Chapter 2Data, definitions and diagnostics
2.1This chapter discusses the evidence received by the committee in relation to:
the challenges present in diagnosing concussion in contact sports, including inconsistencies around the definition of concussion and the limitations of current diagnostic tools; and
the need for better data collection on the prevalence of concussion across all levels of contact sports in order to improve prevention and treatment outcomes.
2.2It concludes with the committee’s views and recommendations on these issues.
Challenges of diagnosing concussion in sports
2.3Considerable evidence to the committee indicated that there are challenges present in accurately diagnosing instances of concussion in the sporting context due to limitations in the current protocols and tools for the assessment of concussion.
2.4As noted in Chapter 1 of this report, various definitions of concussion exist in sporting, research and medical settings. Additionally, the term ‘mild traumatic brain injury’ (mTBI) is also often used interchangeably with concussion, particularly in medical settings.
2.5Some submitters contended that the competing or inconsistent definitions of concussion used by stakeholders in sport led to confusion and the risk that concussion is not always diagnosed accurately. The Public Health Association of Australia argued it was important to ensure there is a clear definition of concussion and related evidence-based guidelines available for sports clubs and associations to follow. It highlighted that inconsistency in how concussion is defined in key documents, such as position statements from the Australian Institute of Sport (AIS), led to confusion for stakeholders.
2.6For example, the AIS Concussion and Brain Health Position Statement 2023 states that a concussion occurs through a collision with another person or object where biomechanical forces to the head, or anywhere on the body, transmit an impulsive force to the head/brain, resulting in ‘transient neurological impairment’.
2.7It goes on to state:
The current clinical definition of concussion does not distinguish persistent symptoms, or the underlying processes that impair brain function or any potential brain abnormalities. To overcome this limitation, the Berlin panel of the Concussion in Sport Group (CISG) defined concussion as “a traumatic brain injury induced by biomechanical forces”.
2.8After including the above characterisation of concussion as ‘traumatic brain injury’, in its next paragraph the position statement goes on to note:
It remains unclear whether concussion involves microscopic structural changes, which would position it within the traumatic brain injury spectrum, or whether it’s limited to physiological changes.
2.9The Public Health Association of Australia raised concerns with this conflicting information from the AIS. It flagged that the 2023 position statement could confuse readers given that in one sentence the AIS appears to identify concussion as a traumatic brain injury, and in the next sentence queries whether concussion is on the traumatic brain injury spectrum at all.
2.10Concussion Australia also observed that there is no consistent definition of concussion. Similar to the Public Health Association of Australia, it raised concerns with the ‘incorrect information’ disseminated through the AIS position statement.
2.11In response to these concerns, the Australian Sports Commission (ASC) informed the committee that research into concussions in sport is ‘continually developing’, and ‘the updated 2023 position statement reflects the current information and medical advice available’.
2.12The Royal Australian College of General Practitioners (RACGP) drew attention to the lack of consistency in defining concussion, and pointed out that this has flow-on impacts for the treatment and management of the injury in the context of contact sports. It recommended that ‘standardised, evidence-based clinical guidelines’ for concussion and repeated head trauma be developed, detailing:
While an updated International Consensus Statement is expected to be published in 2023, recommendations are needed that provide context to the Australian health system and contact sports commonly played in Australia. The current lack of a consistent definition of concussion results in confusion and an inconsistent approach to its treatment and management. Additionally, concussion protocols vary between different contact sports, contributing further to confusion between coaches, managers, players, carers and medical professionals. Standardising concussion protocols across all sports should be a priority.
2.13The submission from Connectivity Traumatic Brain Injury Australia (Connectivity) also noted that the inconsistent use of definitions and medical coding makes it difficult to establish the true epidemiology of concussion, which in turn limits both research capacity and effective health service planning. It further reported that in medical settings the term ‘mild traumatic brain injury’ is often used interchangeably with ‘concussion’, which could lead to confusion amongst community members.
2.14Dr Reidar Lystad PhD, a full-time research fellow at the Australian Institute of Health Innovation in the Faculty of Medicine, Health and Human Sciences at Macquarie University with particular expertise in the epidemiology of sports injuries, traumatic brain injury, and paediatric trauma, submitted to the inquiry in his private capacity. He observed that while a clear and consistent definition of concussion is important, the debate around the definition of concussion could be a distraction from the significant issues pertaining to the impact of traumatic brain injuries and repetitive head trauma in sport. He cautioned that definitional disagreements among academics and health professionals should not be used as an excuse for inaction.
2.15Other submitters to the inquiry contended that inconsistencies in the definition of concussion were not an issue. The ASC advised the committee that concussion is defined as ‘a traumatic brain injury induced by biomechanical forces’ because it can occur through a collision with another person or object where biomechanical forces to the head, or anywhere on the body, transmit an impulsive force to the head/brain, resulting in neurological impairment. It noted that concussion can also occur with relatively minor knocks to the head or body.
2.16The ASC indicated that it is ‘not aware’ of inconsistencies in the definition of concussion. It stated that the essential components included in definitions used by ‘most reputable bodies’ include:
A rapid onset, transient disturbance of neurological function, secondary to a trauma to the head, or trauma to the body where forces are transmitted to the head.
Evolution of symptoms in the minutes, hours and days after the acute trauma.
Spontaneous recovery over days or weeks.
Clinical signs and symptoms which cannot be explained by drug, alcohol, or medication use, other injuries or other comorbidities.
A broad range of symptoms in the acute and subacute phases.
2.17Dr Andrew McIntosh also noted that while there are a range of definitions of concussion, there is a ‘high level of consistency’ between those definitions in the context of sport.
2.18The National Health and Medical Research Council (NHMRC) informed the committee that it is Australia’s leading expert body in health and medical research. It has a legislated role in issuing guidelines and advising the community on ‘matters relating to the improvement of health and the prevention, diagnosis and treatment of disease’.
2.19The NHMRC told the committee that there were no current NHMRC-produced guidelines on concussions or repeated head trauma, nor were there any relevant NHMRC-approved guidelines produced by third parties.
2.20The NHMRC did, however, inform the committee that it had played a historical role in regard to these topics. For example, in 1994 the NHMRC published its Boxing Injuries report, that:
… was developed by a panel with expertise in sports medicine, neurosurgery, ophthalmology, radiology, general practice, neurology and neuropsychology, and provided new directions for those concerned with public health and legislation appropriate for boxing. The report highlighted the non-neurological injuries that can follow repeated head trauma in boxing, such as damage to the eye, neck, nose and ears and hearing, and reported that protective equipment may not reduce the risk of brain injury.
2.21Additionally, in 1994 the NHMRC released its Head and Neck Injuries in Football: Guidelines for Prevention and Management (1994 Guidelines for Head and Neck Injuries in Football) along with an accompanying document titled Concussion: Notes for Referees, Umpires and Coaches. The NHMRC submission set out:
The guidelines were developed by a panel of medical specialists in neurosurgery, sports medicine, plastic surgery, neurology, rheumatology, trauma and rehabilitation. The panel included medical experts representing the Australian football codes including the International Rugby Football Board, Australian Rugby League, ACT Rugby Union, the Australian Soccer Federation and the Australian Football League.
The guidelines made broad recommendations on management and administrative arrangements, data collection, equipment (such as fitted mouthguards) and research and education. In addition, the guidelines contained recommendations on the management of concussion, post-concussion and return to play (adapted from International Rugby Football Board recommendations), and the management of severe head injury.
The accompanying notes for referees, umpires and coaches made a recommendation that, because concussion destroys judgement, head injured players should not be allowed to influence the decision of a referee, umpire or coach about whether the player should be removed from play. The notes point out that the player’s health and the reputation of the game are at stake.
2.22The NHRMC advised that the guidelines are now considered to be ‘out of date’ and were rescinded in 2004. It noted that it was usual practice for it to rescind guidelines after several years, in recognition that the evidence reviews relied upon to produce the guidelines would be out of date. It stated that the guidelines have not been updated given that ‘other agencies have been established to manage and provide up-to-date advice about the issues discussed in the NHMRC guidelines’.
2.23Griffins Lawyers raised concerns regarding the NHMRC’s decision to rescind these guidelines. It submitted:
The NHMRC Publications were two of twenty NHMRC publications that were rescinded on 16-17 September 2004. The review process involved public consultation held between October 2003 to October 2004 and included letters sent to stakeholders to advise them of the process. It has been noted that only three submissions to the review process were received in response, with two of those written by or on behalf of the incumbent AFL Medical Officer Dr Paul McCrory. The first was a submission by Dr McCrory on behalf of the Australian College of Sports Physicians, and the second was a submission from the Australian Association of Neurologists (AAN). The submission from AAN was that Dr McCrory be its expert medical representative on any concussion related issues going forward.
Both submissions, largely verbatim asserted that the “reports require major revision or rewriting primarily due to the new and extensive scientific evidence that has been published in medical literature on each of these topics,” and that the NHMRC should form a new expert panel to revise the publication. This is the panel AAN sought Dr McCrory to be invited to join. The documentary material suggests that the rescission of the NHMRC Publications were predominantly based on these two submissions.
2.24In response to further questions regarding the circumstances surrounding the decision to rescind its 1994 Guidelines for Head and Neck Injuries in Football, the NHMRC told the committee that as part of a large-scale review overseen by its Health Advisory Committee, this publication was among several others that were identified for review based on their currency.
2.25The NHMRC explained that this process was also informed by public consultations, which invited individuals to comment on the strengths and weaknesses of the existing publications, issues that had emerged since publication, and any other relevant matters. Contrary to the claim made by Griffith Lawyers, the NHMRC noted that 44 submissions were received, and at the conclusion of the review the Health Advisory Committee recommended that ‘the research base for, and recommendations and guidelines in, Football Injuries of the Head and Neck are no longer current’.
2.26The NHMRC informed the committee that the NHMRC Council accepted the Health Advisory Committee’s recommendation to rescind the guidelines in 2004. It also noted that the Health Advisory Committee did not recommend the football guidelines to be updated and in its advice to the NHMRC Council, it identified the ASC as the appropriate agency to which documents should be referred.
Limitations of diagnostic tools
2.27Several submitters highlighted challenges and limitations in relation to the tools that are currently used in the diagnosis of concussion and mTBI.
2.28MindMirror, an organisation of emergency doctors and software engineers which provides diagnostic solutions and tools, outlined that to ensure public confidence in the participation in contact sport, diagnostics for concussion and mTBI must be ‘democratised’. It explained that current approaches to the diagnosis of sport-related mTBI rely on guided, subjective assessments by health or sports professionals and that these assessments take time and are not available at all levels of competition. It added that an ideal diagnostic tool would be:
… available to all; be non-invasive, require minimal training and provide a reliable, objective and reproducible diagnosis. Such an objective tool could also be used to track the recovery from mTBI, providing an indication of when it would be safe for a participant with diagnosed concussion to return to play.
2.29The ASC informed the committee that there is currently no specific diagnostic test that confirms the presence or otherwise of a concussion. It stated that concussion remains a ‘clinical diagnosis’ identified based on a person’s history, symptoms and signs upon physical examination by a qualified medical practitioner.
2.30The 2023 AIS Concussion and Brain Health Position Statementexplains:
…in diagnosing concussion, medical practitioners need to conduct a clinical history and examination across a range of domains including the mechanism of injury, symptoms and signs, cognitive functioning and neurological assessment, including balance testing.
2.31As part of the overall clinical assessment to assess potential concussion, medical professionals can use the Sport Concussion Assessment Tool 5 (SCAT5) for athletes aged 13 years and older, which encompasses both an on-field and off‑field component.
2.32The SCAT5 is a standardised tool for evaluating concussions designed only for use by physicians and licensed healthcare professionals. It cannot be performed correctly in less than 10 minutes, and children aged 12 years or under should be assessed using the specific Child SCAT5.
2.33The SCAT5 encompasses an on-field assessment to be used at the time of the concussion, as well as a brief history of the injury, a Glasgow Coma Score and a series of questions known as ‘Maddocks questions’. According to the AIS Concussion and Brain Health Position Statement 2023, these questions have been validated as an indicator of concussion and are more sensitive in the sports‑context than standard orientation questions. The position statement details:
The questions assess athlete orientation (in time and place) and they should be preceded by: ‘I am going to ask you a few questions, please listen carefully and give your best effort.’
The modified Maddocks questions are:
What venue are we at today?
Which half is it now?
Who scored last in this match?
What team did you play last week/game?
Did your team win the last game?
2.34The remainder of SCAT5 is for use off-field, in the medical room or in the consulting room after a referral for a suspected concussion has been made.
2.35There are a possible 22 symptoms of concussion listed in SCAT5:
Table 2.1Concussion symptoms listed in SCAT5
Headache | Neck pain | Dizziness |
Balance problems | Sensitivity to noise | Feeling like ‘in a fog’ |
Difficulty concentrating | Fatigue or low energy | Drowsiness |
Irritability | Nervous or anxious | Blurred vision |
Pressure in head | Nausea or vomiting | ‘Don’t feel right’ |
Sensitivity to light | Feeling slowed down | More emotional |
Trouble falling asleep | Confusion | Sadness |
Difficulty remembering | | |
Source: Australian Institute of Sport, Concussion and Brain Health Position Statement 2023, p. 15.
2.36The committee received evidence advising that there were limitations to the SCAT5 tool.
2.37For example, the 2023 AIS position statement notes that SCAT5 is ‘relatively insensitive and describes non-specific symptoms’. It also makes comment on the limitations of SCAT5 in regard to its use with culturally and linguistically diverse (CALD) cohorts:
It is important to note that SCAT5 was developed in English, which limits its use in culturally and linguistically diverse populations. There is no evidence that SCAT5 is a culturally appropriate tool for Aboriginal or Torres Strait Islander peoples and Australians with culturally and linguistically diverse backgrounds, especially for those individuals whose first language is not English and might have a different second language.
2.38Headsafe raised a number of concerns with the efficacy of SCAT5, including that:
SCAT5 ‘has not been validated as a concussion tool’;
the 22 symptoms listed are ‘vague and unavoidably subjective’;
parts of the tool require relatively advanced levels of numeracy and literacy;
the physical and coordination tests are subject to observer inconsistency and error; and
it is ‘not clear’ how to reach an overall conclusion on whether some sections should be marked as ‘passed’ or ‘failed’.
2.39When asked whether the current protocols on assessment of concussion in sport are adequate, Dr Adrian Cohen, Chief Executive Officer of Headsafe, referenced SCAT5 in his response:
They're woefully inadequate. We're so used to this terminology now when we look at our television: 'Oh, he's gone for an HIA [head injury assessment]. Oh, they're going to have the SCAT test.' It's like people think Moses came down from Mount Sinai with these tablets with the HIA written on them. It's a terrible test, and everybody knows it's a terrible test, but, hey, it's the best we've got. It's only the best we've got because we, the sporting codes, are part of the groups that form the Concussion in Sport Group that actually decides that's good enough.
2.40The committee heard that major professional contact sports routinely conduct mandatory pre-season concussion baseline measurement of athletes in order to facilitate interpretation of post-injury test scores. However, Headsafe contended that it was ‘well recognised’ that professional athletes are being ‘coached’ as to how to ‘game’ or ‘sandbag’ baseline SCAT5 tests in order to influence their baseline results. It asserted:
…performing poorly sets a low baseline pre-season so if/when they sustain a concussion the true nature of it can be hidden to an inexperienced assessor. Sandbagging is now so prominent that players actually boast of it. They tell other players to “go slow” the first time around, to either create a false impression or to create an “invalid” test that cannot later be used.
2.41It further argued:
Subjectivity in answering questions about symptoms (especially for a player keen to return to playing) is well recognised, and even some medical professionals have been criticised as being less than completely objective when facing pressures from coaches, players and parents as to a player’s performance on tests designed to ascertain their concussion status.
2.42A submission from neuropsychologist Dr David Maddocks also made reference to the temptation for sport participants to ‘fake bad’ on baseline testing so as to potentially conceal concussive injury or the effects of injury.
2.43The AIS Concussion and Brain Health Position Statement 2023 highlights the Concussion Recognition Tool 5 (CRT5) as the most appropriate tool for concussion assessment in recreational sport, particularly as medical professionals often rely on self-reported symptoms to diagnose concussion in individuals who play recreational sports.
2.44CRT5 is a free resource, suitable for use by individuals without medical training, that can assist to identify concussions in children, adolescents and adults. It is a simplified summary of the key signs, symptoms and ‘red flags’ that should raise concern about a possible concussion, although the position statement noted that, similar to the SCAT5, it is relatively insensitive to non-specific systems.
2.45In addition to highlighting the CRT5, the AIS Concussion and Brain Health Position Statement 2023 promotes the ‘if in doubt, sit them out’ messaging. It states:
At the recreational level, the athlete should be permanently removed from play if an athlete, coach, first aider/sport trainer, parent, match official, or dedicated spotter has any suspicion of a concussion, particularly given medical professionals, sideline spotters, and sideline technology may not be available.
2.46The AIS Concussion and Brain Health Position Statement 2023 highlights that the diagnosis of concussion is based on the clinical judgement of a healthcare professional. However, it notes that while in some instances it is obvious there has been a significant injury (e.g. where the athlete immediately suffers a loss of consciousness, has a seizure or has significant balance difficulties), in other instances the signs and symptoms of concussion can be ‘variable, non-specific, subtle, and may be difficult to detect’. It explains:
Symptoms that are initially subtle can become more significant in the hours and days following the injury and require repeat/serial evaluations. Owing to delays in presentation, it may take up to 48 hours following a head contact to exclude a diagnosis of concussion. Parents, coaches and attending medical personnel need to be alert to behaviour that is unusual or out of character.
Potential of emerging technology
2.47Some submitters to the inquiry drew the committee’s attention to emerging technological tools which they asserted could be used to improve the process of diagnosing or detecting concussion in sports.
2.48The AIS Concussion and Brain Health Position Statement 2023 observes that detecting a concussion in routine brain imaging is difficult as it is predominantly considered a functional neurological disturbance rather than a structural injury. However, it points out that there is a growing interest in Point of Care (PoC) devices that use biomarkers to provide an objective assessment tool to assist with concussion diagnosis and clinical decision-making. It states:
For instance, in a prospective observational study of 1,028 male professional players, salivary small non-coding RNAs were identified as unique signatures of concussion. There is also research underway to explore the potential clinical utility of blood biomarkers as an objective PoC to diagnose concussion.
2.49The position statement also notes that although imaging modalities may be useful in research settings to detect changes consistent with concussion, current evidence does not support the clinical use of these modalities to diagnose or manage concussion.
2.50It concluded that although the prudent use of technological advancements may improve concussion assessment over time, there was not yet sufficient evidence to prove the accuracy or efficacy of the emerging imaging or biomarker tools. It outlined:
…caution needs to be exercised when using such tools and validation is required before their global adaptation. At present, the evidence base is insufficient to recommend the routine use of any medical imaging or biomarker tests in the diagnosis and management of concussion.
2.51The committee also heard evidence from HITIQ, an Australian business which builds and distributes technology to assist in the surveillance, detection, assessment and diagnosis of sports related brain injury. HITIQ informed the committee of its instrumented mouthguards which are worn by athletes and contain sensors that can detect both concussive and sub-concussive impacts.
2.52HITIQ advised the mouthguard technology was developed to ‘identify, collect, and quantify all head impacts exposures in training environments’ and emphasised that accurately quantifying the number and magnitude of head impacts experienced by contact sport participants is vital. HITIQ also advised that the mouthguards are currently being utilised in the Australian Football League (AFL), SuperRugby and United States College Football.
Challenges in diagnosing Chronic Traumatic Encephalopathy
2.53As outlined in chapter 1, Chronic Traumatic Encephalopathy (CTE), also known as CTE Neuropathological Change (CTE-NC), is a neurodegenerative disease characterised by the accumulation of the abnormal tau protein within the brain. It is associated with a history of repeated head trauma.
2.54Some inquiry participants explained that currently, CTE can only be diagnosed post-mortem, based on histopathological examination of brain tissue.
2.55For example, the ASC submitted that CTE-NC has ‘unclear clinical diagnostic criteria’ and is unable to be diagnosed during life. The ASC added that most research data available on CTE-NC is obtained from sports brain bank studies. Whilst the work of various sports brain banks in Australia is discussed further in chapter 3, the ASC considered that the mode of retrospective clinical analysis used by sports brain banks is ‘insufficient for creating a robust clinical diagnostic criteria for CTE‑NC in living patients’.
2.56Consultant Neurologist Dr Rowena Mobbs explained that Traumatic Encephalopathy Syndrome (TES) is the ‘in-life syndrome of CTE’. In contrast to other submitters, Dr Mobbs considered that, just as Alzheimer’s disease is diagnosed clinically over time, she is confident in assessing patients as having TES, or suspected CTE during life.
2.57The AFL also referred to these matters in its submission. The AFL considered that the diagnosis of CTE or TES during life may lead to ‘unintended negative consequences such as a sense of hopelessness and fatality’ and added:
In such cases, problems with cognition that are perhaps associated with psychiatric illness, rather than neurodegenerative changes in the brain, if treated pharmacologically and with counselling, might lead to functional improvement. If the person is told that their symptoms are related to CTE, they may be less likely to seek alternative diagnoses and treatment options.
The need for a national data set
2.58Some submitters informed the committee that there was a lack of data on the rates of concussion in sports across Australia, and argued there was a need for a consistent, national dataset for both diagnosed concussions and identified sub‑concussive events.
2.59Brain Injury Australia estimated that every year in Australia more than 3000 people are hospitalised after being concussed participating in sport; however, it emphasised that hospitalisations ‘radically underestimate’ the incidence of concussion in the community across all age groups and external causes.
2.60Dr Reidar Lystad noted that the true incidence of concussion in Australia is not known due to limitations of existing data collection, and this precluded the effective monitoring of trends and the proper evaluation of potential policy changes and interventions. He suggested that a potential solution could be to implement mandatory reporting of concussion and head trauma by all sports governing bodies.
2.61Dementia Australia recommended the establishment of a centralised database that collects information on brain injuries at all ages and levels of contact sports. It stated that rigorous reporting and collection of brain injury data is key to improving understanding about the risks and long term impacts of brain injury in contact sports.
2.62Neuroscientist Professor Robert Vink suggested there was merit in a national concussion registry for professional athletes, given they are ‘the most at-risk group’ for developing CTE. He stated that such a registry could help ensure that affected athletes receive appropriate personalised care after each concussion, including return to play management, and assist in tracking their brain health over time. He also noted that such a registry would be extremely useful to identify best practice and update concussion management guidelines as required.
2.63Making a similar point, neurologist Dr Rowena Mobbs recommended that sporting organisations be required to implement a public register of suspected and confirmed player concussions.
2.64Dr Alexandra Veuthey PhD, a lawyer specialising in sports law, submitted to the inquiry in a private capacity. She posited that while many sports governing bodies collect data on concussion in order to assess the effectiveness of their prevention strategies, or even make comparisons with other sports, in the absence of guidance on how to collect and share data, current data on concussion is ‘inconsistent and often difficult to access’.
2.65Dr Stephen Townsend, a historian specialising in the history of sport, health, and exercise from critical sociocultural perspectives, highlighted that there is a lack of consistency in sport-related concussion reporting protocols in non-elite competitions. He argued this is a ‘major problem’ that needed to be addressed immediately, noting that ‘even before exclusion periods and recovery protocols can be discussed, it is necessary to first identify when a brain injury has occurred’. He also commented on the difficulties in tracking the prevalence of concussion in non-elite sport, compared to professional elite sports:
Diagnostic challenges exist even in professional competitions, where players are under the scrutiny of coaches, medical staff, media, and spectators. These challenges are greatly exacerbated in non-elite and recreational contact sport, where athletes play the same games without oversight from medical staff and the media.
2.66To address this challenge and overcome the lack of data, Dr Townsend recommended that the contact sports national sporting organisations in Australia introduce a sport-related concussion reporting tool for non-elite competitions that is based upon the SCAT5 protocol, mandatory, digitised and free, simple, culturally safe, and linked to a central database.
2.67Dr Townsend stated that a consistent and universal reporting program will also provide epidemiologists and public health researchers with more reliable data on the real incidence of brain injuries in sport. He noted that epidemiological data on incidences of sport-related concussion is ‘patchy at best’ because it relies mostly on extrapolated data from hospital admissions, and isolated academic studies of sports-related concussion in a single league, team, or season. He also suggested that a national reporting program would remind recreational sportspeople that concussion is a serious injury that can occur at all levels of contact sport. Dr Townsend also flagged that the NHMRC called for a ‘centralised injury register’ of head and neck injuries in football almost 30 years ago.
2.68Australia does not currently have a national sports injury surveillance system. The AIS Concussion and Brain Health Position Statement 2023 notes that as a result, precise data on the incidence, frequency, and prevalence of sport-related concussion in Australia is undetermined. The position statement also notes that this is compounded by a lack of recognition of the signs and symptoms of concussion, under-reporting, and a failure to seek medical advice.
2.69The ASC informed the committee that the risk of concussion and repeated head trauma varies across sports and that precise data on incidence, frequency and prevalence is ‘unavailable’. It stated:
Precise data on the incidence, frequency, and prevalence of concussion and RHT [repeated head trauma] in Australians, including First Nations Communities, and long-term impacts of concussion is unavailable. This is further compounded by a lack of recognition of the signs and symptoms of concussion, under-reporting and failing to seek medical advice. For example, under-reporting of concussions and failing to seek medical advice range from 17% to 82% across different sports.
2.70The ASC submission also stated that concussion is a ‘common experience’ amongst individuals who have played a contact or collision sport for five years or more in their adult lives, although for the majority of those individuals, concussion is experienced on ‘a small number of occasions during their sporting lives’ and they ‘report no long-term consequences’.
2.71The ASC noted that data on concussion and long term brain health (including CTE-NC) in Australia is ‘lacking’. It further stated that it is difficult to determine accurate incidence, frequency and prevalence of concussion due to the absence of an Australia-wide injury surveillance system, inconsistent reporting methods, and a lack of recognition of the signs and symptoms of concussion.
2.72The committee also heard that there is a lack of research on the prevalence of concussion in First Nations individuals. Connectivity stated that overall there is a paucity of research on the causes, prevalence and outcomes of concussion and repeated head injury among First Nations people, noting that there is also limited research conducted investigating Indigenous knowledge and perceptions of concussion.
2.73Dr Stephen Townsend also highlighted this issue. He explained that as is the case with mTBI more broadly, the incidence rate of sport‑related brain injuries amongst First Nations peoples is unknown. However, Dr Townsend noted that a 2022 article in the Medical Journal of Australia indicated that First Nations people are approximately 1.7 times more likely to suffer traumatic brain injury (TBI) than non-Indigenous Australians, though the portion of these TBIs that are attributable to sporting injuries is unknown.
2.74Dr Townsend also flagged that First Nations people make up approximately 3.8per cent of the Australian population, but represent around 11 per cent of AFL player lists and 13 per cent of NRL players. Dr Townsend submitted that it therefore stands to reason that this correlates with an overrepresentation of FirstNations individuals with sports-related concussions.
2.75Additionally, the ASC noted that the current data regarding concussion-related injuries of First Nations individuals may be ‘heavily underreported’, owing to a lack of culturally appropriate health services which may result in health assessments where there is a ‘failure to elicit appropriate information, incorrect assumptions are potentially made, and diagnoses are missed’.
2.76The Department of Health and Aged Care (the department) also acknowledged that precise data on the incidence of sport-related concussion in Australia ‘requires further collection and analysis’.
2.77It observed that potential limitations to obtaining accurate data on incidence include a lack of recognition of symptoms, as well as under-reporting and failure to seek medical advice. It concluded that these barriers provide further impetus to develop innovative and evidence-based research and resources to support those affected by sport-related concussions.
2.78The Australian Institute of Health and Welfare (AIHW) advised that sports injury data is limited by a lack of sport activity data being collected outside of the admitted hospitalisation data in the National Hospital Morbidity Database (NHMD). It acknowledged that this limits the monitoring of the types and numbers of concussion in sports to inform policy and prevention activities.
2.79The AIHW further noted that better data on the risks of sports injury within a sport can inform injury prevention programs and decrease injury risks to benefit individuals, sporting organisations, sport performance outcomes, and health systems.
National Sports Injury Database
2.80The AIHW stated that in light of this evidence gap, the ASC has contracted the AIHW to implement a National Sports Injury Data Strategy (the strategy) which will encompass:
$2.8 million over 4 years from the 2022–23 Budget;
publishing a data strategy in early 2023;
developing data in partnership with stakeholders such as sporting organisations and insurers, which will include a framework to guide data collection, a data dictionary, and support to encourage better sports data collection including concussion data;
bringing together data sources into a national sports injury data asset;
developing new methods to analyse data; and
publishing and communicating findings.
2.81The goal of a national sports injury data asset will be achieved through the development of the National Sports Injury Database (the database), which will better capture nationwide sport injury data, including concussion in sport. The ASC informed the committee that although the database will not solely focus on concussion reporting, it is included within the project purview.
2.82The draft consultation report for the strategy (consultation report) that was published in February 2022, confirmed that Australia lacks a national database that can provide information about the frequency and cause of sports injuries. It also specifically recognised that Australia does not currently collect community sports injury data at a national level.
2.83The consultation report described how a national sports injury data asset would address these issues, and benefit Australian sporting communities, individuals, and organisations:
The collection of sports injury data across community sport aims to provide data to the public, sports organisations and researchers so that the risks of participation are understood and prevention programs can be prioritised. Ongoing data collection will also help us understand how prevention programs are working in community sports and inform adjustments over time. An ongoing data collection will also provide early detection of emerging issues to enable more rapid responses. Better data are anticipated to support injury prevention and improve sport participation and physical activity.
2.84The consultation report also explained that alongside data collection from existing sources, a new online sports injury data collection tool will be developed to address the data gap in the area of community sport organisation incident reporting. The tool aims to provide a simple way to record injury on a smartphone, tablet or computer, using dropdowns and buttons as much as possible to minimise text entry.
2.85Further, the consultation report outlined that in all stages of the National Sports Injury Database Strategy, including data collection, data storage, data analysis and data reporting, the privacy and confidentiality of individuals and organisations will be protected.
2.86The department advised that it is a member of the National Sports Injury Database Steering Committee. In regard to the aims of the database it stated:
When established, the Database will allow for analysis of sport injuries trends, including concussion, which can be utilised by sporting organisations alongside provision of the latest evidence for treatment and prevention. The Database will aim to keep participants safe and identify areas where further initiatives are required to support the prevention of injuries and development of new treatments.
2.87Additionally, the ASC advised that this database would also facilitate a better understanding of concussion rates in First Nations communities.
2.88The Queensland Department of Tourism, Innovation and Sport told the committee that it supported the concept of a ‘harmonised injury reporting system’ such as the National Sports Injury Database. It commented that such a project may help to promote safer sporting practices, as well as influence future injury prevention strategies. It further noted:
Development of any such data surveillance mechanism will require ongoing consultation with the active industry to ensure proposals take into account the operational constraints of grassroots clubs and their largely volunteer-based workforce and the importance of medically trained personnel being responsible for accurately identifying and categorising injuries to ensure the integrity and validity of an injury database.
Committee view
2.89The evidence to the committee shows that competing or inconsistent definitions of concussion used by stakeholders in sports contribute to confusion and the risk that concussion is not always diagnosed accurately.
2.90The committee sees a clear need for a consistent, trusted, and independent definition of concussion, tailored to the sports context, to help guide stakeholders and inform protocols across all levels of sport in Australia.
2.91The committee believes there could be a place for the NHMRC to guide or facilitate this work, or to at least conduct an independent approval process for a definition or set of guidelines produced by another body (such as the ASC).
2.92Additionally, while the committee is encouraged to see that there may be potential for emerging technologies to assist with the diagnosis of concussion in sport in the future, it is mindful that there must be sufficient peer-reviewed evidence base available to validate any new tool before it can be safely utilised.
2.93The committee has heard the concerns from submitters about the distinct lack of data on the rates of concussion sustained during sports across Australia. It is clear that there is an urgent need for better data collection of the incidence of concussion in contact sports in Australia.
2.94It commends the idea of the National Sports Injury Database and urges the Australian Government to prioritise the establishment of this data asset. The committee understands that establishing this nationwide, population level dataset, will significantly improve the understanding of the frequency and cause of sports injuries in Australia amongst researchers, policy makers, the sports sector and the public alike. It considers that part of this work should include requiring professional sporting codes to collect and publish data on concussions and identified sub-concussive events.
2.95Additionally, the committee sees value in the National Sports Injury Database collecting information such as the sport and level in which the injury was sustained, as well as the demographic information of the individual injured. It considers that this will assist in producing a fuller picture of the prevalence of concussion and repeated head trauma in contact sports, which will in turn be beneficial to creating guidelines and protocols for the prevention and treatment of these injuries.
Recommendation 1
2.96The committee recommends that the Australian Government establish the National Sports Injury Database as a matter of urgency, noting this will significantly help address the lack of sports injury data available in Australia, including at the community level of sport.
2.97With a view to increasing transparency, the committee recommends that professional sporting codes collect data on concussions and identified sub‑concussive events and share this data with the National Sports Injury Database.