All this on top of recent events such as Boyd Cordner’s concussion in the first state of origin rugby league game, the latest in a large number of concussions for the New South Wales captain. Earlier in the year we found out that AFL great Graham “Polly” Farmer was diagnosed with chronic traumatic encephalopathy (CTE) at post-mortem after his death at the age of 84, having been first diagnosed with dementia 20 years previously. Former St Kilda captain Danny Frawley had a long history of mental health problems, possibly related to head knocks he received during his playing career, prior to his tragic death. He was also found to be suffering from CTE at post-mortem.
Concussion is the No.1 problem for sports throughout the world. In the US a large number of former NFL players have been diagnosed with CTE following premature deaths often associated with dementia or violent behaviour. The NFL settled a class action mounted by 4500 former players in 2012 for $US765 million ($1 billion). There have been similar threats of class actions from former NRL and AFL players.
Over the past 20 years there have been significant rule changes in all codes to reduce the chances of impact to the head. Even accidental head contact is now penalised in a number of sports, and concussion subs have been introduced to make it easier to remove players from the field. Cricket has mandated the use of helmets while batting at all levels of the sport, and introduced neck guards following the tragic death of Phil Hughes in 2014. Earlier this month, respected cricket writer Malcolm Knox suggested it was time to ban the bouncer, even though he admitted “cricket will be a lesser entertainment when the bouncer is gone”.
What is the state of knowledge regarding concussion? There is a large amount of research being performed around the world in relation to its diagnosis and management. Certainly in the past decade or two, attitudes to concussion have changed significantly and now any suggestion of a head injury will result in the player being removed immediately from the field of play, assessed by medical staff and, if diagnosed with a concussion, prevented from returning. In professional sports, pitch-side team medical staff have access to video replays enabling them to review blows to the head.
A concussion assessment tool, the SCAT5, has been developed and is used widely around the world. The SCAT5 records symptoms and assesses in a basic way the various effects of concussion on the vestibular (balance) and cognitive functions. Computer-based tests of cognitive function are also commonly used, with players tested before the season to establish a baseline for comparison after they receive a head knock.
Even though the SCAT5 test is an improvement on previous assessments, we still lack a definitive diagnostic tool for concussion. Standard head scans such as a CT scan or MRI are not sensitive enough to diagnose concussion. Researchers are looking at more sophisticated tools including newer types of scans and blood tests as well as more complex tests of function than the SCAT5.
Once the athlete is diagnosed with a concussion, the management revolves around waiting until all symptoms resolve, and then undertaking a graduated return to play (RTP). Once the symptoms of concussion eg. headache, dizziness, blurred vision, fatigue, poor concentration etc, have completely disappeared, and the SCAT5 and any other tests return to normal, the athlete is cleared to commence the return to sport program.
Most sports have adopted a five- to seven-day RTP program in which activity levels are gradually increased each day. If at any stage in that period the symptoms return, then they have to start the program again. In line with this protocol, the least amount of time that player can return to full training or competition is five to seven days, but it is often considerably longer.
Occasionally athletes, particularly after multiple concussions, have prolonged symptoms and take months to recover. This has led to a number of footballers in various codes retiring from the game.
The concern that all players with multiple concussions have is the long-term effect of these repeated injuries. CTE is a progressive brain disorder associated with behavioural, mental and cognitive impairments, and diagnosed at post-mortem by the characteristic appearance of the brain. It appears to be more common in athletes who have repeated blows to the head, although similar appearances are seen in non-athletes.
The development of CTE seems to be related to the large number of sub-concussive head knocks sustained in sports such as NFL, ice hockey, AFL and the rugby codes. In the NFL the use of the helmet as an attacking weapon was common until outlawed relatively recently and NFL players are thought to sustain hundreds of these sub-concussive blows in a season. A former Welsh rugby union player diagnosed with dementia in his 40s was calculated to have had 100,000 sub-concussive episodes in his 14-year career.
While rules to protect the head have been introduced, the size (in particular the muscle bulk) of the players, and the speed and intensity of the games, and as a consequence, collisions, have increased considerably which may have led to more of the sub-concussive head knocks occurring.
We know that a proportion of those who played in the previous century, where head contact was frequent and those with concussions were sent straight back into the fray, have developed brain damage. Not every player from that era has had problems and it may well be that genetic susceptibility plays a role.
What we don’t know is whether those who have played in the past decade or two, after the introduction of rules giving greater head protection as well as the more conservative approach to the management of concussion, will also develop problems.
Cricket is a somewhat different scenario to the football codes. There is a minimal amount of sub-concussive episodes so that may mean there is less of a long-term problem. What we don’t know is what effect repeated concussions with apparent full recovery in between has in the long term.
Over time, we will have the answers to these questions, but that does not make the present management any easier.
So far we have been talking about concussions and sub-concussive episodes at the professional sporting level. What about in community sport such as local football? Here there are rarely any trained medical personnel present at the time of the concussion and none of the sophisticated testing available, however each club should have someone trained in the administration of the SCAT5 test.
A cautious approach is paramount, with the athlete being removed from play if there is any sign of a concussion, and not allowed back to training and games until cleared by a medical practitioner, preferably one experienced in the management of concussion. It is absolutely imperative that players are honest about their symptoms and not try and “hide” their concussion. It is their brain they are talking about, after all.
If in doubt, sit it out!
Dr Peter Brukner OAM is Professor of Sports Medicine at La Trobe University