Current treatment practices for concussion leave a lot to be desired, particularly when new evidence suggests even small knocks can do a lot of damage.
By DONAL STOTT
Concussions are a dangerous and regular injury on the football field, and current diagnostic practices may be little better than guessing, experts in the field say.
As it stands, doctors and sports trainers must rely purely on observation when attempting to diagnose the full extent of a player’s head injury.
Dr Alan Pearce, deputy director of the Cognitive Neuroscience Laboratory at Deakin University, has researched the efficacy of concussion testing and is concerned about the limitations of current procedures.
“Even all the sports medicine doctors on the sideline are not able to clearly and reliably diagnose a concussion,” he says.
At the community sport level this is even harder, with most football teams having to rely on sports trainers rather than doctors. Their education is focused mainly on strapping and basic first aid with very little time spent on concussion.
Courtney Farley is a registered nurse and volunteer sports trainer. Her team is fortunate as her training and experience as a nurse gives her a better knowledge base than many of her colleagues.
This season, Ms Farley has seen several players under her care suffer concussions and, despite her training, has struggled to identify all players who should have been taken off the field.
“A concussion may be difficult to assess and manage,” she says.
“It requires knowledge and understanding of concussion, including the mechanism of injury, signs and symptoms, complications, assessment and management.”
The basic concussion management dictated by the AFL to the lower levels of the competition involves the use of a SCAT-2 card, which simply suggests questions and physical actions to determine a player’s mental capacity and balance.
According to Dr Pearce, this test doesn’t enable a sports trainer to accurately diagnose an injured player.
“We need to do more. I think everyone is trying to address the problem, they are realising they need to do more than a card,” he says.
The problem isn’t just when to take a player off the field, but also when to allow them to play again after suffering a concussion.
After being identified as having a concussion, amateur footballers have to see a sports doctor and be cleared to play. Dr Pearce believes community doctors simply don’t have the experience or equipment to accurately clear a patient.
“They can do some very rudimentary pupillometry, look at some basic reflexes, there’s no specialised equipment for them to look at what’s happening in the brain,” he says.
He has also seen research that shows players often don’t seek medical advice after receiving a knock to the head, and even when they do, they don’t follow the advice they’re given.
“In community rugby, 78 per cent of players with suspected concussion did not receive return-to-play advice; of those who did get the advice, 100 per cent did not comply,” he says, reading from a recent study authored by researchers from a number of Victorian universities.
The full recovery time for concussion is still not known, but Dr Pearce believes that in most cases an injured person will need over a week to fully recover.
Dr Pearce’s research also shows multiple concussions can have drastic long-term effects on sports players’ health. And research being conducted in the US indicates sub-concussions – which are smaller and undetectable – might be even worse.
Danger of small knocks
According to Dr Pearce, it’s not the big hits that are the most dangerous, but rather the repeated unnoticed hits that do the most damage.
“For every serious concussion, we don’t know how many sub-concussions have occurred … we can’t identify them, we don’t know how we can test for them,” he says.
“It’s the effect of multiple concussions and also sub-concussions … which can then lead to changes down the track.”
The effects of concussion can range from short-term memory loss, mood swings and even Alzheimer’s-like symptoms, which often don’t emerge until decades after the initial injury.
The danger of head injuries has become well known through campaigns by the AFL and other major sporting bodies, but despite this, players at all levels continue to play through concussions.
Despite the introduction of stronger measures around concussion management in the AFL's senior ranks, one of the AFL Medical Officers Association bosses, Dr Hugh Seward, has expressed reservations to The Age about the long-term dangers of concussions in regard to AFL.
“We’ve got no evidence to suggest that the condition we’re seeing in America from multiple head knocks – up to 1500 in a season - is akin to what we see in Australian football,” Dr Seward said.
“We’re not naïve. We’re trying to understand players and current players to understand it properly. At the moment we have no evidence that CTE [Chronic Traumatic Encephalopathy] is an issue, and the long-term brain damage that they’re talking about in America may not exist in Australia.”
CTE is a progressive degenerative disease of the brain that affects people who have a history of repetitive brain trauma, typically professional athletes in contact sports.
Definitive diagnosis of the condition has until recently only been possible in an autopsy, but a recent study has used brain scans to identify it in a number of retired American footballers.
Part of the problem, Ms Farley believes, is that concussions may be considered by players to be insignificant or less significant than a musculoskeletal injury.
“Players may be encouraged by other players or coaches to ‘walk it off’,” she says.
Ms Farley believes player education is the biggest factor in harm reduction.
“Players should be required to undertake education and training regarding concussion, including the mechanism of injury, signs and symptoms, complications, assessment and management,” she says.
Dr Pearce agrees it is the basic culture of “male bravado” that needs to be addressed before any real differences will be seen in player’s actions.