When will we stop butting heads over sporting concussion?

There’s a certain beauty and pragmatism to the culture of organised sports. Borne out of an endeavour to display manly prowess and disciplined toughness, the inherent risk of physical injury  is accepted by both the courts of law and sports people. The colloquial Australian phrase “she’ll be right” captures that relaxed logic nicely.

A public debate on concussion policies has erupted between two high-profile personalities. 

On one hand, rugby league footballer James Graham wants players to decide for themselves whether they are rested following a concussion, rather than defer to medical professionals. The St George Illawarra prop argues that concussions are part of the risk (and thrill) of the game.  Overly risk-averse policies infringe on the self-determination and rights of players to use their bodies to earn their living, Graham argues. He bases much of his argument on the incompleteness of the science and on his own research into the topic.

On the other hand, we have Peter FitzSimons, a former rugby union professional and now columnist with The Sydney Morning Herald, who is a strong proponent of preventative policies for sporting concussions. FitzSimons has even committed his brain to the Australian Sports Brain Bank upon his death. He, too, argues his position is based on the science and years of research.

In many ways, their debate mirrors the deliberations of judges deciding sports injury legal cases and how much society should tolerate, perhaps encourage, inherently dangerous sports. Where do we strike the balance between benefits and costs?

No scientific position is ever 100 per cent conclusive or stuck in time. Much like the science, legal and policy decisions and community attitudes evolve. The history of this debate dates to a 1928 article, "Punch Drunk", in the Journal of the American Medical Association, about "drunken" and "stupefied" boxers struggling to walk and speak clearly. It showed for the first time that multiple hits to the head could lead to degeneration of the brain tissue.

In the past decade, there have been deeper scientific studies on the impact of concussions in the various football codes where players can be hit in the face or head. While not empirically conclusive, it’s nonetheless strongly persuasive. The global increase in negligence lawsuits may in part reflect that scientific shift.

Chronic Traumatic Encephalopathy (CTE), in simple terms, is the breakdown of the brain tissue seen when an autopsy is done. It is a gross change that is seen in the brain after a (usually long) period of degeneration. But the concussed player may have many neurological symptoms, especially soon after the injury, suggesting microscopic changes that cannot be seen on current imaging technology.

Which is why we speak of an "association" and not a "correlation": this is the debate that Graham and FitzSimons are having, missing the forest for the trees.

In a recent systematic review of 3819 studies for potential long-term effects of sport-related concussion, the authors showed multiple concussions to be a risk factor for cognitive impairment (an early neurological damage).

What we don't know yet is how many or what type of concussions, who is at risk of developing CTE, and how long it takes to manifest. We also don’t know what can be done to prevent, halt or reverse the damage.

Graham may be partly correct in his position that many areas of concussion are unresolved and he may have a point that athletes should be allowed to enjoy a career in sports in the meantime. But are athletes who have just suffered a concussion best placed to make such decisions on their (long-term) career?

There is much still to be researched, including on the diagnosis of concussion and the period of refraining from sport. These studies take time, something not helped by the lack of Australian research funding, especially for sports that are inherently Australian such as AFL.

But the research we already have strongly indicates some kind of derangement in the brain,  and supports a preventative approach. Scientific data based on ex-footballers from Boston, Toronto, London and Glasgow, as well as emerging Australian studies on retired players of the various football codes, already point to a strong risk for neurological impairment.

Australian research has further shown that young players are less likely to reveal their concussion, or voluntarily "bench" themselves, for fear of letting their teammates down.

Lay individuals not uncommonly use their individual brand of medical and scientific evidence to support their arguments. Anti-vaccination campaigns and climate science deniers come to mind.

The tagline used by the Scottish government and sporting association – “if in doubt, sit them out” –  has much merit.

Ben Koh is a medical doctor and honorary associate at the Australian Centre for Olympic Studies, UTS Business School. Alan Pearce is a neuroscientist and Associate Professor at La Trobe University.

This opinion piece was first published in the Sydney Morning Herald.