Post-traumatic amnesia

[injuryupdate]

Irrespective of the outcome of the "concussion" defence for Danny Williams, it can not be a case of "post-traumatic amnesia" that excuses him. This means that he can't remember something after a head knock, which might explain the way he was in the dressing room.

However, at the time he COULD remember that it was O'Neill who hit him, as he went straight for the correct player.

His excuse should be something else - that he was on "autopilot" or was functioning as an automaton, as post-traumatic amnesia would mean he couldn't remember being hit and wouldn't be seeking revenge for anything (not remembering what had happened).

[Monica]

Ha ha, yeah it's all a bit suss to me. As a veteran of the game, Williams should just face the music and cop his punishment sweet. He knew what was going on at the time, and things like this just further degrade the game... it wouldn't have been such a the huge controversy if he just shut up and accepted responsibility (given that he walked towards the man for a cheap shot - premeditated)... even if he couldn't remember that later on, surely he's seen the footage of what happened a few times this week?

What do you reckon?

[injuryupdate]

I tend to think he might deserve a tiny bit of leniency for having copped a head high shot from O'Neill seconds before, however 99% of concussed players don't go and hit someone straight after their concussion. If anything they don't feel like fighting because their head is spinning.

I'm not a legal expert, but I originally thought 8-10 weeks and still feel this would be about the correct decision.

[budz]

8-10 weeks? I was thinking something more in the 15 week region. I find this as a much worse act than the Greg Bird kneeing incident. The intent in this was much more malice than the Bird one.

[Plugger]

Perhaps Dr. Gibbs should be investing less of him time into creating miracles at the rugby league judicary and more time creating some at the Sydney Swans medical centre. Another day another blasted hamstring for the Swans - their goes Schneider, their goes our finals campaign, there goes my fantasy footy.....On a positive note if there was a ladder for injuries we would be number 1 this year. When we have not won a flag for so long, we have to take what we can. Seriously though why have the Swans had so many injuries this year - who can I point my finger at?
Swans 4 September! Plugger

[sydunisportsmed]

The question as to why some teams get more injuries than others is a very interesting one. Teams tend to have 'runs' of certain injuries (e.g. a club will often either have no one at the club suffering from a hamstring strain or 3-4 players at the one time carrying one). The Swans had a good run with injuries last year, but are struggling this year, similar to Penrith in the NRL.

This website has plans for 2005 to put up a weekly 'injury ladder' for both the NRL and AFL so that fans can follow the injury fortunes of the various clubs.

[injuryupdate]

Williams got 18 weeks which seems like a fair verdict, as he deserved something heavy. It can be hard to read consistency in the NRL charges though. I don't have any sympathy for Williams, but how Gorden Tallis got zero weeks for punching Ben Ross three times in the opening round last year bewilders me. I admit a key difference is that Ross didn't get badly injured and he was facing Gordie at the time, but O'Neill seems to have provoked Williams more than Ross provoked Tallis. Yes the punch was a lot worse but 1 punch = 18 weeks vs 3 punches = 0 weeks. I guess the NRL may admit now that the Tallis decision was wrong and that is one contribution to the judiciary chairman being different this year to last.

[budz]

Tallis is an 'elite' player which makes him immune from things like that.

[Jim Rancoon]

I want to know how the 3 judicary panel members (all ex-players) went reading through the 20 pages of neuroscience and neurology that was presented!

[Monica]

Like i said... if he'd admitted he was wrong, he would have been better off... that Gordy (and Ben Ross) had knowledge of the act, and was obviously guilty, at the time probably helped also. I have no sympathy for Williams. Even after the head shot on him, he should have kept his cool.

[injuryupdate]

Here is the text from McCrory's paper (from Br J Sports Med) on automatism that he used to support the prosecution case regarding Williams:

Automatism or automatic behaviour was originally described
in the Hippocratic corpus in relation to sleepwalking
and other nocturnal behaviours.1 Despite its long
history, this area of automatism remains confused and
imprecise in the medical and legal literature. Within English
common law, it is a fundamental principle that the
intent (mens rea) and the act (actus reus) must occur
together to constitute the crime.2 As such, the absence of a
mens rea means that the person at that point in time lacks
the intent to commit a crime.
In the legal view, post-traumatic automatism is a form of
“sane” automatism because it results from an external factor,
for example, a blow to the head, rather than from a
disease of the mind (which is responsible for “insane”
automatisms).3 4 As a legal defence under English law, if
successful, post-traumatic automatism leads to acquittal
rather than the judge deciding the disposal as in the case of
insane automatism.5
In recent years, a number of cases of footballers appearing
before disciplinary tribunals for striking and other
charges have claimed in their defence that they suVered a
prior concussive injury and at the time of the alleged incident
were suVering from a “post-traumatic automatism”
and as a result were not responsible for their actions. In one
celebrated case in Australian football, this defence was
successful and resulted in the sport’s administrative body
developing specific guidelines to outlaw this potential
defence. This topic of post-traumatic automatism has only
a limited amount of published information to guide practitioners,
players, administrators, and lawyers and this paper
seeks to establish appropriate medical guidelines in this
area.
The medical view of post-traumatic automatism
Automatism may be defined as “the existence in any
person of behavior of which he is unaware and over which
he has no conscious control”.6 It has also been defined
without reference to consciousness simply as “... involuntary
movement of the limbs or body of a person ...”.7 Posttraumatic
automatism implies the presence of a head injury
and subsequent amnesia for the automatic events that
occur during its existence.
Fenwick more specifically defines automatism as “an
involuntary piece of behavior over which the individual has
no control. The behavior is usually inappropriate to the
circumstances and may be out of character for the
individual. Afterward the individual may have no recollection
... of his actions ...”.7
Although the definition of automatism has been
established, in the setting of head injury it implies a disturbance
of consciousness that is often imprecise in nature.
Normal consciousness necessitates an intricate and
complex relation between the various components of the
brain and the environment. The limits of consciousness are
hard to define satisfactorily and quantitatively and we can
only infer self awareness in others by their appearance and
their acts.
The legal view of post-traumatic automatism
Although the medical and English legal definitions of
automatism diVer slightly,7 in courtrooms the legal one
clearly takes precedence. The most accepted legal
definition is that given by Viscount Kilmuir LC in the
House of Lords appeal in the case of Bratty v Attorney
General for Northern Ireland. This case involved a defence
of automatism caused by epilepsy. He ruled that “... the
state of a person who though capable of action, is not conscious
of what he is doing ... it means unconscious, involuntary
action and it is a defense because the mind does not
go with what is being done ...”. In the same case, Lord
Denning said: “... no act is punishable if done involuntarily
and an involuntary act in this context ... means an act
which is done by muscles without any control by the mind
... a reflex action ... or an act done by a person who is not
conscious of what he is doing, such as an act done whilst
suVering a concussion . . . However to prevent confusion it
is to be observed that in the criminal law an act is not to be
regarded as an involuntary act simply because the actor
does not remember it ...” (Bratty v Attorney General for
Northern Ireland: [1961] 46 Cr. App. R. 1, 7, 8. AC 401)
Traumatic brain injury and concussion
Traumatic brain injury encompasses a spectrum of injury
ranging from mild to severe. This injury spectrum is
usually subdivided according to the Glasgow Coma Score,
which is a standardised score administered at six hours
post-injury.8 A mild injury would score 13–15, a moderate
injury 8–12, and a severe injury <8. This scale is largely
dependent on the patient’s level of conscious state.
Consumption of alcohol may be a confounding factor in
accurately assessing such a scale.
Mild brain injury may be subclassified further and the
term “concussion” is often used to describe the mild end of
this injury subtype. Such injuries are commonly seen in
sport, following falls or assaults, and after motor vehicle
crashes. It is important therefore to clarify what is meant by
concussion and how the behaviour of such a patient reflects
the clinical stages of recovery from such an injury.
The Committee on Head Injury Nomenclature of the
Congress of Neurological Surgeons has developed a
definition of concussion. The American Medical Association
and the International Neurotraumatology Association
have subsequently endorsed this “consensus” definition
of concussion, which has now become the accepted
definition by most researchers in this field.9 10 The
Congress of Neurological Surgeons definition states that
concussion is “... a clinical syndrome characterised by the
immediate and transient post-traumatic impairment of
neural function such as alteration of consciousness, disturbance
of vision or equilibrium due to mechanical forces”.
The clinical “stages” of concussion
There is a relatively limited range of clinical symptoms and
psychological eVects that is seen following a concussive
injury. The subject usually passes through a series of stereotyped
stages of recovery.11 The typical sequence of recovery
from a concussive injury would be as follows:
Stage 1: Immediately post-injury—There may be a period of
unconsciousness for seconds or minutes but the subject
usually awakens spontaneously. On waking, there may be
little in the way of retrograde memory disturbance (that is,
memory loss prior to the accident) although this becomes
www.bjsportmed.com
more prominent in the ensuing minutes to hours. The subject
may be unsteady if attempting to stand. If questioned
the subject will appear confused and disorientated. He or
she will not be capable of responding to questions or commands.
If an observer approaches the subject in this phase,
the subject usually repetitively says “what happened” every
few seconds and is incapable of understanding any
explanation. Some purposeless motor activity may be
present. This motor phenomenon is often termed “cerebral
irritability”. This stage lasts for a variable period of time
but generally has recovered by 20 to 30 minutes
post-injury. In the stage of post-traumatic amnesia, a subject
may show automatisms.
Stage 2: Following recovery of post-traumatic amnesia—Once
the period of acute post-traumatic amnesia has resolved
(over 20–30 minutes) the subject is then capable of
responding to command, is orientated to time, place, and
person, and will be able to remember information
presented to him. Any unsteadiness will have resolved by
this time. The subject may report headache, blurred vision,
and/or nausea at this time. Headache is a universal
although non-specific symptom post-injury. If neuropsychological
testing is performed at this time, characteristic
deficits such as slowed information processing, will be
evident.
Stage 3: Clinical recovery—The acute symptoms (headache,
nausea, etc) settle over several days. During this period, the
memory functions normally although the subject continues
to show deficits on formal neuropsychological testing.
Such deficits may not be obvious to an observer or often to
the patients themselves.
Stage 4: Cognitive recovery—The clinical symptoms have
fully resolved by this time and the neuropsychological
function returns to normal over a variable period, depending
upon the severity of injury, but typically would vary
from 3–4 days for a mild concussion up to 2–3 weeks for a
severe concussion.
Ritchie Russell12 made a number of observations about
the clinical phenomenon of concussion and automatic
behaviour. He described a stage of “cerebral irritation”
that: “... is seen in all degrees of concussion. The concussed
football player often moves his limbs restlessly or talks
meaninglessly, and not a few cases of head injury are
violent and abusive when seen in the outpatient department.
Though in slight injuries, the duration of this stage is
brief when compared to what may be seen in severe cases,
it seems that the condition has the same significance in
both types of case. In the stage of irritability, consciousness
is not fully recovered and the patients have no subsequent
recollection of their actions. It is probable that these irritable
states merely represent a stage in the recovery of
consciousness. The mental and higher cerebral functions
have not yet recovered, and owing to the lack of their control,
the more primitive and less vulnerable motor activity
is running wild ...”
In medical parlance, Russell’s concept of “cerebral
irritability” reflects the legal parlance of a post-traumatic
automatism.

continued next post....

[injuryupdate]

Automatism in the setting of concussion
Although not well studied in this setting, the consensus of
expert opinion would regard “automatism” or irritability
following concussion to be typically manifest by signs such
as:
+ Thrashing or flailing limbs in a non-directed manner
+ Refusing to be directed (for example, onto a stretcher or
into an ambulance)
+ Wildly swinging arms if directly confronted or restrained
+ Aimless wandering in a “robotic” fashion.
Furthermore, any automatisms by definition could only
occur during the phase of post-traumatic amnesia
following the trauma. This period usually resolves over
20–30 minutes following a typical concussive injury. Posttraumatic
automatisms do not encompass goal directed or
purposeful activity. The typical occurrence is a concussed
footballer rolling about on the ground or attempting to try
and get up and who is incapable of following directions to
get onto a stretcher. If such a player does get to his feet an
observer may describe them as resembling a robot or
automaton staggering around but with no purpose.13 In
many ways, the increasing complexity of behaviour directly
reflects more specific intent in that specific activity.
In practice, establishing a defence of post-traumatic
automatism depends largely on a thorough knowledge of
the clinical and neuropsychological features of mild brain
injury, clinical assessment, and review of the evidence.
Transcripts of witness statements, police interviews,
especially if video or audiotaped, and contemporaneous
notes by police or medical staV often provide the most useful
sources of information on which an opinion in this
regard may be based.
The criteria that would need to be established to prove a
defence of epileptic automatism were originally proposed
by Fenwick7 and modified by Wright and colleagues.14 In
this paper, we propose a more comprehensive requirement
specifically for post-traumatic automatism. This should
include:
(1) The presence of a documented concussive brain injury
(2) The automatism occurring in the stage of posttraumatic
amnesia (Stage 1 above) as evidenced by
documentation of post-traumatic amnesia or impaired
memory for new learning
(3) The automatism behaviour represents a reactive
and/or purposeless response to stimulation or confrontation
(4) No premeditation, planning, or concealment is demonstrable
(5) The absence of goal directed, purposeful, or proactive
behaviour.
The usefulness of forensic psychiatric examinations is
limited in this setting.15 16 In the absence of intent due to
post-traumatic automatism, psychiatric determination of
the person’s state of mind adds little to this process.
Psychiatrists seldom have clinical experience of acute head
injury and are ill equipped to judge the neurological
aspects of this problem. Although the psychiatrist may correctly
concern himself with the individual’s capacity to
form intent, nevertheless in the case of post-traumatic
automatism, this is not usually relevant. Intent is not a psychiatric
concept.17 In court, the issue of intent is usually left
to the jury to determine (see R v Maloney [1985] AC 905,
[1985] 1 All ER 1025, [1985] 2 WLR 648).
Conclusion
The issue of post-traumatic automatisms is complex, with
diVerent legal and medical views on the subject. Although
the phenomenon of automatic behaviour is well established
following epileptic seizures or in the setting of sleepwalking
or other nocturnal parasomnias, the issue of post-traumatic
automatisms is complex as the issue depends on a characterisation
of the individual’s conscious state and the stage
of concussion they were in at the time of the alleged behaviour.
This paper seeks to establish guidelines for the assessment
of this phenomenon.
P MCCRORY
Neurologist & Sports Physician

[injuryupdate]

The NRL judiciary reached a verdict on the Danny Williams case, suspending him for 18 weeks, in a decision that was the predicted verdict but which came two weeks later than expected. Read more at Foxsports. In what was supposed to be a routine decision at the initial hearing, the script had Danny Williams being suspended for up to 18 weeks for his assault on Mark O'Neill in the Storm-Tigers game. However, the Storm pulled out a wildcard at the initial hearing using medical evidence from Dr Nathan Gibbs in its defence. Gibbs is the current doctor for the Sydney Swans and former rugby league player himself and he gave the plausible but controversial evidence that Williams may not have been in control of his actions when he hit O'Neill due to the effects of concussion, even though Gibbs was not present at the game. The Storm backed this up with other expert witnesses, including ex-Wallaby and neurologist Paul Darvineza, none of whom were present at the game, although there was no additional evidence presented by the Storm's own medical staff. Certainly the NRL contributed somewhat to the credibility of the concussion-reaction theory by charging O'Neill with a high tackle on Williams, which occurred only seconds before the other incident. However, the common sense verdict seems to have been reached, as the NRL would never have wanted to set a precedent that after receiving a high tackle that a player could be so much out-of-control of his actions that he could take a free swing at the opponent that hit him. The NRL itself presented expert testimony from Dr Paul McCrory, including a paper he had previously written on this exact topic - the medicolegal aspects of automatism in concussion.