Concussion discussion involves two people. Everyone else should stay on the sideline

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In the desperation for regaining the ball, it only took a split-second for Sydney Swans defender Paddy McCartin’s head to tap the SCG grass. In distressing scenes, the AFL star lay injured on the ground, before being helped up by trainers and stumbling from the field with what is believed to be his 10th concussion.

Commendably, the commentary team expressed concern about this relatively innocuous incident on Saturday night, rather than it being celebrated as part of the rough and tumble of the game. Sport has come a long way from the fisticuffs of seasons gone by, but where does this leave players like McCartin for the season if they so readily sustain concussion after concussion? If only we had a window on the brain.

There is growing debate about the number of concussions before a player is struck off, following a general shift to a safer stance. Should it be two, five or 10 concussions? Should players continue to have their say, or is it up to the doctors and club staff to call it?

We should be careful not to take a reactive stab at this, and to remove players unnecessarily, leaving them to agonise over what might have been. Lest we judge from afar and cause players like Paddy McCartin more harm than good. Previous protocols have suggested that as little as two concussions are enough to call the season, while others do not comment at all, and as a neurologist, I would suggest there is no magic number.

For the professional ranks like McCartin and the formidable but fallible cricketer Will Pucovski, the crescendo effect of repeated and more easily sustained concussion, a weak jaw in the old days, is a blight on their career and a major concern in their personal lives.

Will Pucovski after suffering a head knock against India in a tour match in 2020.Credit: Getty Images

Plenty of players, somewhere between 15 and 50 per cent, go on to suffer prolonged post-concussion symptoms which can be ruinous to their ability to think clearly, endure even the most simple daily tasks, and keep their family on side. The lesser known phenomenon of chronic migraine after concussion is in many respects identical to concussion symptoms like fog, fatigue and dizziness, but is a readily treatable condition. Most importantly, repeated concussion can rarely lead to death, as in the case of second impact syndrome, where the brain swells until crushed. Therefore, players – whether professional, amateur or youth – should consider seeing their doctor or a local neurologist for individualised treatment and a review of their neurological wellbeing.

The science is less precise on repeated injuries, but what it does have is mounting evidence on single concussion, trending towards a longer mandated rest after head injury, whether the sports and vested interests like it or not. When we consider our youth in sport it’s easier to accept the rationale. The brain does not fully develop until the mid-20s, and psychologically perhaps to the 30s, and won’t repair the same way as an achilles strain. We have recently seen the football codes battle it out, publicly claiming that each has the best evidence-based guidelines, but this cannot be true with such variation among them, be it seven, 11 or 12 days off.

Players who have suffered a concussion in the 2023 NRL season: (Clockwise from top left) James Tedesco, Alex Johnston, Kalyn Ponga and Jordan Rapana.Credit: Getty Images

It has been tumultuous for sporting clubs this year, but for good reason. Medical experts are pushing for an even safer stance in line with international shifts. When professional players retire due to repeated concussion it can be lifesaving, in that it stems the flow of symptomless impacts, so-called sub-concussions, and minimises neurological harm.

The duration of exposure to sub-concussion plus concussion, usually over at least a decade, is enough to trigger the microscopic cascade of tau-protein and eventual young-onset dementia. Chronic traumatic encephalopathy or CTE has become a mainstream concern for NFL teams in the US. What has become most alarming is the extent of exposure to head injury in grassroots football. Many of my everyday patients sustain more than 50 concussions over 20 years of play in football codes, without a season off.

The discussion on whether a player should retire will remain a delicate one that balances the benefits and risks for that player, until we develop usable biomarkers for concussion and CTE. These tests will take measurements from blood, sweat, saliva or use brain imaging to confirm injury and validate concussion recovery. Many approaches are being studied but none have come through to standard medical practice. During the recent parliamentary inquiry into concussions and repeated head trauma in contact sports, there were calls for the development of nationally applied protocols that relieve the sporting bodies themselves of making the tough calls and provide the right scaffold for athlete safety.

Medical advice sits firmly on the side of the benefits of sport socially, physically and intellectually. For those vulnerable to concussive injury, we must ensure a balance is had, with reasonable measures to minimise risk. The excitement of AFL and other sports will endure, for it’s as much about the run of the ball and the skill of a team in sync as it is about the contact. But training modification, longer recovery periods after concussion, tougher penalties for dangerous play and regulated consideration of earlier retirement are important and obvious steps.

For now, the concussion discussion on retirement is equally about the art as the science. It should remain the private remit of the player together with their independent doctor to determine the best path for that athlete’s future, and everyone else should stay on the sidelines.

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