Mark Duncan-Smith: Concussions will continue to shape and change the AFL going forward

Can a nursery rhyme alter the great game of football ?

It’s raining its pouring, the old man is snoring, he bumped his head and he went to bed and he couldn’t wake up in the morning.

In short, the answer is that it already has.

The nursery rhyme is the story of head injury to the old man. Most likely more than just a concussion, but that is the reason he can’t get up in the morning.

The common types of head injuries in AFL are concussions.

A concussion does not always mean the player becomes unconscious. In fact, in 90 per cent of concussions in AFL, the player remains conscious. This is the situation of “being out on their feet” as opposed to being “knocked out”.

Concussion is a type of mild traumatic brain injury and is considered more severe if there is loss of consciousness. The longer the period of unconsciousness, the greater the risk.

Post-concussion syndrome can last weeks to months and hinder a return to the playing list. Symptoms can include poor concentration, problems sleeping, irritability and fatigue. It is also indicative of a player in whom long term damage may be evolving.

Sub-concussive impacts to the head also occur frequently in AFL.

These are repeated minor head knocks that don’t cause any symptoms at the time. They are however thought to be implicated in the formation of long term brain damage and are linked to the development of chronic traumatic encephalopathy.

CTE is a chronic degenerative brain disease related to repetitive brain injury.

Both concussion and repeated minor head trauma are implicated in its development.

It is currently only definitively diagnosable after death at post-mortem. Symptoms can include progressive cognitive decline with confusion and memory loss, aggression, depression, anxiety, poor attention, poor executive functions (organising, planning), and dementia.

In the nursery rhyme, the old man suffers most likely an intracranial bleed that can be inside the brain matter itself or under the linings of the brain.

A subdural haematoma is a slow bleed under the outer linings of the brain that puts pressure on the brain, can cause unconsciousness and even death if untreated. Fortunately, intracranial bleeds are uncommon in AFL players but can occur.

Second impact syndrome is an extremely dangerous condition where a player gets a second concussion before they have fully recovered from the previous concussion.

This typically would occur within a week of the last concussion. Fortunately very rare, but can be fatal as it can be associated with severe and rapid brain swelling.

SIS is the reason that players are removed from play immediately if they have a concussion and can not return.

Given that the most common type of concussion is not associated with unconsciousness, it is also why AFL medical staff in attendance are highly trained at identifying concussion. It is also a reason for concussion protocol being a minimum of 12 days.

The AFL is using an evidence-based approach to concussion in both the short and the long term consequences. Central to this are protocols and tools developed by international groups including the International Olympic Committee and FIFA.

Head injury and its long term consequences have already changed the game of AFL and will continue to do so.

The medical sub rule allows a player to be removed immediately from the field and replaced. The mandatory 12 day concussion protocol was introduced in 2021.

Rules have changed to reduce the incidence and severity of head trauma.

These include the tough penalties for dangerous tackles such as head high contact and sling tackles for example.

Bumping rules have also changed to reduce the risk of head injuries. As other parts of the game are identified as being high risk for head injury, more rule changes will occur to minimise those risks.

Head injury in AFL is the highest priority for club boards and the AFL currently as they move to minimise the risk to players, and there is no doubt more changes are to come.

Dr Mark Duncan-Smith is a plastic surgeon and former president of the Australian Medical Association WA branch