I have been writing a lot about head injury lately, and it appears that contact sport concussion awareness is growing, albeit with some sobering caveats.
The latest cause for optimism is the position taken by AFL general manager of football Brad Scott, who has been reported by the ABC as warning players that next season “they will be “in trouble” if they are late to contests and make contact with opponents’ heads.”
There are some heartening comments in the story, AFL tells players they face increased scrutiny over head knocks in 2022 season, especially in reference to the AFL match committee paying closer attention to concussion and its long-term effects.
“What was acceptable eight-plus years ago is not acceptable in 2021 and beyond,” Scott said after Tuesday’s meeting of the AFL Competition Committee. “There was unanimous agreement from the committee that attitudes, particularly as [they] relate to concussive-type head trauma, have changed and have shifted.”
If you’ve been sharing my articles and helping to get more awareness about head trauma, especially when arising from sport, thank you; you should feel pleased to have been part of the change in community attitudes that Scott is referring to.
Contact sport concussion awareness and lingering “out” clauses
Meanwhile, in a previous article from this year, we are reminded that we should be careful in thinking the fight is over, due to what neuroscientist Alan Pearce calls “vanilla rhetoric”.
In the story, Concussion expert Alan Pearce warns AFL, NRL have ‘out-clauses’ in protocols for players missing time after head knocks, Pearce highlights that despite some postive signalling from the AFL and rugby codes, they still have out clauses when it came to issues of concussion and standing down players.
The challenge here is that often the wording of regulations looks tough but the codes have a way to get players back onto the field early.
Both codes have what I call ‘get out of jail’ clauses. In the AFL’s release (on stand-downs) they talk of presumptive concussion. If a player comes off and the doctor presumes they are concussed, but after further examination they say they weren’t concussed, they can either return to the field or don’t have to enter the 12-day stand-down period. That needs to be cleared by the chief medical officer. In the NRL, with the 11-day stand-down, the club can go to an independent neurologist or independent doctor, who may say they’ve recovered and can be returned to training or competition before the 11 days are up.
Interestingly, and this cuts to the heart of the matter, Alan contrasts the demands of a code (gate takings and television revenue based on having colourful players on the field) and expectations of fans for players to ‘step up’, with the humans behind the great AFL and NRL names. At the end of the day, it is players and their families who live with the repercussions of repeated blows to the head and repeated episodes of concussion, which can develop into Chronic Traumatic Encephalopathy (CTE), a progressive brain condition, evidence of which has been found in post-mortem examinations of the brains of sporting greats like Danny Frawley and Shane Tucks.
When is one more concussion too many?
While Pearce notes the codes are trying to do better, a new study published in Australian Doctor notes that “there may be a number of concussions beyond which it is unsafe to continue playing contact sport”.
The article, Multiple concussions can disrupt brain connectivity: study, was presented at the Radiological Society of North America annual meeting, and it looks like we might be coming close to having some decisive guidelines to safeguard young and professional sports people, based on data suggestion concussion is a “two-tier disease”.
According to Dr Thomas Johnson of the University of Rochester Medical Center, in New York, when someone suffers multiple concussions the pathology is very different.
“Suffering three to five concussions has the potential for long-term disruption of cognitive processes. We need to determine our tolerance for concussions. When do we say no more contact sports? We need more evidence to set some limits for people.”
Dr Johnson wants to do repeat resting-state fMRI scans on study participants in five years to see whether or not disruptions in the default-mode network (DMN) remain, because he notes such tests could serve as a marker of progress and provide means of monitoring recovery in patients with prolonged post-concussion syndrome after mild traumatic brain injury.
Final thoughts about Australian Rules Football, in particular
While most of this article has generalised the information across all contact sports, a 2020 paper by Alan Pearce et al, Chronic traumatic encephalopathy in a former Australian rules football player diagnosed with Alzheimer’s disease, raises the stakes for the guardians of and participants in Australian Rules Football (ARF).
The paper details the first case of Chronic Traumatic Encephalopathy (CTE) in an ARF player, who died in his 90s after playing 350 first-grade matches and who was diagnosed with Alzheimers Disease in his mid-60s.
Of particular note that should give pause to anybody involved in ARF, are these final passages:
This case represents only the second ARF player brain donated to the recently established Australian Sports Brain Bank, and the first to be diagnosed with CTE. While we can make no claims of CTE incidence in ARF based on this index case, the distinctive and severe pTau pathology is something we have not encountered in our busy clinical practice outside of ex-contact sports players. That it exists at all should serve as a call to action to recognise and research CTE, and the very clear association with repetitive head injury. Claims of a lack of demonstrated ‘causality’ are unhelpful, and arguably irrelevant when assessing a public and occupational health issue such as CTE.
As you can see, the evidence is mounting to support our position and, indeed, our campaign on this topic. Sport can be a lucrative career pathway, let alone an enjoyable pasttime, but the more we all agitate to make sure sport concusion awareness continues to grow, the sooner we will all be able to have our sport and live well too.