With the help of science, football is getting smart about concussed players.
ONCUSSION is one of the most topical issues in football, as barely a week passes without it raising its head, pardon the pun. It’s not that concussion is by any means new to football – quite the contrary. Concussion is dominating the medical talk around footy because there is a small but growing body of evidence pointing to serious long-term neurological problems as a result of multiple concussive or sub-concussive head impacts. In response to this emerging research, AFL medical officers have changed their concussion guidelines so a player diagnosed with concussion will not return to play on the same day. The AFL is now following world’s best practice on management of this injury and only time will tell if these changes make a measurable change in long-term player health. As well as considerations for health long after they have left football behind them, players are now better protected from the rare but devastating condition known as second impact syndrome. A concussed player is more likely to sustain a second concussion if they return to play and the second injury can be worse than the first. In some cases a second impact can lead to catastrophic brain swelling with grave consequences. As well as this very serious potential outcome, a concussed player may be more likely to sustain other injuries if returning to play as their brain is not functioning at 100 per cent. We’ll never know if Swans midfielder Kieren Jack could have avoided the ankle injury that sidelined him for weeks had he not returned to the play after suffering a heavy knock to the head at the opening bounce against the Magpies in Round 14. So what if a player has taken a blow to the head, appears obviously concussed, leaves the field for an assessment and then comes back on? Prior to the new rule change in 2011, would that player have been diagnosed with concussion? Probably. Sports and Exercise physician and commentator Dr Peter Larkins explains that a dilemma appears with a player who is clearly unsteady on his feet after a knock to the head, appears disoriented for a short time but is not ruled out for the rest of the match with concussion by the team doctor. The player is often reported to have just been dazed or unsteady for a while. How can that be explained? If it’s not concussion, what is it? “For 20 years that was concussion by medical definition. It was a mild concussion that recovered in seconds and players always returned to the field on the same day,” Dr Larkins said. “Now doctors say that wasn’t concussion because if they are concussed they are not allowed to go back on. I’m calling it a transient brain event or a TBE.” The Consensus Statement on Concussion in Sport clearly states that it is important to avoid physical activity while recovering from concussion and avoid or minimise activities that
HEAD HIGH: There are medical reasons for substituting concussed players.
Wednesday, August 3, 2011
require concentration or attention. These activities – and the use of alcohol, sedatives or recreational drugs – can also make symptoms worse and possibly delay recovery. Though never again will we see a player concussed, stretchered off then later return to play as we did with Hawk Jordan Lewis in a Round 3 clash against the Bulldogs in 2010, if given a choice, many players would be back in the fray without hesitation. Dr Larkins said that players tend to have the “it won’t happen to me” attitude when it comes to the potential for serious consequences if returning to play with concussion symptoms. He added that in the past players have admitted to being untruthful about their concussion in attempts to fool their doc and get back on the field, but new testing tools and medical experience have made this far less likely. “Like a lot of things in life, you don’t really realise the impact of a situation because you haven’t been in it,” Dr Larkins said. “The players have had better education about what concussion is from the club doctors and the AFL so I think there’s no excuse that they haven’t had the opportunity to understand that a strong stance has been taken on concussion in the interests of their health in the long term but do they understand that? “No, because they’re professional sports people and their interest is getting back on, the same way you do when you’ve got a dislocated finger or ankle and you strap it up, jab it up and you go back on.” “Concussion” comes from a Latin word meaning “to shake violently”. With the average weight of an AFL player at 87 kg and the potential to accelerate at over 10 kmh in one second to speeds of over 30 kmh, it should come as no surprise that the forces resulting from such large masses colliding at speed can easily result in concussion. In fact, at an average of six to seven concussions per club per season, that’s over 100 concussions to AFL players each year. Although the brain is cushioned from minor impacts by surrounding fluid, if the head is caused to move suddenly then stop, the brain also moves suddenly then collides with the inside of the hard bony skull. This can cause physiological and biochemical changes in the brain. Concussion can be caused by a blow to the head, neck or body where the force is transferred to the head. Signs and symptoms of concussion include headache, dizziness, blurred vision, loss of consciousness, loss of memory, irritability, slowed reaction times and sleep disturbance. Dr Larkins emphasised that a person did not have to be knocked out to be concussed. “Concussion is nothing to do with losing consciousness. It’s to do with brain function,” he said. “Whether you get knocked out at all bears no relationship to the long-term post-concussion symptoms that you might develop the next day or two days later.” It’s particularly important for children playing Aussie rules that if they sustain a concussion, they do not return to play that day and are assessed by a doctor
Inside the game 21 who has experience with concussive injuries. A GP may not necessarily be the right doctor to make an accurate assessment. As with AFL players, children need a graded return to training and competition plan. The good news is that a preliminary concussion assessment is simple to do and can be done while the player is still on the field. In fact, it is not mandatory for a player who has taken a knock to the head to leave the field. This initial concussion test is called the Maddocks Score Sideline Assessment and involves a short series of simple questions including: At which venue are we at today? Which half is it now? And who scored last in this match? The Maddocks Score is part of a more comprehensive concussion assessment called the Sports Concussion Assessment Tool 2 or SCAT2. If a player scores poorly in the Maddocks Score, the remainder of the SCAT2, which includes questions about physical health as well as memory, balance and co-ordination testing, can be implemented with the player off the field before a concussion diagnosis is made by the doctor. The SCAT2 can be implemented for any athlete 10 years or older and can be completed in eight 10 minutes. Dr Larkins said there was massive pressure on club doctors under these circumstances, that doctor honesty was paramount and clubs needed to be patient and give the medicos the time to perform thorough assessments. He said that in assessing concussion, familiarity with the player helped with making a correct diagnosis in conjunction with the assessment tools. This point argues against the use of an independent concussion assessor. Not to mention that the use of an independent assessor would imply that club doctors were putting the match result ahead of their patients’ health, when in fact the opposite is always the case. A concussed player will have their condition assessed and monitored over the days following with the “CogState” computerised assessment that all AFL clubs use. This tool assesses more subtle changes in a player’s thinking speed and accuracy. “CogState” testing enables baseline testing of players during pre-season, which enables comparison of pre and post-concussion test results. New software developments have made it more difficult for the players to fool the doctors during this assessment. There is no set time for recovery from concussion but it generally takes seven to 10 days to become symptom free; sometimes longer for kids. A mandatory exclusion time after a concussion is not supported by medical science, waiting for signs and symptoms to go is the best advice. It’s important to know that there is no evidence supporting the use of protective headgear to guard against concussion; though effective in preventing or reducing the severity of a skull fracture, a helmet
'It’s important to know that there is no evidence supporting the use of protective headgear to guard against concussion.’
PLAYERS AT RISK: Concussed players can find themselves with CTE.
doesn’t protect the brain from colliding with the inside of the skull, which is what causes concussion. Although research is ongoing, possible links between repeated sportrelated concussion and increased risk of clinical depression, dementia and Parkinson’s disease are under examination. Former Melbourne player Daniel Bell is seeking compensation for brain damage linked to his history of concussions. The AFL Medical Officers Association’s Dr Hugh Seward describes a current AFL study of retired footballers looking for evidence of adverse long-term consequences for previously concussed players. This study requires ex-players to complete questionnaires and undergo specific tests of cognitive function, and will compare previously concussed players with non-concussed players. Dr Seward says the AFL will be monitoring the new guidelines and track to see whether players appear to recover better from concussion by having a more conservative approach. One concussion related condition gaining widespread media attention of late is known as chronic traumatic encephalopathy – or CTE. Formerly known in boxers as “punch drunk syndrome”, can have devastating
STUNNED: Jack Riewoldt was reluctant to stay off the ground after being KO’d.
effects on health. The condition develops as an accumulation of a protein called tau in brain cells. Symptoms of CTE include memory loss, headaches, slurred speech, confusion, irritability, aggressive or violent behavior, cognitive decline, unsteadiness, depression, movement Inside Football
abnormalities consisting of staggered, slowed or shuffled gait, paranoia and apathy, according to an article written by Dr Ann McKee, an international expert in CTE studies from the Boston University School of Medicine. Though most frequently seen in boxers, CTE has now been identified in the brains of deceased former NFL
Wednesday, August 3, 2011
players. There’s no question that NFL and AFL are vastly different sports. NFL players use their helmets as weapons and many experience McCRORY dozens of subconcussive blows to the head in every game. Over the coming years, many donated brains from ex-NFL players will hopefully help researchers to understand more about this disease. Dr Paul McCrory, neurologist and director of the Centre for Health, Exercise & Sports Medicine at the University of Melbourne, says that very little is known about what type, frequency, or amount of trauma is necessary to induce the accumulation of the proteins in the brain that are so damaging. Also, since there is no test for this disease, it can be diagnosed only once the brain can be sectioned into slices and stained with a dye for the tau protein – and of course, this can be done only after death. Although CTE has never been diagnosed in an ex-AFL player, these findings do suggest that a portion of AFL players may not be immune to some of these devastating and irreversible changes to the brain under certain circumstances. The introduction of new AFL concussion guidelines, a more conservative approach to concussion management, is a great leap forward in best protecting players while researchers continue to work to find answers to the many questions about these conditions. In the meantime, it would be most irresponsible of players, officials and administrators at all levels of football to do anything less than adhere to the new regulations, irrespective of how much a player is needed by his team. n The Consensus Statement on Concussion in Sport, and the Sports Concussion Assessment Tool 2 (SCAT2), are freely available for download and distribution from: http://scienceofelitesport.blogspot.com