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What really happens inside Australia’s sports concussion labs

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20th May, 2021
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There’s a certain apprehension associated with submitting to a neurobiological concussion study.

What if I find that I’m impaired? A likely candidate for early-onset dementia or similar? Is that something I really want to know?

Recounting my past concussion history formed part of the initial assessment. A couple of serious head knocks as a kid, with mum and dad forcing me to sit out sport for a week or two, then another couple mid-career, the standard type when the bells start ringing and everything goes vague for a minute or two, and you know you have to lay off the grog for the night.

And then one later on in the final year before I stopped playing rugby, where, having been concussed on-field, and had over a dozen stitches to essentially re-attach my ear, I foolishly allowed myself to be bandaged up like Elephant Man with headgear, to play the following weekend, stitches still in, headaches still prevalent. Because that’s what the team needed.

Associate Professor Alan Pearce has forged a growing reputation as an expert in sports concussion, and it is his laboratory, located within Melbourne’s Latrobe University, where I am subjected not only to testing, but to learning more about his work and to discuss the topic of concussion in sport.

The term ‘laboratory’ conjures up all sorts of images. Last Sunday, a posse of politicians descended upon Latrobe to trumpet a multi-million dollar investment into a facility to house women’s football and women’s rugby in Victoria. This on top of an existing, modern, high-class indoor/outdoor facility on campus.

It’s clearly a worthy investment, but the contrast couldn’t be starker walking the drab corridor into Pearce’s lab, sited not more than a couple of decent punt kicks away. Think 1960s Eastern Europe, minus the drug cheating, and you get the vibe.

That such important work isn’t better funded, given the amount of money generated by Australia’s leading professional sports, borders on criminal. But Pearce himself isn’t complaining.

“Of course, funding is an important issue for me, my work is honorary and reliant on funding via a charity. But it is more important that this work isn’t compromised by any association with ongoing funding provided by the sports, whereby outcomes might be perceived to be influenced or shaped to suit an external agenda,” he explains.

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Pearce has now published three papers using subjects drawn variously from AFL, NRL, boxing, car racing and rugby union. In his view, the science is in. Concussion causes microdamage to areas of the brain that in turn leads to an increased likelihood of outcomes such as mental health decline (often leading to suicide), impaired motor function, loss of memory, early-onset dementia, Alzheimer’s disease, Parkinson’s disease, Chronic Traumatic Encephalopathy (CTE) and others.

His 2017 study found that a group of 25 retired NRL players, who averaged eight concussions throughout their playing career, performed 40 to 50% worse on cognitive testing than a control group of men of a similar age.

Pearce’s current research project – the one I am participating in – uses transcranial magnetic stimulation to investigate the neurobiological basis of ongoing symptoms following sports concussion.

Stimulation of nerve tissue in the brain is obtained via connection to a machine and a magnetic coil placed on the head, after which muscle activity is recorded through small disc electrodes, which is then translated into a series of waveforms, for analysis.

In the second part of the testing, subjects complete sensory testing via light vibration stimulus, which measures response times to various stimuli using a cortical metrics device.

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The purpose? Results are expected to contribute to a better understanding of the underlying activity in the brain, of people with ongoing symptoms of concussion and with a history of concussion.

In the meantime, Pearce watches sports flounder around and skirt the edges of the concussion issue with bemusement. Concussion management and return to play protocols are improving, but they still fail to adequately address what the science is saying.

“My research shows that the brain needs up to 30 days to fully recover from a concussion. The AFL recently increased the mandatory stand-down for concussed players, but it still falls below half of this time,” he says. “In rugby league and rugby union, it is still possible for a concussed player to be managed through protocols and, if he exhibits no further symptoms and meets the daily hurdles, play again the following weekend.”

The point being made by Pearce is that concussion symptoms in themselves are not a reliable indicator of concussion. Witness the desperate action of the NRL in April of this year to re-define what constituted concussion, merely to try to take the heat out of a situation where they were under fire for the high incidences of concussion in rugby league in 2021.

“The NRL would have us believe that incidences of concussion had halved overnight, when in fact what they were really saying was that half of the players who failed HIAs, after a period of time, were no longer exhibiting symptoms of concussion. This doesn’t mean that those players weren’t concussed,” Pearce clarifies.

The issue of sideline concussion tests, or HIAs, is another bone of contention.

Adam Clune HIA

(Photo by Speed Media/Icon Sportswire via Getty Images)

Pearce steps me through the SCAT5 test used by all of the major codes in Australia, a standardized test developed by the international Concussion in Sport Group, which itself has come under increasing scrutiny for being a closed-shop self-serving bureaucracy, too closely linked to certain sporting organisations, and for its failure to accept tests from independent neurosurgeons.

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The test takes around ten minutes to complete and comprises a mix of motor function tests and a series of questions, all of which are then compared to a baseline result obtained from players during the pre-season.

The flaws in the process are immediately obvious. I dismally fail a one-legged balancing exercise, an outcome I put down to diminished strength in my quadriceps following a knee replacement. And that’s how it works in practice — there is nothing to stop a player telling the testing doctor that ‘I might be a bit wobbly but that’s not because I’m concussed, I got a whack on the leg as well.’

It gets worse with the questions. Memory tests are drawn from only a small handful of sets of words and the same words that are used in every test, over and over. Any professional player with time on their hands would have no trouble at all in memorising these words to recall them later during an HIA.

Then there’s the matter of the baseline itself, where multiple players from AFL and NRL have admitted to fudging the original test, so as to have a lower bar to cross should they be required to undertake a test, during a match.

The amount of subjectivity involved in the assessment is a concern for Dr Adrian Cohen, whose Headsafe headquarters is based in Sydney’s Surry Hills. It is here where I find a small team of scientific and clinical researchers sitting at powerful computers, developing cutting-edge technology for the fast, portable and objective assessment of brain function.

Cohen’s goal is the elimination of preventable head and neck injuries through advocacy, awareness, research and education, and his focus is on what he calls “Event-Related Potentials” (ERPs), which can occur in the vestibular, acoustic and visual systems.

“In the event of a concussion, these ERPs change, then come back to normal as the patient recovers,” he explains. “Because concussion is an energy disease, more energy equates to more damage, and there is a cumulative effect as well.”

“Thus, if you understand the pathology, the SCAT5 is fundamentally wrong, and is an unreliable indicator. Doctors are diagnosing symptoms of concussion, not actual concussion,” says Cohen, agreeing with Pearce.

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What is apparent is that the assessing doctor is relying on the honesty and common sense of the player to make a diagnosis. And, given the predilection of NRL players in particular to keep hitting each other in the head, how can there be confidence that they are best placed to determine themselves, or influence those responsible for the decision, whether they are fit to continue to play or not?

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This week World Rugby announced that the current trans-Tasman Super Rugby competition will trial eye-tracking technology to use in conjunction with the SCAT5 assessment, and in addition to Cohen’s work, there are other technologies, including saliva testing, in various stages of development.

But until there is a reliable, real-time, objective pitch-side measurement of concussion, expect to see inconsistencies and confusion reign across all our major contact sports.

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So, where do things head from here? The AFL is bracing itself for legal action from a large cohort of ex-players who have been affected post-retirement by concussion-related conditions.

Rugby Union is being faced with a similar action in the UK, from a smaller group of ex-players, although with respect to Australia, the situation is murkier because, unlike the AFL and NRL, the laws of the game are set by an overarching world governing body, who can point to years of evidence-based research and action with respect to endeavouring to make the sport ‘safer’.

Rugby League has just entered a surreal zone where the NRL’s leading administrators have finally announced a crackdown on illegal dangerous play in a belated effort to minimise incidences of concussion. The implementation has been almost laughably ham-fisted, with the concussion message somewhat diluted in a wider-ranging attempt to clean up multiple aspects of the game.

With it has come the inevitable push-back from many within rugby league, and a culture war for control of the essence of the sport is now being waged, which will no doubt continue in the weeks ahead.

Another bemusing outcome is sections of the rugby league media, who have largely sat silent through years of rugby league players continuing to hit each other in the head, now lecturing fans on the dangers of concussion, as if it’s always been the most obvious thing in the world.

What is actually driving all of this is that the NRL’s lawyers have finally convinced administrators to act, and to be seen to act, in order to mitigate any potential future legal action.

Otherwise, if the safety of players was as paramount as ARL Chairman Peter V’landys now insists it is, the current crackdown would have happened years ago.

ARLC Chairman Peter V’landys

(Photo by Matt King/Getty Images)

Remember, it was only a few short weeks ago when NRL Head of Football, Graham Annesley, said that he had no problem with Melbourne Storm’s Felice Kaufusi not being sent to the sin bin for his sickening elbow strike to the head of Parramatta’s Ryan Matterson.

Cynicism aside, any outcome that results in fewer players being concussed is a good one, and it will be interesting to see how the NRL goes about embedding these changes into the fabric of the game, or whether they become a short-term, flag-waving exercise. Let’s hope it’s the former.

In the meantime, there was a nervous moment or two before I opened the email from Associate Professor Pearce containing the results of my neurological tests.

“Your memory, concentration and balance testing were fine,” it read. “Your neurosensory testing was overall very good too. Your brain stimulation data supported all of this by showing a healthy response for your age.”

So, there you go. A bullet dodged, although the downside is that I’ll now have to come up with another excuse for forgetting someone’s name or failing to come home from the supermarket with all of the items I was sent to fetch.

There will be others like me, however – ex-players, professional and amateur, from all of the football codes and other sports – who won’t be so lucky. We’ve all seen some of the famous ones already, suffering on our TV screens, and many of us who played at all levels know ex-teammates who have suffered similarly.

We all know that there is an inherent risk in any activity we participate in, and that accidents can and do happen. It is no solution to wrap ourselves and our children in cotton wool.

But it is to be hoped that the work done by Pearce and Cohen, and other concussion experts like Professor Michael Buckland and Dr Rowena Mobbs, is taken increasingly seriously, and that the longevity of all of our sports is assured by the collective actions of administrators and medical professionals and – dare I say it – the common sense of participants.

What we do know for certain is that just because the NRL has finally announced itself as a concussion crusader, and has started to send head-hunting players from the field, the issue of concussion in sport is far from solved.

Any player or ex-player from any sport who has a history of suffering from concussion, is based in Melbourne and would like to participate in Associate Professor Alan Pearce’s current study, is invited to contact him at alan.pearce@latrobe.edu.au.

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