Concussion
Concussion in sport continues to be in the news in 2020 and its’ prevention and management continues to be an evolving and ongoing challenge. The historic revelation in February 2020 that former AFL legend player Polly Farmer has been diagnosed with chronic traumatic encephalopathy (CTE) following post mortem examination of his brain last year has further ignited the ongoing debate. Farmer died in 2019 at aged 84 and in the later part of his life suffered from debilitating mental dysfunction which had been diagnosed as alzheimer’s disease. The CTE diagnosis now raises the possibility of further cases in Australian sport being detected as more players are offering to donate their brain for medical research after their deaths. Just to emphasise that the diagnosis of CTE can only be made by brain tissue biopsy and therefore is only confirmed as a diagnosis after an individual’s death. Currently there is no reliable ??? study which shows the brain structural changes that are associated with this neurodegenerative disorder. This is an ongoing area of medical research.
Sport concussion remains a worldwide challenge and will be analysed in minute detail in the forthcoming World Concussion Conference to be held in Paris in October 2020. This will be the 5th international conference on sport concussion and is expected to significantly review the management of concussion sport guidelines including developing an updated version of the sports concussion assessment tool (SCAT), the most widely used sideline assessment test for competition day concussion episodes.
There is no double that has been significant advances in sport concussion management in recent years. I have previously written articles on concussion management in 2010 and updated again in 2014. Even since I wrote those articles there have been huge advances in our understanding and management of sport concussion. However, there is still much to do. There is an emerging number of players who have sustained multiple concussions (or even a single severe concussion) during their sporting careers who are now experiencing medical problems which they firmly believe are related to their head knocks. These symptoms include memory disturbance, depression, anxiety, alcohol abuse, and behavioural change including uncontrolled anger outbursts or even suicidal thoughts. There is a pending class action of past AFL players who have had documented concussions and are now experiencing post career issues.
Firstly, let’s look at the advances that have taken place in the management of sport concussion in recent years.
1. Rule Changes
Most sports (with the exception of boxing) have introduced more stringent regulations to protect the players head and therefore the brain. Changes at AFL level have included protecting the player who has their head over the ball, so that they cannot be contacted above the shoulder either front on or side on. This protects both the brain the cervical spine. Dangerous tackles such as the sling tackle and spear tackle have been outlawed and there has been a larger “exclusion zone” introduced for bumping a player who is not immediately in the contest. The duty of care message has been strongly emphasised to all players so that they do not inflict potential injury to their opponents. Whilst these rule changes are, in the main, stringently applied at professional level, I have concerns they are not functioning so well at the non professional and community level, including junior sport.
2. Management of Competition Day Concussion
Prior to 2012 it was common place for a concussed or head injury player to return to the match on the same day as the incident. In fact it was seen as a show of strength and “badge of honour” to return having been knocked out or suffered a concussion which may have even included removal from the contest on a stretcher. Return to play was universally praised by team mates and frequently spectators. From a personal perspective it was always a very ugly sight to me.
Rule changes around the world have now mandated that a concussed player is excluded from returning to competition on the day of the incident. Despite some initial push back this has been widely accepted by most sporting associations, administrations and coaches alike. It has certainly taken the pressure off team doctors who are often pressurised by non medical personnel to return a head injury player to the competition.
Unfortunately these mandatory exclusion cases are not as common at non professional, community and junior level sport. The message needs to be more clearly sent to these organisations and furthermore the need for experienced sideline assessment personnel is obvious in order to make the diagnosis clear. At the present time any suspected head injury should be excluded from returning to play at these levels as a matter of course, regardless of whether a true concussion diagnosis is made. It should be a matter of “safety first” for the participant rather than issues of team success being paramount. This particularly applies to the young developing brain (to age 18 years) where the long term effects of concussion episodes are poorly understood.
3. Post Concussion Follow Up
Apart from the match day exclusion changes there are now more rigid protocols in place for players to be assessed in the days following a concussion episode. This includes repeated use of the SCAT test as well as more detailed neuropsychological evaluation and medical assessments to determine complete resolution of any detectable symptoms. Only after this protocol has been completed are players permitted to return to the competitive stage. In past AFL seasons this decision could be made as late as the morning of the impending match, but new conservative guidelines in the 2020 season have meant that a player must be determined to be completely symptom free 5 days before the impending contest before they are allowed to participate. The effectively means that more players are likely to miss the following week’s contest in 2020 as there will not be sufficient time to obtain complete resolution of symptoms as well as the compulsory 5 day training programme to be undertaken before selection is permitted. This is another move in the more conservative management direction.
Unfortunately there are many sports that do not have a structured protocol for return to participation and if the guidelines internationally are appropriately followed then a minimum of 5 to 7 days is required to go through the gradual stages of training, match simulation and competition preparation that is required. Frequently this process is short circuited in the interests of players being available for an upcoming important contest, particularly during finals time. In addition the players’ honesty in reporting symptoms and performing the tests in a truthful manner have a subject of concern in the past. There are a number of players currently complaining of post concussive symptoms who have publicly admitted that they have “fudged” the testing protocols in order to make themselves available to play for the team. This makes no sense from a health perspective and has been largely driven by an inappropriate sense of team loyalty and sometimes financial incentives related to player contracts. I have no doubt there have been occasions of outside non-medical influences leading the player to make themselves available when no fully recovered. I am sure any court of law would look quite unfavourably on a player who has readily admitted that they were no honest in reporting symptoms or completing the post concussion assessment process.
One intriguing development in recent years has been the concept of sub concussive episodes being potentially important in long term brain dysfunction. A sub concussive episode is poorly defined as an episode of head trauma or low level brain injury which does not immediately manifest as any of the traditional concussive symptoms (eg. Dizziness, headache, blurred vision, balance disturbance etc). There is now emerging evidence that multiple sub concussive episodes may have an accumulative effect on brain health and also result in the potential for long term neurodegenerative dysfunction in athletes. The dilemma remains in how to identify these sub concussive episodes which are frequently not obviously aware to the observer on the sidelines (or perhaps indeed the player themselves?). If every potential head knock or sub concussive episode required the player to undergo further medical assessment on the sideline it would certainly change the dynamic of how many sports competitions are undertaken and lead to a lot of unwelcome interruptions. Nevertheless, if the sub concussive concept proves to be relevant then this may need to be case. It would require a significant buy-in by coaches and sports administrators to allow these interruptions to take place, so I do not see this happening in the immediately foreseeable future.
What about prevention of concussion?
Whilst the focus has been on identifying concussive episodes and there subsequent medical management, the real challenge is preventing these head injuries occurring in the first place. The rule changes mentioned previously go a long way to reducing the risk, but by the very nature of many of our sports, they are collision and contact sports and it does not require a direct blow to the head to result in head trauma. A heavy bump or an awkward tackle can jar the brain just as much as a direct head injury. Reducing the exposure to these incidents would result in significant changes to the way many games are played including AFL and would mean a significant shift in the traditional fabric of the game. I am not sure how acceptable this would be to sports administrators and general public, but we need to look at strategies of prevention rather than management after the incident.
This raises the topic of whether helmets are useful?
Contemporary expert evidence and consensus statements still promote the reasoning that the brain is not protected by the wearing of a helmet in the event of a direct head trauma because the brain is like a bowl of jelly sitting in a liquid environment surrounded by a hard bony structure. The shaking of the brain that occurs in a rigid skull is not prevented by the wearing of a helmet. In fact, some studies would suggest wearing a helmet increases the likelihood of a head knock because the size of the target is clearly increased when any form of headgear is worn. This has perhaps been best borne out by the American NFL studies.
However, I have always advocated that there are many other types of head trauma that can be prevented by the wearing of a protective helmet. These include skull fracture, orbit fracture, check bone (zygoma) fracture and mandible (jaw) fractures. In addition soft tissue injuries including laceration which often lead to the player being removed from the field due to bleeding can also be limited by the wearing of protective headgear. Some studies at junior level have suggested that wearing of a helmet makes young players more likely to take risks in the belief that they are immune to head injury by wearing this protection. I feel this is simply a matter of education for the young athlete to help them understand that the wearing of a helmet does not make them bullet proof with respect to head injury, but certainly is likely to assist with the myriad of other head injuries beyond concussion. We do not question the role of the mouthguard in protecting the teeth and jaw so the helmet argument needs further discussion.
The evolution of the sport concussion story continues.Whilst we have made excellent progress with respect to identifying concussive episodes and post concussion management the challenge of prevention is still real.Nevertheless, the message continues to be spread and ultimately we only have one brain (there is no such thing as a brain replacement, unlike a knee injury), so we need to respect all head injury and introduce mandatory rule and management changes at all levels of sport including junior level.I look forward to the Paris meeting in October to further shed light on research and updated information of this extremely important medical field.