AFL doctors reject KO research
By Caroline Wilson
March 15, 2005
The 16 AFL clubs are resisting an international push to upgrade their matchday approach to concussion, rejecting computerised testing of players during games as impractical, expensive and unnecessary.
The Age believes that most AFL club doctors were unimpressed when the recommendations from the 2004 International Symposium on Concussion in Sport were delivered at the annual meeting of the AFL Medical Officers Association.
The symposium, sanctioned by the International Olympic Committee and world soccer's governing body, FIFA, has dictated that concussed players should not return to the field in professional sport unless they have successfully completed a computerised response test not unlike a series of simple card games.
Coming at an annual cost to each club of about $1000 a year, the test, produced by the Australian company CogState, would require internet access in players' rooms and take at least 11 minutes to complete.
Former Collingwood club doctor Paul McRory, a world expert on concussion, outlined the new requirements at the AFL medical officers' meeting earlier this month to a sceptical response from the 16 club doctors who either attended the meeting in person or over the telephone.
The reaction from Kangaroos' doctor Con Mitropoulos, whose 21-year-old midfielder Michael Firrito was badly concussed during a practice game last month, was typical of club doctors contacted by The Age.
"The really big decision is whether our clinical judgement should be overridden by something we are suddenly obliged to do because some research tells us we should," Mitropoulos said.
"The computer testing has a place during the week - we used it three or four times to test Michael Firrito the week after he was concussed - but the general consensus was it will be extremely difficult to use during a game.
"Michael's case was not a difficult one in that it was a classic concussion. He was thrown to the ground rugby-style and his head hit the knee of another player and he completely blacked out for about 90 seconds. When he came to, he was away with the fairies.
"He wouldn't stay on his stretcher. He was aggressive and irritable and frightened. After 15 minutes of testing, there was no improvement, so there was no question of him returning to play.
"The management was simple. He was sent by ambulance to hospital for a brain scan and we used the computer tests during the week to monitor his improvement.
"The test is very, very detailed into the brain function - but if you're in a game, in a final, and a player's been knocked out and there is 20 minutes to go before the final siren and you have an 11-minute test and something goes wrong with the internet response? I don't know," Mitropoulos said.
"The things we've been doing with footballers for years have been working for years and I'm not sure we've made too many wrong decisions over the years."
AFL medical officer Hugh Seward said: "The management of concussion at AFL level is already of a very high standard and the incidents of significant problems are already very rare.
"We have to decide how far to go to provide everyone with computerised testing.
"I think we should always aim to undertake best-practice methods but we also have to consider the practicalities, the time it takes to do the test and the fact that a phone line is required to log on to the internet and get a result during a game. The question . . . is how much better is this test than a clinical assessment we are already providing."
McRory is co-author of an article in next month's edition of the British Journal of Sports Medicine on the treatment of concussion on matchdays.
THE CONCUSSION TEST
* The player sits at a laptop in his club rooms and responds to a series of choices involving playing cards, pressing 'D' for yes or 'K' for no.
* The key to the test is speed and accuracy.
* The test should take between 10 and 15 minutes, with 11 as the norm.
* It is regarded as more accurate than the pen-and paper test currently used as it looks at the players attention devices, reaction times and memory.
* Once the player has finished the test it is sent down the phone for processing. A result is expected within seconds.
* The new system would cost each club about $1000 annually.
Detailed testing is probably more relevant in the rugby codes when the amount of head trauma is more significant than AFL. The liklihood of players experiencing multiple brain injuries (which can result from secondary minor trauma) within a short period of time and subsequently suffering potentially catastrophic or fatal consequences due to second impact syndrome is also more likely. However, the average age of an AFL player is younger than a rugby code player and it is known that adolescents are particularly susceptible to second impact syndrome. What concerns me is you've got probably the world's guru on concussion who also has the street cred of being involved with an AFL club saying this is the best thing to do. This shows that producing research and an evidence based approach in sports medicine will (for at least this generation) continue to come second to 'clinical experience' and anecdotal evidence.
If you want to be the man, you've got to beat the man
McCrory also let Gavin Brown go back onto the field in the 1990 AFL Grand Final after he was absolutely decked by Terry Daniher and unconscious for a few minutes. Obviously Cogstate wasn't around in those days and so based on examination, observation and probably DSST McCrory made the decision that Gavin Brown had fully recovered sometime during the second half and therefore was right to go back on. He didn't suffer further injury and in a football sense it turned out to be the 'right' management to let him go back on the field (in the same match after at least a moderate concussion).
I haven't read the new guidelines yet, but I hope they are phrased something like this:
- players can only go back on the field (without extra risk of further injury) if they have 100% recovered from the concussion. The MOST accurate way to assess this is a Cogstate test, but DSST testing, and other basic clinical tests can also give a fairly accurate guide to recovery.
The Gavin Brown management of 1990, when McCrory made his best assessment in the absence of Cogstate, is really no difference to the semi-professional team of 2005 that decides that it can't afford a broadband connection to Cogstate in its away change room, and therefore has to make the best assessment possible with the instruments available on the day.
Saying that players are only safe to go back on the field on match day with a Cogstate test is just like saying if a guy sprains his neck, he is only REALLY safe to go back on the field after an MRI of his neck (and you poor bastards still looking after football teams can work out how to get your team to pay for an MRI scan in the change rooms).
A 15 year old reference is perhaps not the best counter-argument. I doubt this is the reason for clubs not wanting Cogstate, but AFL clubs can be fined up to $250,000 for having a player on the field with symptoms of concussion (ruling out the 'Danny Williams defence'). Cogstate would provide an objective measure of cognitive status, that the AFL (or AFLPA) may request a copy of. The grand-final scenario may occur where the Dr for the teams sake would want the gun player on the field regardless of what Cogstate says. There are also important medicolegal considerations in regard to the value of a documented assessment in an athlete's career with any team. Regardless a gold standard test must be developed and adopted as head and brain injuries are rated more serious than a neck injury (for which MRI is not the gold standard anyway to diagnose strain/sprain). As for cost of Cogstate, $1000 per season per club is loose change.
If you want to be the man, you've got to beat the man
The cost issue would be with respect to the cost of computers and broadband connections at all dressing rooms (home and away) which could be quite substantial. Also, I think that Cogstate charges per test which might average $1000 per club at the moment but if there were a heap more tests getting done then the price would rise.
Irrespective of financial cost, the cost in wasting time to connect to the net, do the test, have the remote website analyse and compare and then report back, when in all this time if the player is OK he could be on the field kicking goals.
As I understand it, when the guidelines were put to the AFL club doctors, not one club said "great, these new guidelines are exactly what we are currently doing, so we support them".
I don't have a problem with a gold standard, just as MRI is the gold standard for diagnosis of many injuries, when clinical examination is often the silver standard.
Saying that the gold standard is the only acceptable standard (when in current circumstances it is impractical) is inviting lawsuits. When no one is meeting the gold standard, it can't be the only yardstick that best-practice guidelines mention.
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