Chapter 1Introduction
1.1Australia has long prided itself on being ‘a sporting nation’. As a country, we have high participation rates across a range of sports, host a number of major sporting events, and often outperform on the global stage.
1.2The vast social, developmental, physical, and mental health benefits of playing, participating in and watching sport are well established, and for many Australians, sport is a significant part of life. As one submitter highlighted, sport forms ‘an integral part of our society’s fabric, bringing together a diverse community under the dual banners of belonging and competition’.
1.3Increasing participation in sport and physical activity at the community level, as well as improving international success, have long been policy objectives of Australian governments at all levels. Currently, the Australian Government’s goal is for Australia to be the world’s most active and healthy nation, known for our integrity and sporting success. Australia’s National Sport Plan, Sports 2030, was developed to achieve this vision.
1.4According to the Department of Health and Aged Care, more than 90 per cent of Australian adults have an interest in sport, with 13 million adults and 3million children taking part in sport each year, and 3.1million Australians volunteering in sport and active recreation each year.
1.5Contact sports are also highly popular amongst Australians. For example, the Australian Football League (AFL) reported over 517 000 participants in 2022, the National Rugby League (NRL) reported over 170 000 participants for the same year, and over 127 000 Australians regularly play Rugby Union in Australia. These sports also attract significant match attendance and broadcast audiences each year.
1.6In recent years there have been increasing reports and concern, both in Australia and internationally, about the growing evidence of the link between sport‑related concussions and repeated head trauma, and short and long-term impacts on athletes’ health, including links to neurodegenerative diseases such as Chronic Traumatic Encephalopathy (CTE).
1.7Even as this report is being drafted, significant developments such as various classactions and individual proceedings, key policy and rule enforcement changes by the major sporting codes, and new cases of CTE, including the tragic case of the late HeatherAnderson (aformer AFL Women’s player who has become the first, known professional female athlete to be diagnosed with CTE) have emphasised how quickly and significantly this space is developing.
1.8During the course of this inquiry, the committee heard confronting accounts from former athletes and their families of the impacts that sport-related concussion and head injuries had on them and their loved ones. The committee heard of former athletes suffering from anxiety, depression, psychosis, hallucinations, dizziness and brain fog, and how those closest to them watched their rapid decline.
1.9However, evidence to this inquiry has clearly highlighted that the link between concussion, repeated head trauma and contact sport is a contentious issue and space, with sporting organisations, medical, research and legal professionals, governments, the media and the community alike, all grappling with its evolving complexities and evidence.
1.10The purpose of this inquiry is to explore the current evidence and challenges regarding contact sport-related concussion and repeated head injuries, and consider measures to improve the identification and prevention of these injuries, as well as reduce their short and long-term impacts.
1.11The committee recognises that sports in Australia are largely governed by private organisations and businesses, and acknowledges that this makes the role of the Australian Government less straightforward. However, given the significant public health issues involved, the committee considers that there is still a pivotal role for government to play in this space.
1.12Finally, the committee does not intend for this report to discourage sport participation or to create unnecessary fear about the risks relating to concussion in sport. As evidence from the Royal Australian College of General Practitioners (RACGP) highlighted, Australians should be encouraged to undertake regular physical activity (which may include contact sports), but the safety of people who participate in sports, especially junior players, is of utmost importance. The committee agrees with the RACGP that widespread participation in sporting activities will only be achieved if sports are made safe, and are also perceived to be safe.
Referral of inquiry
1.13On 1 December 2022 the following matter was referred to the committee for inquiry and report by 21 June 2023:
Concussions and repeated head trauma in contact sports at all levels, for all genders and age groups, with particular reference to:
(a) the guidelines and practices contact sports associations and clubs follow in cases of player concussions and repeated head trauma, including practices undermining recovery periods and potential risk disclosure;
(b) the long-term impacts of concussions and repeated head trauma, including but not limited to mental, physical, social and professional impacts;
(c) the long and short-term support available to players affected by concussion and repeated head trauma;
(d) the liability of contact sports associations and clubs for long-term impacts of player concussions and repeated head trauma;
(e) the role of sports associations and clubs in the debate around concussion and repeated head trauma, including in financing research;
(f) the lack of a consistent definition of what constitutes ‘concussion’;
(g) the prevalence, monitoring and reporting of concussion and long-term impacts of concussion and repeated head trauma, including in First Nations communities;
(h) workers, or other, compensation mechanisms for players affected by long-term impacts of concussions and repeated head trauma;
(i) alternative approaches to concussions and repeated head trauma in contact sport, and awareness raising about its risks;
(j) international experiences in modifying sports for children; and
(k) any other related matters.
1.14On 16 June 2023, the Senate granted an extension of time for reporting until 2August 2023. On 1 August 2023, the Senate granted a further extension of time for reporting until 5 September 2023.
Scope of the inquiry
1.15As set out in the terms of reference, the committee’s primary focus is on concussions and repeated head trauma in contact sports. However, the committee acknowledges that the issues raised as part of this inquiry are not limited to traditional contact sports, and that many of these same issues pertain to non‑contact sports including but not limited to cycling, horse riding and gymnastics. Correspondingly, many of the recommendations made in this report also apply to non-contact sports.
1.16The committee is also aware that the prevalence and risk of concussions and repeated head trauma are significantly heightened in combat sports such as boxing and mixed-martial arts.
1.17Finally, the committee is cognisant that concussion does not just occur in a sporting context, but that it is also a significant concern for other groups including victim-survivors of domestic violence, other physical assault victims such as from one-punch attacks, defence force personnel and veterans, motor vehicle accident victims, and for those who have experienced accidents during recreation and play.
1.18Whilst concussions that occur in these contexts sit outside the scope of this inquiry, the committee acknowledges that concussion should be prevented and responded to in many different contexts, and believes the insights from this inquiry have application in terms of the importance of prevention, better management, and response to these injuries regardless of their cause.
Conduct of the inquiry
1.19Details of the inquiry were published on the committee’s website and the committee invited organisations and individuals to lodge submissions. The committee received 92 submissions which are listed at Appendix 1.
1.20The committee held a number of public hearings across Australia:
30 January 2023 – Western Sydney, New South Wales;
22 February 2023 – Brisbane, Queensland;
1 March 2023 – Canberra, Australian Capital Territory; and
26 April 2023 – Melbourne, Victoria.
1.21The committee also held a number of in camera hearings.
1.22A list of witnesses who gave evidence at the public hearings is available at Appendix 2 of this report.
1.23In this report, references to Committee Hansard are to both proof and official transcripts. Page numbers may vary between proof and official transcripts.
Structure of this report
1.24This chapter sets out general information outlining the conduct of the inquiry and provides background information relating to concussions, repeated head trauma and contact sports in Australia and around the world.
1.25Chapter 2 discusses the challenges present in determining the incidence of concussion in sport in Australia, including inconsistencies around the definition of concussion and the limitations of current diagnosis tools. It also outlines the need for better data collection on the prevalence of concussion and head trauma across all levels of sport to improve prevention and treatment outcomes.
1.26Chapter 3 explores the various perspectives that inquiry participants have on the impact that concussion and head trauma have on long‑term brain health. Additionally, it discusses various research initiatives which are currently underway, concerns about research integrity in this space and the need for further, independent and unconflicted research going forward.
1.27Chapter 4 outlines how cultural factors and a lack of understanding about sport‑related concussion and repeated head trauma can contribute to the under‑reporting of incidents, concealing of symptoms and poor management of concussive injuries. It also outlines the need for increased education and public awareness measures at all levels, and discusses the need to improve the capacity of the health system and health professionals to better deal with concussive injuries.
1.28Chapter 5 outlines on-field harm minimisation strategies and return-to-play protocols to help prevent and reduce the impact of concussions and repeated head trauma. It also discusses the need to encourage and enforce better adherence to the wide variety of concussion related safety policies and rules which Australian sports have in place.
1.29Chapter 6 discusses the support available to sportspeople who have suffered from the impacts of sport-related concussions and head trauma, including insurance, remediation and compensation measures.
Acknowledgements
1.30The committee thanks all those who contributed to the inquiry by making submissions, providing additional information and appearing at public hearings.
1.31In particular, the committee would like to acknowledge the individuals who shared their lived experiences of concussion and repeated head trauma in sport, including those who experienced these injuries themselves and those who shared how this issue has impacted loved ones. These personal testimonies have been vital in deepening the committee’s understanding of the impacts that concussion and repeated head trauma in sport is having on Australian individuals and families.
Sport in Australia
1.32According to the Department of Health and Aged Care, 13million Australian adults and 3 million children take part in sport each year. Additionally, 3.1million Australians volunteer in sport and active recreation each year and over 90percent of adults have an interest in sport.
1.33The Australian Institute of Health and Welfare (AIHW) reports that in 2019–20, the most popular team sports in Australia by estimated number of participants aged 15 and over are:
soccer (1.1 million participants);
basketball (831 000 participants);
netball (622 000 participants);
Australian rules football (537 400 participants);
cricket (480 000 participants);
touch football (337 900 participants);
rugby – league and union combined (296 400 participants) and
hockey (169 600 participants).
1.34Estimates also indicate other popular physical activities for people aged 15 and older in Australia include cycling (estimated 2.9 million participants) and combative sports (estimated 878 500 participants).
Contact sports and scope of the inquiry
1.35Various definitions of contact sport exist, both from general dictionary sources and from sporting bodies. Many of these descriptions are general in nature; however, typically they reference sports that involve tackling, or where impact of one person against another is an inherent part of the sport.
1.36Several inquiry participants encouraged the committee to adopt a broad definition of contact sport throughout the inquiry and urged the committee to consider non-contact sports in addition to contact sports.
1.37Submitters pointed out that there is also risk of head impacts in other sports, including but not limited to, soccer, netball, basketball, cricket, cycling, gymnastics, equestrian and water and winter sports.
1.38Notwithstanding the well documented physical, social and mental benefits of participating in sport, the committee understands that participation in any sport can increase a person’s risk of injury. However, as described by the PublicHealth Association of Australia, the committee is aware that this ‘risk‑benefit balance’ is most tested in sports where there is a greater chance of players’ heads receiving a biomechanical hit.
Organisation of sport in Australia
1.39In Australia, sport is organised and governed by a range of bodies that span across non-government organisations, private sector organisations and government regulators and oversight bodies. According to the AustralianGovernment’s National Sports Plan, over 75 000 not-for-profit sporting organisations operate at national, state and local levels.
Federal government
1.40The Department of Health and Aged Care (the department) stated that the Australian Government’s interests in regard to sport are:
… to encourage greater participation in sport by all Australians and contribute to a competitive, sustainable, and clean sports sector, based on the pursuit of excellence, integrity, and leadership. Sport also assists to achieve broader health, social, economic, and cultural outcomes.
1.41The Office for Sport within the department is responsible for providing support and advice to the Minister for Sport, including:
new policy development and implementation;
appointments;
international engagement and sports diplomacy;
delivery of commonwealth government sports grants;
coordinating Australian Government support for the staging of major international sporting events; and
portfolio agency support to the Australian Sports Commission, Sport Integrity Australia, the National Sports Tribunal, and the Australian Sports Foundation.
1.42The department’s submission states that it recognises ‘the growing concern in Australia and internationally about the incidence of sport-related concussion, as well as the potential long-term consequences of multiple concussions and the health ramifications for athletes’. It noted that the Australian Sports Commission currently leads work on concussion and repeated head trauma for the sports portfolio.
Australian Sports Commission
1.43The Australian Sports Commission (ASC) is the Australian Government agency responsible for supporting and investing in sport at all levels. The ASC’s strategic vision is ‘to ensure sport has a place for everyone and delivers results that make Australia proud’.
1.44According to a submission from the ASC, it plays a leadership role in guiding sporting organisations and the sport sector in relation to a range of issues impacting sport (including sport-related concussion), though it is not a regulatory authority and has no power to enforce compliance or regulations. The ASC also includes the Australian Institute of Sport (AIS), the high‑performance arm of ASC.
1.45In 2019, the AIS released its Concussion in Sport Australia Position Statement. This position statement was recently updated in February 2023, with the new document titled Concussion and Brain Health Position Statement 2023.
State and territory governments
1.46State and territory governments generally focus on developing and delivering policies and programs regarding community sport and active recreation participation, and sports facility and infrastructure development.
1.47States and territories also have a role in high-performance sport and talent pathway development, with each jurisdiction administering their own academies of sport to assist their high-performing athletes.
Non-government sector
1.48The greatest number of sporting organisations sit outside government in the non-government sector, consisting of:
international peak sporting organisations;
national sporting organisations;
state or territory sporting organisations;
local sporting clubs;
university and school sport associations; and
peak advocacy and professional organisations for sporting interests.
Concussion, sub-concussive impacts and repeated head trauma
1.49Various definitions of concussion exist in sporting, research and medical settings. The term ‘mild traumatic brain injury’ (mTBI) is also often used interchangeably with concussion, particularly in medical settings.
1.50The ASC defines concussion as ‘a traumatic brain injury induced by biomechanical forces’.
1.51The United States Centres for Disease Control and Prevention provides a more detailed description:
A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.
1.52According to the ASC, symptoms of concussion are broad ranging and can vary from case to case. They can include:
loss of consciousness
seizure
balance disturbance
confusion
blurred vision
headache
‘don’t feel right’
‘pressure in the head’
difficulty concentrating
neck pain
difficulty remembering
nausea or vomiting
fatigue or low energy
dizziness
drowsiness
sensitivity to light
emotional lability
sensitivity to noise
irritability
feeling slowed down
sadness
feeling like ‘in a fog’
nervous or anxious
sleep disturbance.
1.53The ASC explained that concussion is an evolving injury and that currently no specific diagnostic test to confirm a concussion diagnosis is available:
It should be noted that concussion is often an evolving injury, therefore, signs and symptoms can change or be delayed reflecting the underlying physiological injury status of the brain. Currently there is no specific diagnostic test that confirms the presence or otherwise of a concussion. Concussion remains a clinical diagnosis, which is identified based on a person’s history, symptoms and signs on physical examination by a qualified medical practitioner.
1.54‘Sub-concussive impacts’ or ‘sub-concussion’ were also terms used by many inquiry participants to describe head impacts that do not cause the person to experience acute symptoms after a hit to the head. Similar terminology that was used included sub-concussive events, episodes, knocks and blows, as well as sub-clinical concussion.
1.55Repeated head trauma is a broader term, which includes concussions, as well as sub-concussive impacts that may not meet the threshold of a concussion, or result in its symptoms. The ASC described repeated head trauma as follows:
Repeated head trauma (RHT) includes head impacts that lead to a concussion or a mild traumatic brain injury, as well as head trauma that do not cause an individual to experience any subsequent symptoms.
1.56The committee heard that some people experience persistent post-concussion symptoms, such as headaches, migraines, fatigue, dizziness, cognitive difficulties and emotional changes. Further, some inquiry participants also referred to ‘second impact syndrome’, which a witness described as a ‘fatal complication that can happen when someone sustains a concussion while still suffering the symptoms of an earlier one’.
Concussion and traumatic brain injury hospitalisation data
1.57Data for sport‑related concussions and repeated head trauma is under‑reported, with the AIHW noting that its concussion and head trauma data holdings related to sports activities are limited to concussions that require a hospital admission.
1.58Noting these limitations, the most recent AIHW data indicated that of 52 262 sports injuries that led to hospitalisation in Australia in 2019–20, 2305 cases were due to concussion caused by sports. Of the 2305 cases:
1608 (70 per cent) were male and 697 (30 per cent) were female;
the most common age group being hospitalised for a sport-related concussion was 15–24 years old (37 per cent);
approximately 730 occurred while playing some form of football; and
approximately 440 occurred while cycling.
1.59The AIHW also provided data around health service use for patients with traumatic brain injury more broadly (not just sport-related injuries). Analysis indicated that in a cohort of 23 445 patients under 65 who were hospitalised with a traumatic brain injury:
most patients were male (70 per cent);
most were aged 15 to 24 (37 per cent);
concussion was the most common traumatic brain injury diagnosis (74percent); and
2708 (11.5 percent) of traumatic brain injuries occurred in sports and athletic areas.
Chronic Traumatic Encephalopathy
1.60There has been growing evidence that suggests a link between sport‑related concussions and long-term impacts on athletes’ brain health. Of particular concern is the link between repeated head trauma and Chronic Traumatic Encephalopathy (CTE).
1.61In general terms, CTE 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. Currently, CTE can only be diagnosed by post-mortem examination of brain tissue.
1.62The committee heard that typical symptoms of CTE include memory loss, confusion, impaired judgment, emotional instability, erratic behaviour, impulsive anger-control problems and depression.
1.63Brain Injury Australia provided an overview of CTE and summarised its signs and symptoms:
Chronic traumatic encephalopathy (CTE) is a progressive degenerative neurological disease. Researchers who have found evidence of CTE in the brains of retired athletes state that it “results in a progressive decline of memory and cognition, as well as depression, suicidal behaviour, poor impulse control, aggressiveness, parkinsonism, and, eventually, dementia.
1.64Several inquiry participants also used the terminology Chronic Traumatic Encephalopathy Neuropathological Change (CTE-NC) to describe this condition. Throughout the report, the committee predominantly uses the term CTE, however will refer to CTE-NC when quoting directly from an inquiry participant that has also done so.
History of sport-related concussion and international landscape
1.65Brain injuries in sport are not a new problem, with historical research indicating that there has been notable scientific and public concern about the long-term effects of sports-related concussion since the late 1800s.
1.66In Australia specifically, evidence to the committee highlighted that there has been over a century of media reporting on the medical dangers of sport-related concussion, with a period of particular interest in the early 1930s.
1.67In 1994, the National Health and Medical Research Council (NHMRC), identified several precautionary recommendations directed to the administrators of the four football codes (AFL, NRL, rugby union and soccer). These guidelines were rescinded in 2004 after its review by NHMRC’s Advisory Health Committee and assessed as being ‘out of date’.
1.68More recent interest and concern has been generated in response to DrBennetOmalu publishing the first case of CTE in American football in 2005, and the 2012 class action against the National Football League (NFL) which resulted in a settlement of over US$1 billion in 2015 for over 5000 former players. The players alleged that the NFL ‘failed to take reasonable actions to protect players from the chronic risks created by concussive and sub-concussive head injuries and fraudulently concealed those risks from players’.
1.69A class action is also underway in the United Kingdom in respect of various rugby codes, where players allege that ‘… rugby’s governing bodies negligently failed to protect them from concussion and non-concussion injuries that caused various neurological disorders, including early onset dementia, chronic traumatic encephalopathy, epilepsy, Parkinson's disease and motor neurone disease’.
1.70Other recent international developments have also spurred local interest. The United States, England, Scotland and Northern Ireland have introduced bans and/or rules to reduce headers in football for children. In another example, Hockey Canada has banned those under the age of 13 from ‘body checking’ (slamming into another player to keep them away from the puck) in ice hockey.
1.71Some jurisdictions have introduced legislation to address this issue. In Canada, the Ontario Government passed ‘Rowan’s Law’ in 2018, requiring sporting bodies to implement and maintain mandatory concussion awareness resources, including a ‘Concussion Code of Conduct’ amongst its officials, athletes and parents. Rowan’s Law was developed following recommendations of a coronial inquest into the death of 17-year-old high school student, Rowan Stringer, who died following multiple concussions over a short number of days which resulted in second impact syndrome.
1.72Similarly, the state of Washington in the United States passed the ‘ZackaryLystedt Law’ in 2009, promoting concussion education for athletes, coaches, parents and guardians. The law also requires young athletes suspected of sustaining a concussion to be removed from practice and play, and prohibits them from returning until cleared by a medical professional. Similar legislation has since been adopted in all 50 states in America.
Concussion in Sport Group
1.73In 2001, the first Concussion in Sport Group (CISG) international conference was held in Vienna, Austria. The conference brought together a range of major sporting bodies, academics and other medical professionals, with the aim to ‘provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, football (soccer), and other sports’.
1.74Subsequent meetings of the group have been held approximately every four years since 2001, with a ‘consensus statement’ containing the group’s findings and outcomes published following each meeting. The most recent meeting of the group was held in Amsterdam in 2022, hosting an expanded group of 11 national and international sporting organisations, including the AFL and NRL. The consensus statement following the 2022 Amsterdam conference was published on 30 June 2023. The 2022 consensus statement acknowledges the importance of conducting further research into the potential long-term effects of concussion and repetitive head impacts on mental health and neurodegenerative conditions and recommended the formation of an interdisciplinary group to allow more time and attention on this topic.
1.75Due to the timing of this inquiry’s public hearings and submission due dates, submitters and witnesses referred to the consensus statement published in 2016 following the CISG’s 5thinternational conference on concussion in sport held in Berlin.
1.76The CISG has been, and continues to be, an influential body in relation to sport‑related concussion policies and guidelines across the globe, with CISG ‘consensus statements’ over the years long being the reference point of concussion policies of many countries and sporting organisations. For example, almost every Australian sporting body that participated in this inquiry indicated that their concussion management approaches and policies are informed by the CISG meetings and consensus statements to some extent.
1.77The committee heard that the integrity of the CISG has been called into question over recent years, including concerns regarding the group’s methodology and transparency behind its publications, and lack of disclosure regarding potential conflicts of interest among its members.
1.78The influence of the CISG and the importance of independence and integrity of research in this space will be explored further in Chapter 3 of this report.