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Sports-related concussion, more than a legal matter

The Australian Institute of Sport and the Australian Medical Association published a paper in January 2017 to define sport-related concussions and provide recommendations to be implemented in sport settings to reduce the incidence of a concussion. The ultimate goal of the article is to define what a concussion is and raise awareness to ensure safety and welfare of Australians participating in sport by providing the latest guidelines on concussion diagnosis and management.
This topic is particularly close to me as I have been passionate about traumatic brain injury research for over 25 years, mostly on the severe spectrum of the condition.

Concussion and the law

The recent US$ 765 million settlement of the class action initiated by 5,000 retired football players against the National Football League has generated a global coverage on the topic, raising widespread arguments from the entities involved including sports associations, colleges & schools, medical associations, research institutions, and most importantly the people suffering from early neurodegenerative symptoms.
In the prominent US lawsuit, “plaintiffs accused the NFL Parties of being aware of the evidence and the risks associated with repetitive traumatic brain injuries, but failing to warn and protect players against the long-term risks, and ignoring and concealing this information from players”. In re: National Football League Players’ Concussion Injury Litigation, No. 2:12-md-02323

Concussion and Chronic Traumatic Encephalopathy

In addition to the legal implications, the medical fraternity is confronted with several challenges surrounding the impact of concussion in sport, including its definition, diagnosis, management and prevention not only in the US, but also in Australia where sport is broadly practiced in our communities at recreational and professional levels.
Sport-related concussion remains an underestimated epidemic. It has been reported that in the US alone, a range of 1.6 to 3.8 million concussions occur with every year. In the Australian Football League it is estimated at 5-6 concussions per team per season, whereas in Australian Rugby a higher incidence of 10% of all players have sustained a concussion over 1-3 seasons.
The condition caused by repetitive concussions was reported in 2005 by a neuropathologist, Dr Omalu, who demonstrated dramatic changes in post-mortem brain of a professional football player who sustained multiple concussions over his career. I recommend the recent movie: Concussion, about this topic. The condition was defined chronic traumatic encephalopathy or CTE. This is a neurodegenerative disease that develops over years or decades following the effects of multiple head traumas. In the 1970s it was known as dementia pugilistica as it was defined pathologically in older boxers.
The culprit of the association between brain injury and CTE arose when several retired football players claimed to have developed a premature cognitive decline, behavioural changes and depression that led to their suicide. Some of these sportsmen donated their brains to research laboratories in hope to help define the pathophysiology of their condition and help their peers with studies that could elucidate and ultimately prevent complex neurodegeneration. Although a concussion does not show any structural changes on a magnetic resonance scan, microscopic analysis revealed profound atrophy of brain tissue and a global activation of cellular inflammation with deposition of pathological proteins (phosphorylated tau) in a pattern similar to Alzheimer’s brains.
Although controversies remain about the impact of concussion on the development of CTE, most scientists believe to be a true phenomenon.
What is a concussion?
A concussion is a transient dysfunction of the brain associated with a variety of neurological symptoms, which usually resolve spontaneously over a few hours to days or longer. Distinct from other forms of brain injury, a concussion does not necessarily require physical impact to occur and may be the result of biomechanical forces transmitted to the head. Evidence shows that rotational forces have a greater detrimental effect on the brain.
The onset of symptoms following a concussion can occur immediately after an impact or over 24-48 hours, with no clear association or memory of a traumatic event. Symptoms include loss of consciousness, confusion, amnesia, disturbance of vision, balance and sleep, dizziness, headache, irritability and more.
A medical examination conducted by team doctors at the sideline is the first approach to diagnose a suspected concussion. Protection of the cervical spine is recommended until any damage has been excluded. Following the initial examination, the Sport Concussion Assessment Tool 3rd Edition (SCAT3) is recognised internationally to assess a concussion.
It is a standardised questionnaire to be used only by medical professionals that is divided into eight sections to determine:
  • Consciousness via the Glasgow Coma Scale;
  • General symptoms: How you feel, awareness via the Maddocks score;
  • Cognitive assessment;
  • Neck examination;
  • Balance;
  • Coordination;
  • Immediate memory;
  • Concentration and delayed recall via the SAC delayed recall.
Unfortunately, there are no other means that help the diagnosis of a concussion. Intensive research in this area is rapidly expanding with the scope to develop blood biomarkers of brain damage and more sensitive magnetic resonance technology that may detect subtle structural brain changes.
Prognosis and Return to play policy
Resolution of symptoms in a concussed individual varies and depends on its severity, persistence of the symptoms and medical judgement. Given the vulnerability of the child/adolescent brain as well as female brains, criteria vary substantially. Return to sport policy requires the player to be symptom-free for at least 24 hours in individuals above 18 years of age, and 48 hours for those below 18 years of age. The rehabilitation begins with light aerobic activity and gradual increase in physical demand prior to a full return to contact sport games. However, with the reappearance of the symptoms the player will be tested again and set back in the rehabilitation program. It is accepted that upon diagnosis, a child should not return to play prior to 14 days. To give the brain a chance to heal, not only physical activity but also cognitive tasks at work and school should be suspended and resumed gradually. Persistence of symptoms for 4 weeks or appearance of new delayed symptoms lead to a debilitating syndrome defined as post-concussion syndrome.
Repetitive concussions – Second impact syndrome
It is widely accepted that if a second concussion, even of a milder degree, occurs soon after the first concussion, the damage will amplify, possibly leading to more severe consequences. This is due to metabolic changes elicited by the first concussion that make the brain more vulnerable to a second hit, precipitating neurochemical responses. There is evidence that a player who sustained a concussion is also more likely to have a second one.
Increasing the awareness of concussion in sport by informing players, coaches, teachers and children/adolescents is of paramount importance. Certain sport practices and specific roles within a team clearly increase the risk of a concussion. A recent law suit by student athletes against the American National Collegiate Athletic Association led to a settlement of US$75 million in 2016, whereby US$ 70 million will be used for a medical monitoring program for college athletes and a US$5 million invested in a program “to research the prevention, treatment, and/or effects of concussions.” This includes a wide educational program to an estimated 4.4 million students.
Implications in Australia
There is intense debate on prevention of concussions in Australian sport.
Many interests are at stake, which may have resulted in denial of the occurrence of a concussion during a game. A player may minimise the symptoms to continue participating in an important game; a coach may not want to risk the success of a game by removing a pivotal player from the field; a team doctor may feel an overwhelming responsibility in deciding to stop a player from the game. The pressure on all team members is strong and poses a risk on players’ wellbeing. The precedent of the large lawsuit settlement in the US has positively contributed to instate many precautions aimed to:
  • inform all team members on the characteristic symptoms of a concussion;
  • introduce internationally recognised diagnostic tools (SCAT3);
  • assess players who have sustained a hit on the head to ascertain whether they have been concussed;
  • remove players when a concussion is suspected based on the principle: If in doubt, set them out.

Introducing Academic and Clinical Psychiatrist

Professor David Barton
Not to be confused with other medical experts of the same name, Professor David Barton is an Academic and Clinical Psychiatrist, bringing a breadth of knowledge to inform his medico-legal examinations and reports.

Professor Barton works as a Senior Consultant at Ballarat Health Services, a Consultation Liaison Psychiatrist within the Acquired Brain Injury Unit at Caulfield Hospital and is the Director of Mental Health Services at South Eastern Private Hospital. He is a Senior Research Scientist at the Human Neurotransmitter Laboratory at the BakerIDI Heart and Diabetes Institute, where his  major research interest is in the links between psychiatric illness and cardiovascular disease. He is also an Honorary Principal Fellow at the University of Melbourne and is an Adjunct Professor at Monash Alfred Psychiatry Research Centre.

Professor Barton specialises in general adult and older persons Psychiatry and has a particular interest in the field of Neuropsychiatry, Traumatic and Acquired Brain Injury and the association between Depression and Cardiovascular disease.

To book a client with Professor Barton, please contact Lex Medicus reception on: (03) 9827 8093 or
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Wine and Pain Seminar, 9 February 2017

Thank you to all who attended our Wine and Pain seminar on 9 February 2017, and contributed to an enjoyable and informative event. Together we raised over $900 for the Royal Children's Hospital.

Dr Peter Blombery presented on medico-legal aspects of Chronic Pain, followed by a robust question time by lawyers and other medical professionals.

We would love to see you at our upcoming events, where our Lex Medicus consultants will be speaking on a range of topics:
  • Australian Lawyers Alliance Conference, Queensland on 17-18 February 2017 - Mr Thomas Kossmann will be presenting on the Fundamentals of Spinal Surgery;
  • Our next Lex Medicus Wine seminar on 20 April 2017, with further dates and details to be announced shortly.
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