By @DrJohnOrchard

I have just started working in my 15^th season as a professional NRL (National Rugby League, Australia) team doctor but with respect to one injury feel as uneasy as I ever have at any stage of working in sports medicine. In theory I should be more experienced and therefore more relaxed at being able to cope with what the game can throw up at me. I am worried about one of my players suffering a minor concussion in a game, which is almost certainly going to happen in the next 6-8 weeks.

I’m not worried about one of my players suffering a significant concussion, which probably also will happen. By significant, I mean either than he is knocked out (for, say, >=10 seconds) or he is disoriented and reports are coming through that he doesn’t know where he is or what he is doing in the match. In this situation, the management will be simple – the player will come off the ground, I’ll recommend that he doesn’t come back on and the coaching staff for my team (who have a very responsible attitude towards injured players) will take my advice, with the player done for the day.

Why am I more worried about the so-called ‘minor’ concussion than the more serious one? Because the NRL has just brought in a rule that if a doctor assesses a player as having had a concussion (irrespective of whether he has been deemed to have recovered), then the player must not be allowed to return to play in that game. In bringing this zero-tolerance rule in, the NRL are following international trends and appearing to be doing the right thing by players. The problem is that the NRL haven’t really properly defined concussion (which doesn’t distinguish them too badly as even the consensus panels struggle to give a good definition) and, more importantly, haven’t defined a severity cut-off. I’ve seen players in the NRL before get knocked out cold for 60 seconds, come off on a Medicab, and 20 minutes later return to the field. I agree that this is not a good look and in the current climate we need to stop it happening with rule changes. So there is a part of me that is happy that the regulators are trying to stamp this sort of practice out.

The part of me that isn’t comfortable came out at an internal club meeting we had the other day. I told the coaching and training staff that the new official rule was that if I examined a player and determined that he had been concussed that day that, under the new rules, I couldn’t let him return to the field and the club couldn’t overrule me. However, it was quickly pointed out, if I didn’t examine the player, then the rules would allow him to continue. I think everyone can see where this is heading. An anonymous NRL player has blatantly recorded in the Sydney papers that players will avoid doctors and lie to them to make sure they aren’t removed from the field under the new rules.

Thus, I am either going to be put in one of the 3 uncomfortable positions very soon:

1. That I am going to be pulling players out of the game who I have been comfortable letting continue for many years, and possibly hurting our team’s chances of winning games.
2. That I am going to turn a blind eye and not examine or fully assess a player who looks as though he is fit to continue.
3.  That I am going to re-name something I used to call “mild transient concussion” something different like “traumatic migraine” so the player can be allowed to continue, even though deep down I think that the player has probably had a very mild concussion that has quickly recovered.

Over the past 14 years I have overseen about 10000 player games and have recorded approximately 250 concussions (about one in every 40 player games). I would also expect that maybe even second incident that could count as a concussion I wouldn’t even see/record (i.e. a player wouldn’t necessarily report symptoms to me). Of the 250 I did record, about 100 (less than half) left the field on the day, with 68 coming off for good and the other 32 being allowed to return to the game at some stage with a careful eye being kept on them by me and the on-field trainers. I am not aware of any of these players coming to long-term harm as a result of the concussions they have suffered – certainly none seemed to in the time that they were with the team.

I am aware that there is now a massive question mark over the long term effects of concussion, in that ex-footballers seem to have a higher rate than normal of erratic behaviour, including depression and suicide. The problem is whether you can pin these characteristics on concussion or simply playing professional team sport which attracts risk-taking, mood-swinging behaviour types. Cricketers are also renowned for having psychological issues post-retirement, yet the rate of concussion is very low. We obviously need some well conducted case-control studies (by well-conducted I mean where players with depression aren’t prompted to remember their previous concussions any more than players who are living happily). Sadly we aren’t going to get much further high quality research before we get the hysteria associated with the NFL concussion lawsuits, where retired players who have managed to blow their post-football life are going to have a crack at arguing that the concussions they received in the NFL were responsible. I’m not suggesting that they have no right to take action, but I think everyone can understand that in the absence of definitive scientific evidence that such a case will be decided by emotive arguments to a judge rather than a proven scientific link being established.

Will team doctors become the meat in the sandwich? Collision sports have rules which encourage a limited amount of violence and you win games by dominating the opposition players. If players are injured and come off the park, teams lose games. Perhaps there will be a trend for the leagues to pin the responsibility for player safety on the team doctors, yet the doctors get paid by the teams whose primary responsibility is to try to win games. One thing that the leagues can do, and which the NRL did very well last week, is crack down on high contact and increase penalties and suspensions to give a disincentive for players to tackle in such a way that concussions could result.

I was previously comfortable with a middle-ground approach to concussion – removing those who had moderate to severe symptoms from the game and watching those with mild symptoms which recovered quickly to make sure they didn’t get worse or become recurrent. It is probably a responsibility of the collision sports to ensure that players with moderate or severe concussions do not return to play on the same day (but to allow for enough substitutions so that teams aren’t disadvantaged by medically doing the right thing). A further dilemma for the contact sports is on how to handle the so-called ‘minor’ concussions where a player doesn’t get knocked unconscious but has transient symptoms lasting for less than a minute. Removing all of these players for the day is very problematic (and if it is mandated it becomes very difficult to police). No doubt it will be a major topic of discussion in the 4^th concussion in sport consensus statement conference  in Zurich this November.

Related BJSM Publications

International Olympic Committee’s special BJSM issue – Injury Prevention and Health Protection (IPHP): Read about that here.

BJSM publication of the proceedings of the 3rd International Conference on Concussion in Sport (Zurich 2008).

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John Orchard BA, MD, PhD, FACSP, FACSM, FFSEM (UK), is a Sports Physician, and an Adjunct Associate Professor at the University of Sydney, School of Public Health.