Closed shop? Sport needs more voices to reach real consensus on concussion

The Guardian

May 6, 2021

Late in October 2016, Dr Richard Sylvester arrived at the Ritz-Carlton Hotel in Berlin for the first day of the fifth International Conference on Concussion in Sport. Sylvester is a consultant neurologist at the UK’s Institute of Sport, Exercise and Health, and has worked as a concussion adviser for both the Football Association and World Rugby, but this was the first concussion conference he had attended.

“And when I came to it I felt I didn’t understand what on earth was going on. I was like: ‘Am I missing something?’” he says. “Because this is not the approach I would have taken, you know? I thought to myself, ‘I don’t understand this. This is weird’.”

Sylvester specialises in brain injuries. “That’s what I do all day. [But] these guys were sports doctors, not neurologists, and it was almost like being in a kind of parallel universe. And that’s not a criticism. I just think it explains some of the polarisation, and the divided opinion.”

Over the last week, a series of articles published by Guardian Australia have drawn attention to the research being done there into the long-term consequences of head trauma in sport, and, with it, the need for what Sylvester describes as “more collaboration on an international scale to try and answer some of these difficult questions”.

The Australian campaigner Peter Jess says “this is universal, across all nations, but because we speak English, we tend to think ‘well, this is the research that we’ve got’ whereas there’s compelling evidence in all countries that tells us these collision-based sports are creating long-term neurological trauma for past, present and future players”.

That collaboration is exactly what the concussion conference is supposed to be for. The first one was in 2001, and they’ve been held every four years since. The sixth, delayed by the pandemic, will be held in Paris this October. It is supported, and paid for, by the IOC, Fifa, World Rugby and other governing bodies. In Berlin there were 420 guests from 24 countries, but the most important work happened on the third day, when a lot of them had already left and a much smaller, select group of experts held a closed session to collaborate on their latest consensus statement summing it all up.

Clara Fitzpatrick of St Kilda Saints is carried off with concussion during the 2020 AFLW match against Adelaide Crows at Richmond Oval in February. Photograph: Matt Turner/AFL Photos via Getty Images

“The consensus statement is incredibly influential,” says Sylvester. “You know, certainly all of the sports I’m involved with in the UK base their guidance on that statement. It is seen as the current gold standard of practice.” If you suffered a concussion while playing almost any sort of amateur or professional sport in the last four years, the way you were diagnosed and treated was influenced by the conversation in that room.

Which begs the question why, five years later, some of what they came up with in Berlin now looks so very wrong. Take the return-to-play protocols, which govern the length of time a player needs to rest after suffering a concussion. The consensus statement says athletes “take a minimum of one week to proceed through the full rehabilitation protocol once they are asymptomatic”. Which often means (“rather conveniently”, as Sylvester puts it), that they’re back available for the next match. It’s now widely acknowledged that six days isn’t long enough, and in Australia the AFL has just doubled the length of its own return-to-play lay-off, from six days to 12.

That’s just one example. Another would be the insistence that “the notion that repeated concussion or subconcussive impacts cause CTE remains unknown”. For a consensus paper, it’s a hugely contentious claim.

Sylvester is only one of a group of people who have criticised the methodology behind the consensus. He put his concerns on record at the recent hearings on Concussion in Sport held by the Department for Digital, Culture, Media and Sport. “I think the issue is that, to me, this does feel a little bit like a closed shop, and it feels like it’s run by people who’ve been doing this sort of thing for years and haven’t really got anywhere,” he says.

Dr Michael Turner, who used to be the chief medical adviser to both the British Skiing Federation and the British Olympic Association, describes himself as a “conservative” in his field and is on the conference’s expert panel. “The consensus doesn’t have to please everybody in the world,” he says.

If you’re in the room and disagree, you’re welcome to write a minority report explaining why. No one ever has. And as for everyone else, they’re welcome to “go set up their own concussion consensus group and come up with a set of guidelines of their own”. Turner puts Sylvester’s complaints down to his “frustration at not being part of something that is the most widely quoted concussion document in the world”.

Sylvester laughs. “Maybe he’s read my mind. And, you know, I think that there is some point to what he says. But the counter to that is that if you’re producing a consensus agreement that non-participants struggle to feel confident in because they weren’t in the room, I would argue that something’s not quite right in the process.”

Turner argues that, imperfect as it is, the consensus process they use at the conference is “the best way we have of finding agreement on the way forward. I mean, what’s your view on it?” he asks me. “Do you think it’s a sort of old boys club funded by Fifa that gets together for a three-day jamboree in a smart hotel and at the end of it they come up with a whole lot of things that suit them?”

I tell him that not being in the room, I wouldn’t presume to know.

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