Deep in a concussion sinkhole, the CISG lends the NRL a shovel to keep digging

The starship that is the NRL enterprise shows no signs of slowing down anytime soon. Attendances in 2023 are up and TV ratings are strong; largely reflective of an attractive, fast-paced product and a log-jammed competition ladder where the old cliché, ‘any team can beat another on any day’, really is true.

Clubs are clamouring over the top of each other to get the nod for a trip to Las Vegas in 2024, and with match two just around the corner, focus has once again shifted to the NRL’s perennial banker, State of Origin.

Not only does it feel like rugby league is bullet-proof, the NRL has the strut and confidence of a body that knows it’s bullet proof.

What other reason can there be for an organisation, so often a laggard when it comes to recognising the dangers of head injury and putting prevention measures in place, this week sending out its Head of Football Elite Competitions, Graham Annesley, as some kind of educator on concussion?

Focusing on explaining the NRL’s on and off-field concussion protocols, Annesley’s weekly briefing for Round 15, was instructive; just not for the reasons the NRL might think.

Stationed alongside a large interactive touch-screen, Annesley gave off strong Professor Julius Sumner-Miller vibes; tackling the thorny issues around the NRL’s concussion protocols, explaining, for the benefit of media and fans, “why is it so?”

Ostensibly in response to criticism of Tom Trbojevic being concussed in State of Origin 1 yet, after the Manly club challenged the diagnosis, being allowed to play nine days later, Annesley clarified the league’s treatment of in-play concussions.

In short, where an independent doctor located in the NRL’s bunker observes a player exhibiting category #2 symptoms (which include lying motionless, slow to stand, potential facial fracture), the player is removed from the field for an HIA, conducted or observed by the club doctor.

If the player passes the test they are allowed back on. If not, they are deemed concussed and enter a graduated return to sport (RTS) protocol.

Where the independent doctor observes a player exhibiting category #1 symptoms, (which include loss of consciousness, balance disturbance, no protective action when falling) the player is removed from the field and, according to the NRL’s own protocols, is unable to return to play.

But here’s where it gets murky. Annesley explained that in these cases, despite the independent doctor deeming a player to be exhibiting category #1 symptoms, the club doctor at the ground conducts an HIA and, if satisfied that no concussion has occurred, has the discretion to allow the player to return to the field.

Further, as in the case of Trbojevic, this determination allows the player to sidestep the NRL’s mandatory 11-day stand-down, and – providing the player satisfies the graduated conditions of the RTS – play the following week.

The pecking order is clear. Despite there being concerns about independence and potential pressure being brought to bear by coaches and players themselves determined to ‘shake it off and play on’, the ultimate decision-making responsibility still sits with the club doctor.

Ryan Matterson of the Eels is attended to by a team trainer (Photo by Cameron Spencer/Getty Images)

What then, of the independent doctor? As Dr Julius might ask; ‘why are they so?’ Perhaps think of their role less as doctor and more as a ‘concussion spotter’, identifying cases for the club doctors to say ‘I’ll take it from there, thanks’.

Annesley justified this chain of command on the grounds that being at the match, conducting an assessment in person, the club doctor was in best position to make a diagnosis. What Annesley didn’t explain was why the NRL doesn’t simply provide an independent doctor at each match; something that Super Rugby, a competition with far less money than the NRL, manages to do.

What Annesley is effectively saying, is ‘trust the club doctor’. Fair enough, but how many club doctors start from a point of doing what they can to keep a concussed player out of the game until there is no doubt that they are fully recovered?

Or, how many doctors work to satisfy the wishes of coaches and players to get them to return to play as quickly as possible?

We know that doctors care. But that different framing and emphasis is critical.

To what extent are matters influenced by the clubs? It is self-evident that in rugby league, there are numerous people at all levels of the game who are uncomfortable with evolution and change where it might turn rugby league into something different from the sport they know and love. Vocal and influential coaches and club executives are among this cohort.

For that reason, when it comes to head injuries, recognition of the need for change, and the implementation of change has been painfully slow.

Some measures have been accepted; others not. Bumping sympathetic club doctors down the pecking order, below newly appointed independent doctors from outside the inner sanctum of the sport is, it seems, a bridge too far.

With respect to RTS, Annesley explained – without any hint of irony – how clubs can apply for an exemption to the 11-day mandatory stand-down where the player is assessed by an “independent neurological expert appointed by the NRL”.

The use of “independent” and “appointed by the NRL” in the same sentence is some high-grade chutzpah.

Anticipating questions around reasons why there exists an 11-day stand-down period, Annesley then went on to say, unashamedly, “There’s no magic around 11 days. There’s no medicine around 11 days”.

Why then, 11 days? Because, Annesley stated, it fell within the range of what some other sports were doing. No magic. No medicine. Just whatever floats.

Benchmarking other codes might be convenient were it not for the fact that head injury incidences remain far higher in the NRL than in other sports. Every week, players continue to forcefully hit each other in the head; sometimes accidentally, other times not.

Last weekend, Canberra’s Jordan Rapana, after suffering a severe head injury in April, was hit high in the first half of their match against the Warriors, and was subjected to an HIA, which he passed.

With four minutes to play, Rapana received another high shot, and was taken from the field, visibly affected. TV match commentators duly noted that Rapana would now undergo a second HIA in order to be allowed to return to play.

Not only was it not articulated how a test that takes between 10-15 minutes to complete could provide for Rapana’s return to a match with only four minutes of playing time remaining, but how was the notion that a player with a concerning recent history of head injury, could suffer two more significant head impacts in a subsequent match, and still be a chance of passing an HIA in order to keep playing, deemed even possible or desirable?

To this extent, the idea that Annesley make himself available to lecture or educate the rugby league media on concussion makes sense. But only insofar as it doesn’t become an exercise in the blind leading the blind.

To illustrate, in outlining the NRL’s RTS strategy, Annesley quoted stage 3, “where a player can return to running or skating drills”.

Skating? Was this an insight into Trbojevic’s recuperative powers? Apparently not; rather a tired cut and paste job taken from the Concussion in Sport Group (CISG) consensus statement of – wait for it – 2008!

As it happened, the CISG released its 6th consensus statement yesterday, coming six years after the previous statement, released in 2017.

Graham Annesley (Photo by Matt King/Getty Images)

With prominent and influential CISG figurehead Dr. Paul McCrory having resigned from the group last year following a plagiarism scandal, expectations were high around the new statement. But as Melbourne neurophysiologist Dr Alan Pearce explained to The Roar, “a statement that has promised so much, has actually delivered so little.”

“It’s hard to conceive of any other medical or academic paper that carries such a long list of acknowledgements of conflicts of interest held by the various authors,” Pearce noted.

In that respect, it is little wonder that, when compared to the previous statement, so little progress has been made, particularly when it comes to the acknowledgement of Chronic Traumatic Encephalopathy (CTE).

Sought for comment, an Australian Concussion Legacy Foundation (CLF) spokesperson provided The Roar with the following statement; “The absence of any reference to a relationship between contact sport participation and CTE is disappointing. The public need to be properly informed of the dangers. There is evidence to show that repetitive head impacts sustained during contact sports could be linked to an increased risk of CTE.”

“We need to pay attention particularly for our children who commence playing contact sports as early as five. Parents should be informed of the risks and sporting codes should be doing more to mitigate those risks otherwise a failure to take action could have detrimental effects on the future health of athletes and their families,” the statement concluded.

Also raising concerns is a disparity between symptom recovery and the physiological and psychological readiness to return to play. Based on research considered by the CISG, they determined that the mean recovery time following a concussion was 19.8 days.

Again, the question must be asked of the NRL (and other football codes); with respect to their own RTS protocols, on what basis is an 11-day stand-down period for concussed players, deemed safe or appropriate?

Pearce is concerned that the new statement will do little more than continue to provide a shield for sports administrators to conveniently hide behind. “The problem with such a weak statement, one that doesn’t even begin to address concerns over CTE, is that it provides a veil of credibility for any sport that wishes to limit their actions around prevention of brain injury, and appropriate management of injured participants,” he said.

As for Annesley and the NRL, the new concussion statement contains another banana skin, in the form of a specific recommendation to disallow body checking in ice hockey.

When it comes to head injury the NRL might be skating on thin ice, but it will be interesting to note if, at his next ‘concussion update’, Annesley has managed to update his slide deck so as not to confuse audiences with curious ice hockey references.