News Review
6 OCTOBER 2023 ausdoc . com . au
Is concussion guidance leaving GPs in a daze ?
Landmark concussion report is a ‘ wake-up call ’, but big clinical unknowns remain .
AAP
Rachel Carter
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WHILE playing , we become institutionalised on how we ’ re treated medically . “ We never have to book an appointment . There are no referrals and no waiting lists for surgery .
“ If you ’ re sick or you have a problem , you call the club doctor on their personal mobile phone , and the issue is addressed almost instantaneously .”
This is what former rugby league star James Graham told the landmark Senate inquiry into concussions and repeated head trauma in contact sports , which released its findings in September to much media scrutiny .
But Mr Graham went on to add a twist : the more mundane reality of accessing care when you retire in your mid-30s .
Former players described it as “ too hard ” or said they “ can ’ t afford it ”, “ didn ’ t have the time ” or were “ messed around ”, according to Mr Graham .
The recommendations from the inquiry include the creation of a national sports injury database as “ a matter of urgency ”.
This would include both elite professional athletes and those hurt playing at the community level .
And it suggested that the Australian Government should consider how to encourage Australians to donate their brains to ‘ brain banks ’ after death to assist scientific research on chronic traumatic encephalopathy ( CTE ).
The concerns about the long-term impacts of concussion — including the possible link with CTE — have been around for some time .
The trigger was the 2002 autopsy of famed US National Football League player Michael Webster that found he had CTE .
Before his death , he had been living out of his pick-up truck , experiencing amnesia , dementia and depression and rejecting help from his friends .
As the debate began over the cause of his CTE , some doctors claimed he had been in the equivalent of “ 25,000 automobile crashes ” in more than 25 years of playing football at the high school , college and professional levels .
Despite time passing since Mr Webster ’ s death and the considerable soul-searching that has gone on in all contact sports , Australia ’ s Senate inquiry says research is still needed into the impact of repeated concussion , how best to detect the damage when it does occur and then what to do about it when it is identified .
It remains a clinical area of considerable unknowns .
For GPs — who are often the first point of contact for grassroots players with a suspected concussion — there is a lengthy discussion in the inquiry ’ s final report focused on whether they lack the necessary education and support to manage patients .
Shine Lawyers , for example , told the inquiry that GPs who identified the symptoms were “ often at a loss as to who to send their patients to for treatment ”.
Professor Melinda Fitzgerald , a neurotrauma expert from Perth ’ s Curtin University and chair of the Federal Government ’ s traumatic brain injury working group , said some studies had shown that GPs did not feel comfortable managing someone with concussion .
The RACGP ’ s own submission to the
inquiry explained that medical students got “ basic information ” on concussion management during training , with some further education on the job as GP registrars .
So it called for “ standardised , evidence-based and easy-to-access concussion and head trauma guidelines ” to be developed and made available to GPs at the point of care .
College spokesman Professor Mark Morgan said , while GPs might be the front door for a lot of these cases , head injury and traumatic brain injury “ does not form a major part of most GP work ”.
He said : “ Having rapid access to relevant information , and knowing where to look to get this information , is more appropriate than further education
‘ Multiple impacts , concussions and collisions coupled with poor choices — the outcome is not hard to predict .’
— James Graham programs for GPs — given that estimates indicate that , on average , a GP would see someone with a head injury or traumatic brain injury just under once a year .”
The inquiry ’ s report accepted the need to provide GPs with more guidance — or to use the exact phrasing : “ The committee recommends that the Australian Government , in partnership with state and territory governments , consider how best to address calls for the development of standardised , evidence-based and easyto-access concussion and head trauma guidelines for GPs .”
That does not sound as though anything helpful is coming soon .
The RACGP ’ s submission , written back in April , also stressed that there should be greater investment in longer general practice consultations for people with concussion , repeated head trauma and other complex needs .
The committee also accepted this , saying the Federal Government should consider how best to support GPs through funding longer consults .
In reality , the committee is out of date given that this year ’ s budget did include a pledge for a new Medicare item for GP consults lasting more than an hour as a result of RACGP and AMA lobbying .
AFL player Angus Brayshaw , who wears a helmet because of prior concussions , lying unconscious after a clash last month .
It should be in place in November , with a rebate of $ 184 .
In response to the inquiry report , RACGP president Dr Nicole Higgins said the college would be “ keeping a close eye ” on progress .
“ As a GP and a mum of children who play contact sport , I know only too well the importance of getting all the policy settings right when it comes to concussion and head trauma ,” she said .
“ This report should act as a wake-up call , and with the right kind of action taken by government , we can limit the damage caused by concussion and head trauma .
“ We don ’ t want kids and adults walking away from contact sport — far from it .”
To make clear what is at stake , it is worth quoting the rest of Mr Graham ’ s testimony , referring to one of his former colleagues .
“ He keeps getting sent away . He ’ s clearly got some issues , but he doesn ’ t know where to turn , or it becomes too difficult .
“ Unfortunately , I also see a lot of self-medication , and in terms of the after-effects of concussion and degenerative brain diseases , I see a lot of self-fulfilling prophecies being lived out , with people saying : ‘ I ’ m doomed anyway , so what ’ s the point ?’
“ From what I understand , you can ’ t cease the decline , but you can put the brakes on the progression and can certainly hit the accelerator , which unfortunately , I see a lot .
“ This happens far too often . Multiple impacts , concussions and collisions , coupled with poor choices — well , it ’ s not that hard to predict the outcome .”