This is the third part of our in-depth series on concussion. You can sign up as a subscriber to receive full access to not just this series, but to all of our premium content. You can access part one here part two here.
As discussed in the two previous parts of this series on concussion, it’s believed the major contributor to neuro-degenerative diseases for athletes isn’t concussion, but repeated impacts to the head over a lifetime.
But that’s not to downplay the seriousness of a concussion. It’s an injury and should be treated as such by professional sport.
The major difference in treatment though, is it’s one of the very few injuries that relies heavily on subjective assessments by both the patient and medical professionals.
Throughout this series, the experts we’ve spoken to have largely wanted to see two outcomes from the research being conducted and has been conducted over the previous decade:
- An objective treatment and assessment of concussion
- Methods and tactics to reduce overall exposure to head impacts
In part two Dr Michael Buckland from the University of Sydney mentioned strides are being made in the detection and objective assessment of concussion as close to home as Melbourne.
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Transcranial Magnetic Stimulation
That looks like a mouthful to say. Most experts just call it “TMS”. But it’s a technique at the forefront of assessing concussion.
Dr Alan Pearce from La Trobe University is a neurophysiologist and Victorian head of the Australian Sports Brain Bank.
Dr Pearce uses TMS to stimulate the brain and see how it responds by flashing lights into the eyes of patients and measuring the brain activity.
Unlike MRIs or CT scans, the brain isn’t being imaged, which he says is mostly ineffective when it comes to assessing concussion.
“TMS is not like MRI or CT and the reason why I wanted to get into this space is we all talk constantly about the fact that MRI and CT imaging doesn’t show up anything around concussion but for some reason we still keep using it.
“TMS, by stimulating the brain cells and getting the response can actually demonstrate functional changes in the brain, it looks at the electronics of the brain, not pictures of the brain. So when you stimulate the brain and you read the response, what we have found immediately after a concussion is that the brain processing becomes more inhibited.”
Dr Pearce says being able to objectively measure concussion isn’t just about player safety, but also performance. If a player’s brain isn’t fully recovered from a concussion, then their ability to process information is impaired.
Even if it’s only by fragments of a second, in elite sport that can mean the difference between winning and losing.
It’s the winger unable to get their legs in the air early enough as they dive for the corner, or the middle forward unable to react quickly to a change of direction.
If medical science can bring concussion assessment up to the same level as other injuries, then it’s a benefit to not just player health, but performance.
“What we find after a concussion is that this inhibition starts to rise so that the brain is not able to process in general terms as efficiently or as optimally as we would like… So the implication for that is if a player goes back too soon, if their brain is still inhibited by 20 or 30 milliseconds, that could be the difference between making a sound decision to go in for a tackle or a contest in Australian football or even evading an opponent,” says Dr Pearce.
In addition to not only making the game safer, an objective test would help to take the pressure off club doctors and players when it comes to assessing fitness.
In the same way a doctor wouldn’t be asked to clear a player returning from an injury to their ACL if it wasn’t healed, an objective test would remove the subjectivity around concussion.
“One of the things about this technique and I guess any sort of objective markers, whether it’s blood, saliva or whatever, players actually feel relieved when they don’t have that responsibility to actually say I’m okay.
“They can go, if I’m not okay, then I’m not okay. They’re not trying to pretend that they’re still committed and a lot of players feel quite relieved that it’s far more effective and that’s what we need to try and get through.
“With ACLs or with hamstrings, whatever, you can see that tear or you can see the injury, there’s an objective way of scanning or showing that they’re not quite right and that makes it easier for coaches to say “you’re not right to come back, we don’t want you to come back unless you’re 100%”
“I think now, if we can start to show the objective data, that completely changes the attitudes positively, not just for players, but for coaches and administrators as well.”
Just how long could it take players to recover from a concussion? Dr Pearce says research from New Zealand indicates it could take up to a month for the brain to fully heal.
“A colleague of mine in New Zealand, Doug King, who is big in rugby, and we’ve found physiological changes up until around 30 days.
“We’re seeing about three to four weeks for full physiological recovery and symptom resolution tends to resolve within seven to 14 days.”
Options
While Dr Pearce’s work remains lab based, there are medical experts looking to use both his research as well as other biomarkers such as blood or saliva to develop sideline tests.
A cheap, effective sideline concussion test would benefit not only elite athletes, but the amateur Sunday warriors who are sometimes lucky to have a first aid medic on the sideline, let alone a doctor.
“There are sideline tests that are fairly objective as well. The King-Devick for example, there’s Eye Guide, there’s potentially saliva biomarkers, blood biomarkers, I think we’ll see something in the next 10 years, maybe not quick enough but technology takes time and we really don’t have the same amount of funding in this area as we would like.
“Given the amount of people who get some form of a brain injury, not just in sport but at work, car accidents, falls and whatnot, it would be nice if there could be some increase in investment in this area.”
In Australia, one of the products being developed is a system called Nurochek, which is a wearable headset based on Dr Pearce’s work. It sends a visual signal to the patient and monitors the brain’s response.
Overseas, in the United Kingdom, research from the University of Birmingham indicated that a simple saliva test could detect a concussion with 96 per cent accuracy.
At the moment, it requires laboratory analysis to process the test, but the researchers are trying to develop a sideline version. For now, it is being used to detect concussions after matches.
However, as any doctor will tell you, prevention is better than cure.
It’s great being able to detect and treat concussion and head knocks, but what if there was a way to reduce the number of impacts to the head?
Dr Chris Levi is one of the experts working on that alongside Associate Professor Andrew Gardner, and they’ve enlisted the help of dual international Timana Tahu.
The former Knight, Panther and Eel outside back announced the research project in March 2021, saying he wanted to see if changing the traditional tackling advice of aiming for the hips would lower the risk of head impacts for defenders.
“There is some interesting work that we’ve been involved in around testing tackle technique modifications. The Timana Tahu tackle technique, we’re trying to package up into an intervention that we can test in a clinical trial to see whether it reduces concussion rates and we’ll be looking at putting a grant together for that and trying to get some funding for that in due course,” says Dr Levi.
“Currently that technique is still being tested in the biomechanics labs. That’s quite exciting because that’s where we’ve got to put more emphasis in reducing risk.”
Tahu is not alone in concerns for his own health, with Melbourne Storm propChristian Welch saying his concussion history does worry him.
“Yeh I’ve had a couple (concussions). It’s certainly not an injury you want to have. Football is great but it’s not the be all, end all for me. I wouldn’t risk my long term health and just keep playing with it,” says the Queensland forward.
Crackdown
As the NRL has become more and more aware of concussion and head knocks being an issue in the sport, it has sought to address it.
It has introduced the Head Injury Assessment protocol where players suspected of suffering a concussion are removed from matches and assessed by a doctor in the dressing rooms.
It has gradually introduced more stringent guidelines around return to play with 2021 seeing clubs having to consult an independent concussion expert if a player was trying to return to the game within 11 days of having been concussed.
And in round five of the 2021 season, the game’s first concussion substitution was introduced, allowing a team to activate its 18th man if three players fail their HIA or a player suffers a match-ending injury caused by foul play and the offender is sin binned or sent off.
But the biggest magnet for controversy was the NRL’s decision just before round 10 to introduce a crackdown on high contact.
Players, commentators, coaches, experts and fans have since debated the effectiveness and the point of the crackdown.
The move was seen as an ill-thought out knee jerk reaction to a number of incidents earlier in the season, while some experts questioned why it had taken so long for the NRL to begin to act on high contact.
“They seem to have been late to the party. Having said that, both the NRL and the AFL have been a bit slow to respond. I take my hat off to the executive for making those big changes in Magic Round.
“That was pretty ballsy I thought, to do that. Let’s hope they’re catching up I guess. It’s very hard to criticise this year with all of the COVID lockdowns. Everyone is barely scrambling to get their games on, so I think it’s certainly a very good start,” says the University of Sydney’s Dr Buckland.
What he means by being late to the party, is in reference to the strides other sports have taken in recent years.
While the NRL has tinkered with peripheral changes such as HIAs, sports such as the NFL and rugby union have directly sought to make the game safer by altering the rules.
The NFL has made multiple rule changes such as outlawing helmet-to-helmet contact, protecting players that are in mid-air while also limiting full contact practices.
In rugby union, the sport undertook a years-long process of research and analysis in reducing contact with the head.
They started with analysing the risk factors for concussion and HIAs, then looked at how to lower those risks, and finally utilised trials at lower levels to assess the impact on not just player health, but the game itself.
It’s something the NRL hasn’t done, and with very few lower grade games available to trial the rules crackdown on, it caused plenty of controversy.
It is also important to note that experts and players alike don’t necessarily disagree with what the NRL is trying to do in preventing contact with the head. However, players believe the rules could have been introduced with more consultation.
“I just think when you bring in a raft of changes and you haven’t run them through NSW Cup or Queensland Cup and you don’t have a true understanding, you get unintended consequences. It’s a full contact sport, we’ve got to remember,” says Welch.
“With the amount of speed and fatigue that they’ve introduced into the game, players are getting caught in really tough situations; barely getting back to the line, turning trying to make tackles, and obviously we’ve seen a rise in those sloppy tackles and I just feel like it’s been very reactionary.
“It’s like we’ve created this monster where there is more poor, sloppy contact because players are so stuffed and then what do we do? To be honest, I feel sorry for the refs. They’ve been sent all these directions from HQ and they’re doing their best. It’s such a hard sport to referee. It’s not black and white. I think they’re doing a fantastic job.”
In terms of a rise in sloppy tackles, NRL Physio Brien Seeney published a list of the number of club reported concussions for the last five seasons, comparing them with the AFL and rugby union.
The total number of reported concussions in the NRL for the 2021 regular season is pegged at 120. A 29 concussion increase on 2020 and a 28 concussion increase on 2019.
In many ways, 2020 was the canary in the coal mine in this regard. Its 91 total concussions was only one fewer than 2019 despite having five fewer rounds.
The lowest season for concussions was 2018, with 78, which also coincided with the NRL’s rules crackdown that saw many more penalties blown each game.
While correlation does not equal causation, it is interesting to note that in the same season the NRL says it is very concerned with impacts to the head, the number of concussions have increased by 30 per cent.
Other Sports
Concussion, CTE and head knocks are not a rugby league only problem. Nearly every contact and partial contact sport is wrestling with the issues being brought to the surface by dedicated researchers.
While boxing has had concerns around long term brain health for 100 years, the NFL was the first sport to face the issue head on in the 21st century.
Since then rugby union, football, Australian rules, cricket and even cycling have all looked at how to address the danger of head impacts.
Dr Nowinski says the NFL has made a lot of changes and continues to make changes not just in game play, but also in training.
“They’ve made 10 or 20 changes to the game, focussed on neurological health. That includes their testing protocol, there are independent doctors on the sideline, there are many reforms to the game in terms of prevention, so penalties, how they do kick offs, how you can tackle someone, how you can block someone, how they practice. There are massive limitations on how they can practice. There has been a lot and there is a little more each year as they identify the problems,” he says.
The NFL has its entire concussion protocol and return to play requirements available on its website.
In rugby union, the code undertook long term research, combined with trialing rule changes to make the game safer for both attackers and defenders.
In cricket the game introduced a concussion substitute, while cycling and AFL both have HIA protocols.
Since the UCI, cycling’s governing body, introduced more stringent concussion protocols, riders are now being withdrawn from races following heavy crashes.
As Dr Buckland points out, while the NRL looks to continue protecting players during games, perhaps the biggest strides in player safety can be made at training.
“It’s a no brainer that you can get rid of half the cumulative exposure by just changing the practice, without even touching the game.
“It’s not monitored like it is on game day. I don’t have any specific inside knowledge, but the scrutiny that happens on game day with the Bunker and multiple camera angles. I just can’t imagine there’d be that level of scrutiny.
“I’m very happy to say that whatever changes there are, the focus should be on reducing cumulative head impacts and also I believe the two ways of doing that, maybe practice and looking at the age of when full contact football is introduced.
“Because if you can knock off years of exposure to repetitive head injury to those younger people, then you’re buying time at the other end.”
And what of those younger people? Concussion after all isn’t confined to our professional athletes at the highest level.
It impacts our children and local players at the amateur level.
It’s something that Dr Nowinski feels very strongly about when it comes to protecting children.
“I don’t believe we should be giving children brain diseases in sport for any reason. There is no reason that is good enough in soccer, or rugby, or football that is worth a brain disease for a child. So one of the things we’ve already decided in this group over here, is that we shouldn’t be hitting kids in the head like we hit adults in the head.
“Ethically it’s inappropriate based one what we know today. One important thing that we’re trying to say is start exposure to head trauma later in life. Right now we’re trying to promote not hitting kids in the head 100 times a year until they’re at least 14. Let’s get there and then let’s reset.”
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Part four will look at what is being done at the local level to both protect amateur players and educate the wider community on concussion. Subscribe for $5/month to get access to the full series and all other content, while also receiving your first month FREE.
Sounds like a lot of research happening behind the scenes which will hopefully better inform the payers, administrators, families and spectators. One of the most important strides forward was the change in culture when everyone stopped talking about a player that staggered back into the line and would not leaver, was both courageous and a hero.