Chapter 5On-field harm minimisation strategies and return to play protocols
5.1This chapter discusses a range of on-field or in-play measures that can be taken to prevent and/or reduce the risks of concussion and repeated head trauma in sport. Such strategies that will be discussed in this chapter include:
rule modifications, including age minimums for children;
skill development and strength and conditioning training;
the use of head gear; and
stand-down and return to play protocols.
5.2This chapter will also outline evidence regarding the enforcement of compliance to these measures, before ending with the committee’s views and recommendations.
The importance of prevention and risk reduction
5.3The committee heard compelling evidence about the importance of prevention and risk reduction in relation to concussion and repeated head trauma in sport.
5.4The Public Health Association of Australia emphasised that a ‘safety‑first perspective’ of preventing injury in the first instance keeps people independent and healthy, results in fewer people getting hurt, and reduces demand on hospital systems, general practitioners (GPs) and other medical services.
5.5The Australian Health Promotion Association similarly described the benefits of injury prevention:
AHPA recommends a focus on preventing concussions and repeated head trauma in contact sports. Injuries are preventable. Health promotion and illness prevention save lives and money and delivers the best public return on investment in health.
5.6Child Neurologist Professor Karen Barlow, on behalf of the Queensland Paediatric Rehabilitation Service, also outlined the importance of prevention, as well as secondary and tertiary measures:
The old adage that “prevention is better than cure” is certainly true in concussion. Yet in addition to primary prevention, secondary and tertiary (preventing further concussion in those at risk) prevention strategies are also key considerations to improve outcomes.
5.7Whilst it was made clear to the committee that prevention is multi-faceted and that a range of measures are required to reduce the risk of sport-related concussion, several inquiry participants outlined in particular the importance of on-field rule changes and skill development measures to prevent and reduce the impact of these injuries.
Rule modifications
5.8The Public Health Association of Australia submitted that rules are a key tool in the primary prevention of concussion and repeated head injuries and that they are ‘the foundation of safe conduct in sports because they set expectations for behaviour and define infractions’.
5.9The Public Health Association of Australia added that the implementation of safer rules has been shown to decrease the incidence of concussion in sport. Injury epidemiologist Dr Reidar Lystad similarly outlined that the most effective and successful strategies to reduce head trauma and concussion rates in sports have involved policy and rule changes.
5.10Whilst these measures vary depending on the sport, the Public Health Association of Australia explained that such changes have included banning or limiting the use of certain drills or techniques, forbidding dangerous tackles, as well as other specific alterations, as explored further in the sections below.
International examples of rule modifications to reduce and prevent concussions
5.11The committee received evidence on a range of international examples where rules or regulations have been altered to reduce the impact or prevent concussion and repeated head trauma in sport.
5.12Many inquiry participants cited the example of the banning of ‘body checking’ (slamming into another player to keep them away from the puck) in hockey in Canada.
5.13Dr Reidar Lystad explained that according to academic studies, prohibiting body checking in Canadian youth ice hockey reduced concussion rates by 64 per cent for under 12s, 40 per cent for under 14s and 51 per cent in under 18s, with no subsequent increased risk of injury or concussion for children with less body checking experience.
5.14Dr Lystad also referred to other studies relating to American football, which suggested that rule changes to reduce or limit full contact tackle practice reduced head impact exposure by 42 per cent, and practice concussion rates by 57 per cent.
5.15In terms of football (soccer), several participants cited how some organisations and jurisdictions have introduced bans for ‘headers’ (using your head to redirect the ball) for certain age groups or competition levels.
5.16Dr Alexandra Veuthey PhD, an expert on the regulation of concussion in sport, explained that countries including the United States, England, Scotland and Northern Ireland have moved to ban and/or reduce headers in soccer for children.
5.17The Australian Sports Commission (ASC) also outlined international examples where headers have been banned or limited for children, though it suggested that the evidence regarding the efficacy of these measures is contested:
There has been discussion in the medical literature regarding the possibility that heading the ball in soccer may contribute to concussion, and cause long-term detrimental effects on brain health.
… Whether banning soccer heading by children will lead to any change in health outcomes remains to be seen. The efficacy of banning heading in children’s soccer (where heading is uncommon) is contested. The decision to ban or restrict heading in the US and the UK appears to be based on an approach of ‘an abundance of caution’ rather than any strong evidence that such restriction will impact short or long-term effects of concussion.
Rule modifications in the context of Australian sports
5.18The committee received some evidence about what rule modifications Australian sporting organisations have implemented to prevent or reduce the impact of concussions and repeat head trauma across various codes and levels of sport.
Australian football
5.19The Australian Football League (AFL) submitted that it has made approximately 30 rule changes to its Regulations and Tribunal Guidelines since 2005 ‘to assist in the deterrence of conduct causing or giving rise to the risk of concussion and other head trauma, and to both encourage and enforce change of behaviour on field’.
5.20For junior players, the AFL outlined that it has adopted modified rules to regulate contact in a ‘significant proportion’ of junior competitions. The AFL explained that tackling and other related skills are introduced in ‘an appropriate sequence’ which includes:
a) For under 8s:
i) No tackling or holding of an opponent;
ii) No pushing (fending off), bumping or barging another player;
iii) No smothering, stealing the ball or knocking the ball from an opponent’s hands;
iv) No shepherding;
v) No kicking off the ground;
b) For under 9s and 10s:
i) Modified tackling (wrap tackle only) introduced; and
ii) No other contact allowed as per Under 8s.
5.21The AFL noted that the prevention of concussion and repeated head trauma remains a key priority of the league, but explained that ‘no specific decisions have been made for further rule modifications in the sport for children and adolescents’, although a review would be conducted in 2023. It suggested that any successful prevention program should adopt a broad approach and needs to be underpinned by a robust injury surveillance system to ‘identify potential high-risk game situations and to monitor the outcome of any changes made, including the identification of any undesired effects’.
Rugby league
5.22The committee is not aware of any recent on-field rule changes the National Rugby League (NRL) has implemented to specifically prevent or reduce the impact of head injuries, but understands that the league’s ‘laws of the game’ stipulate that contact with the head or neck of an opposing player is illegal at all levels.
5.23Mr Jamie Buhrer of the Rugby League Players Association (RLPA) outlined that the RLPA is supportive of modifications that enhance player health and safety and suggested there is further opportunity to address exposure to contact by modifying the amount of contact in training:
We've always been supportive of modifications for player health and safety… I know that we need to continue to explore around training; that's probably where the growth area is for rugby league—in the training environment, where all eyes are on the games, and we've got spotters, and commentators and even fans alike can understand that, when a concussion's taken place, they need to get off. Sometimes it's the training. I think, as a player association, we'd be open to modifying the amount of contacts in training. In the first instance, we need to get, from our perspective, the governing body, the clubs and the players all aligned on an approach. I think if we can actually develop an approach together, with ownership for all parties…
5.24In relation to community and school rugby league, the NRL highlighted its ‘NationalSafePlay Code.’ The NRL stated this code was developed to promote safety via a set of rule modifications for competitions involving players aged 6to 15 years. It explained that rule modifications include:
… the banning of tackling techniques that pose an unacceptable risk, as well as other techniques, such as palming (fending off with outstretched arm) an opposition player in the head or neck and slinging tackles.
5.25The NRL also explained League Tag, an alternative format of rugby league available to participants that removes tackling and replaces it with the act of removing a tag. The league stated it ‘encourages participants to try rugby league with the opportunity to develop the basic skills, whilst further reducing safety concerns’.
Rugby union
5.26In the context of rugby union, Dr Warren McDonald, Chief Medical Officer of Rugby Australia, recognised that the greatest risk of the sport is in tackling. He explained that tackle heights have been reduced over the years and that this continues to be reviewed:
Head contact has always been illegal in our sport, but we recognise that it does happen incidentally or accidentally in some circumstances. There has been a reduction in the tackle height within rugby over several years. Even as we speak, the height at which one should tackle is being reviewed again. We recognise that the greatest risk in our game is in the tackle situation, and the greatest risk is to the tackler, the person undertaking the tackle. The current demarcation is around the armpit. There is a move to reduce the tackle height down to around the sternum region. The concept there is to take the tackler's head, in particular, away from another player's head or shoulder so we don't end up with an untoward incident. That's where our sport is going. I believe it will be safer for doing so.
5.27Rugby Australia also outlined its ‘Head Contact Process’ which forms a part of the code’s efforts to reduce the risk of head injury through ‘strong and consistent on and off field sanctioning’ for dangerous tackles, illegal head contact and potential acts of foul play.
5.28In terms of junior players, Rugby Australia explained how aspects of the game are introduced to children in a phased approach which includes modified rules for the purpose of increased player safety and welfare, including:
No contact (tackling) until under 8s meaning all tackle laws apply from under 8s.
Variations to lineouts and scrums including playing uncontested until under 10s.
No lifts until under 12s with phased restrictions on the way players are lifted and how they bind until under 15s.
5.29Rugby Australia acknowledged there are some calls to delay tackling until players reach ages 12 to 14. It outlined its view that such measures would carry a greater risk to players as ‘players would be learning to tackle too late and at a time when there is a greater variation across players in size and strength’.
Soccer
5.30At the elite level in Australia, the committee heard that the A-Leagues (including A-League Women, A-League Men and A-League Youth competitions) have implemented a rule to allow ‘concussion substitutes’.
5.31Professional Footballers Australia explained that a concussion substitute can occur if the referee stops a match for a potential concussive injury to a player. The team doctor is then required to make a clinical assessment of the player and if clear symptoms present, the team can apply to replace the player with an additional permanent concussion substitution.
5.32As noted in chapter three, the committee heard from MrJosephDidulica, a former goalkeeper who played in Australia’s national league and believes he suffered his first concussion when he was five or six years old. Mr Didulica observed that the concussions would become more prevalent when he was a teenager, and as a goalkeeper he would suffer a knock to the head and would continue to play through the game. Mr Didulica recounted the following incident which occurred prior to 2006:
I remember one game where the ball hit me in the head hard. I continued on to half time and the coach said, 'You've got to go out there.' So I went out there not knowing where I really was. After five or six minutes I started to become nauseous, and I was looking for a place to chuck. I was oblivious to what was going on in the game. I walked 25 metres to a defender, because I didn't know what was happening. I stopped, and then the game stopped and I got taken off. The players were winning goals. After the game I was obviously concussed. It was 'Go home. There's a game next week.'
5.33The banning of headers remains a key issue for community and junior soccer players. On this matter, Mr Mark Falvo, Chief Operating Officer at Football Australia, told the committee that Football Australia’s approach has firstly been to focus on understanding the frequency of headers in the game:
Different football associations have begun to respond to this risk in different ways, and you're right: there are a few that have elected to ban heading of the ball outright. Our approach, which is very comprehensive, is to firstly understand the degree to which heading is occurring in a game … data suggests that the frequency of headers per match is very low. For example, in some matches in Australia for the ages of under 10s to 12s, the range of heading frequency is zero to two headers per match, based on current data. That's something that we'll continue to monitor and revise.
5.34Mr Falvo noted that Football Australia has implemented other measures to reduce the frequency and impact of headers for junior players, including the introduction of a smaller ball:
… we've taken active steps for some time now, dating back as far as 15 years, to modify the format of the game, principally through the introduction of small sided football for participants of the age of under 6 through to under 12. This reduces the space in which the game is played, reduces the number of players that are involved and, as a result, reduces the incidence of both contact with the ball, from a heading perspective, and also heavy impact, from a body-to-body point of view… This is an important risk mitigation measure that has been taken for some time…
5.35Mr Falvo added that other modifications at younger ages have included requiring kick-ins rather than throw-ins, and requiring goalkeepers to roll or pass the ball along the ground, rather than lofting it.
5.36Mr Falvo also stated that Football Australia’s current curriculum, which provides guidance on how to coach and teach the game, outlines that heading ‘should occur with a deflated ball, a lighter ball or a smaller sized ball’. He also explained that further advice is under development to include information on exercises to strengthen neck muscles and other forms of training techniques to help prevent or reduce the impact of headers.
5.37When asked if Professional Footballers Australia would support modifications such as those implemented internationally regarding headers in soccer, Co‑Chief Executive Mr Beau Busch told the committee that whilst evidence continues to develop, cautious approaches that protect player health are favourable:
There are certainly measures you can take. But I think that our overarching view is that, if there is uncertainty and we can adopt a high standard that safeguards people whilst we understand more about concussion, then that's certainly what we would be in favour of. We would prefer to have been too conservative to protect health, particularly of young players that are coming through.
Cricket
5.38Dr Alex Kountouris, Head of Sports Science and Sports Medicine at Cricket Australia, explained that Cricket Australia has introduced two key rule changes in recent years, including the introduction of concussion substitutes and mandating the use of helmets.
5.39Whilst the helmet mandate is discussed in further detail later in this chapter, Cricket Australia submitted that Australia was the first cricket playing nation to introduce a concussion substitute in an elite domestic cricket competition. It also explained that this rule had now been adopted by the International Cricket Council and applied across all elite cricket competitions.
Calls for further action regarding rule changes
5.40Some witnesses and submitters encouraged further action in terms of rule changes in Australian sports.
5.41Mr Leon Harris, Clinical Legal Educator and PhD candidate in the area of concussion in contact sports in Australia, raised concern that the modified policies that Australian contact sports codes have in place are not as adequate as those implemented internationally:
The contrast with Australian sports is stark. In rugby league, “no players will be able to participate in tackle rugby league until midway through the under 7s season”. In AFL, tackling is banned in Auskick until around the age of 11, although it appears a form of tackling is introduced around 9 years of age. In rugby union, tackling is introduced in under 8s.
It is clear Australia does not have the same modified policies in contact sports played here that some countries have adopted in their contact sports. With increasing evidence the earlier a child start contact sport, the more likely it is they will suffer some sort of neurological condition later in life, the early ages at which Australian sports start contact is problematic.
5.42Further, the Concussion Legacy Foundation Australia broadly advocated for modified, non‑contact versions of full contact sports until children reach the age of 14 years. Similarly, the Royal Australian College of General Practitioners (RACGP) noted that it is important that safe versions of contact sports continue to be encouraged and normalised.
5.43Consultant neurologist Dr Rowena Mobbs also commented that modified games such as ‘tag’ or ‘flag’ versions for children should be more widely adopted.Dr Mobbs explained that these formats of sport offer alternative pathways where children can still obtain the vascular benefits of sport, whilst delaying head impacts. DrMobbs recommended that contact skills be commenced at a later age, and advised that commencement in adolescence is ‘neurologically preferable’ to earlier childhood.
5.44Several other submitters outlined the ongoing and crucial role that national sporting organisations have in regard to modifying rules going forward. For example, Professor Jack Anderson, an academic specialising in sports law, acknowledged that whilst many sports are predicated on risk-taking, he noted that ‘it is the regulatory duty of a sports body to monitor, and update, by way of an evidence-based approach, the rules of its sport to avoid unnecessary risks’.
5.45Professor Terry Slevin, Chief Executive Officer of the Public Health Association of Australia, implored that sporting bodies must ‘lead the charge’ in terms of changing rules to reduce the prospect of head collisions, and added that more research and evidence is vital.
5.46The Public Health Association of Australia’s submission reiterated that more research must be conducted to demonstrate the impacts of rule changes, but also encouraged that if a rule is believed to help reduce the incidence of sports‑related concussion, then it should be implemented as a precautionary approach, regardless of any research deficit.
5.47Neuropsychologist Dr David Maddocks similarly advised that all reasonable steps to change rules should be taken to minimise risk. He also raised the importance of ongoing review and changes to rules where necessary:
… all reasonable steps should be taken in activities that involve a significant risk of head impacts to minimise the incidence of such trauma. I believe that such steps have already been adopted in a number of contact sports and ongoing review and changes where necessary and reasonable should continue.
5.48Additionally, the Public Health Association of Australia emphasised that referees and other officials have a key role to play in terms of enforcing rule changes. Further evidence relating to the enforcement and compliance of modified rules and return to play protocols is discussed in greater detail later in this chapter.
Skill development and strength and conditioning training
5.49The committee received some evidence about how certain skill, strength and conditioning development through training can help prevent or reduce the impact of concussions and repeated head trauma in contact football codes and soccer.
5.50The Public Health Association of Australia submitted that safe tackle training is a key prevention mechanism. It explained this is where players are taught safer ways to tackle, like avoiding head-to-head or elbow-to-head collisions, spear tackling and ensuring their own head is positioned upwards. The Public Health Association of Australia acknowledged that this already occurs in sports to some extent, but that it should be further promoted and encouraged at all levels of contact sports.
5.51The committee received some evidence outlining the programs and measures that Australian contact sports codes including the AFL, NRL and Rugby Australia have in place regarding safe tackling skill development.
5.52In relation to soccer, the committee heard that heading is a skill that needs to be specifically developed. Professional Footballers Australia cited the research of physiotherapist and sports injury expert Dr Kerry Peek in this area, which outlines that heading technique is vital, yet does not always need to include ball to head contact. Dr Peek’s research suggests that teaching good heading technique includes:
… body positioning, tracking ball trajectory, timing of runs and jumps (which can all be practised in part without ball-head contact), introducing neuromuscular neck training to improve head-neck-body stability and reduce head impact magnitude on ball contact ...
5.53Professional Footballers Australia pointed out that Dr Peek is a strong advocate for neuromuscular neck training, which a recent study has found can reduce head impact magnitude during heading in high-level football players aged 12 to 17 years.
Protective head gear
5.54The committee heard some evidence about the merits of helmets and protective head gear to reduce the impact of concussion and repeated head trauma in sport, though views on this matter were varied.
5.55Neuropsychologist Dr David Maddocks cited concerns around ‘risk compensation’ behaviour whereby players feel more protected when wearing headgear and therefore go into collisions or contests harder. He explained this phenomenon and called for improved awareness about these risks:
… improve public awareness of the 'pros' and 'cons' of helmets (hard hats) and "head gear" (soft shell), including the risk that individuals wearing helmets/head gear may take greater risks in the course of participation because of "risk compensation" (put simply, when wearing a helmet in contact sports, a participant might put their head where they normally would not put it due to a perception of reduced risk), which may lead to increased exposure to head impacts.
5.56The Public Health Association of Australia submitted that headgear is ‘not the solution’ for preventing concussions:
Helmets and headgear are not [sport-related concussion] proof. They can significantly decrease the risk of other nonfatal and fatal head injuries, but are not the solution for preventing concussions. Wearing helmets and headgear can also give players a false sense of security, which can embolden them to hit harder than usual.
Education about equipment limitations and how to safely make contact with another player is required to avoid a false sense of security and to ultimately protect players.
5.57The Australian Institute of Sport’s Concussion and Brain Health Position Statement 2023 outlines that whilst research is ongoing, personal protective equipment, including helmets, have not yet been proven to prevent concussion:
Personal protection equipment (PPE) such as helmets, soft-shell headgear and mouthguards have not been shown to prevent concussion, in studies to date. PPE can reduce other injuries such as lacerations, skull fractures and dental trauma. PPE research continues investigating the use of novel materials but at this stage PPE cannot be recommended for the purpose of preventing concussion.
5.58The NRL’s Coach Handbook for community codes 13 and over, similarly states there is no conclusive evidence that head gear prevents concussion:
… Additional protective equipment such as head gear and shoulder pads can be worn to help with confidence or to protect against bumps and abrasions. Remember there is no conclusive evidence that headgear prevents concussion.
5.59In contrast, Dr Andrew McIntosh PhD, who specialises in biomechanics, ergonomics and accident investigation and safety, reported:
There is a view that a form of risk compensation or behavioural adaptation will occur if athletes wear protective clothing... However, our observational studies in rugby and AFL have not provided evidence that wearing headgear is associated with a change in injury risk for the wearer or anyone else.
5.60Dr McIntosh submitted that there is potential for padded headgear to offer considerable protection in training and games:
Padded headgear that reduces substantially the forces applied to the head during direct impacts has the potential to prevent concussion. This type of padded headgear will also reduce the forces in direct head impacts that would not normally cause concussion, but which some people believe are nonetheless hazardous. Therefore, effective padded headgear has the potential to offer considerable benefits when worn during training sessions involving contact, and/or games.
5.61However, Dr McIntosh acknowledged that current commercially available headgear is ineffective, and that athletes and families in Australia are offered a ‘limited choice’ in padded clothing, which they assume to be protective. He also noted that there are no mandatory safety standards for padded headgear and other protective equipment used in contact football, and suggested that more attention be directed to developing appropriate and effective headgear options:
In my opinion, the opportunity to reduce the incidence of concussion and head impact exposure through the wearing of fit-for-purpose padded headgear has not received sufficient attention. Padded headgear can offer protection to the brain, if it is designed to meet appropriate biomechanical performance criteria. Current commercially available padded headgear is likely to be ineffective because it has not been designed to control the impact forces that occur in contact football.
5.62He added that improvements to protective equipment can be achieved through design and material selection, and that standards and technical specifications are proven methods for improving personal protective equipment performance. Dr McIntosh highlighted the example of Cricket Australia implementing such standards:
… Cricket Australia set a very positive example through its engagement with British Standards and the inclusion of minimum performance criteria for neck protectors in BS7928:2013+A1:2019 (Head Protectors for cricketers).
Even in a relatively short time period, we were able to have a modified version of a popular commercially available headgear manufactured that outperformed the standard version.
5.63Dr McIntosh proposed that roundtable discussions with national sporting organisations, sporting goods suppliers, players, club and school officials, parents and experts are conducted to devise a coordinated approach and identify performance criteria for padded headgear.
5.64He noted that further research and development would be needed to assess the headgear, but that the ultimate outcome would be:
… a range of headgear models on the market that are acceptable to players (usability/comfort/aesthetics/price), which offer a minimum agreed level of head protection … and for which there is a scientific evidence base.
Evidence regarding head gear in different sports
5.65Former Olympic and Commonwealth Games track cyclist Ms Julie Speight, who continues to suffer the effects of sport-related concussions, called for reforms to ensure cyclists are racing with safe and up-to standard helmets:
As far as cycling is concerned, there is an awareness of the dangers of head injury but not for after-care of head injury or replacement of helmets. I believe that we need to take more care with our helmets… I propose that the government work with helmet manufacturers to provide reasonable costing to allow for racing cyclists to be able to purchase two helmets at the beginning of the racing season and a scheme whereby they can send damaged helmets back to the manufacturer and be able to buy a replacement at a reduced price. Certainly, helmet inspections prior to racing need to be rigorous, and if the helmet is found to be damaged it should be confiscated and the spare helmet used. The challenge is to be able to determine when the helmet has suffered a substantial blow and should be replaced, when it is doubtful that an eager rider will divulge this information if it means having to destroy his or her expensive helmet that may look fine.
5.66In terms of boxing, the committee heard that there is inconsistency in rules regarding the use of head guards between genders and level of competition, where elite men are the only cohort not required to wear head guards. MsDinahGlykidis, Chief Executive Officer of Boxing Australia, told the committee:
In our sport, open elite men's is non-helmeted, without head guards. Everyone else—so under 18-year-olds—all must wear head guards, including our open women's… It's only in our open men's that they don't need to wear one. That's [based] off our international rules.
5.67The Western Australian Combat Sports Commission commented that the use of head gear in boxing is contentious:
The use of padded head gear, particularly in the sport of boxing, is a contentious issue. Whilst padded head gear can prevent or minimise facial lacerations it is the CSC [Combat Sports Commission] understanding that numerous scientific research papers are either inconclusive or have concluded that head gear does not prevent or minimise concussion.
… There are concerns over head gear providing a false sense of security and potentially leading to some contestants willingly accepting more hits to the head or developing poor head defence techniques as opposed to those not wearing head gear. It may appear to be counter intuitive but the removal of head gear, rather than the enforcement of head gear may be an alternative approach and has been adopted at Olympic level boxing.
5.68In the context of cricket, Cricket Australia reported that at an elite and community level, it is a requirement that all junior players wear cricket helmets while playing the sport. Cricket Australia acknowledged that ‘whilst cricket helmets do not eliminate the risk of concussion, they do reduce the likelihood that that head trauma will result in concussion’.
5.69For other cricketers, Cricket Australia outlined that it makes recommendations regarding the use of helmets and neck protectors in community competitions, which includes recommendations that local associations adopt the same compulsory use of helmets as the elite-level cricket players.
Stand-down and return to play protocols
5.70Return to sport rules and regulations have changed significantly over the past two decades. Twenty years ago, over 50 per cent of players suffering concussion in some sports returned to play on the same day they suffered the injury or were not even removed from play at all. As submitted by the ASC, it is now very unusual for elite athletes to return to play in under six days, and several organisations, including the Australian Institute of Sport (AIS), have introduced protocols which make it highly unlikely for athletes to return in less than 12days.
5.71The guidelines and practices that contact sports associations and clubs follow when concussions occur vary from sport to sport, and, although some associations and clubs support and endorse the AIS Concussion and Brain Health Position Statement 2023, it was noted by Concussion Australia that they can have conflicting material in their own guidelines.
5.72Within competitive sports globally there also exists a strong incentive to win, and compelling social, normative, and economic factors that can influence decision‑making. In Australia, several professional players have asserted that the decision regarding their fitness to return to play should be theirs to make— irrespective of the risk disclosures by any club doctor. These players argued that bodily autonomy and their rights over health-related decisions should prevail, despite any contrary medical advice and scientific uncertainty regarding the long‑term harm such decisions may have.
Varying perspectives on appropriate return to play protocols
5.73A number of inquiry participants provided the inquiry with their perspectives and views on the current return to play protocols and made a number of suggestions on how they thought these protocols could be improved. The following discussion canvasses a number of these perspectives and suggestions.
5.74Some inquiry participants urged for consistency and uniformity in return to play protocols across all sports. For example, the Public Health Association of Australia urged for standardised guidelines at all levels of sport:
The management of these injuries should not vary so widely. We urge that there be standard SRC guidelines which are mandatory for all sports at all levels to follow. These guidelines should be formed primarily by experts in the health field, including head trauma doctors, public health advisors, pediatricians, researchers, and neurologists. It is important that the expert body be independent of any sporting code affiliation to avoid conflict of interest. Sports association doctors should be consulted, but only to gain perspectives of on-field experience, not to weaken the guidelines. We believe this will ensure that the guidelines are up-to-date, consistent, and clear. The guidelines must be mandatory for all levels of sport, updated regularly and implemented with education campaigns.
5.75Concussion Australia similarly recommended that a uniform set of guidelines is developed by independent medical practitioners for use in all Australian sports.
5.76The Chair of the Expert Working Group at Mission for Traumatic Brain Injury, Professor Melinda Fitzgerald, said:
… recovery needs to be managed carefully to ensure that symptoms have completely resolved, even when exercising, before returning to the field of play. We need a different recovery path for every person. There's no one-size-fits-all approach. It's key that the people managing it speak with all ages, levels and locations with the education to guide this best-practice approach. If people return to play early, they're at greater risk of another concussion, and their recovery from that will take longer.
5.77The Community Concussion Research Foundation submitted that research suggested that it is dangerous to return to play inside the 'vulnerability window' of one month without the completion of multi‑modality tests. It stated that a stand down period of 12 days was inadequate and that there was evidence that AFL players were returning to play with high levels of damaged brain cells—putting them at risk of long-term harm.
5.78Noting that players face incentives to avoid disclosing their symptoms, the Community Concussion Research Foundation also argued that these individuals need to be thoroughly evaluated by a health care provider experienced in working with concussions before being cleared to return to play.
5.79Injury epidemiologist and member of the Scientific Advisory Committee at Sports Medicine Australia, Dr Reidar Lystad, said:
… most sporting codes rely heavily on the Concussion in Sport Group international consensus statement, which is, unfortunately, open to interpretation … and they've changed their position across their evolution within their five consensus statements. Initially they had stated that recovery was typically within seven days. That has been expanded to 10 to 14 days. And they do have some wording around children potentially having a prolonged recovery time, without providing any specific guidance further along those lines.
My view is that the only workable way to reduce the lack of consistency across the sector in terms of concussion guidelines and protocols, which typically rely heavily on the international consensus statement, is for the government to take a more active role in governance of concussion in sport in this country.
I would like the government to consider giving the Australian Sports Commission a mandate to take a governance role in this space. That includes developing and implementing an Australia-wide concussion guideline and policy applicable across sporting clubs.
5.80Professor Karen Barlow from the Child Health Research Centre at the University of Queensland said:
I find at the moment that the rules around resting or not returning to contact sport after a concussion quite arbitrary and based on the sport than the actual injury. I'm quite perplexed by why that is.
5.81Neuroscientist Professor Alan Pearce highlighted the confusion that currently exists regarding return to play protocols, both across different sports and within the same sport, and argued that the government has a role to play:
Anecdotally I get to speak to a lot of sports at the club level in particular. A lot of feedback coming to me is that they're confused. There is confusion between different sports. There's a bit of confusion even within a sport. I think if the government is able to have some form of policy or law that we get people to sit out, whether it's kids for a certain period of time or adults for a certain period of time, at least then the sports will be obligated, particularly at club levels, because they don't have the same infrastructure as the elite levels. At the moment, players are returning on the Tuesday after a Saturday concussion because they go to their local GP, who clears them to play.
5.82When asked whether there is a minimum time that is appropriate for a person to return to play after a concussion, a neurologist and senior lecturer at Macquarie University, Dr Rowena Mobbs, stated:
… there is evidence at one month of brain abnormalities. In fact, there are some studies on mild traumatic brain injury with abnormalities at one year. Of course, we don't want kids out of sport for a year. It's tricky. In terms of adults, I would generally advocate a conservative path of four weeks off from play, inclusive of that weekend's games—none of this sort of 11- or 12- day approach where you can scoot in for the fortnight's games!
For kids, it should be longer, and there's talk of six weeks. There was also talk, 30 years ago, in the concussion guidelines from NHMRC, of: 'If you have two concussions in a season, perhaps you should take that season off.'
5.83In his submission to the inquiry, Dr David Maddocks, a neuropsychologist, highlighted some issues with having mandatory exclusion periods. He said:
… the debate about mandatory exclusion periods has been going on for many years in contact sports. There is clearly intuitive appeal in setting a conservative period before which a player cannot return. I believe mandatory exclusion periods are reasonable to adopt. However, for completeness, I understand the reason why some sports did not previously implement a mandatory period was because it was believed that, at professional levels (with readily available expert medical opinion), each case could more appropriately be assessed clinically on a case-by-case basis to determine when a player was fit to resume. Further, a mandatory exclusion period could tempt players, trainers and coaches at lower levels of competition and parents (in the case of a child athlete) to believe that the player is safe to return as soon as the period has passed, when they might not be.
5.84Miss Lydia Pingel, a former player in Queensland Australian Football League Women’s (QAFLW) and division one leagues who was medically retired after sustaining multiple concussions over a three-year period, recommended that there be a one month imposed stand down period after sustaining a concussion. She recommended this be the case regardless of whether the concussion was sustained during training or a game, and that, after three diagnosed concussions in a season, there be a mandatory 12 month medical stand down period.
Specific protocols for children and young people
5.85A number of inquiry participants specifically commented on return to play policies for children and young people, including whether this cohort takes longer to recover than adults, and whether they should return to schooling prior to sport.
5.86For example, the Tasmanian Government submitted that children and young people’s experience of concussion recovery is different to adults, with this cohort more likely to develop post-concussion symptoms and take longer to recover. It explained that a growing body of research indicates a slower rate of recovery in children and adolescents under 18 years, and that a more conservative approach to concussion is recommended. It added:
Children and adolescents may be more susceptible to concussion due to a variety of factors, including decreased myelination, poor cervical musculature, and increased head to neck ratio. The role of cerebral blood flow alterations in the pathophysiology of concussion may be more significant in children than in adults.
… Early targeted multidisciplinary management can reduce the risk of complications and speed of recovery for children and young people affected by concussion.
5.87The Murdoch Children’s Research Institute (MCRI) asserted that concussion and repeated head trauma is ‘inherently different in developing children compared to adults’ and that the prevention of long-term effects require diagnosis, management and recovery protocols that are specific for children.
5.88MCRI highlighted research from over 90 000 children who were concussed, which indicated that children take twice as long to recover compared to adults, and with one in four children still experiencing symptoms one month post‑concussion.
5.89MCRI also submitted that research indicates that less than 50 per cent of children with concussion present for medical attention and recover without intervention. It added that of those that seek medical attention, approximately 70 per cent are symptom free within 10 days and the remaining 30 per cent experience symptoms for longer (up to three months), with a small proportion experiencing symptoms after that time.
5.90Neurologist Professor Karen Barlow, on behalf of the Queensland Paediatric Rehabilitation Service, outlined that the impacts of concussion are greater in children due to the period of rapid developmental and psychological change which occurs in childhood.
5.91The Queensland Paediatric Rehabilitation Service presented different research which indicted that 50 per cent of children have symptoms that last at least a month, and that between 14 per cent to 33 per cent of children have symptoms lasting three months or longer, experiencing symptoms such as headaches, difficulty concentrating, remembering and paying attention in class, balance problems, dizziness, poor sleep, visual and mood disturbances.
5.92The Queensland Paediatric Rehabilitation Service submitted that it is unknown how long it takes for the brain to fully recover post-concussion, and that further research is needed to improve understanding of the best and safest way to get children back to school and play.
5.93A 2018 Kidsafe WA childhood injury report, which investigated sporting inquiries suffered by children, found that children bear particular risks from a concussion:
Children are especially susceptible to concussions and often present with varied symptoms due to physiological differences in their brains……. Following a concussion worse outcomes are seen in younger groups with an added risk of further injury if play is not stopped immediately. Second impact syndrome can occur when a brain that has not healed from a previous concussion experiences additional trauma. Most reported cases of second impact syndrome that have led to death or disability have occurred in younger athletes.
5.94Dr Reidar Lystad made the following comments regarding recovery periods for children:
In terms of whether or not children take longer to recover, we know that at least one-third of children experience concussion symptoms at the four‑week mark, which is an estimate that it's higher than it is for adults. So the answer is, yes, they probably do take longer to recover.
5.95When asked whether 12 days was enough time for children to recover before returning to play, Professor Barlow said that it probably wasn’t, and suggested that 30 days would be more realistic before a child continues with contact sports.
5.96When answering the same question about minimum stand down periods, the Chief Executive Officer of Headsafe, Dr Adrian Cohen, said:
It depends on the individual—in this case, the child—their history, the sport, the incident. And the codes themselves don't really do that; they just make blanket rules, which they have to. So we have to individualise it. They need to have guidelines that are enforceable, so that they can't skirt around the edges, and, as I talked about before, play one sport on one day and then go to another sport two days later because nobody knew that they were injured in the other one. So mandatory reporting of concussion should be high on the agenda.
5.97When asked whether children should be returning to school before sport after incurring a concussion, Dr Paul Bloomfield said:
… the return to sport should wait until a successful return to school. There are guidelines—mostly published by the Concussion in Sport Group—around return-to school protocols. There is staged return; but, again, depending on levels of symptoms, that can be as short as a day or as long as many weeks. But a successful return to school should occur before a return to sport.
5.98On this same issue, Dr Lystad said that return to learning should take precedent over the return to sport. Dr Lystad also referenced research he recently conducted into the effect of concussion on school performance. He explained the research showed significant impacts of concussion on school performance, including failure to achieve minimum standards of NAPLAN assessment and higher risk of incompletion of high school.
5.99The Tasmanian Government also explained that post-concussion symptoms can have an impact on all areas of a child’s life, including participation in school, employment, other community activities, social withdrawal, and a high risk of mental health concerns such as anxiety and depression. In terms of return to school, the Tasmanian Government submitted that children and young people may need to take more regular breaks, rests and increased time to complete tasks.
Guidelines for non-elite sport published by the UK Government
5.100In April 2023, the United Kingdom (UK) Government released guidelines for non‑elite, or grassroots, sport. This was the first ever UK-wide concussion guidance published to help people identify, manage, and prevent concussion affecting players in grassroots sport. Amongst other things, these guidelines stated the following:
anyone with one or more visible clues, or symptoms, of a head injury must be immediately removed from playing or training and must not take part in any further physical sport or work activity—even if symptoms resolve—until an assessment can be made by an appropriate healthcare professional;
return to education and work takes priority over return to sport;
individuals with concussion should only return to playing sport which risks head injury after having followed a graduated return to activity and sport program;
all concussions should be managed individually; however, there should be no return to competition before 21 days from injury; and
anyone with symptoms after 28 days should seek medical advice from their general practitioner.
The position of the Concussion in Sports Group
5.101In its 2017 consensus statement, the Concussion in Sport Group (CISG) outlined its approach to return to play after an athlete sustains a sport‑related concussion. It provided a recovery process which followed a graduated stepwise rehabilitation strategy:
After a brief period of initial rest (24–48hours), symptom-limited activity can be begun while staying below a cognitive and physical exacerbation threshold (stage 1). Once concussion-related symptoms have resolved, the athlete should continue to proceed to the next level if he/she meets all the criteria (eg, activity, heart rate, duration of exercise, etc) without a recurrence of concussion-related symptoms.
Generally, each step should take 24 hours, so that athletes would take a minimum of 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest. However, the time frame for [return to sport] may vary with player age, history, level of sport, etc, and management must be individualised.
In athletes who experience prolonged symptoms and resultant inactivity, each step may take longer than 24 hours simply because of limitations in physical conditioning and recovery strategies outlined above. This specific issue of the role of symptom-limited exercise prescription in the setting of prolonged recovery is discussed in an accompanying systematic review.
If any concussion-related symptoms occur during the stepwise approach, the athlete should drop back to the previous asymptomatic level and attempt to progress again after being free of concussion-related symptoms for a further 24 hour period at the lower level.
The position of the Australian Sports Commission
5.102Both the Concussion in Sport Australia Position Statement issued in 2019, and the updated AIS Concussion and Brain Health Position Statement 2023(position statement) advocate for athletes to be removed from sport when there is any suspicion that a concussion has been sustained. This approach is reflected in the 'if in doubt, sit them out' catchphrase.
5.103The position statement also outlines a graduated return to sport process where it is highly unlikely that an athlete would return to play in less than 12days from sustaining a concussion and, in many cases, the duration for a return to sport would exceed this length of time.
5.104The timeframe for returning to play is modified for individuals who are aged 18years and under. For these athletes, they must be symptom-free for a period of 14days before a return to contact activities can be considered. This approach means that if a young person has symptoms that continue for 14 days after they initially incurred a concussion, they will not be eligible for return to sport for 28days (that is, 14 days with symptoms plus 14 days without symptoms equals 28 days in total). The ASC noted that this cautionary approach is based on evidence that young people take longer to recover from a concussion.
5.105The degree of caution exercised is also modified if an athlete has a history of repeated head trauma—with the duration of time required before returning to play being increased, particularly where there have been recurrent concussions within short periods of time. Further, where an athlete has sustained multiple concussions, a medical practitioner provides counsel regarding the dangers of repeated head trauma, its potential long-term impacts, and the need for the athlete to consider their continued involvement in high-risk sports.
5.106Although advocating for a collaborative multi-disciplinary approach for concussion management, with shared decision making, the position statement outlines that any final return to sport decision should be made by an appropriately qualified medical professional. Summarising its position on this issue, the ASC said the following in its submission to the inquiry:
The best way to avoid both short-term and long-term effects from concussion is to treat each concussion seriously. Any individual with suspected concussion should be removed from the sporting environment and not be permitted to return to sport until cleared to do so by a qualified medical practitioner. Individuals with concussion should follow a graduated program for return to sport. They should not return to sport until they have fully recovered from the effects of the previous concussion.
Longer stand down periods and their impact on reducing CTE
5.107The ASC considered that it will be difficult to predict the effect that having more prolonged periods of stand down (such as 12 days) will have on the incidence of recurrent concussion and Chronic Traumatic Encephalopathy (CTE). It noted that the existing cases of CTE that have been reported in the media relate to individuals who played contact sports in an era when they were either returned to play on the same day that they suffered a concussion or were not removed from play at all—and when cumulative concussions did not result in longer periods of stand down.
5.108The ASC concluded that it will likely take years, if not decades, to assess the efficacy of the more conservative guidelines. Commenting on calls made by others to impose even lengthier stand down periods, such as 28 days, the ASC said the following:
There is no evidence base to support one stand down period over another, apart from a general principle that it is better to have a greater duration of time between exposures to head trauma risk.
The various positions of Australian sporting codes
Australian football
5.109The AFL submitted that an athlete’s recovery following a diagnosed concussion is variable and, hence, management should be individualised. Given this, it currently implements a three-stage protocol for returning to play:
First, a brief period of relative rest.
Second, a period of recovery where progressive increases in physical and cognitive activity is encouraged. This period continues until the player no longer has concussion-related symptoms at rest, or with activity, and they have returned to 'normal' on their tests of balance and brain function.
Third, a graded return to full activity with progressive addition of contact and monitoring for any recurring symptoms under maximal physical and cognitive load and fatigue, and confidence to return to play.
5.110Since 2021, the AFL and Australian Football League Women’s (AFLW) concussion guidelines have prescribed minimum timeframes for the completion of each stage and have also mandated clearance points between each stage. The AFL stated that, as a result, the earliest a player can return to play in a match following a diagnosed concussion is on the 12th day after the day on which the concussion was sustained. Notwithstanding this, the AFL submitted that over the 2022 AFL and AFLW seasons, one in four players missed more than one game as a result of the management of their concussion.
Rugby league
5.111The Australian Rugby League Commission (ARLC) recently approved changes to the NRL’s head injury protocols, including the introduction of a mandatory 11-day stand‑down period following a diagnosed concussion—regardless of whether the concussion was sustained during a game or at training. In announcing this change, the ARLC noted that it was approved following a 'review of the data and advice from a range of experts'.
5.112The Chief Medical Officer of the NRL, Dr Sharron Flahive, highlighted that not all concussions are the same. On this point she said:
The most important part in this is that if that player has a history of a concussion with the last three months, a number of concussions in their career or a concussion that has prolonged symptoms following it or any complex concussion history, then that concussion is viewed very differently with regard to their return to play. The window closes down and we are more and more conservative in our management when it comes to what are called complex concussions.
Rugby union
5.113In its submission to the inquiry, Rugby Australia stated that if a player suffers a concussion, then a graduated return-to-play process—comprising six stages—must be adhered to. This process was updated in July 2022 to emphasise the individualisation of the rehabilitation process, as informed by each individual’s risk profile, and only commences once a player is symptom free at rest.
5.114This risk profiling is informed by the number of concussions the player has had across the prior three months, 12 months, and their lifetime, as well as whether the player has experienced prolonged recoveries previously, or has exhibited unusual symptoms—including issues with mental health.
5.115Players who do not require a more conservative rehabilitation may be eligible to return to play on day seven; however, those who do require a more conservative approach will only be available for selection on day 12, at the earliest. Rugby Australia submitted that this approach means that the majority of players will not return to play before day 12.
Various combat sports
5.116Boxing Australia currently has a minimum 30-day mandatory stand down period following a concussion sustained during a competition. This period progressively increases following further concussions and knockouts and prohibits an athlete from both competing and sparring. Muay Thai Australia has also introduced concussion guidelines which require a 30-day stand down period, but from competition only.
Limitations of ‘self-regulation’ and improving compliance with rules and return to play protocols
5.117The committee heard compelling evidence about the limitations of national sporting organisations ‘self-regulating’ concussion safety policies and the need to improve adherence to many of the rules and protocols that have been discussed throughout this chapter.
5.118Australian Health Promotion Association submitted that multiple examples of voluntary codes of conduct or practice have shown to be insufficient in achieving widespread change. It further noted its support for the implementation of comprehensive and mandatory measures to prevent concussions and repeated head trauma.
5.119Dr Lystad similarly outlined that despite past efforts, there has been a general failure of self-regulation of concussion in sports. He reported that there has been inadequate implementation of concussion guidelines, policies and protocols in many sports in Australia. He explained:
… Season after season, there are media reports of players being returned to the field of play on the same day after sustaining a head impact and suspected concussion. Players are sometimes being cleared to return to play despite video footage showing visible signs of concussion.
5.120The Community Concussion Research Foundation also argued that self‑regulation by Australian sporting organisations had failed and added that these self‑regulatory approaches among Australian sports had, in several cases, led to ‘inconsistent application, haphazard enforcement and mixed messaging’.
5.121Dr Annette Greenhow, a lawyer and expert in the regulation of sport-related concussion in Australia, further explained the limitations of self-regulation within this sporting context:
Sports associations and clubs are essential in providing and delivering sport in Australia. They are centrally rooted in their sport and typically thought to possess higher levels of expertise or technical knowledge about their sport. However, there are gaps and areas for improvement in how the sports have privately self-regulated SRC [sport-related concussion]. There are many competing or colliding interests to manage, coupled with the disruptions presented by SRC in some full [body] contact sports.
5.122Evidence from Professor Jack Anderson, a sports law expert, and former professional track cyclist Ms Julie Speight, highlighted that a particular test of adherence to return to play protocols arises in the case of big sporting events such as the OlympicGames or grand finals. For example, if a player suffers a concussion in a semi-final and then has to miss the grand final the following weekend.
5.123Additional lived experience accounts from former athletes, such as MissLydiaPingel, also demonstrated that whilst concussion protocols and guidelines may exist, they are not always followed or adhered to.
5.124Several other submitters with lived experience of the impacts of repeated head trauma in contact sport broadly called for measures to enhance the enforcement of concussion safety protocols, including Mr Peter ‘Wombat’ Maguire, MrRobinMcGilligan, Belinda Vardy, Mrs Kathy Strong, and Geoff and Jean Cook.
5.125Some inquiry participants outlined the need for government leadership or regulation to help address the issues surrounding self-regulation of concussion protocols by sporting codes.
5.126Dr Greenhow submitted that public oversight and leadership is needed to direct the sport-related concussion agenda, to champion the public interest, and take leadership in designing regulatory arrangements with the public’s interest in mind. Dr Greenhow also suggested that legislative measures could be used, or funding to sports could be tied to the implementation and compliance of concussion protocols.
5.127Griffins Lawyers outlined a similar case for public oversight:
The many stakeholders seeking to influence the management of concussion in Australian sport emphasises the need for an impartial central public authority to manage concussion in accordance with an ethical framework and via an integrated systemic approach.
5.128Mr Gregory Griffin, Principal of Griffins Lawyers, added that a public authority should be responsible for the creation and enforcement of concussion guidelines and return to play protocols.
5.129Amongst other measures, Dr Reidar Lystad similarly proposed that a regulatory body be established to govern traumatic brain injury and repetitive head trauma in sport.
5.130The Insurance Council of Australia submitted that governments should play a central role in the implementation of clear, unambiguous and effective concussion and head trauma health and safety guidelines and procedures for sporting organisations to minimise and manage instances of concussion and long-term injury, as well as ensuring these guidelines and procedures are applied.
5.131Shine Lawyers asserted that consistent concussion protocols should be enforced and that penalties for failing to comply should be legislated.
5.132As mentioned earlier in this chapter, the Public Health Association of Australia highlighted that referees and other officials also play a key role in enforcing adherence to rule changes:
Without enforcing adherence to the rule changes, concussion risk is not mitigated. If referees are too lenient, players may take advantage and become aggressive during play. Officials must be frequently re-trained about rule changes and the seriousness of head injuries. Another way to ensure implementation might be to review video playbacks of games and assess whether officials are enforcing safety rules. Officials who fail to enforce rules that affect player safety should be disciplined. Greater penalties for dangerous play should also apply to players and their coaches.
5.133Dr Annette Greenhow suggested that the remit of various existing agencies should be looked at to determine where the regulation or custodianship of these issues could sit in the future. She also noted that Sport Integrity Australia’s remit was originally anti-doping, but has since been expanded into other areas.
5.134Mr Griffin also suggested that Sport Integrity Australia ‘would be the ideal government agency to take control of the entire management of return to play protocols and concussion issues’.
5.135After attempting to make a complaint to Sport Integrity Australia, regarding gymnastics safety issues, Ms Aisha Stewart told the committee she was advised by the agency that they ‘would like sports to educate players about the high risk of concussion, but they don't have any mandate to insist that that happens and they don't have any powers to penalise sports for not providing or deciding to withhold that information’.
5.136Whilst the committee did not hear directly from Sport Integrity Australia throughout the course of the inquiry, the committee understands that sport‑related concussion safety issues are not within the scope of its mandate. Sport Integrity Australia’s current role is to provide advice and assistance to counter the:
use of prohibited substances and methods in sport
abuse of children and other persons in a sporting environment
manipulation of sporting competitions
failure to protect members of sporting organisations and other persons in a sporting environment from bullying, intimidation, discrimination or harassment.
5.137Evidence provided by Mr Kieren Perkins OAM, Chief Executive Officer of the ASC, indicated that the ASC may not be best placed to enforce rule changes or concussion protocols given it is not a regulatory authority. However, Mr Perkins added that the ASC does play a critical role in ‘guiding sporting organisations and the sector in relation to a range of issues impacting sport, including sport related concussion’.
Committee view
Rule modifications and skill development
5.138The committee recognises that some national sporting organisations in Australia have taken some steps in recent years to amend rules and/or promote skill development to reduce the quantity or severity of head impacts in their game.
5.139Whilst the committee welcomes these measures, evidence to the inquiry highlighted that bolder strategies have been implemented internationally to modify rules to keep participants safe, particularly in regard to children and adolescents. The committee is encouraged by evidence which indicates many of these measures have effectively reduced the exposure and impact of concussion and repeated head trauma in a range of sports.
5.140The committee recognises that not all international precedents for rule modifications will directly apply to the Australian sporting context, and that evidence regarding the effectiveness of rule changes continues to emerge. However, on balance the committee considers that if it appears that a modified rule could help reduce the incidence of sport-related concussions, particularly for children and adolescents, a precautionary approach should be adopted and strong consideration be given to adopting the rule modification.
5.141The committee recommends that national sporting organisations in Australia explore further rule modifications for their respective sports in order to prevent and reduce the impact of concussion and repeated head trauma. This work should prioritise modifications that protect children and adolescents, and take into account emerging evidence both domestically and internationally.
Return to play protocols
5.142The committee is concerned that the disparate protocols currently in place across the various sports in Australia have created a high level of confusion within the community. The committee considers that the time frame required before a person returns to play should be determined by the severity of the head injury that they have sustained, and the person’s history with head trauma and concussion—not the particular sport that they were playing when they incurred the injury.
5.143The committee also heard that the return to play guidelines that many codes currently have in place are insufficient, and that stand-down periods post‑concussion should be longer than 11 or 12 days.
5.144To reduce this confusion and increase certainty, the committee believes that the Australian Government should take a more proactive role in the governance of concussions and repeated head trauma in sport in Australia. Such an approach would reduce the inconsistencies that currently exist, and ensure all sportspeople are not risking their long-term health by returning to play prior to their full recovery.
5.145The committee notes the UK Government has adopted a similar approach for non-elite sports by recently publishing a set of guidelines, which recommended that all concussions should be managed individually, but there should be no return to competition before 21 days from injury. The committee is of the view that a cautious approach be adopted across all levels of sport, and considers the guidelines to be an important resource for people to help identify, manage, and prevent concussions in grassroots sport. The committee supports the development of a similar publication by the Australian Government.
5.146The committee also considers that it is vital that children and young people have adequately recovered before they return to play any form of contact sport, including training, and recognises that they likely need a longer period to recover from a concussive injury compared to adults. One witness suggested that a 30-day stand-down prior to returning to contact sport would be more appropriate. The committee supports this conservative approach for children and also agrees with inquiry participants that children should return to their schooling prior to recommencing their participation in sport after sustaining a concussion.
5.147The committee recommends that the Australian Government, in collaboration with medical experts, develops return to play protocols, adaptable across all sports, for both children and adults that have incurred a concussion or suffered a head trauma. The committee envisages that protocols may include lengthier stand-down periods for children and individuals who have a history of repeated head trauma.
Enforcement and compliance
5.148The committee heard that despite there being various concussion safety policies and return to play protocols in place across a range of sports, enforcing adherence and compliance to these rules remains a key challenge.
5.149The committee is concerned by evidence from some submitters indicating that there is inadequate implementation of and adherence to concussion guidelines, policies and protocols in many sports in Australia.
5.150In the committee’s view, the value and efficacy of concussion protocols and guidelines are severely limited if they are not uniformly and properly adhered to by national sporting organisations across all levels of sport. Given that the current approach of self-regulation by national sporting organisations does not appear to be achieving widespread change, the committee considers that a different strategy is warranted.
5.151The committee acknowledges that given the ASC is not a regulatory authority, it is not in a position to enforce rule changes or concussion protocols. However, as the ASC itself noted during the inquiry, the ASC does play a critical role in guiding sporting organisations and the sector more broadly on a range of issues impacting sport, including concussion and brain health.
5.152As acknowledged in Chapter 1, the regulatory role of the Australian Government is less straightforward given that sports in Australia are largely governed by private organisations. However, in light of the significant public health issues involved with sport-related concussion and head trauma, the committee is of the view that there is still a role for the Australian Government to play in monitoring, overseeing and/or enforcing the adherence to return to play protocols and other key concussion safety measures by sporting clubs and governing bodies.
5.153The committee recommends that the Australian Government consider developing a national strategy to reduce the incidence and impacts of concussion, including binding return to play protocols and other rules to protect sport participants from head injuries. Consideration should be given to whether any existing government bodies would be best placed to monitor, oversee and/or enforce concussion related rules and return to play protocols in Australian sports.