Unpacking concussion – Big League
Concussions have been in the headlines prominently this year. Three clubs were fined a total of $350,000 for not following concussion protocol; James McManus is suing Newcastle Knights for management of his head injuries.
And in early March, debate raged whether Knights fullback Brendan Elliott should have been removed from the field after two head knocks.
Big League asked the NRL’s Chief Medical Officer, Dr Paul Bloomfield, to clarify concussion, the protocols and whether there is a case for independent doctors to be used.
First of all, what is a concussion?
It’s essentially a disturbance of brain function caused by force to the head. It can be either direct or indirect force and a player doesn’t have to lose consciousness to have concussion.
Concussion would be suspected in the presence of physical signs (unsteadiness), symptoms (headaches, blurred vision, dizziness, nausea), impaired brain function (confusion) and abnormal behaviour (change in personality).
“Concussion is an evolving condition,” says Bloomfield.
“Some symptoms go away quickly. Some are more subtle, such as delayed concussion.
“Eighty percent of concussions are better in 7-10 days, whereas some have lasting symptoms. These need to be monitored and is dependent on player honesty.”
What are the protocols to treat concussion?
Testing starts during the pre-season, where doctors conduct a SCAT3 (the third version of the Sport Concussion Assessment Tool, soon to be a SCAT5). This is a tool that assesses different parts of the brain and involves testing of symptoms, concentration, memory, coordination and balance.
The SCAT is used during game day as well as a head injury assessment. This assessment has two categories of symptoms, depending on the significance of the injury.
Doctors also do a computer-based cognitive test to determine whether a player can return to play after suffering a concussion. This looks at balance, concentration and memory.
Treatment doesn’t just stop during a game either, says Bloomfield.
“If a player has come off for a head injury assessment, they can go back on, but it need to be followed up and reassessed in 24-48 hours. They need to repeat the SCAT until everything is normal, to gradually return to play.”
As there is no ‘pass or fail’ type test, the onus is on doctors to make the right choice and look after the player’s welfare. But this can be a contentious relationship too, as coaches want their best players out on the paddock and real-time footage doesn’t always show the extent of a concussion’s damage. It’s also confusing for the players.
What is the NRL doing to educate players, staff and coaches?
Mid-last year, more than 5000 players and coaches received a short talk on concussion, led by Kangaroos head trainer Craig Catterick as well as a neurosurgeon. During pre-season, trainers and doctors were given advice about the rule changes and further education.
Rugby League Players Association chief executive Ian Prendergast acknowledges concussion is a complex issue but feels more education needs to happen.
“I acknowledge the improvement we have seen regarding understanding and commitment in relation to the management of concussion. But in my dealings with players, there is still further work to be done.
“Education needs to be more targeted so that all players understand and respect these measures put in place to support people too.”
Bloomfield meets with CMO’s in other codes 2-3 times per year, including the Australian Rugby Union, Cricket Australia, Australian Football League and World Rugby, to ensure protocols align.
Many players used to feel playing through concussion was a ‘badge of honour.’
Apart from education initiatives, what is being done to change the approach to concussion? Prendergast believes it is about allowing players to speak up and be honest.
“It’s about having honest conversations around issues. In my experience, if you empower the players in particular, as well as the support staff, you can better understand the culture of organisation. People are speaking up.
“More players are sitting out a week, which means there’s no risk of doing further damage.
“We need to continue to shift the attitudes to people regarding injuries, and respect measures to mitigate potential risks around concussion and its impact having on short and long-termhealth.”
The bottom line: players and coaches need to treat concussion the seriousness it demands.
It’s the NRL Grand Final and a team’s fullback smacks his head on the turf. He’s key to their chances. In the cauldron of a final, the pressure on a doctor is magnified by a hundred.
Is it time to employ independent doctors who aren’t employed by clubs?
Bloomfield says the NRL have considered it before but are happy with the current approach.
“Firstly, it is important to point out that doctors report directly to the club’s CEO rather than coach. They also report to the board of their club (3-4 times a year).
“We do constantly look at it. If at any stage we were to go down that pathway, the team doctor would be intimately involved in the team assessment.
“The thing with concussion is the doctor who is going to be treating them really needs to be involved in the initial consultation and assessment as well for a variety of reasons. They need to know what they are like at that stage to be able to determine if they are changing, for the better or worse.
“They also need to know the subtleties around behaviour and personality change that the independent doctor might not notice.”
Breakout box: how the NRL are dealing with concussion:
- There was an increase in Head Injury Assessments from 210 in 2015 to 276 in 2016. Comparatively, there were 155 HIAs in 2014.
- 66% of these cases in 2016 were cleared to continue playing, compared to 54% in 2015.
- Two venues now use Hawk-Eye technology in order for club medical staff to review incidents.
- All Head Injury Assessments are reviewed at the end of every round, using the Bunker technology. Every angle of every incident is assessed through the process.
Published in Big League as of 13 April 2017.