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Tackling football concussion with technology

Football

Football medicos liken understanding the impact of concussion to “walking into a dark room”. Could technology be about to shine a light? Michelangelo Rucci reports.

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St Kilda hero Nick Riewoldt pulled apart the AFL’s new concussion protocols at the start of the season by describing the enforced 12-day lay-off for concussed players as an “arbitrary figure”.

How the AFL medical men came up with 12 days is as contentious as the diagnosis and treatment of concussion – more so when there is no common recovery timeline for head knocks as there is for hamstrings (21 days) and serious knee injuries (12 months).

This could be about to change with significant advances in technology.

In Adelaide, local businessman Chris Fox is fronting leading international firm Saccade Analytics’ plans to introduce “Neuroflex” as an answer to the concussion puzzle. He has taken this technology to the SANFL for a mass rollout next season.

At the same time, former Port Adelaide Football Club chief executive Keith Thomas has passed up grand opportunities to stay in sports administration – such as national basketball club, the Adelaide 36ers – to become chief executive of Australian company, Spark.

Thomas is testing his company’s technology, first developed for stroke victims at the University of California, with 600 players in the “amateur” Adelaide Football League where, unlike the professional AFL, there is no club doctor watching a television screen to closely monitor every head knock to a player.

“How reassuring would it be,” says Thomas, “to have a device that is easy to apply and instantly tells you if you have a concussion or not.”

Concussion is now big business in sport, and not just for lawyers such as Adelaide-based Greg Griffin, who have lined up several former players for a class action against the AFL. Technology is seeking to ease the pain – physical, mental and financial.

Considering American football’s National Football League in 2013 paid out $1.3 billion in claims to former players suffering from dementia and other concussion-related health issues, it is understandable why lawyers and medics want answers in sport’s most-confused debate.

In an era when leading sports medicos such as former Australian Olympic team and Adelaide Football Club doctor Andrew Potter have described the task of understanding concussion as “walking into a dark room”, the light switch could be on a laptop.

Potter, now advising the SANFL on its concussion protocols, has introduced Neuroflex to the State football league. Next season, every SANFL player, following the path of Australian, New Zealand and South African rugby players this year, will strap on virtual reality goggles. Readings will be taken to serve as “baseline” data – objective information – on the players’ health when they are not concussed.

This will give team doctors a more reliable test than the questionnaires players fill out in the pre-season; exams some AFL players have admitted to fudging to set up a low baseline score and thereby increase their chances of staying on the field when suspected of suffering concussion.

“Neuroflex gives objective measures on important aspect of the brain’s health and functioning; it cannot be tainted,” Fox said of the power of technology. “We take the bullshit out of all the testing.

“I have lived that era  as a player and coach in the amateur football ranks, where you had to be a man, you had to be tough. We did not care about the brain. We weren’t coming off the field if we were concussed. We didn’t want to be seen as soft. Well, we were wrong.

“We need to protect the players (from themselves); players will always seek to stay on the park if they don’t feel traumatised but are at serious risk by a knock to the head,” adds Fox. His point is any hit to the head – even those that do not cause concussion – should raise alarm bells in sport.

Fox adds technology will support rather than frustrate medicos and sports leaders with clearly defined information in a puzzle today loaded with more questions than answers.

“We aim to give doctors an additional tool,” Fox told InDaily. “We are not looking to make life harder for sports administrators. We want to set up the next step in this discussion,” he adds, frustrated that the debate does not advance to focus on player health rather than just player safety.

The “dark room” described by Potter is still filled with confusion and contradiction, as highlighted by the differing opinions between the Adelaide Football Club medicos and AFL chief medical officer Dr Peter Harcourt over Crows defender Tom Doedee last month.

On July 9, Doedee reaffirmed his courageous style while colliding with Essendon forward Anthony McDonald-Tipungwuti in a marking contest at the Docklands Stadium in west Melbourne.

Adelaide’s medicos insist Doedee took a hit to the sternum and not the head. Harcourt demanded Doedee work through the concussion protocols, and refused to clear him for play in the game against West Coast at Adelaide Oval nine days later.

Adelaide senior assistant coach Scott Burns detailed the confusion between club and league headquarters saying: “We didn’t take Tom out of the game because of concussion, but the AFL doctors now can overrule or have their say. They were confident enough that there were concussion symptoms and they wanted him to have the week off.

“It was not a one-off. This has happened with other players and other clubs as well.”

It is not hard to imagine an AFL player seeking legal advice if such a ruling was made in the lead-up to a major final, in particular a grand final.

Technology, with objective data, could spare sport another legal complication in the concussion debate. But there also is the question of which technology serves a meaningful purpose. Even here there is much debate among experts, as there is over the merit of helmets in sport.

NeuroFlex was developed by Saccade Analytics, led by Dr Mimi Galiana, a researcher with almost 30 years of study in eye and head movement at McGill University in Montreal, Canada. The technology measures and records the horizontal and vertical movements of the eyes and head while players wear virtual reality goggles for eight to 10 minutes. Within seconds, a team medical unit has objective data for diagnosing and managing concussions.

The technology is finding purpose from school sport to the elite. In Queensland, former Crows player Sean Tasker is trialling Neuroflex in Brisbane schools.

Students trialling Neuroflex. Photo: Sean Tasker

In the big leagues, the AFL Players’ Association looked at Neuroflex last year with former Port Adelaide vice-captain Brad Ebert using the technology after he was forced into retirement with another knock to the head during a marking contest with Jack Riewoldt in last year’s preliminary final against Richmond at Adelaide Oval. Ebert was wearing a helmet at the time.

Hall of Fame coach Kevin Sheedy took Ebert’s last act in 260 AFL games, during which he sustained numerous head knocks, as a warning that demands change.

“We don’t need a death in our game,” Sheedy said. “We have to protect the players from themselves. I don’t care how we can change this, but the onus is on the AFL to at least look at it before someone dies. We admire the courage Brad Ebert showed, but sooner or later someone is going to die.”

World Rugby has put Australian and New Zealand players into trials with Neuroflex since March. The governing body of rugby says it is seeking “objective tests” that “could further improve rugby’s approach to brain health, supporting doctors to make the right decision”.

“Numerous scientific studies have demonstrated that oculomotor (eye movement) functions are altered at the time of, or shortly after, a concussion,” World Rugby said in announcing its “shadow trial” with Neuroflex.

The code’s chief medical officer Dr Eanna Falvey is embracing technology noting the potential benefits lead to “care of players in our sport, from community rugby to elite competitions”.

The debate on the AFL’s handling of concussion – or, at least, awareness of the topic – heightened again last week with the forced retirement of West Coast premiership player Daniel Venables. An AFL medical panel advised the 22-year-old midfielder to avoid all contact sport.

Venables has not played since suffering a brain trauma injury in a marking contest while representing the Eagles in the AFL against Melbourne in May 2019. The youngest member of West Coast’s 2018 premiership team at 19, Venables suffered seven bleeds to the brain after the collision at Perth Stadium where he played his 21st and last AFL match.

Venables adds to the growing list of warnings related to head knocks in sport. It seems the library of studies on concussion and head knocks grows by the week.

This month began with Professor Willie Stewart at the University of Glasgow publishing a study revealing professional footballers who play as defenders in soccer games are five times more likely to develop dementia than people in the general population. This is from repeated blows to their heads while colliding with attacking players or from heading the leather ball.

For much of the past decade, the rising concern on preventing concussions has moved from ineffective helmets, to changing rules in a hectic collision sport, to finding greater understanding and care for players who suffer head knocks.

“The game (of Australian football),” says Fox, “has never been safer. The rules have dealt with head-high tackling. The cameras have caught out the king hits.

“The AFL is taking concussion seriously. The SANFL is wanting to be better placed at identifying concussion; this says they are serious. But this is the discussion today … concussion.”

Fox does not hide his frustration with how the bigger agenda item of head knocks is constantly overtaken by a singular focus on concussion.

“The debate always falls back to concussion – and that is self-defeating,” Fox said. He prefers to focus on all head knocks, warning repetitive hits to the head might not cause concussion but are just as dangerous in their long-term health implications. And some head knocks do not draw immediate intervention, such as the 12-day lay-off in AFL ranks.

On this front, Dr David Stevens from Flinders University – a “sleep technician” – is working with the NeuroFlex team to develop sounder data on the diagnosis and treatment of head knocks to athletes.

If this topic is in a “dark room” for doctors, it is understandable there will be confusion among players, coaches – and fans. The lightbulb moment comes when Dr Stevens simplifies the complex with the basic theme of “cleaning the brain”.

A hit to the head can lead to the brain releasing proteins that cause neurodegenarative diseases that include Alzheimer’s and Parkinson’s. Sleep is critical to “cleaning” the brain of these damaging proteins.

But sleep can be difficult for footballers after heavy head knocks, as noted by Venables who kept suffering from migraines, headaches, fatigue and “pressure through my head” after his collision in 2019.

“I still barely sleep now,” Venables said.

Therefore, the AFL’s 12-day protocol on concussion is – as questioned by Riewoldt – an arbitrary figure.

“A brain injury is not a broken leg or an ACL (knee injury) where, bang, you will be right after 12 months,” Venables said.

So how does 12 days work for AFL players after concussion? Fox notes sports medicos scrambling through the “dark room” of concussion – and looking to minimise the risk of malpractice suits – will live to the theme: “If in doubt, sit it out”.

But is that enforced lay-off for a week, 12 days or longer?

“A skeptic,” says Fox, “would (like Nick Riewoldt suggests) think the AFL’s charter is designed to keep the players on the field. Those 12 days have you miss a game, but not two.”

Nick Riewoldt’s mocking of the AFL’s 12-day protocol does echo in sport medical rooms.

“Doctors need more objective data, another layer of defence,” Dr Stevens said while dismissing there is a magic number in recovery time for concussed players. “Some players could be fine in three days. Others need more time. Females appear to need longer recovery time from concussion; there is very little research here.

“There is a risk – such as doubling the prospects of depression and anxiety – in having a player who has not fully recovered return to play after 12 days.”

That dark room on concussion becomes, as Fox puts it, “more murky” when those defending the legal class actions being filed by former footballers argue lifestyle issues such as alcohol and drugs could be contributing factors to the health issues being attributed to concussion.

The counter argument is repeated head knocks, and returning to play before the brain is healed and suffers more from other head knocks, can lead players to bad lifestyle choices to overcome depression and anxiety.

“We can’t underplay this,” says Fox. “Contact sport around the world has removed thuggery from play, but the problems from head knocks remain. We also have bigger bodies moving faster to become bigger weapons on the sports fields.

“Regular testing is the answer. And it is not just about the professionals; we need to look after everyone involved in contact sport.”

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