Repeated head injuries highlight gaps in sports concussion management

Jonathan Brown is not the only professional football player to recently retire because of head injuries. AAP Image/Dave Hunt

Brisbane Lions champion Jonathan Brown’s premature exit from the AFL this week after suffering yet another concussion was in many ways unsurprising. His friends and fans describe him as a “warrior” who is “hard as nails”, but Brown’s tally of concussions and facial fractures has concerned onlookers for several years.

Brown has always brushed off these concerns. But in the end even he acknowledged the cumulative effects of these injuries, and concluded it would be dangerous to continue playing to the end of the season, as planned:

It’s become evident after my concussion last week that I don’t respond or bounce back like I used to from those hits. I had pretty strong medical advice this week that it was in my best interest to stop. It wasn’t worth the risk of going out there and copping another head knock and jeopardising my future with my wife and kids.

Brown is not the only professional football player to recently retire because of head injuries. A 2013 neuropsychological case study of a rugby league player with brain atrophy and cognitive impairments reported that he had suffered at least ten concussions during his professional playing career. At only 29 years of age he too was advised to retire to avoid further concussive injuries worsening his condition.

How do players get to the point that it becomes unwise or dangerous for them to risk another concussion?

According to concussion management guidelines the AFL and National Rugby League (NRL) adopted in 2011, players diagnosed with concussion are prohibited from playing on the day of injury and must follow a graduated return-to-play schedule until they are symptom free (typically seven days).

These measures are ostensibly designed to improve the safety of these sports but it is debatable whether they succeed. The governing bodies of these sports have not always enforced these guidelines. It took until 2014 for a team to be sanctioned for breaching these guidelines, despite the Chief Medical Officer of the NRL admitting there had been breaches in the preceding three seasons.

Governing bodies have tolerated conflicts of interest among team doctors. Competing loyalties have the potential to undermine proper concussion management if the interests of the team are prioritised over the interests of the patient. They have similarly tolerated links that their own concussion advisors have to companies who market computerised neuropsychological tests for concussion – tests which are now mandatory in the AFL and NRL.

But it is of greatest concern that these rules do not prevent players from suffering repeated concussions each season throughout their playing careers. NRL player Liam Fulton has suffered four separate concussions this year. When asked about his long-term health, the Wests Tigers player said:

I’ve been knocked over ten times… I’ve been knocked out that many times if I’m going to get dementia I’m going to get it, it’s just what it is.

Liam Fulton during the NRL round one match between the St George Illawarra Dragons and the Wests Tigers. AAP Image/Action Photographics, Colin Whelan

It is odd that collision sports can claim “player safety is a key priority” when their policies do not seek to prevent repeated head injuries. Although the AFL and NRL claim to take concussion very seriously they have avoided enacting measures to prevent repeated concussions by arguing there is no definitive proof that concussion causes long-term cognitive impairment or neurological deterioration.

Medical officers and researchers linked to the AFL have claimed that concerns about the long-term risks of multiple concussions are anecdotal and overhyped by the media. And yet Jonathan Brown and other players have been advised that they put their long-term health at risk if they suffer further head injuries.

The merits of many potential measures to reduce the risk of repeated concussions have not yet undergone a thorough examination. These may include various rules to significantly reduce contact, slow down play, or require players to take more extended breaks after a concussion.

Of course, heavy collisions and a tough style of play are undoubtedly part of the appeal for many fans. A fear that rule changes will fundamentally alter the nature of collision sports (and their commercial success) may contribute to the governing bodies’ reluctance.

Collision sports bodies could argue that adult athletes are autonomous agents who freely choose to participate in collision sports and hence accept the risks of concussion and any future health problems that this may cause. But this approach would also need to ensure that players really do make an informed and autonomous decision.

A truly informed decision would require better management of coercive pressures and conflicts of interest that circumvent concussion management, and a clearer acknowledgement of the potential long-term harms of suffering repeated head injuries.

Currently, the codes prefer to profess a primary concern for the well-being of their players while doing little or nothing to protect them from the effects of repeated concussion, as exemplified in the career of Jonathan Brown.

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