As the Australian rules football seasons draws to a close with tomorrow’s grand final between Sydney Swans and the Brisbane Lions, questions are being asked about what managing concussions “conservatively“ should look like at an elite level.
The sport – among the most popular in Australia – is run by the Australian Football League (AFL). It is a physical contact game but players rarely use protective body equipment. Multiple serious concussions have resulted in the AFL peak body issuing rules for the treatment of brain injury at community level and different guidelines for players at the top level where doctors and specialists are immediately available.
Concussions continue to plague the sport at all levels.
During the semi-final two weeks ago when playing the Hawthorn Hawks, Port Adelaide Power player Todd Marshall experienced an injury in the second quarter when the knee of another player hit his head.
Marshall has a history of concussion and had only just come back from a previous concussion which he suffered a month earlier playing against the Melbourne Demons.
After being hit with the knee in the semi-final, Marshall was taken off the ground immediately, but he passed a concussion assessment test known as SCAT6 (Sport Concussion Assessment Tool 6). He returned to play.
There is some doubt about what happened next, and neither Port Adelaide Football Club nor the AFL got back to Cosmos with details, although they said they would.
It’s been reported elsewhere that Marshall was subbed off again when he began to feel symptoms of concussion.
Following the game, Port Power says Marshall failed a “secondary concussion test” and entered the standard AFL “concussion protocols,” missing out on playing in the next game, a preliminary final. If he had sat out of the game for 12 days, he might have been assessed as being healthy enough to play in the grand final, but Port Power didn’t make that game anyway.
After the semi-final in which Marshall was injured, during a media interview club spokesman Tyson Goldsack said: “It’s unfortunate, and he’s had a history [of concussions], so we want to make sure that him as a person is okay. And you know, footy is second to that.”
The incident reignited concern over concussion management, with Professor Alan Pearce from Swinburne University in Victoria asking: “What’s the price of a premiership, if in 20 or 25 years’ time, you’re struggling to remember your kids’ names?”
“The concern that I had with Todd is, that was his fifth concussion in three years,” says Pearce.
The AFL Community Concussion Guidelines state: “In cases where the doctor has conducted a thorough sideline assessment and is satisfied that the player does not have a concussion, then the doctor can clear the player to return to play.”
The guidelines also highlight that the onset of concussion can often occur hours after the initial incident. Therefore, even if a player passes a concussion test, the AFL still require the player to be “managed conservatively” on the day of the injury.
“The concern is that the optics of a player going back on after they’ve been concussed, tells the community and tells junior sport, well, if it’s good enough for ‘x player’ from this AFL club, well then it’s okay for me to go back on too,” says Pearce.
Another concussion specialist, Professor Graeme Jackson from The Florey Institute of Neuroscience and Mental Health at Melbourne University in Victoria, says it’s a complex matter. “AFL is a contact sport, and to some extent, head knocks are a part of it,” Jackson says.
“As in all medical cases, there are straightforward decisions, and cases that are harder to be certain of. Delayed symptoms are, unfortunately, a reality in concussion, and it is hard to see how we can avoid all difficult cases like this that lie between a head knock and a concussion.
“The major issue is that it is important to avoid a second hit while at a vulnerable stage after a first concussion. Therefore, when there is any suggestion of a significant head hit or concussion, caution should prevail,” says Jackson.
“How long after a concussion before returning to play is a critical and unresolved issue. Current rules are 12 days, but arguments based on research findings can easily be made that it should be longer – up to 21 days.”
In terms of taking a conservative approach to concussions and brain injuries, Pearce argues for a “if in doubt, sit them out” philosophy.
Earlier this year, the AFL extended the concussion rest period in March to 21 days for community players and 12 days for elite players.
Since 2003, the AFL has changed more than 30 rules to protect players’ heads and avoid the risk of concussion, but Pearce argues more can be done.
“I’ve been calling for an independent club doctor since about 2016,” say Pearce.
“The independent doctor is not there to undermine the club doctor’s decision. The Club doctor’s got a lot on their plate. They’re trying to deal with players with a rolled ankle, hamstring, or shoulder.”
“They’ve got 18 players to try and deal with. All they have to do is turn their back and in that moment, a player can be hit and they haven’t seen it.”
“For me, having the independent doctor there is to support the club doctor and say, ‘Look, I saw this. They showed this, and this sign’.”
Junior players who return after a concussion too quickly are at risk of second-impact syndrome, where the brain catastrophically swells after a second brain injury.
“Junior players want to emulate their heroes. So you know, if it’s good enough for Todd to get back next week or whatever, then it’s good enough for me,” says Pearce.
Last year, a 20-year-old man from Adelaide in South Australia was declared brain dead after returning to play after a concussion and suffering an additional head trauma.
“What AFL need to do is move this away from just purely a medical-legal issue, and what they need to do is turn it into a socio-cultural issue,” says Pearce.
Earlier in the year, AFL Western Bulldogs player Tom Liberatore, was sidelined after suffering 2 concussions over three weeks. Additionally, six players have announced early retirement this season due to sustaining multiple concussions in a short period of time.
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