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Issue One CONCUSSION A SPECIAL REPORT ON THE LATEST SCIENCE

Does concussion lead to brain injury?

Why top athletes want research

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A MESSAGE FROM

Professor Pankaj Sah QUEENSLAND BRAIN INSTITUTE DIRECTOR

CONCUSSION IS EMERGING AS A MAJOR HEALTH ISSUE. ore and more professional sportspeople are discussion about the wide-ranging and too-often tragic speaking out about their experiences of head consequences of head injuries? injury, including well-known former rugby It’s not just major head trauma that we need to worry about league players such as Mario Fenech and Peter or the short-term consequences of head impacts. Research on MFitzSimons. Furthermore, concussions have forced a growing the brains of former athletes is raising awareness of the long- number of current athletes to take time out from or cut short term neurological damage that can be caused by repeated, their sporting careers, including rugby league professional apparently minor knocks to the head. James McManus, who plays with the Newcastle Knights, At the Queensland Brain Institute, we have the expertise former Australian tennis powerhouse Casey Dellacqua, former to be able to explain some of the confusion surrounding Australian cricketer Chris Rogers and former Brisbane Lions concussion and to explore many of the unanswered questions. player Justin Clarke. new public awareness campaign surrounding concussion and is the spate of ‘one-punch’ attacks that has plagued young Wetraumatic have produced brain injury. this booklet as the first part of a major AustraliansOutside of since sport, the but turn also of garnering the century significant – responsible attention for Our intention is to inform and support a community response with this appalling phenomenon that has also ignited public condition affecting the lives of a growing number of us. Thealmost BRAIN 100 series deaths since 2000. Where does concussionQBI.UQ.EDU.AU/CONCUSSION fit to what is emerging as a significant and confounding health CONTENTS

CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4

WHAT IS TRAUMATIC CONCUSSION KIDS & CONCUSSION? BRAIN INJURY & SPORT CONCUSSION What causes concussion, The symptoms and major The changing attitudes of There is growing awareness how is it defined and who is causes of traumatic brain our sporting codes to the of the potential long-term most at risk? injury (TBI). dangers of concussion is a consequences of head injury positive. in young people. Detecting the signs and Helmets in sport. Do they effects of concussion and help to protect the brain? Prominent sporting figures post-concussion syndrome. share their experiences and How concussion has Our fragile brain comes insights into the impact that affected Australian tennis with its own protective concussion has had on their player Casey Dellacqua. packaging. lives. The long-term consequences of concussion: Dr Bennet Omalu and the discovery of chronic traumatic encephalopathy (CTE). CONTENTS

Publisher Professor Pankaj Sah Editor Karen McGhee Online Editor Donna Lu Clinical Editor Assoc Prof Terry Coyne Writers Donna Lu, Alan Woodruff Bianca Nogrady Additional Sub-editing CHAPTER 5 CHAPTER 6 CHAPTER 7 Kirsten MacGregor Additional Editorial Support Carolyn Barry DIAGNOSING LONG-TERM TESTING FOR Designer CONCUSSION CONSEQUENCES CONCUSSION Ivan Chow QBI Photography Diagnosing concussion A protein called tau, Striving for better Nick Valmas Medical Illustrations through changes in brain and its association with concussion diagnosis Dr Levent Efe function. dementia and Alzheimer’s in realtime on the Marketing and Communications Mikaeli Costello disease. sporting fields. Kirsten MacGregor Andrea Markey Publishing Consultant Kylie Ahern On the cover Tatafu Polota-Nau of the Wallabies, and Jude Bolton, ex-. Photography Mark Nolan/Getty Images For any queries please contact Mikaeli Costello at [email protected] The Queensland Brain Institute is located at The University of Queensland, at St Lucia, QLD, 4072

The Queensland Brain Institute would like to thank the following people for their volunteer work around this important issue. The Brain Series: Concussion Rebecca Appleton / Beatrice Bowen / Caroline Chalmers / Richard Chalmers / Brooke Connell / David Croft / Clare Fox was produced by the Queensland Brain Sarah Grant / Lucy Gundelach / Amanda Haack / Lyndsey Henderson / Liza Jane Loch / Hamish Maclean / Marcus Maclean Institute in partnership with the Australian Jeff Maclean / Stephanie Maynes / Terry McCoy / Marnie McLaren / Simon O'Brien / Jonathon Stewart / Zachary Tan Athletes’ Alliance (AAA), the peak body for Alexis Wallace / Kelly Wilkes / Sally-Ann Williams / Jeremy Willink. Australia's elite professional athletes. Chapter 1. WHAT IS CONCUSSION?

MEDICAL ILLUSTRATION LEVENT EFE

WHAT CAUSES CONCUSSION? brain can move so that it strikes the skull or twists upon itself. Just as for any body part that is struck, bruising and cell damage can blowhe brain to thefloats head, inside face the or skull, neck, suspended or from an within impact a occur. When those cells are neurons, however, concussion is the toprotective somewhere cushion else ofon cerebrospinal the body, can fluid.create A a direct force outcome. Because the brain is so central to our lives, controlling that shakes the brain. When that force is strong mood, perception and movement, the effects of concussion can be T enough, or comes from a particular direction, the far-reaching. CHAPTER 1. WHAT IS CONCUSSION?

WHO IS MOST AT RISK FROM CONCUSSION? he connection between contact sport and concussion has been widely publicised. In the general population, however, concussion is in fact extremely common. Typically caused by a fall or car accident, it can also be sustained by a wide variety of other activities. TThe outcome of a blow to the head can be either mild or severe. While anyone who has been ‘knocked out’ has usually suffered concussion, you can be concussed without losing consciousness. When concussion occurs in sport, players in most cases remain conscious, and the condition often goes undiagnosed. And while protective headgear prevents skull damage during high-impact knocks, it doesn’t prevent the brain from moving inside the skull. People in certain sports have a higher risk of being concussed than the general population – rugby players and boxers, for example. People in the military who are exposed to explosions and victims of domestic abuse are also at particularly high risk. These groups are also more likely to suffer repeated concussions.

HOW IS CONCUSSION MEDICALLY DEFINED? CONCUSSION IS THE MILDEST FORM OF TRAUMATIC BRAIN INJURY (TBI). THERE IS NO UNIVERSALLY ACCEPTED DEFINITION OF CONCUSSION, BUT IT RESULTS IN:

Rapid A variety of Disturbance Symptoms � impairment in � symptoms, but � to the brain’s � that gradually brain function that is not necessarily loss function rather improve over time, temporary and gets of consciousness than physical but which may be better by itself structure, which prolonged in a small means that standard percentage of people neuroimaging tests such as MRIs and CT scans can’t detect any changes

PHOTOGRAPHY EUGENE ONISCHENKO/SHUTTERSTOCK.COM CHAPTER 1. WHAT IS CONCUSSION? SIGNS AND SYMPTOMS WHAT ARE THE SIGNS OR SYMPTOMS OF POST-CONCUSSION OF CONCUSSION? SYNDROME Many people who sustain a concussion have no observable signs, which can make diagnosis difficult. Recognising the condition often depends on the affected person reporting the symptoms they are experiencing. These can occur either immediately after the head injury or minutes to hours later. PROBLEMS WITH BALANCE & STABILITY MEMORY & LEARNING PROBLEMS DOCTORS LOOK FOR THE PEOPLE WHO HAVE SUSTAINED FOLLOWING SIGNS IN SOMEONE A CONCUSSION MAY ALSO SUSPECTED OF SUFFERING REPORT THE FOLLOWING FROM CONCUSSION: SYMPTOMS: Confusion and inability Headache or a feeling of to speak coherently pressure in the head DIFFICULTY SLEEPING DOUBLE OR BLURRY Disorientation Confusion or difficulty OR STAYING ASLEEP VISION, SENSITIVITY (e.g. unaware of time and place) concentrating TO LIGHT Lack of co-ordination Dizziness (e.g. stumbling, inability to walk in a straight line) Changes in vision (e.g. ‘seeing stars’) Loss of memory (e.g. about the causative event) Ringing in the ears FATIGUE & WEAKNESS DIFFICULTY Slurred speech Nausea and vomiting CONCENTRATING Delayed response to questions Fatigue Appearing dazed or with a Sensitivity to light vacant stare Loss of smell or taste Inappropriate emotion (e.g. crying for no reason) DIZZINESS & DEPRESSION Any temporary loss of HEADACHES consciousness CHAPTER 1. WHAT IS CONCUSSION?

“I WAS SO DESPERATE TO JUST FEEL MYSELF AGAIN BUT I STRUGGLED TO DO EVEN DAILY ACTIVITIES SUCH AS THE GROCERY SHOPPING.”

RECOVERING FROM CONCUSSION n terms of short-term recovery, the brain changes that occur after a single concussion don’t appear to have clear long-term cognitive effects. Return to contact Isport should be gradual: the ‘if in doubt, sit it out’ rule- of-thumb is now adhered to by many sporting codes. A very small percentage of people who sustain a concussion go on to develop what is known as post-concussion syndrome. Symptoms usually develop seven to 10 days after a concussion, and can persist for weeks, months, and sometimes years. Why the syndrome occurs remains unclear. This was the Left: experience of Australian tennis player Casey Dellacqua. Concussion from a freak accident Dellacqua, who suffered a heavy on-court fall in October while competing in a 2015, wrote in a blog post that post-concussion syndrome doubles tournament was “honestly some of the scariest stuff” she had experienced. in Beijing, in October 2015, Her symptoms included headaches, inability to sleep, memory forced Australian problems and constant drowsiness. “I was so desperate tennis player Casey Dellacqua out of the to just feel myself again but I struggled to do even daily game indefinitely activities such as the grocery shopping,” she wrote. in 2016.

PHOTOGRAPHY MARK NOLAN/GETTY IMAGES CHAPTER 1. WHAT IS CONCUSSION?

Former THE LONG-TERM NFL player CONSEQUENCES OF (below) CONCUSSION THE MESSAGE

hile the short-term symptoms of concussion WHEN SHOULD YOU SEEK are reversible, research suggests that MEDICAL ADVICE? even a single knock to the head can have Wsevere consequences later in life. For example, figures from one study that analysed the records Because the symptoms usually of more than 160,000 trauma patients identified resolve by themselves, a that, in patients aged 65 and older, just one concussion is best managed concussion was associated with a 22-26% increase with physical and cognitive in dementia risk in the following five to seven years. rest. However, stories about the Even clearer is research showing that neurological potentially tragic consequences damage accumulates with multiple knocks of undetected brain injuries are to the head, even when they are apparently difficult to ignore. Symptoms symptomless, or ‘sub-concussive’. Repeated of severe TBI can develop concussion has been linked to increased risk of over several hours. Therefore, neurodegenerative conditions such as Alzheimer’s after a knock to the head, it’s and Parkinson’s disease, as well as chronic traumatic important to be alert for the first encephalopathy (CTE) – see page below about 24 hours. Some symptoms are the medical identification of this condition. red flags for more severe brain Data from studies of former American injury: if a head injury results footballers is staggering. A survey of more than in a loss of consciousness, 2000 retired professional players found that increasing confusion, vomiting those with a history of multiple concussions were or a worsening headache, the three times more likely to have been diagnosed person should seek medical with clinical depression. Another study of death advice. It’s important that a certificates found that the death rate from doctor makes an assessment neurodegenerative diseases was three times higher to rule out more severe TBI. for pro-footballers than the general population.

PHOTOGRAPHY GEORGE GOJKOVICH/GETTY IMAGES CHAPTER 1. WHAT IS CONCUSSION?

CTE was first discovered by neuropathologist THE NEED Dr Bennet Omalu (left) in the brain tissue of FOR EARLY former NFL player Mike DIAGNOSIS Webster. Their story has been depicted epeated head trauma in the motion picture Concussion. doesn’t always lead to R CTE and it is likely a person’s genetic background also plays a role. Currently, the only way to diagnose CTE is post-mortem, which means it’s impossible to determine how prevalent the condition is in the general population or catch the condition at an early stage. The next challenge for TBI researchers is to develop techniques that can identify CTE in living brains. QBI’s Dr CHRONIC TRAUMATIC Fatima Nasrallah is using the support of a Motor Accident ENCEPHALOPATHY (CTE) Insurance Commission Senior TE is a progressive disease with Alzheimer’s-like symptoms. It was first Research Fellowship to work discovered by neuropathologist Dr Bennet Omalu in the early 2000s C in the brain of Mike Webster, a former (NFL) develop an early diagnostic test player. When Omalu looked at Webster’s brain tissue under the microscope he foron TBI,concussion. specifically She tohopes try and to observed concentrations of a material known as tau. This is one of two proteins use biomarkers and imaging known to accumulate in the brain in Alzheimer’s disease. Since then, CTE has to develop a test that will be been found in the brains of 76 out of 79 former NFL players who have donated able to detect even subtle their brains to research. changes in brain function following a head injury.

PHOTOGRAPHY IDA MAE ASTUTE/ABC VIA GETTY IMAGES Chapter 2. TRAUMATIC BRAIN INJURY (TBI)

WHAT IS TRAUMATIC BRAIN INJURY? MAJOR CAUSES OF TRAUMATIC BRAIN INJURIES* raumatic brain injury (TBI) is an injury to the brain caused by an external force. Common causes (see right) include falls, car accidents, as- T sault or being struck by objects such as might occur during sport. TBI perspective this judgment is based on what’s known as the Glasgow Coma Scale is(GCS), classified which according assesses motor,to its severity: verbal and mild, eye-opening moderate orresponses. severe. From The scalea medical runs from 3 to 15, where 3 is assigned to someone who is dead or comatose and 15 is normal. Someone with a mild TBI generally has a GCS of 13–15. In the absence of clinical assessment, TBI is considered moderate-to-severe if there is a loss of consciousness that is longer than 30 minutes and amnesia – memory loss – lasts for more than 24 hours. It’s mild if those conditions are not met. . Concussion is classified as a mild TBI *Based on information from the National Center for Injury SYMPTOMS OF TBI Prevention and Control, CDC MODERATE TO SEVERE TBI MILD TBI Accounts for 10% of all cases Accounts for 90% of all cases (based on WHO information) 1% SUICIDE % SYMPTOMS: SYMPTOMS: 11 ASSAULT l slurred speech l headaches 19% STRUCK BY OBJECTS (INCL. SPORTS) l l profound confusion dizziness & fatigue % l seizures l sleeping difficulties 20 MOTOR VEHICLE ACCIDENTS % l persistent headaches l memory & concentration problems 21 OTHER l coma l blurred vision 28% FALLS ILLUSTRATION LIGHTSPRING/SHUTTERSTOCK.COM CHAPTER 2. TRAUMATIC BRAIN INJURY (TBI)

PROMINENT TBIs BRAIN HAEMATOMA he tragic outcomes of a spate of one-punch attacks – so-called ‘coward punches’ – in recent years has drawn considerable attention and Tresulted in harsher sentencing laws for perpetrators.

Manyor doesn’t researchers have any in apparent the TBI field immediate argue the effects, tough the laws head aretrauma justified can lead because to irreversible even when consequences a single punch years isn’t orlethal, decades later. Recent highly publicised cases of severe TBI have included Formula One driver Jules Bianchi who died as the result of head injuries received when the car he was driving crashed during the 2015 Japanese Grand Prix. Retired Formula One driver Michael Schumacher continues to receive intensive treatment for severe head injuries that he suffered during a skiing accident in France, in 2013. In both of these cases, a severe TBI resulted in an immediate and prolonged loss of consciousness. However, a loss of consciousness isn’t always necessary for the consequences of TBI to be catastrophic. In 2009, British actress Natasha Richardson knocked her head while skiing. Thinking she care on multiple occasions before later experiencing headaches that prompted herwas to fine, go toshe hospital. refused medical Richardson subsequently died due to an epidural Natasha Richardson haematoma, a build-up of blood between the skull and the membrane that surrounds the brain (see illustration right). Haematomas are considered secondary injuries, Michael meaning that the damage done to the brain doesn’t Schumacher coincide directly with the blow to the head. MEDICAL ILLUSTRATION LEVENT EFE PHOTOGRAPHY KHALED DESOUKI/AFP/GETTY IMAGES; PHOTOGRAPHY EVERETT COLLECTION/SHUTTERSTOCK.COM CHAPTER 2. TRAUMATIC BRAIN INJURY (TBI)

CONCUSSION BY NUMBERS (ESTIMATES ONLY)

The ratio The proportion THE MESSAGE of men to of injuries women that are head who are injuries in rugby Most blows to the head are likely to union, league suffer and Australian minor and nothing to worry concussion. rules football. about, producing no symptoms other than pain and perhaps a small tender lump. However, Number of concussions per the Natasha Richardson case 1000 hours of highlights the fact that even playing rugby seemingly innocuous head union, league or knocks can later produce Australian rules Number of concussions per devastating effects. Warning football. 1000 hours of playing soccer. signs to watch for after any form of head injury, no matter how minor it might seem, include: persistent headaches, balance The number problems or cognitive changes. of annual If a head injury results in The percentage of traumatic brain concussions a loss of consciousness, injuries that are concussions. worldwide. increasing confusion, vomiting or a worsening headache, the person should see a doctor. The percentage The percentage of concussions of all sporting that may go injuries that unassessed concussion by medical makes up. professionals. CHAPTER 2. TRAUMATIC BRAIN INJURY (TBI)

Why is this the case? Helmets are designed mainly to dissipate force. Most sports helmets consist of a hard outer shell and an inner foam layer, normally of polystyrene. The hard shell spreads or dissipates the impact force over a larger area. Meanwhile the HELMETS: foam inner section also reduces the peak impact by extending the WHAT ARE distance of head deceleration – meaning that it takes longer for THEY GOOD the head to slow down, which makes the movement less abrupt. The foam layer also crushes and deforms, which absorbs as much FOR? of the remaining energy as possible. While these factors decrease the level of the impact force, they do little to address rotational forces caused by head movement and any concussion this might cause. There is no evidence that the soft headgear players in some efore describing how helmets work and what they’re Australian football codes wear protects against head injury. capable of, it’s important to understand how injuries can Many current attempts to improve helmets still focus on result from head impact. A blow to the head can cause the decreasing impact by using new materials, or on developing Bbrain to move back and forth (translational movements) or rotate different foam and shell arrangements. However, the growing and twist on itself (rotational movements). concussion crisis has led some researchers to try to limit In translational – back and forth – movements, the brain rotational forces as well, with helmet manufacturers now looking crashes against the skull, potentially even rebounding in the other to incorporate elements that slide against each other upon direction and receiving a second impact with the opposite side impact. of the skull. The damage is done by direct impact and is much like bruising. In rotational movements, as occurs when the head is struck at an angle, the brain itself twists, causing damage as neurons rub against each other in a shearing fashion. THE MESSAGE Hard helmets protect reasonably well against translational reducing the risk of skull fractures and bleeding inside the Helmets, of course, are good for protecting against movementsskull – intracranial and the bleeding. impact injuries They are they far cause, less effective significantly against brain injuries. But they don’t do a good job against rotational movements and it’s these that researchers believe are all types of head impact. Different impacts cause responsible for most concussions. This means that a helmet may different head movements, and different head protect the head better against severe TBI, which is caused by movements result in different injuries. translational forces, than against concussion.

ILLUSTRATION SPENCER SUTTON/SHUTTERSTOCK.COM CHAPTER 2. TRAUMATIC BRAIN INJURY (TBI)

Several layers protect the fragile brain. The meninges are membranes that lie between the brain and the hard skull; the dura is the toughest of these layers and adheres to the skull, providing a sac that limits brain movement. Cerebrospinal fluid cushions the brain when the head moves around, limiting contact with the skull. The FRAGILE BRAIN ILLUSTRATION BY LEVENT EFE CHAPTER 2. TRAUMATIC BRAIN INJURY (TBI)

Despite this, Rushworth began a graded Perspectives return to work as a journalist at the ABC NICK RUSHWORTH in Sydney, and was back working full-time EXECUTIVE OFFICER, six months following the accident. Initially, BRAIN INJURY AUSTRALIA he found the noise of the busy newsroom environment challenging, but feels fortunate that his working life was able to continue more or less unaffected. ick Rushworth is more familiar than “I had a really easeful return to work, most CEOs with the effects of given the severity of my injury,” he says, traumatic brain injury (TBI). Twenty adding however that this isn’t the case N for the vast majority of people who suffer years ago, he was in a major bicycle accident involving a head-on collision with a brain injury. “For a lot of people, the a car. He was hit mid-leg, breaking both lack of public awareness about brain his femur and the bicycle frame. injury means that, in a return-to-work “I was catapulted over the bonnet context, their inability to concentrate, to of the car and took the full force of the “THE LACK OF PUBLIC pay attention, and their fatigue — which is impact near my right ear,” Rushworth AWARENESS ABOUT BRAIN a huge issue post–brain injury — is often says. “I pretty much fractured my skull INJURY MEANS THAT, IN mistaken for laziness.” right around.” A RETURN-TO-WORK Behavioural problems, Rushworth adds, Motor vehicle accidents are the CONTEXT, THEIR INABILITY are sometimes perceived as simply being second-most common cause of TBI in TO CONCENTRATE, TO PAY “who’ve they’ve always been as a person”, Australia, after falls. Depending on its a misconception that he says is “re- severity, TBI can cause a range of long- ATTENTION, AND THEIR FATIGUE disabling” for the injured individual. term disabilities and changes in feeling, IS OFTEN MISTAKEN FOR Rushworth is now the Executive Officer thoughts and behaviour. LAZINESS.” of Brain Injury Australia, the peak body Rushworth has no memory of his for more than 700,000 Australians living accident — nor of the proceeding two cared to listen about the story of my with acquired brain injury. In this role, he weeks he spent in hospital. “My almost- accident, and tell them repeatedly,” raises awareness about the causes, types, continuous memory starts again when he says. and effects of brain injury, ranging from I was discharged from hospital into A neuropsychological assessment concussion in sport to more severe brain rehabilitation, but even then, it was very brought sombre news: it found “that injury resulting from assault or accidents. fragmented,” he recalls now. my intellectual capacity, my ability to “The aim,” he says, “is to make He also suffered short-term memory concentrate, to plan, to organise, was someone’s return to work or return to impairment. “I used to tell anyone who going to be ‘radically impaired’.” community life as easeful as it was for me.” Chapter 3. CONCUSSION & SPORT

t’s not often a major Hollywood if a concussion diagnosis is made. movie is devoted to a single Professor Davis says the AFL medical condition. But in has been ahead of the game on I Concussion concussion, working with concussion was released, telling the story of experts for many years and convening latea forensic 2015, pathologist’sthe film attempts a concussion working group in 2010, to shine light on the American long before head knocks began National Football League’s hidden grabbing headlines. That working secret of chronic traumatic group has developed guidelines to encephalopathy (CTE) – a long-term help doctors, coaches and players complication of repeat concussions. diagnose and manage the estimated 6–7 cases of concussion that occur per in public attention on a condition team per season across all levels of that The had film’s previously release representednot been a peak AFL competition. The key principles of discussed much outside medical these guidelines are that concussion is circles but suddenly seemed to be a complex and still poorly understood ‘IF IN DOUBT, SIT IT OUT’ condition that needs to be managed using 2009. In the years since then, attitudes Melbourne-based neurosurgeon and an individual-based approach with a worryinglytowards concussion common. in The professional film is set sportin concussion expert Professor Gavin Davis have come a long way. Concussion is now says the general attitude to the condition l A period of rest widely recognised as a medical issue for just 10 years ago was that players should numberl Monitoring of steps, for including:ongoing or changing signs many sports. In many codes it’s team ‘get over it and get on with it’. Today it is no and symptoms longer seen as a sign of weakness to be l Neuropsychological tests to monitor about if and when a player can return to ruled out of play because of concussion. In recovery doctorsplay after who a head are beinginjury given. Most final importantl say y, the Australian Football League (AFL), there l A graduated return to activity in they’re being given the authority to conjunction with monitoring apply medical reasoning to override the such as a mandated 20-minute period l A doctor’s OK before returning to play wishes of coaches and even the players areoff the specific ground rules to completearound head a concussion knocks, These recommendations are now found themselves. medical assessment, and no return-to-play in a similar form in many other sport

PHOTOGRAPHY NEALE COUSLAND/SHUTTERSTOCK.COM CHAPTER 3. CONCUSSION & SPORT concussion guidelines around the world. “Whatever sport you play it’s a short stand career. TATAFU POLOTA-NAU The overarching mantra, however, is ‘if in You want to make the doubt, sit them out’. most of it but there’s life s a player with the NSW Waratahs and to live afterwards,” says Tatafu Polota-Nau, Australian Wallabies, Tatafu Polota-Nau FROM NATIONAL LEAGUES (pictured below). has had his fair share of concussions and Aknows how tough it can be to accept the doctor’s TO SCHOOL COMPS The heightened awareness of concussion advice to take a break from play, even for a short at the professional level has also time. “Straight away, your basic instinct as a rugby player tells you that you need to get back on the field straight away,” he says. “But in hindsight, you look at says Professor Caroline Finch, director the [television] footage and you see clearly you were filteredof the Australian down to community Centre for Research sport, in a dazed state. into Injury in Sport and its Prevention “That tension is felt by player, coach and doctor – a unit based at Victoria’s Federation because they’re looking after the game and the University Australia. Unfortunately, the health of the player too. It’s a hard one to judge, and messages about concussion are often especially in a final game – there is no bigger stage.” mixed or misinterpreted. Some parents The changing attitudes to concussion have had a are so concerned about the risks and big impact on players, and ultimately on the teams consequences that they keep their and game. “It has been a big eye-opener, particularly for professional players because although you think you’re doing the right thing by your team mates by Others see professional players return playing on, you’re not because you’re not 100% in child off the sports field altogether. focus,” Polota-Nau says. “At the end of the day, a game, and assume therefore that becoming more mature with it but also having a bit of toconcussion the field afterisn’t thata head serious. knock Professor during experience means you can definitely tell what’s better Finch says concussion guidelines also for the team initially and also for your health as well.” apply to community sport. But without There’s also the awareness now that repeat the same level of medical support concussions could have longer term implications that’s available to professionals, those for players; something that Polota-Nau says made guidelines aren’t always implemented him more aware of proper technique, so as to reduce the chance of him suffering a concussion with as much rigour. However, it’s an issue from, for example, a ‘flying superman’ tackle. taken seriously by many codes, some “Whatever sport you play it’s a short stand career,” he says. “You want to make the most of it but there’s targeted at the community level. life to live afterwards.” of which issue guidelines specifically PHOTOGRAPHY MARK NOLAN/GETTY IMAGES CHAPTER 3. CONCUSSION & SPORT

Players’ Perspectives approach at the helm of the RLPA. “It’s really our job to continue educating people about the respect they need to CEO, RUGBY LEAGUE have for the measures that are being put PLAYERS ASSOCIATION in place,” he says. Another priority is limiting the number of incidents that go unnoticed or aren’t properly assessed. “From a health and safety point of view, there’s a huge ormer Australian Rules footballer amount of money generated from the Ian Prendergast has seen a big performance of players, so equally change in attitude to head injuries there needs to be a huge amount of F investment in protecting their safety on since he was playing professionally for the in the early the field,” Prendergast says. 2000s. “Back in my day, there wasn’t as These days, players are being forced much awareness around concussion,” he to take concussion much more seriously says. “It was almost a badge of honour than they once did. “Now, I think there’s for players to continue playing after a a greater acceptance of the need to serious knock.” report any symptoms that may be Now, educating coaches and players linked to concussion so that you can be about concussion is an integral part properly assessed and removed from the of his working life. After finishing his game if necessary,” Prendergast says, career as a player, Prendergast went adding that there is more work to be on to represent the interests of elite done. “We still need to be able to assess footballers at state, national and in a more objective way the impact that international levels, first as a general concussion is having, both immediately manager for player relations at the AFL after the incident, but also with respect Players’ Association (AFLPA) and now “BACK IN MY DAY, THERE to the recovery and treatment required as Chief Executive Officer of the Rugby WASN’T AS MUCH AWARENESS to rehabilitate a player.” League Players Association (RLPA). AROUND CONCUSSION. IT WAS Prendergast believes that finding During his time at the AFLPA, the answers to the unknowns about association worked closely with the ALMOST A BADGE OF HONOUR concussion is crucial. “Research is key sporting code to push for a conservative FOR PLAYERS TO CONTINUE because knowledge is power,” he says, approach to concussion management PLAYING AFTER A SERIOUS “and the more information we discover, and Prendergast is taking a similar KNOCK.” the better informed our approach can be.”

PHOTOGRAPHY DYLAN ROBINSON/NEWSPIX CHAPTER 3. CONCUSSION & SPORT

innocuous ones can be the worst. Players’ Perspectives “I know that having sustained JUDE BOLTON multiple concussions puts me in a high- RETIRED AFL PLAYER, risk category. I would hate to think SYDNEY SWANS that the way I played may contribute towards potentially having something like dementia, CTE or depression later in my life.” uring more than a decade Bolton emphasises, however, that playing first grade with the he doesn’t want the sport to change. D Sydney Swans, retired Australian “AFL is a tough and sometimes brutal Football League (AFL) star Jude sport that I love,” he says. “I never want Bolton experienced several major head to see the physicality taken from the collisions. game, nor do I ever want families to not He concedes that throughout his allow their kids to play sport. There are career he prided himself on resilience at so many health issues that kids and the expense of his brain and once wore adults have just through not being as concussion as a badge of honour. “That active as they should.” meant taking any hits and just getting Bolton says better protocols and up and getting on with it,” Bolton increased awareness are important recalls. “I remember my grandfather steps forward and senior players always saying, ‘It’s better to wake up sitting out of the game for a week, in an ambulance than to duck out of a or not returning to the game after a contest.’” concussion, are wonderful examples for But concern about the long-term young players to look up to. consequences has since made him an He believes science is the key to advocate for player welfare. “It was improving player safety: “I would love actually my same grandfather who to see the research be to a point where then said to me after I sustained two “A BRAIN INJURY IS NOT LIKE we have absolute certainty on the concussions in one game – and played ANY OTHER INJURY. EACH protocols and that kids, families and the following week – ‘You don’t want to all sporting clubs know what to do if a be a dribbling mess when you’re an old HEAD KNOCK IS DIFFERENT concussion is sustained, and have an man’,” Bolton explains. “A brain injury AND SOMETIMES THE ability to limit any long-term effects. is not like any other injury. Each head INNOCUOUS ONES CAN BE “In the end it is just a game. You only knock is different and sometimes the THE WORST.” get one brain.” CHAPTER 3. CONCUSSION & SPORT

that advice,” Clarke says. Players’ Perspectives But calmly taking medical advice can be JUSTIN CLARKE a different story when a player sustains a RETIRED AFL PLAYER, head knock during a game. Clarke agrees BRISBANE LIONS that concussions are common in sport, particularly football, and believes that managing how they are diagnosed and ustin Clarke has no memory of treated is crucial. An objective field-side the head knock that ended his test would be ideal, he says, as it would promising Australian Football override a player’s often-skewed self- J assessment. “A player in that moment— League (AFL) career at the age of just 22. Nor can the former Brisbane Lions whether it’s for the best or not—they’ll defender recall the three weeks following want to be back out there. I wanted to that concussion. be back out there,” Clarke explains. “It’s “That period was a tough time because about being able to control how much I wasn’t able to do much,” Clarke says, say that player has in that moment, and explaining that he had a severe headache, being able to ensure their safety first and and spent most of that time in the dark, foremost.” because his symptoms became worse in Clarke says increased awareness of the light. “Every little thing sort of set me off, symptoms of concussion is also important. and I struggled to get outside much.” “Amateurs experience concussions just Clarke sustained the concussion during as much as professionals do,” he says, a routine training session, and footage adding that his message to young players of the collision appears innocuous. “I is, “there’s no need to be a hero and go just got a little shove in the back and He was assessed separately by back out into the field if they’ve been that propelled me into a bloke who was three doctors and each urged that he concussed or have concussion symptoms.” running in the opposite direction, into avoid future contact sport – a heavy But Clarke doesn’t hesitate in his praise his knee,” he says. The impact knocked recommendation for a young athlete with of AFL. “I would be really encouraging of Clarke unconscious. He had sustained his entire football career ahead. Although my kids to play contact sports because head knocks in the past, but soon realised his decision to retire, in March 2016 after it’s such a wonderful environment to this concussion was different. One month four years playing with the Lions, has been grow up around,” he says. “It’s such an later, his symptoms still hadn’t improved. heartbreaking, it wasn’t difficult. “When important thing that we can increase His brother had gone through a similar you have three specialists all tell you that concussion awareness, and increase experience and Clarke “had an inkling that you’d be pretty silly to play footy again, research into it, so that people can keep things might not turn out for the best.” then you’d be a stupid man to go against on playing the sports that they love.”

PHOTOGRAPHY TARA CROSER/NEWSPIX CHAPTER 3. CONCUSSION & SPORT

“My first experiences with concussion prevalent,” she says. “I would love the Players’ Perspectives and hockey came at an U21 Nationals opportunity to educate a wider audience JOCELYN BARTRAM when a teammate missed six consecutive about the importance of looking after your HOCKEY PLAYER, games due to a concussion and at an brain whilst playing contact and non- HOCKEYROOS international level when I witnessed a contact sport at all levels.” Great Britain team member escorted In hockey, players are at risk of colliding away in an ambulance after she fell and during play when they go in to contest the her head collided with an ball, during a low defensive ocelyn Bartram was destined for a opponent’s knee resulting tackling situation. career in sport. She was an active, in a major concussion,” Goalkeepers are at even outgoing child who always wanted Bartram says. “Personally, higher risk due to the J just a few months ago I nature of the position. to be involved in any sporting activity that was going and eventually followed missed a training session “Although, I feel I have in the footsteps of her mum and brother after I collided with a team a good understanding of who played hockey. mate in a contest for the the range of effects that “Despite playing soccer, water polo, ball, where my helmet was concussion can result in, basketball and tennis during my childhood knocked off, and I suffered I think some sportspeople and adolescence,” Bartram recalls, a reasonable headache. are not aware but also “hockey has always been my most loved I was monitored for the feel ‘that it won’t happen sport and passion.” remainder of the day and to me’, especially in non- Through years of perseverance and concussion-tested to contact sports, where hard work, she finally caught the attention make sure I hadn’t suffered concussions aren’t as of national selectors and has been part of any further damage.” regular as other more the development squad for the Australia Bartram was attracted visible injuries,” Bartram women’s national field hockey team – the to QBI’s concussion says. She believes that Hockeyroos – for the past 18 months. Now campaign because growing just because concussion she’s set her sights up as a hockey goalkeeper, isn’t a visible injury, it firmly on this year’s Olympics in Rio. with a parent in the shouldn’t be taken lightly. Despite its sticks, hard balls and the medical profession, she was always very “It’s important to have a strict concussion furious pace at which it’s played, hockey aware of both the short- and long-term protocol in place and, although it may is not a contact sport and so it’s not potential effects of concussion. feel like a bit of overkill at the time of your normally an activity that springs to mind “As I’ve grown older and started concussion, it will make all the difference in when concussion is mentioned. And yet studying exercise and sport science, the the future when you have moved on from Bartram has experienced concussion importance of concussion awareness elite sport and are living the next chapter regularly on the hockey field. and treatment has only become more of your life.” CHAPTER 3. CONCUSSION & SPORT

or netballer Gabi Simpson, at all. It probably took a week-and-a- Players’ Perspectives who plays mid-court with the half for me to be fully symptom free.” GABI SIMPSON Queensland Firebirds, the most Since the incident, Simpson has gained F a greater awareness about head injury NETBALLER, eye-opening aspect of sustaining a QUEENSLAND FIREBIRDS concussion was that it initially went and its lasting impacts. “The thing that unrecognised. Netball at the elite level is scares me the most is that we didn’t intensely physical but is not classified as know I had concussion,” she says. a contact sport. Although concussions Simpson agrees that loyalty to a do occur, they are rare. team often factors into a sportsperson’s During a game, decision to play on after 23-year-old Simpson “I ENDED UP sustaining an injury. “As was accidentally hit by HAVING TO BE IN A an athlete, you’re there a teammate. “She was for your team. Your culture running backwards and I DARK ROOM FOR is that you’d do anything got an elbow to the jaw,” THREE DAYS — for the team, anything for Simpson recalls, explaining NO SCREENS, NO the win,” she says. “So if that the impact threw her LIGHT AT ALL. you do get a knock, you head backwards, resulting IT PROBABLY TOOK think, no, I’m going to in whiplash. “I felt my eyes A WEEK-AND-A- stay on for my team.” go a bit blurry, but I didn’t HALF FOR ME TO Now her own concussion experience has shown think anything of it. I did get BE FULLY SYMPTOM some migraine symptoms Simpson the importance pretty soon after, but we FREE.” of recognising, and not thought that was because ignoring, the symptoms. of the whiplash effect on my neck.” Athletes put their minds and bodies Unaware that she had just sustained on the line, but it’s about “knowing a concussion, Simpson continued to when it’s time to stop,” she says. play. It wasn’t until three days later, on Simpson believes that research is her way to a university class, that her the key to more accurate concussion symptoms worsened and she sought diagnosis. “The more information we medical attention. Simpson experienced know, the stricter we can be on our a severe headache, sensitivity to light, reaction to concussion,” she says. “I and vomiting. “It was pretty horrific,” she think that’s extremely important. says. “I ended up having to be in a dark “I value my brain, and I study, and I room for three days — no screens, no light need to think about the long term.” Chapter 4. KIDS & CONCUSSION

ost parents would lobes of the brain – regions say childhood is a responsible for executive concussion waiting functions and processing Mto happen. Whether it’s sensory input – continue toddlers with a fascination for maturing into the early 20s. staircases, children who love Damage to still-developing riding bikes, or adolescents areas has the potential to result playing sports with reckless in detrimental long-term effects. enthusiasm, at some point However, most children many young people will thump recover fully from concussion. their head hard enough to For children who have make a parent’s heart stop. suffered a concussion – or Just as with concussion other mild traumatic brain in adults, there is growing injury – studies have found awareness of the potential long-term consequences of the THE DEVELOPING BRAIN There is still only a limited in learning performance in injury in young people. Where Because children have weaker understanding of the effects of noschool-aged significant students differences compared once a child or adolescent necks and torsos than adults, concussion on the developing to their peers. However, in might have been sent back less force is needed to cause a brain, partly because studying another study of students to the playground or back to brain injury. Most concussion school after a head impact, cases occur in young people brain responds to trauma more severe post-concussion now parents, teachers and aged 5 to 14. In children and thesedifferently is difficult. to the Theadult developing brain, agedsyndrome five to symptoms 18, the presence was of doctors are taking a much adolescents, the two most and is in some respects more associated with more school- more conservative approach to common causes are sporting vulnerable to damage. related problems and poorer managing concussion. and cycling accidents. The frontal and temporal academic performance.

In 2016, the Australian Medical Association (AMA) and Australian Institute of Sport (AIS) released a joint position statement on concussion. They recommended that parents, coaches and sports administrators should “err on the side of caution” and not allow any child or teenager with a potential concussion to return to the sporting field until at least two weeks after being cleared of symptoms. See ama.com.au/position-statement/concussion-sport-2016 PHOTOGRAPHY SERGEYNOVIKOV/SHUTTERSTOCK.COM CHAPTER 4. KIDS & CONCUSSION

CLEAR COMMUNICATION or whether they are having GRADUAL RECOVERY plan tailored to their recovery. IS KEY trouble concentrating. Another recommendation This recovery can take a Children often play sport in One challenge with made by the guidelines was long time. A recent US study an informal setting with little diagnosis, particularly in a gradual return to activity, found that while the more supervision. As a result, many adolescents, is that many with both physical and well-known and immediate concussions in children and of the typical symptoms cognitive rest. For example, symptoms of concussion, such adolescents go undiagnosed of concussion are also the an adolescent who has as headache and dizziness, can and unmanaged, which can typical ‘symptoms’ of being a experienced a concussion ease, emotional disturbances lead to repeat concussion normal teenager. One US study might be prescribed a period of can linger. The study of and is best avoided. No child found a remarkably high more than 200 young with a suspected concussion prevalence of concussion- people presenting with should be allowed to return to like symptoms, such concussion showed that play until medically cleared, as fatigue, headaches, irritability and sleep as the risk for subsequent disturbances lasted 16 concussion is increased. concentrating and trouble days on average, while Diagnosis in children is also sadness,sleeping, difficultyin a group of frustration and poor high-school athletes concentration lasted an with communication. who had not actually average of 14 days. Young complicatedWhile adults bymay difficulties be able experienced a concussion. people who have sustained to recognise and articulate The authors of multiple concussions their symptoms, younger Canadian guidelines on are more likely to children can struggle, which concussion in children experience prolonged means parents and doctors and adolescents, released symptoms. have to be a little more in 2014, recommended that Professor Kaye stresses that direct in their questioning. one way to address this followed by a guided return while it’s important to be aware Professor Andrew Kaye, a could be to conduct baseline 24to school to 48 hours but not of physicalcomplete rest, of the risk of concussion, and to neurosurgeon at the Royal neurocognitive testing in manage it appropriately when Melbourne Hospital, says the children and adolescents concussion is judged by a it does happen, the low risk best approach is to ask simple who play sports with a activity,doctor to and have finally, resolved, when a thefull of a concussion in children’s questions, like asking the child return to activity. Throughout sport is far outweighed by the if they have a headache, feel such as football, soccer, this process, their symptoms dizzy, nauseated or unwell, significantbasketball andrisk hockey.of concussion, should be monitored, and their that come with playing sport. benefits of physical activity PHOTOGRAPHY PAOLO BONA/SHUTTERSTOCK.COM Chapter 5. DIAGNOSING CONCUSSION

isualising concussion- the white matter. White related changes in the matter is like the ‘skeleton’ brain is particularly of the brain; it’s a framework challenging.V Unlike the made up of the main parts bleeding inside the brain that of nerve cells – the long might occur with a severe sections known as axons – head impact, no obvious and glial cells, which are structural changes accompany the most common type concussion. This lack of of cells throughout the obvious damage means that central nervous system. much of the imaging research These disruptions to the in concussion focuses on white matter are microscopic changes in brain function breaks that, Professor rather than brain structure. Reutens explains, may affect connectivity and impair brain LOOKING FOR PATTERNS function. Instead of neurons IN THE BRAIN networks, they are out of MRI firingsync. It’stogether like, he in says, coordinated a bunch Although techniques such as of loudspeakers playing the magnetic resonance imaging same thing but slightly out of (MRI) are usually unable to brain. One imaging technique Director of the Centre for time with each other, giving detect structural changes that can currently detect Advanced Imaging at The the sound a fuzzy quality. in the brain following structural changes in the University of Queensland, concussed brain is diffusion says that diffusion imaging MR SPECTROSCOPY specialised MRI scans can. imaging, which looks at is revealing some of the A second approach to aMRI concussion, uses a strong specific magnetic patterns of water movement subtle damage of concussion. studying concussion using through brain tissues. This includes, for example, imaging technology involves build up a picture of the Professor David Reutens, evidence of disruptions in a technique called magnetic field and radio waves to PHOTOGRAPHY FOTOINFOT/SHUTTERSTOCK.COM CHAPTER 5. DIAGNOSING CONCUSSION

A 3D diffusion In Profile spectral imaging scan shows white matter nerve tracts in the brain.

DR FATIMA NASRALLAH

r Fatima Nasrallah has a very personal reason for dedicating her professional life to the study of brain trauma. Her grandmother had dementia and DParkinson’s disease, which worsened dramatically after a fall. Since then, Dr Nasrallah has applied the full spectrum of resonance (MR) spectroscopy, fMRI imaging technologies to advance our understanding of what which looks at changes Researchers can look at is going on inside the brain during and after a traumatic brain in brain chemistry. MR changes in brain function injury. She began her research career studying biochemical spectroscopy is revealing that by using another type of brain changes using imaging, then shifted her focus to use certain substances produced MRI known as a functional MRI to study physical brain changes in animals. by brain cells as part of their MRI (fMRI). This imaging A move to a clinical research facility in Singapore brought Dr Nasrallah into contact with military personnel usual activity are altered by allows us to see regions in who had been exposed to blast injuries. It allowed her to concussion. This is the case the brain that are active. Dr begin exploring how these injuries could be visualised using even in people who don’t show Fatima Nasrallah from the imaging technologies. Dr Nasrallah is now leading a large outward signs of concussion. Queensland Brain Institute QBI study that will follow people with concussion over a long This suggests that in even the has been using fMRI and other period of time. She’s using imaging technologies to study mildest concussion, the energy imaging techniques to study brain changes and the effects of different treatments and processes going on in brain what happens to the brain in interventions to reduce long-term damage from concussion.

cells are altered by the impact. the immediate aftermath of a NICK VALMAS PHOTOGRAPHY

IMAGE ALFRED PASIEKA/SCIENCE PHOTO LIBRARY CHAPTER 5. DIAGNOSING CONCUSSION concussion, as well as in the For her work on brain A US study of former NFL following weeks and months. networks she’s been using players suspected of having then moved to subcortical laboratory mice, which CTE used PET to generate firstareas in and the the midbrain part of region,the examining brain networks, provide good clues to what’s maps of how tau tangles brain that controls anxiety whichSpecifically, are the shedifferent has been going on in our brains because were distributed through the patterns of activity associated like us they’re mammals. brain. Firstly, these tangles up in the cortex. This was in with different brain functions. Dr Nasrallah has also been andcontrast stress, to andwhat finally is seen showed in There are networks in the gathering information about from the brains of people Alzheimer’s patients, where brain that are engaged what happens inside the werewho hadn’t confirmed played to football.be absent In during different activities, for heads of military personnel the ex-footballers the tangles example, during movement exposed to blast injuries, when were present and appeared tauand tangles the entorhinal appear firstcortex, in or emotional responses. they’re not close enough to to follow a particular pattern twowhich areas: are both the hippocampus important in The symptoms in diseases be knocked over but close of formation. They appeared memory and navigation. such as Alzheimer’s and enough to feel shock waves, schizophrenia result from which may shake the brain disruption to these networks. about inside the skull. For concussion, research is showing a similar brain PET THE MESSAGE network disruption, but Positron emission tomography one network in particular is (PET) is a form of imaging Brain imaging studies are helping us understand what affected. It’s known as the that uses a radioactive is going on in the brain during concussion. It’s also ‘default mode’ network and tracer to highlight certain hoped they might show characteristic changes with it’s the one that’s most active types of material in the concussion or CTE that can be used to diagnose these when our brain is in what brain. For concussion, it’s conditions and monitor recovery. The reality is that what could be called ‘idling mode’. being used to study the researchers are likely to find are a series of indicators We don’t yet understand why development of abnormal that can be used by doctors in combination with clinical this network is so important, tau tangles. These are known assessments to make a diagnosis of concussion and or why it is particularly badly to be a feature of chronic assess the recovery time required. That will enable affected by concussion. But, traumatic encephalopathy doctors to predict who is more likely to suffer long- says Dr Nasrallah, changes (CTE), which is a form of term consequences from concussion and allow them to to this network are apparent dementia associated with intervene early to prevent or limit the damage. soon after concussion. repeated concussions. Help us create Australia’s first concussion research centre. Together we can understand more about concussion, improve concussion management techniques and, importantly, develop diagnostic and preventative tools as well as long-term treatment. For more information visit: qbi.uq.edu.au/concussion or Email: [email protected] SMS ‘BRAIN’ to 0437 371 371 to donate Chapter 6. LONG-TERM CONSEQUENCES

rings to describe men Harrison Martland, a who’d taken “considerable ackmedical in 1928 examiner Dr in head punishment”. They Bthe US state of New Jersey, had tremors, a dragging published observations in foot or drooping hand, the Journal of the American hesitant speech and walked Medical Association about a with an unsteady gait. condition affecting boxers It was the earliest published record of what we now NICK VALMAS ILLUSTRATION slugging type”. His article call dementia pugilistica, –was notably entitled “fighters Punch of Drunk the – a disorder found in people a term used around boxing who have suffered repeated concussions. Martland saw it in boxers. But it has since been observed in a range of people Ultrasound can be used to transiently open the blood-brain who suffer head injuries, barrier in models of Alzheimer’s disease, activating the brain’s waste disposal system and decreasing the build-up of amyloid such as professional athletes protein. Another protein that builds up in Alzheimer’s is tau, in other sports and military which is also associated with chronic traumatic encephalopathy personnel exposed to combat. (CTE). Evidence suggests that the risk of developing CTE may be increased with repeated concussion. A PROTEIN CALLED TAU There is now evidence that repeated concussions This disorder has many of a protein called tau. could be associated with of the same physiological In a healthy brain, tau is the development in later hallmarks of forms of found in the axons – the life of a particular kind dementia, including transmission lines – of of degenerative disease Alzheimer’s disease, neurons, where it plays an Dr Harrison Martland called chronic traumatic particularly the abnormal important role in maintaining encephalopathy (CTE). accumulation in the brain the structure of the internal CHAPTER 6. LONG-TERM CONSEQUENCES transport system of these increase the risk of developing nerve cells. In conditions such other neurodegenerative as Alzheimer’s and CTE, tau conditions such as Alzheimer’s THE SOURCE OF TANGLED TAU instead forms tangles that and Parkinson’s disease, as e now have a reasonable understanding of how clump together to disrupt the well as conditions such as the accumulation of tau that can form tangles cells’ transport system. These depression. A study of more damages neurons and causes the symptoms of than 2000 former American dementia.W However, explains QBI’s Professor Jürgen Götz, tangles and sometimes footballers, for example, found we have less of an understanding about what causes tau aresimply known tau tangles.as neurofibrillary They’re that players with a history to accumulate in the first place. One theory, he says, is a cellular signpost of what of multiple concussions that tau is physically dislodged from its orderly structure were three times more inside axons by the impact of a concussive head injury, the group of degenerative likely to have been diagnosed altering its conformation and localisation in a nerve cell. arediseases known associated as tauopathies: with with clinical depression aggregations of than the general population. in the brain. These tangles A 2014 report from the are thought to eventually American National Football lead to the death of neurons. Association predicted that As more and more neurons nearly 30 per cent of former die and large areas of brain players may go on to develop tissue become affected, chronic brain conditions symptoms such as those as a result of trauma. memory loss, confusion, CTE RESEARCH BRINGS describedParkinson’s-like by Martland tremors, appear: MORE QUESTIONS walking problems, impaired It’s only since the early judgement, depression 2000s that CTE has been 1 2 3 and personality changes. linked to concussion and, not surprisingly, there CONCUSSION AND is still much work to be 3 PHASES OF ALZHEIMER'S DISEASE. OTHER DISORDERS done in understanding the 1. Healthy neuron. 2. Neuron with amyloid plaques (yellow). Evidence also suggests that relationship between the 3. Dead neuron being digested by microglia cells (red). repeated concussion may two. We are, however, only CHAPTER 6. LONG-TERM CONSEQUENCES just developing ways to see tau using imaging techniques such as positron emission tomography or PET. One majorway to difficulty make a diagnosis with studying is by CTEautopsy is that – looking the only at definitive people’s brains after they’ve died. We also don’t know how many or what type of concussions it takes for someone to develop CTE or how long it takes for the disorder to appear. Most importantly, we don’t know AN ALZHEIMER’S what can be done to prevent BREAKTHROUGH or reverse the damage. The presence of abnormal n 2015, the QBI team led by Professor Götz (pictured above) announced one of the most tau tangles does offer a exciting recent breakthroughs in Alzheimer’s disease research, one that is likely to also have diagnostic and therapeutic consequences for concussion. target, just as it does in IThey discovered that ultrasound – as used to view babies in the womb – can also trigger the other tauopathies such as brain's own waste disposal system to clean up deposits of a protein known as beta-amyloid dementia and Alzheimer’s. in the brains of mice with Alzheimer’s disease (AD). These protein deposits are called amyloid Researchers like Professor plaques, and along with tau tangles, are a key feature of AD. Götz are exploring ways The team found that injecting safe microbubbles into the bloodstream and then pulsing the to remove the tau tangles, brain with ultrasound caused the impermeable blood-brain barrier to open temporarily. This while others are focusing on opening is thought to activate microglia, resident garbage collector cells, which clean up waste products in the brain. imaging techniques that can Professor Götz’s team found that the ultrasound method reduced the amount of abnormal reveal tau when CTE is still protein and was also linked with improvements in the memory of mice with AD. The challenge in its early stages, offering a now is to translate such a method to the human brain, but Professor Götz and colleagues in this greater chance of treatment. field around the world are excited about the potential.

PHOTOGRAPHY NICK VALMAS Helping people live longer, healthier QBI: and smarter lives world-leading brain by understanding the brain. research institute Help us find cures for dementia, stroke, anxiety and depression, concussion, motor neuron disease and more.

TO FIND OUT MORE VISIT: qbi.uq.edu.au/concussion TO DONATE: SMS ‘BRAIN’ to 0437 371 371 Chapter 7. TESTING FOR CONCUSSION

f in doubt, sit it out. That’s the more serious long-term currently the best way to consequences of repeated ensure that a concussion concussions. Iisn’t made worse by a second Developing such a test head impact. But it can be a tough call to make, particularly biomarker – something for a professional sportsperson involves finding a suitable whose career could hang on in response to a head impact. how quickly they get back on releasedThe challenge into our is determining body fluids

a simple their ‘amounts’ are unique to testthe field.using blood or saliva that wconcussion.hich specific biomarkers and could What be if giventhere wwasithin a few It’s still early days, but there minutes of a suspected are already some promising concussion to candidate biomarkers that answer as to could form the basis of such whether a playerprovide was a a test. For example, there are definitive,concussed reliableor safe to rejoin a already blood tests in use match? It could also be used for TBI, such as the S-100B regularly in the days and test. However this looks for a weeks after a concussion to marker of more serious brain determine exactly when the injury, the kind, that would player had recovered enough need neurosurgery. to return to the sport. of A bedside – or in this case, injury would be obviousOn a Damage to the brain as a result of a head injury. A severed axon (above), shown in the centre of the illustration, prevents impulses of enoughsporting that field, a bloodthat sort test travelling from one neuron to another. Blood vessels can also be concussion research. It wouldn’t be needed. torn during head injuries, and the resulting bleeding causes a hasfield-side become – test particularly is a key area A distinctive physiological compression of the axons with the risk of a coma. important in recent years with feature of concussion is the growing understanding of ILLUSTRATION BSIP/UIG/GETTY IMAGES; PHOTOGRAPHY OSTILL/SHUTTERSTOCK CHAPTER 7. TESTING FOR CONCUSSION damage to axons – the main conducted among Swedish tau levels and the severity the injury, but unlike tau, shafts of neurons – caused by ice-hockey players, showed of a TBI, where levels were the shear forces associated that tau levels were higher in patients with a levels are raised in the with a knock to the head or elevated in the blood after a poorer outcome following neurofilament light protein whiplash movement. concussion when compared injury. These studies suggest liquid cushions the brain and Professor Henrik Zetterberg, to measurements taken the potential for tau to be cerebrospinalspine, and samples fluid. canThis only a neurochemist from the at the start of the hockey used as a diagnostic indicator be taken in a sterile hospital University of Gothenburg in season. They also found for concussion. setting. The challenge now Sweden, has been looking at the levels of the protein Another promising indicators of axon damage that S-100B increased following biomarker candidate for the tests for these biomarkers might meet the criteria of a a concussion, although forand researchers use them in is combination to refine marker for more subtle brain not nearly as much as tau light protein. Like tau, this with imaging techniques damage. He says that, so far, increased. concussionis also a marker is neurofilament of damage in order to better diagnose research has singled out two Research has also found a to axons. Levels seem to concussion and assess when correlation between blood peak four to 10 days after it is safe to return to play. protein tau, is already making keya name candidates. for itself The as a first, biological the villain of other conditions such as Alzheimer’s disease. HELP QBI MAKE A DIFFERENCE. Research has shown that Australia has a strong sporting culture. We love our sport: we watch our kids grow up playing amateur boxers have higher it on the weekends, and our professional athletes are household names. The nature of contact levels of tau in the blood sports means that head knocks are sometimes unavoidable. But changing the fundamental stream the week or so after rules of these sports isn’t the only way to make them safer. Through research, we can improve a bout, even if they’re not the diagnosis and management of concussive episodes. Finding a suitable biomarker to test knocked out. These levels for concussion will enable rapid diagnosis and reduce the risk of repeated head injury. And then slowly return to normal imaging technology is helping us understand how concussion affects the brain. Longitudinal studies to track brain changes have never been undertaken before, and are the missing piece around eight to 10 weeks of the concussion puzzle. In the long-term, they are critical to after the impact, as long as the understanding the lasting consequences of head injury, and boxer doesn’t have any more will enable us to intervene early and prevent or reduce lasting head impacts during that time. damage. Through research, we can begin to tackle some of Similarly, a study by concussion’s unanswered questions. Zetterberg and his colleagues, w :www.qbi.uq.edu.au

e :[email protected]

p :+61 7 3346 6300