As we’re about to enter the season of contact sports, we’re no doubt going to see our fair share of head knocks and concussions. The AFL is trying to be a leader in concussion recognition and management, with new regulations implemented over recent seasons to ensure that concussion is accurately diagnosed on the spot, and that no player with concussion (or suspected concussion) is allowed back on the ground. However concussion is also quite prevalent in sports other than Aussie Rules, with rugby having very high rates, but other sports such as soccer, netball, cricket and martial arts also at risk.

The information we can gain from leading sporting bodies like the AFL and Rugby Australia is enormous, because they have the funds and the responsibility to be at the forefront of concussion research. However what we don’t have at a grass roots level is qualified medical practitioners, physio’s, and TV’s to assess the player and the incident.

Despite this disadvantage, as players, parents, trainers, and coaches we all should make it our goal to be more concussion aware, and know the basic recognition and management strategies to ensure our kids (who are a greater risk due to poorly developed neck muscles, increased head to neck ratio, and developing brain cells and neural pathways) have the best possible immediate management.

What Is Concussion?

Basically, our brain floats inside our skull, suspended within a protective cushion of fluid (cerebrospinal fluid). Any direct blow to the skull can cause enough movement of the brain that it either hits the skull, or twists within the skull cavity. If the forces are large enough, there can be resultant bruising and damage to the nerves, or neurones within our brain tissue. It is this trauma to the neurones of the brain that we term a concussion, resulting in a number of potential signs and symptoms that occur due to an impairment in brain function. In reality, concussion is the mildest form of traumatic brain injury. A concussion can result in symptoms such as a changed level of consciousness, illness, headaches, and mood and visual changes, and possible signs such as slow decision making, fixed and dilated pupils, and altered movement patterns.

A critical fact to remember is you don’t have to lose consciousness to have a concussion, and the forces required for a concussion can be relatively small. Speaking from personal sporting physio experience with many teams over many years, I would say my experience is that 9 out of 10 concussions have not involved a loss of consciousness.

Another difficult fact when dealing with concussion is that in some cases there may not be any, or many, immediate observable findings. The athlete may seem fine at first, but it is critical to keep a close eye on any person that has received a head knock, to observe for potential signs of delayed concussion.

Who is most at risk of concussion?

The connection between contact sport and concussion is pretty well accepted, especially in Victoria through the AFL media exposure, and in our northern states with our rugby friends (where rugby gets more media exposure than AFL). In the general population, however, concussion is also in fact quite common. Most typical “everyday” concussions occur with falls, car accidents, or accidental head clashes in the school grounds.

And as mentioned above, our junior athletes are greater risk of concussion than adults, and with what we know now about the potential devastating effects of cumulative concussion episodes, it is essential we are managing our younger children well.

The long-term effects of concussion

Thankfully, the short-term symptoms of concussion are reversible, however it was this knowledge that used to make us think that once a person had recovered from a single concussion, they were completely recovered. Studies now suggests that even a single knock to the head can have dramatic consequences later in life, and even more concerning is the more recent research showing that neurological damage accumulates with multiple knocks to the head. So whilst a person can, and usually does, recover fully and relatively quickly from a single concussion, multiple concussions may lead to an increased risk of degenerative neurological conditions such as Alzheimer’s and Parkinson’s disease, as well as chronic traumatic encephalopathy (CTE), which we’ll cover in a minute. Much of the data regarding the effects of cumulative head knocks has come from the staggering information found in American football players, with one such study of 2000 retired players showing three times the likelihood of having been diagnosed with clinical depression if the player had a history of multiple concussions. And just as startling was the finding that pro footballers in America had three times the death rate due to degenerative neurological conditions compared with the general population.

What is Chronic Traumatic Encephalopathy (CTE)?

 (CTE) is another form of degenerative disease, similar to Alzheimer’s, that has been associated with repeated concussions earlier in life. CTE was first discovered by a neuropathologist, Dr Bennet Omalu, in the early 2000’s, in the brain of a former NFL (American National Football League) player – Dr Omalu found microscopic evidence of concentration of a protein called tau (one of two proteins known to accumulate in the brains of people with Alzheimer’s), and amazingly since this finding, CTE has been found in 110 out of 111 NFL players who have donated their brains to research. Any of you seen the 2015 film Concussion with Will Smith playing Dr Omalu? This film was a documentary on exactly these findings.

Whilst tau is found in brain tissue normally, in CTE the tau forms tangles or clumps that disrupts the ability of nerves to transport signals. These tau clumps can eventually lead to the death of neurones, and as more and more neurons die then large areas of the brain can become affected, leading to dementia type symptoms.

There is no absolute need for panic right now, because repeated concussion episodes doesn’t always lead to CTE – it is thought that genetics also plays a factor, and there is more work to be done to determine the exact relationship between concussion and CTE. In fact at the moment there appears minimal reliable scientific evidence clearly linking sport related concussion to CTE. However we do have enough information to know that we must treat every episode of concussion and head trauma seriously.

So… that’s some of the statistics and research that tells us concussion is an issue that needs to be treated seriously. As parents/trainers/observers/coaches we need to be aware of the need to monitor all head knocks closely, and have an action plan in place in the event someone under our care suffers a head knock. In our next blog, I’ll look at what you can do – the signs and symptoms, testing, recording, when to refer, return o sport and school, and a lot more. Even though we don’t have AFL or NRL facilities, there is still a lot that can be done on the bench of your local sporting club.

We have been lucky to be able to get a leading concussion expert to commit to coming to SSPC for a talk on concussion. Once we have confirmed date and time (likely to be late March) we will email details, so keep an eye on your inbox. This talk promised to be informative and invaluable, and no doubt spaces will go quickly.

Anthony Lance

SSPC Physiotherapist

References available on request.