Football, Head Injuries and the Risk of Dementia 2016 Update Acknowledgements

March 2013 FOOTBALL, HEAD INJURIES AND THE RISK OF DEMENTIA 2016 UPDATE ACKNOWLEDGEMENTS This paper has been developed by the Policy, Research and Information Department, Alzheimer’s Australia NSW. Report authored by Brendan Moore and Kylie Miskovski. © Alzheimer’s Australia NSW The information in this publication is the copyright of Alzheimer’s Australia NSW. Subject to the inclusion of acknowledgement of the source, any written material, visual images, tables and graphs in this publication can be reproduced in whole or part for personal or in house use, without formal permission. Reproduction for purposes other than those stated above requires written permission from Alzheimer’s Australia NSW. February 2016 Alzheimer’s Australia NSW PO Box 6042 North Ryde NSW 1670 Telephone: (02) 9805 0100 Facsimile: (02) 9805 1665 Website www.fightdementia.org.au National Dementia Helpline 1800 100 500 2 Alzheimer’s Australia NSW ALZHEIMER’S AUSTRALIA NSW 2013 DISCUSSION PAPER Alzheimer’s Australia NSW published a or decades after recovery from the initial discussion paper in March 2013 examining effects of concussive or subconcussive the connection between later-life cognitive brain trauma. Symptoms identified by some impairment and dementia (primarily Chronic researchers include: poor concentration, Traumatic Encephalopathy – CTE) in football or attention and memory loss as well as players who suffer multiple concussive and disorientation, dizziness and headaches. subconcussive injuries throughout their People with CTE can experience irritability, playing career. The paper included a review outbursts of violent or aggressive behaviour, of the research available in March 2013, confusion and speech abnormalities. Some examination of media reporting of the issue, research also shows a higher frequency and a number of interviews with specialists of suicide, drug overdose and depressive working in the area of concussion and CTE. disorders during this stage for people with CTE compared to the general population. In this current paper and the 2013 version, As the disease progresses there is a greater Alzheimer’s Australia NSW has used the loss of motor functioningiii. term ‘football’ to describe the four main football codes popular in Australia – rugby CTE may be misdiagnosed as Alzheimer’s league (National Rugby League - NRL), disease or fronto temporal dementia (FTD) rugby union (Australian Rugby Union - ARU), which share similar presenting clinical ‘Aussie rules’ (Australian Football League symptoms. Clinical diagnosis is difficult due - AFL) and soccer (Football Federation to a lack of consensus on diagnostic criteria. Australia - FFA). The only way to definitively diagnose CTE is through post-mortem neuropathological WHAT DID THIS PREVIOUS autopsy and there is no evidence-based PAPER REVEAL? pharmacological treatment available for CTEiv. Research into a type of dementia linked to repetitive brain trauma including concussive Football players may sustain concussive or subconcussive blows to the head has or subconcussive injuries throughout their developed. This type of dementia is a playing career, with research suggesting neurodegenerative disease which involves this may increase their risk of developing a build-up of the toxic tau protein and the CTE. The relationship between concussions progressive death of brain cellsi. Known as and traumatic brain injuries (TBIs) sustained Chronic Traumatic Encephalopathy (CTE), it in football and dementia is complex. was first noticed in boxers and described as being ‘punch drunk’ in 1928. Punch drunk Symptoms of concussion include: inability was later termed ‘dementia pugilistica’, to remember the cause of the injury or literally meaning ‘dementia of a fighter’. events that occurred immediately before or In the 1960s the condition was renamed up to 24 hours after it happened; confusion CTE. In recent years, awareness of CTE has and disorientation; difficulty remembering increased as it has become associated with new information; headache; dizziness; sports such as American football, hockey, blurry vision; nausea and vomiting; ringing soccer and wrestlingii. in the ears; trouble speaking coherently; and, changes in emotions or sleep patterns. The onset of CTE is often in midlife - years Symptoms often appear at the time of the Football, head injuries and the risk of dementia - 2016 Update 3 injury or soon after, yet sometimes they do Director, Mount Sinai Alzheimer’s not develop for days or weeks. Symptoms Disease Research Centervii. are usually temporary and clear up within hours, days or weeks, but they can last Alzheimer’s Australia NSW believes that months or longer. Cognitive changes are the association between concussions and among the most common, longest-lasting other head injuries sustained in football and and most disabling symptoms that can the development of dementia is sufficiently result directly from concussions. The ability concerning for steps to be taken to protect to learn and remember new information, players. We must ensure that the likelihood the capacity to pay attention, organise and impact of risk events is reduced to thoughts, plan and make sound judgements protect players’ current welfare and future can be affectedv. well-being. Potential risk events include: • Accidental head clashes It is important to establish that not everyone who has experienced concussion • Poor tackling techniques (including will develop CTE. In addition, we don’t shoulder charges) know what the other factors are that make • Striking some people more susceptible than others (e.g. genetics). • Falls • Heading the ball “Most people agree that repeated head trauma cannot be good for you… Many of these risk events are accidental We can’t ignore the current data in nature, making it difficult to change and pretend we are immune here in the games’ rules to entirely remove risks. Australia but we need to conduct sound Protective soft headgear is often seen as research of our own before we can a way of reducing a players’ risk of head draw conclusions.” injury. However, according to international experts on concussion in sports, there is Dr Andrew Gardner, Co-Director, Sport no clinical evidence that the protective Concussion Clinic, Hunter New England equipment currently available will prevent Local Health Districtvi. concussion. Headgear and mouthguards are “We don’t yet know whether the risk not effective at preventing concussions or is 1 in 10,000; 1 in a million; or 1 in 10 head injuries as they do not stop the brain million. We also suspect that there are from moving around inside the skull which genetic factors that make some people is what causes concussionviii. more susceptible to CTE. The first one Proper management of concussions when that comes to mind is called APOE4 and they do occur is therefore critical to protect is known to be linked to Alzheimer’s and players’ current and future wellbeing. The to poor outcome from head trauma.” foundation of concussion management is Professor Sam Gandy, Professor physical and cognitive rest until symptoms of Neurology and Psychiatry (Dual resolve and then a graded program of Primaries); Mount Sinai Chair in exertion prior to medical clearance and Alzheimer’s Disease Research; return-to-playix. Director, Center for Cognitive Health and NFL Neurological Care; Associate 4 Alzheimer’s Australia NSW When we published the first paper in 2013, early in the win over South Sydney the four football codes in Australia each had and was seen staggering around for a expressed concerns about the welfare of couple of minutes but stayed on the their players and had developed concussion field. The back-rower scored a try a management guidelines which adhered few minutes later and won the man- to international guidelines. Some codes of-the-match award. You can’t blame have separate guidelines for professional Craig Bellamy [coach] for wanting his and community level players, whilst others best players on the field but if there’s a have guidelines that apply to all players. In rule in place it must be enforced for all addition, each code has different guidelines matches, regardless of whether they for children or junior players. are trials, regular season games, finals or representative fixtures.” Proper management of concussion is an important issue for junior players. The Example of the flouting of concussion human brain is not fully developed until guidelines in the NRL as reported by early adulthood. The prefrontal cortex is one Yahoo Sports in 2012xii of the last regions to develop. This brain region is responsible for cognitive analysis and abstract thought, and the moderation of behaviour in social situationsx. Head injuries to a young developing brain therefore have the potential to result in significant damage. The Sports Concussion Assessment Test (SCAT) now has the Child SCAT3 specifically for young children aged between 5 and 12xi. Although concussion management guidelines were in place for all codes, it was and remains difficult to ascertain to what extent these are enforced, at both elite and community levels. Instances of guidelines being flouted in professional games, with players suspected of concussion remaining on or returning to the field, were identified at the time of writing. “With player welfare becoming increasingly paramount, the NRL introduced guidelines this season that if a player shows signs of concussion he must be replaced and can’t return until he’s cleared by the club’s medical officer. Yet Ryan Hoffman was knocked into Disneyland after

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