How can GPs play a better role in the management of concussion and information regarding CTE?
Suzanne Harrison reports
When Barry Beecroft first started playing professional football for South Melbourne in the early 1970s, he and his teammates were regularly concussed on the oval – and simply kept on playing.
At the time there was “zero” concern about concussion, Beecroft now says from his North Fremantle home.
“I could get knocked out cold about three or four times, a game,” he says of his early days with South Melbourne, later Claremont Football Club (prior to the Eagles) and also with the Sydney Swans.
“Someone might say, ‘you OK, Barry?’ You’d feel a bit strange for half an hour or so, and then feel fine. But you’d keep on playing. I recollect one time being knocked out early in my career and a trainer came out with smelling salts and they got me going again. You didn’t want to lose your position in the team.”
In those days of elite AFL, there were no cameras and only two umpires (now there are four) meaning players had a greater likelihood of getting away with dangerous tackles or deliberate violence. And if you stopped playing due to injury, you either didn’t get paid or your salary was reduced.
“We never stopped playing or missed a week after being knocked out,”
he says.
However, Beecroft – who still works out daily and remains fit – feels he is one of the lucky ones. After retiring from football in the late 1980s, he enjoyed a successful career as a senior corporate executive and has not suffered from any of the common symptoms associated with head trauma, nor have his former teammates.
CTE profile
But for many others, it’s a different story. In recent years, awareness of chronic traumatic encephalopathy (CTE) has become much more widespread, partly due to the deaths of high-profile sporting personalities around the world, alongside dogged research, initially from the US.
A degenerative brain disease, CTE is caused by the kind of repetitive brain trauma seen in contact sports. It can only be diagnosed post-mortem, yet for many, symptoms such as poor impulse control, depression, anxiety, insomnia, aggression and severe headaches, have led to dire consequences.
Danny Frawley, for example, played 240 senior AFL matches for St Kilda between 1984 and 1995. The former Richmond senior coach died in 2019 aged 56. A post-mortem examination of his brain found he was suffering from CTE.
In 2022, it was reported that a post-mortem following the death at aged just 49 of former NRL player and coach, Paul Green, showed he suffered from one of most “severe forms” of pure CTE the neurologist had seen, a disease that would have affected his decision-making and impulse control.
In February last year, the Medical Journal of Australia announced findings that twelve of 21 brains donated by sports players prone to repetitive head injury and assessed by the Australian Sports Brain Bank, were found to have CTE. All but one brain showed some form of neurodegeneration.
The problem is widespread in the US. According to the Boston University CTE Research Centre, the repeated brain trauma (within some sports) triggers progressive degeneration of the brain tissue, including the build-up of a protein called tau in a unique pattern. The pattern of tau seen in the brains of those with CTE is distinct from other neurodegenerative diseases such as Alzheimer’s disease.
“These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement,” the Boston centre states.
The centre’s researchers reported in February this year that they have now diagnosed CTE in the brains of 345 of 376 (91.7%) of NFL players studied.
Local research
In Australia, Dr Sarah Hellewell, senior research fellow in neurotrauma at Curtin University, says that at present, CTE is a terminal diagnosis, meaning it can only be definitively diagnosed post-mortem by the presence of hyperphosphorylated tau, deep in the sulci of the brain. It’s the symptoms that need to be more widely understood.
These symptoms may be cognitive, including memory and attention difficulties and poor impulse control. They can be somatic, including headaches, dizziness, sensitivity to light and noise; mood-related, including depression, anxiety and irritability; or related to sleep, including fatigue, insomnia or sleeping too much.
“There are many symptoms of CTE in the living, and this is part of the difficulty with a living diagnosis, because symptoms may be different for different people, and aren’t static from one day to the next. This means that diagnostic criteria have been hard to agree on,” Dr Hellewell said.
Earlier this year, the Royal Australian College of GPs (RACGP) submitted to a 2023 Senate inquiry into concussions and repeated head trauma in contact sports.
“This submission, among other things, urged for adaptation of rules to prevent concussions from occurring, highlighted the need for consistency in player safety and decisions regarding return to play, and reiterated the need for funding into research on long-term consequences of head injury,” Dr Hellewell said.
Attitudes to concussion have improved substantially, but while sporting, medical and community groups now take it much more seriously than in Beecroft’s playing days – indeed the overall wellbeing of players –there is still a way to go when it comes to CTE.
Misplaced heroics
It’s no news to players such as Beecroft, but Dr Hellwell says that even as recently as a decade or two ago, concussion was seen almost as a badge of honour, par for the course when playing tough and being strong and fearless, “and the symptoms and consequences were ignored or minimised for fear of seeming weak”.
Researchers, she says, didn’t focus much attention on concussion because the traditional thinking was that everyone recovered well in a matter of days or weeks. Similarly, GPs sent concussed patients home with instructions to rest, and rarely followed them up. Part of the difficulty was the long time between head injuries and the onset of neurodegenerative symptoms – often decades – which made it difficult to link a history of sports concussion to symptoms later in life.
“Now we know better. We have evidence of long-term pathology
in the brains of former contact sports players, and we know concussion is a risk factor for several neurodegenerative diseases,” Dr Hellewell adds.
“High profile sportspeople and their families have brought community attention to these issues, and we have reached a certain point that it has now become too difficult to ignore. Governments and sporting bodies are beginning to listen to calls for change in the prevention, diagnosis and long-term management of concussion.”
As for how GPs can deal with the ongoing problem, Dr Hellewell says there are a number of things that can be done to improve the care of people presenting with concussion.
Sentinel GPs
“The most important thing is to ensure their knowledge is up-to-date on concussion management and recovery,” she says. “While we used to tell people to sit in a darkened room until they were no longer symptomatic, evidence now suggests that light exercise can speed up recovery and help to mitigate symptoms for many people with concussion.
GPs could also consider information provided to patients about recovery: reassuring them that it is common to be symptomatic for several days or weeks, and that recovery can be different for everyone, she adds.
Consider providing this information in written form, as patients may be confused and have difficulty remembering instructions. In future consultations with a patient with a history of concussion, Dr Hellewell suggests GPs should be alert for symptoms which may have persisted or developed since the injury, particularly those relating to mental ill health, headaches and cognitive decline.
At the time of the submission to the Senate inquiry earlier this year, RACGP president Dr Nicole Higgins called for stronger action.
“More can and should be done to prevent the damage caused by concussions and head trauma,” she said. “We are learning more and more about the management of prolonged concussion symptoms, such as post-concussion syndrome and suspected CTE, which many people may recognise from an increasing number of concerning media reports following the deaths of sports stars.
“CTE must be taken extremely seriously. It isn’t just something that we need to worry about in adult sport, damage to the brain can happen at an early age, whenever there are repeated knocks to the head.”
GPs, Dr Higgins stresses, play a vital role, and with greater support, can do even more to help patients.
“We are the ones often required to assess and provide clearance for patients to return to play following a concussion, such as a local footy player or netballer who has received a knock to the head. This includes balance, memory and cognitive testing and ensuring the patient does not experience recurring symptoms when exercising.”
Improvements to the current model could be longer GP consults, providing an opportunity for GPs to take the time to assess and address any issues. She said that GPs needed to know what they were dealing with.
News lines
“There is insufficient evidence to fully understand and determine the long-term impacts of concussion and repeated head trauma, and we also need to clarify and standardise the definition of concussion,” she said.
“In addition, the development of an Australian-wide concussion registry will provide a valuable source of data to determine the long-term impacts of concussion and repeated head trauma. First aiders at sporting venues should have access to specific training about head injury and concussion too, particularly in amateur and social leagues where a qualified health-care worker is less likely to be there to help.”
Many ask about the efficacy of helmets in sports such as rugby. When asked about these as a form of prevention, Dr Hellewell concurs with other global research.
“An increasing body of evidence suggests that helmets don’t protect the brain from concussion,” she said. “This is because concussion, and particularly sports concussion, usually has an element of head rotation during the fall or hit to the head or body. This rapid rotation, while the head accelerates downwards, is likely to account for much of the pathology and symptoms of concussion, and head gear won’t prevent that.”
There is even evidence, she says, from American gridiron that the sport adapted with the introduction of helmets, with the helmets being used as ramming weapons in the misguided belief that the head would be protected.
It may come as no surprise that such measures are in their early stages. The history of concussion’s long-term effects and CTE is very new.
According to the US-based group Concussion Legacy (CLF), CTE was first described in 1928 when Dr Harrison Martland characterised a group of boxers as having ‘punch drunk syndrome.’
CLF explains on its site that over the next 75 years, several researchers reported similar findings in boxers and other victims of brain trauma, but fewer than 50 cases were confirmed. Then in 2005, pathologist Bennet Omalu published the first evidence of CTE in an American football player: former Pittsburgh Steeler Mike Webster.
Brain bank
“The publication caught the attention of CLF co-founder Dr Chris Nowinski, who envisioned the world’s first athlete brain bank. Nowinski began reaching out to the families of former NFL players and other athletes who had recently died to arrange brain donations.”
CLF goes on to say that he and Dr Robert Cantu soon founded the CLF and partnered with Boston University and the US Department of Veterans Affairs to form the UNITE Brain Bank, which has now studied the brains of more than 1,300 athletes and veterans.
As for Beecroft, he believes football has come a long way and is supportive for his nine-year-old grandson to play the game, a sport which – coincidentally – his grandson has shown signs of being pretty good at.
“They really look after them now,” Beecroft says, “These days, there’s protocols with concussion. It’s 3000% better than when I was playing. I have no problem with my grandson playing.”
That said, there are still improvements to be made when it comes to how GPs engage with patients about ongoing care following from a concussion, and how parents can monitor their children. Dr Hellwell recommends a number of free resources and training courses for GPs and the community online, such as Connectivity Traumatic Brain Injury Australia.
For more information about CTE, visit https://www.brainbank.org.au/cte-research/