Concussion: how far have we come?

Since QBI launched its concussion awareness campaign two years ago, there has been significant progress in research seeking to better understand concussion, identify improved ways to diagnose the condition, predict its effects, and reduce its most harmful outcomes.

“There are a lot of people in the world working on mild to moderate head injury now,” says QBI Professor Mike O’Sullivan. This has resulted in a rapid increase in the amount of brain imaging data, as well as a welcome rise in data on patient outcomes.

“That’s a big step forward,” he says.

Significant effort is also being directed towards the search for biomarkers that are unique to concussion injuries. Recent studies revealed that concussion-like injury in mice triggers changes in the activity of more than two hundred genes.

If the presence of biomarkers or unique patterns of gene activity could be detected in human blood samples or saliva, they may provide more objective diagnosis and identify early signs of more serious brain damage or unchecked inflammation.

Like many brain conditions, concussion is incredibly complex, notes Professor O’Sullivan. So it’s going to take a multipronged approach to not only improve diagnosis, but also reveal what’s going on inside the brain.

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QBI researcher Dr Fatima Nasrallah agrees. She is taking a comprehensive approach to finding out why some people recover well from concussion while others suffer long term cognitive deficits.

She is using a combination of biological tests, cognitive tests and brain scans on athletes both before and after they experience a concussion. This is enabling her to identify subtle changes within an individual and then examine how they correspond to that their recovery.

Currently, predicting recovery is difficult because the location, direction and intensity of the original impact varies from person to person, and the way the body responds to injury is also highly individual.

The injured region may heal easily, but sometimes a chain of events begin, which leads to ongoing injury and symptoms.

It essence, it has become clear that clinical symptoms don’t necessarily reflect what’s going inside the brain, says Dr Nasrallah.

 "The brain is so powerful in healing itself but you have to give it time," she says.

“Unless we know that the brain has really healed, it’s very risky to go back and risk another concussion.”

The long-term cumulative effect of repeated concussions have been difficult to study in the past, but that’s also changing, says Professor O’Sullivan.

"A big step forward is that there’s now some pathology data."

Pathology studies analyse post-mortem brain tissue to determine how concussion-linked changes in brain cells and their networks lead to conditions like dementia or chronic traumatic encephalopathy (CTE), a degenerative brain disease associated with repeated head trauma and notably present in the brains of former American NFL players.

Such studies are increasing due to the development of ‘brain banks’ which have been established around the world and in Australia, including the recently launched Australian Sports Brain Bank in Sydney.

These facilities enable members of the public, particularly those involved in high-impact sports, to donate their brains to research after they die. As brain tissue samples become increasingly available to researchers, pathology studies will be able to substantially advance our knowledge of the long term effects of concussion.

The increased interest in future donations to these brain banks extends from a rise in public awareness regarding concussions.

Sports recognise the importance of concussion management

Not so long ago, concussions were seen as relatively harmless short-term injuries on the sports field, something that might put a player out of action for a few minutes, a few hours or maybe a few days. But the revelation of possible long-term impacts, as well as public interest campaigns such QBI’s #NoBrainNoGame are helping to shift the conversation, especially in high concussion risk activities, like AFL, NRL and Rugby Union.

The NRL’s Chief Medical Officer, Dr Paul Bloomfield, says there has been a significant turnaround in the way concussion is treated in NRL over the last two years, and that guidelines are now shaped by the International Consensus on Concussion.

“There are improved definitions surrounding certain signs and symptoms, improved education, on-field assessment by trainers and reporting, as well as tighter definitions and protocols surrounding follow-up Head Injury Assessments and repeated concussions,” he says.

Both NRL and AFL now use extensive replay footage to enable medical staff on the sidelines to detect potential concussions.

“Doctors are able to basically review live, or near live, what contacts occurred,” says AFL Media Manager Patrick Keane.

He says there are now clearer policies around what is considered legal and illegal head contact in AFL, with tougher penalties for intentional head knocks.

Coupled with greater awareness of the risks of concussion, this has led to a significant change in player attitudes in recent years, says Keane.

Former Brisbane Lions player Justin Clarke, who was forced to retire due to a severe concussion, says that players are accepting the new, stricter protocols.

“They’re perfectly okay with that because they know that it’s for their own benefit.”

But there’s more work to be done, he says. He wants audiences and the media to understand why a player needs to sit out. When players are criticised for not returning to play immediately after concussion, or called courageous when they do, kids who are watching this could get the wrong message.

Dr David Hughes, Chief Medical Officer at the Australian Institute of Sport (AIS), says stricter protocols around concussion in high-profile sports are helping to improve the general public’s understanding of the seriousness of concussion, and that this is leading to better management of concussion in grassroots rugby and football organisations.

He adds that better policies are also making their way into other sports such as basketball, netball and hockey, which also have high concussion rates. Professional and community organisations associated with these sports are now adopting protocols in line with the Australian Institute of Sport and Australian Medical Association position statement on concussion.

“Coaches are really erring on the side of caution now,” says Dr Hughes.

Communication around concussion is still a work in progress, and can be limited by financial constraints within particular organisations, he says. In light of this, the AIS is working toward improving access to information about concussion for all sporting organisations.

This is important because, as Justin Clarke points out, sport has so much to offer in terms of mental and physical health.

“It’s just a fantastic part of society,” he says, but cautions, “there are risks, and mitigation controls need to be put in place to make sure we’re not putting ourselves at undue risk.”