceedingly important, and it is advised to limit the consumption of “” [PN 6] foods to prevent an imbalance of omega 3s to 6s. Proactive PDs/PNs are strategic and align nutrition support with their athletes’ mindset and recovery goals at the forefront whilst syncing with other back-team members: “” [PN 8]. Participants know their role in injury support and that when implementing nutrition, their concussed athlete needs clear “” [PN 8]. This approach aims to keep the athlete accountable and focused during SRC recovery, making the process less daunting and challenging. quite nauseous to eat a lot smaller meals, more frequently, liquid anti-inflammatory foods…your fruits, fruit and veg, fish pro-inflammatory omega-6s …initially we try to break down even with the physios; we’d break down their rehab into, like, phases …smaller focuses instead of bombarding them all at once

Furthermore, PDs/PNs provide flexible availability with open channels of communication for athletes to seek and receive support during SRC recovery through casual check-ins, “” [PN 5], WhatsApp messaging, and planned one-to-one sit-down meetings around training schedules, either “” [PN 5]. Open channels and connecting with athletes in casual environments are highly beneficial. They provide opportunities to establish trust and build rapport as some athletes may not be very forthcoming. For athletes who may not have as much access to in-person support, PDs/PNs provide “” [PN 5], communication, and support that work around lifestyles and outside stressors that factor into athletes’ SRC recovery trajectory. corridor conversations early from a training session, or you meet them there beforehand Zoom conversations, sharing resources on the screen

Athletes’ attitudes on SRC as an injury and their value on the importance of nutrition and its role in their RTP strongly dictate buy-in and protocol implementation. Athletes tend to place a higher value on more physical injuries. They are more “” [PN 17], creating an adherence motive, compared to the invisible presentation of head injuries and concussions. In assisting athletes’ SRC recovery outcomes, PDs/PNs prescribe daily supplements that are brain-supportive and tick all their nutritional gap boxes. However, the reality is they are unable to control behaviours, as one participant admitted, “” [PN 12]. Meanwhile, PN 5 stated empathetic know-how in the event of injury that “” athletes’ “” [PN 5], commenting that in such incidences, “” to remind athletes to “” [PN 5]. Participants stressed the need to remind athletes of the basics that they should be adhering to habitually and taking, for example, fish oils. However, PDs/PNs are cognisant that adherence is subjective and “” [PN 12]. Unlike measurable supplement adherence evidence, …open to the fact that nutrition can play a role immediately Well, see, I don’t know if that actually taken it! most, or some of their good habits to go out the window …ideally you want to be on to those lads keep on top of the…omegas and the creatine not everyone will take fish oils

PDs and PNs mentioned exploring, considering, and trialling several novel nutrition protocols that may support the recovery of athletes who have suffered SRC. Numerous participants mentioned that their athletes had already been prescribed creatine for muscle mass and performance (i.e., strength) properties. For example, in rugby:

Creatine is considered in combat sports when there is a “known concussion in boxing…” [PN 15] to potentially help “where the boxer has to be pulled out, we have actually put in creatine to try and see if that can help in terms of the recovery from that” [PN 15]. One participant (n = 1/17) recommended a protocol implementing creatine supplementation with concussed Gaelic athletes. It entailed a loading phase, shifting athletes’ everyday prescribed performance dose from “5 g a day” to “20 g a day” [PN 12] following the SRC event (see). Figure 3

Participants cited using omega-3 fish oil supplementation with their athletes; some had no clear rationale, and others prescribed it for brain health, “” [PN 2], and recovery properties. Following SRC, it was cited that athlete’s intake of “” [PN 6] should be increased and their “” [PN 6] reduced. One PN (n = 1/17) recommended omega-3 supplementation following SRC and shared the protocol they implemented with Gaelic athletes. It included using a daily 3 g dose of an omega-3 fish oil to achieve a target ratio of 1.8 to 1.2, EPA:DHA, aiming to get athletes’ “” [PN 12] (see). cognition healthy omega-3s omega-6s DHA levels up a little bit more Figure 3

The next protocol cited by one (n = 1/17) participant involved acute carbohydrate loading, which had been discovered from research findings indicating potential effectiveness in increasing energy availability in the brain after SRC, which may shorten symptom duration [,]. The protocol involved concussed collision-based sports (American football) athletes consuming 400–500 g of carbohydrates daily for 5 days during their RTP to meet post-SRC caloric requirements. The PN mentioned that they were trialling this protocol in their rugby setting by simply ensuring that athletes who had been concussed consumed enough carbohydrate-rich foods acutely following SRC. ^{59 60}

PN 2 stressed the importance of ensuring athletes consume enough carbohydrate-rich foods post-SRC when implementing the protocol on a trial basis to potentially increase energy availability in the brain tissue and support overall recovery (see). Figure 3

The final nutritional protocol includes the use of a probiotic supplement; this was considered by one participant (n = 1/17) and came to fruition after PN 11 shared anecdotal experience after personally sustaining three concussions within 18 months. PN 11 highlighted how fuelling at regular intervals was essential to support their brain recovery and recommended that athletes supplement their food with a probiotic to help the gut–brain connection following concussion (see). Figure 3