As the dust settles on Grand Final season for both the National Rugby League and the Australian Football League, these football codes have a unique opportunity to take a firm stand on concussion in sport and implement important protections immediately.
I have long argued (like a voice in the wilderness) for sports codes to take heed of the seriousness of concussion in children and adults, but this season has spawned more articles and analysis than ever before, and sports guidelines and incentives have been found wanting.
Let’s look at some of the stories that have surfaced and then set out what needs to be done.
Rising awareness of concussion in sport
In June of this year, the ABC ran a story entitled, Rugby league’s existential crisis as concussion threatens the game’s physicality, in which Alan Pearce, Associate Professor in neurophysiology at La Trobe University and a concussion expert, said it’s time the football codes stopped pretending; “they have to accept if you’re going to play a contact sport that concussion will be a risk.”
That article outlined the challenge facing the sport in mitigating that risk because while it’s one thing to clamp down on head high tackles, it’s clear that waist level tackles also risk head injury and concussion by the tackler.
The article then reports on a summary by the NRL’s head of elite football, Graham Annesley, about the complexity of the risks and the fact that the tackler is the person who gets concussed about 70% of the time:
These are collisions involving players of up to 100 kilos or more running at each other with a combined speed of more than 40 kilometres per hour, so it only takes a fraction of mistiming or bad luck to get smashed in the head by a head, hip, shoulder or elbow — all accidental. In other words, tackling high is a risk to the person getting tackled, while tackling either low or high is a risk to the tackler.
The difficulty in policing concussion and responding to it correctly in the heat of the game, was later captured by an article in last month by Matthew Sullivan at news.com.au, ‘Utter disgrace’: Referee slammed for concussion no-call in Manly vs Souths preliminary final.
In this article, hatred and scorn was poured on an NRL referree of the preliminary final between Manly and South Sydney because he didn’t stop play when the Sea Eagles’ Sean Keppie was visibly concussed on the field. Even Fox League commentator, Warren Smith, had his commentary quoted in the article, thus:
Keppie, put in an awkward position there, might have dazed himself. He’s all rubber-legged. All the indicators there of a concussion suffered.
Across at the AFL, yet another article this year shone the spotlight on concussion in Australian Rules Football, not just in the elite levels but, alarmingly, at an increasing level within community competitions.
The article, Head on: Rising concussion rates in community footy exposed amid calls for action on youngsters, in The Age, focusses on the story of a 15-year-old, South Australian footballer, Bailey McInnes, who was knocked out when his head crashed into a larger opponent’s shoulder during a trial for the Norwood Football Club.
Amid the statistics in the article revealing concussion as the leading cause of hospitalisation in community Aussie Rules games since 2013/14, it dug deeply into the fact that Bailey had also received serious knocks to the head on two other occasions, playing for his local club, Athelstone, and ultimately gave up football.
The repercussions of these injuries are shared in the article:
After a delayed reaction to a third concussion in the space of five months, he decided to give up football. But long after he stopped playing the game he had loved since he was a four-year-old Auskicker, debilitating symptoms grew to impact his life away from footy.
He could only concentrate for short periods at school. He withdrew from social situations. He found it hard to be in a noisy room. “Even not in a noisy room, he would say he would find it quite overwhelming with a few people talking,” Tracie McInnes said. It took a while for them to realise these symptoms were a result of successive head knocks.
He was diagnosed with post-concussion syndrome and post-traumatic migraines.
The most potent message from these articles, came from the mouth of young Bailey, who accurately noted:
People are happy to take four weeks off for a broken wrist, but only want to take one off for a concussion when your brain, in the long term, is a lot more important than the function of your wrist.
And this is the situation that those of us in the field of neurophysiology want addressed immediately, before more lives, families, and communities are ruined.
Specific actions to reduce the impact of concussion
Firstly, it is lauditory that football codes are addressing the issue of concussion and head injury in many ways. For example, here are some quotes from the NRL’s Management Of Concussion statement:
The most important element in the management of concussion must always be the welfare of the player – in both the short and long term. All players with concussion, or suspected of having a concussion, should seek urgent medical assessment … Complications can occur if a player continues playing before they have fully recovered from a concussion. Therefore, a player who is suspected of having a concussion must be taken out of the game or training session immediately. A player who has suffered a concussion or potential concussion or exhibits the symptoms of concussion should not return to play in the same game (or on the same day), even if they appear to have recovered. Concussion is an evolving condition which may develop over minutes to hours (and sometimes days). Some symptoms or signs may resolve only to be replaced by others later. The management of head injuries may be difficult for non-medical personnel. It is often unclear whether you are dealing with concussion, or there is a more severe structural head injury, especially in the early phases of an injury. Concussion is considered a medical condition and therefore needs to be assessed and managed by an appropriately qualified doctor. In the period following a concussion, a player should not be allowed to return to play or train until they have had a formal medical clearance using the NRL Head Injury Recognition and Referral form by a doctor.
Secondly, we have seen, as with the NRL referee story, above, that the best policies are only as good as how seriously they are enacted.
For example, there’s a high risk of head injury remaining from “accidental” illegal tackles, plus there’s the inertia of generations of players of all codes who write off “invisible” head injury and don’t treat it as seriously as highly visible injuries like bone fractures.
Thirdly, we need to take note of new research developments, like this from the University of Pittsburgh Schools of the Health Sciences, which reveals that combined rehab programs can help adolescents with concussions.
The findings, published in the Journal of Pediatrics, demonstrate that including vestibular rehabilitation into concussion treatment leads to significant improvements for patients.
Vestibular symtoms include dizziness, imbalance, and vertigo, all symptoms that our concussed sports players will become all too familiar with, and will potentially end up dealing with over a long period of time.
As a neurophysio (a physiotherapist who has specialised in neuro-otology), it’s heartening reading about these findings and being able to add my voice to the other voices arising to demand action.
As the article outlines, young people who undergo early vestibular rehabilitation in conjunction with behavioral management treatment experience a more pronounced improvement in concussion symptoms than those treated only with a behavioral management program.
“Precision interventions targeting vestibular symptoms and impairment in adolescents following a concussion are effective in reducing those symptoms and impairments, above and beyond the positive effects of across-the-board behavioral management interventions,” said lead author Anthony Kontos, Ph.D., research director at UPMC’s Sports Medicine Concussion Program.
I urge everybody on the governing bodies of our major football codes, and administrators and officials at all levels, to read through some of the articles cited above and think deeply about your reponsibility in ensuring the safety of your players (and your sport).