By Wendy Carlisle
Controversial concussion expert Paul McCrory urged the AFL to introduce mandatory breaks of two to three weeks for concussed players before he quit his honorary roles with the league in protest.
Details of the deteriorating relationship between Associate Professor McCrory and the AFL are revealed in emails cited in the recent investigation into McCrory, led by Melbourne barrister Bernard Quinn KC and released last week.
Quinn was appointed after it was revealed McCrory plagiarised other scientists’ work, described by Quinn as an “embarrassing blemish” on McCrory’s career.
McCrory’s criticism was made to fellow members of the AFL’s scientific committee as they formulated draft concussion protocols for the 2021 AFL/AFLW seasons.
McCrory was scathing of a first draft, which proposed players be allowed to return to play after seven days, meaning most would miss at least a game.
The emails show that McCrory urged a more conservative approach.
The AFL handed down a review into McCrory’s concussion advice to the league last week.Credit:Jo Gay
“We should really be trying to push out the RTP [return to play] timeline and encourage missing 2-3 weeks,” he wrote to the group in December 2020.
He argued that “research shows concussion recovery takes longer than the time frame proposed”, and said there was a need to show leadership for “all levels of football”.
“Our own neuropsychological and imaging data (as well as the literature) shows that recovery takes longer than that time frame set out in these (proposed) guidelines.”
McCrory was referring to a study of 20 acutely concussed AFL players using advanced MRI scans, which detected abnormalities one month after head impact.
Referring to another study, McCrory said: “Only this week, Monash reported biomarker abnormalities in community football persisting for at least 2 weeks after their concussion symptoms had resolved. All of this is completely in line with other published work.”
McCrory was referring to a Monash University study of Australian Rules footballers which found brain injury biomarkers were still rising 14 days after players were concussed.
In early January 2021, a second draft of the concussion protocols was circulated by doctor Michael Makdissi.
Makdissi, now the AFL’s chief medical officer, proposed an “incremental change”, to eight days.
The 2021 guidelines introduced a minimum 12-day return to play protocol, although players often sit out for longer.
“I still disagree with this strategy for the same reasons,” McCrory said in response to the second draft. “If this is the final version agreed to by the AFL then please remove my name from the document and the referral network.”
Two days later, McCrory told Stephen Meade, the AFL’s head of legal and regulatory, that the Concussion in Sport Group, of which he was still chair, said the concussion protocols should evolve based on scientific and medical evidence.
“It is not enough to adopt a specific recommendation from 2016 and say that the guidelines have been ‘followed’. Research from the AFL has shown concussion recovery takes longer than the time frame in the proposed 2021 guidelines. Hence my point.
“Given your comments and the way the guidelines are evolving, I can see no option but to ‘resign’ from whatever honorary involvement I have with the AFL.”
In response to questions from The Age, the AFL said the Quinn report had extensively detailed McCrory’s “sudden change in view”.
In a statement, the league said McCrory had “refused to substantively discuss or debate his views or cite any academic literature explaining why his position had changed so diametrically from 2016 when he was first author on the most recent Concussion Consensus statement”.
Read the full statement from the AFL below.
McCrory did refer investigators to 57 academic articles, but the Quinn report found these were not definitive.
After reviewing the articles the Quinn report said: “There is no single biomarker which can be presently relied on for a return to play policy and that individuals should return to play after following a graded rehabilitation program which involves the resolution of clinical symptoms together with a buffer period at the end.”
It added that the proposed 2021 protocols were “not inconsistent with the literature Associate Professor McCrory directed us to”.
In a final twist, concussion researcher Professor Alan Pearce, a consistent critic of McCrory but an advocate for longer stand-downs, applauded McCrory’s decision to resign from the AFL over the dispute.
Pearce, a director of the Australian Sports Brain Bank, said on this occasion he was “absolutely right”.
“Those studies would have struck a chord with Dr McCrory, like they did with all of us,” he said.
Brain injury expert: Dr Alan Pearce.Credit:Simon Schluter
“We have argued for a number of years, players have been returning to competition too quickly.
“The growing evidence at that time was that symptom resolution was not a good indicator of recovery and that the brain was taking at least three to four weeks to recover, so from a scientific perspective, he was right.”
The AFL said it would “shortly undertake its annual review of the elite and community football concussion guidelines with the benefit of the research presented at the Concussion in Sport Group’s conference in Amsterdam”.
McCrory did not respond to requests for comment.
AFL Statement to The Age
The health and safety of players at all levels of the game is the AFL’s key priority and the AFL has made dozens of changes to concussion protocols, tribunal guidelines and on-field rules over the past two decades to further protect the head and improve the response to head knocks in our game in response to current and evolving science.
Each draft of the AFL Concussion Guidelines has resulted in a progressively more conservative approach to management of concussion driven by increasing global concerns regarding outcomes following repeated head trauma and concussion, that show physiological changes in the brain persisting beyond resolution of clinical symptoms and difficulties in objective assessment of recovery following sports related concussion.
The current 11-step, minimum 12-day return to play protocol was formulated by the AFL Concussion Scientific Committee and based on the Consensus Statements issued by the Concussion in Sport Group and informed by feedback from AFL and AFLW Club doctors who sit at the “coalface” of concussion identification and management in our sport at the elite level.
In the 260-page Review of the AFL’s relationship with Associate Professor Paul McCrory, the Panel chaired by Bernard Quinn KC, examined the formulation of the 2021 version of the protocol and extensively detailed the sudden change in view McCrory had with the working draft of the Return to Play protocols in early 2021. Quinn found that Professor McCrory refused to substantively discuss or debate his views or cite any academic literature explaining why his position had changed so diametrically from 2016 when he was first author on the most recent Concussion Consensus statement.
In the course of his review which was released publicly on October 25, 2022, the Panel sought an explanation from McCrory as to the “current and evolving science” that he was referring to in early 2021 and McCrory referred the Panel to 57 academic articles. After reviewing all 57 articles, the Panel observed that “there is no single biomarker which can presently be relied on for a return to play policy and that individuals should return to play after following a graded rehabilitation program which involves the resolution of clinical symptoms together with a buffer period at the end”. Further, the Panel found that the early 2021 proposed return to play protocol “was not inconsistent with the literature Associate Professor McCrory directed us to”.
Whilst the 2021 Guidelines first introduced a minimum 12-day return to play protocol (that is retained in the current 2022 Guidelines) it is important to reiterate that the minimum 12-day period on which much of the commentary and focus has been on since the release of the 2021 Guidelines is a minimum only and more importantly the protocols require (and in iterations prior to 2021 required) a short period of rest, a period to allow “clinical” recovery and then a graduated program of increased physical and cognitive loads (to facilitate assessments of symptoms recurrence, confidence and performance under pressure). As is stated clearly by the 2022 Guidelines, the requirements of a stage must be satisfied before the player can progress to the next one and “[a] more conservative approach is important in cases where symptoms or clinical features persist beyond 48 hours [or] those with any ‘modifying’ factors’ i.e. young players, multiple concussions [etc.]”
The effect of the AFL’s return to play protocol is that many players who suffer concussion sit out for longer than the minimum 12 days. The Quinn Report also warns of the dangers of inducing the under-reporting of concussion symptoms by players by mandating exclusion periods post-concussion which are perceived to be excessive.
The AFL will shortly undertake its annual review of the elite and community football concussion guidelines with the benefit of the research learnings that were presented at the Concussion in Sport Group’s conference in Amsterdam in late October which considered and debated comprehensive literature reviews of thousands of research papers on concussion and head trauma from across the globe. As always, the AFL will be guided by the Consensus Statement emerging from the conference which is expected to be released early in the new year as well as learnings from our own research and highly valuable input from our Club Doctors.
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