CURRENT Australian concussion guidelines being used by professional and amateur sporting codes around the country are “manifestly inadequate” when it comes to the prevention of chronic traumatic encephalopathy (CTE), say experts.

CTE is a neurodegenerative condition caused by repetitive head injury. It is associated with an array of neuro-psychological problems, ranging from mood and behavioural symptoms to cognitive impairment and dementia. It can only be definitely diagnosed post mortem.

Although CTE has been studied since the 1920s (“punch-drunk syndrome”), it came to public prominence in the 2000s via the cases of several American professional sportsmen who were diagnosed after their deaths (here, here, here and here).

Associate Professor Michael Buckland, a neuropathologist at Royal Prince Alfred Hospital (RPA) and the University of Sydney, told InSight+ that he began looking for CTE cases in Australia after seeing literature from the US.

“I was seeing all the pictures of the pathology and thinking, I see a lot of brains and I see a lot of Alzheimer’s but I’ve never seen that pathology. It was different to anything I’d ever seen before,” A/Professor Buckland said in an exclusive podcast.

“It then became obvious that if we wanted to try and find that CTE pathology, we needed to look in the most at-risk population.”

In partnership with the Concussion Legacy Foundation in the US, A/Professor Buckland and colleagues at the RPA set up the Australian Sports Brain Bank (ASBB) in 2018. Up until March of 2021, 21 brains had been donated.

Writing in the MJA, A/Professor Buckland and colleagues detailed their examination of those 21 brains. The results were concerning on a variety of levels.

“The first finding is that, in this population of people that have exposure to repetitive head injury, the most common pathology we have identified is CTE,” he said.

“More than half (12) of our donors had CTE pathology in their brain. That is remarkable. I think it is alarming that there’s definitely CTE here in Australia, and it’s not hard to find when you go looking for it.

“The other finding is that three of the 12 donors with CTE were under the age of 35.

“They had played sport recently, under modern concussion guidelines, including the current Australian Institute of Sport concussion guidelines, and that hasn’t protected them.”

A/Professor Buckland said it was time the Australian concussion guidelines were reviewed, with a wide range of medical professionals involved in the review, not just those connected to professional sports.

“There is room for an overarching guideline for sport in general,” he said.

“But the ones we have at the moment, when it comes to CTE, are manifestly inadequate.

“There have been concerns raised overseas that the majority of doctors that took part in the international consensus conference to draw up the international guidelines (from which the Australian guidelines are drawn) had very close ties to professional sporting bodies.

“There is no doubt that the issue of CTE is downplayed, and the evidence for an association between repetitive head injury and CTE is downplayed or dismissed,” he said.

“I certainly look forward to seeing some new guidelines. And I would not wait for any international consensus. I would like to see a broad group of professionals consulted and take part in that process.”

Other findings from the ASBB review are noteworthy.

“Six of the 12 donors with CTE and one of nine without CTE had died by suicide, suggesting CTE may be a suicide risk factor,” Buckland and colleagues wrote in the MJA. “Screening for CTE in all deaths by suicide is probably impractical, but our finding suggests it should be undertaken if a history of repetitive head injury is known or suspected.”

Although only two of the donated brains were female, and neither showed signs of CTE, A/Professor Buckland warned that women may figure more in CTE statistics in coming years.

“It’s only recently, in Australia, where we’ve had the AFLW and the NRLW,” he said. “It’s an open question now that women are starting to be exposed to the same sort of repetitive head injuries. Will we start finding females [with CTE] in the next 10 years?”

The message for GPs was clear, said A/Professor Buckland.

“If there’s a history of repetitive head injury, like athletes in contact sports, there should be a degree of suspicion,” he said.

“What I have found, anecdotally by speaking to a large number of people and having people contact me is that there’s a not insignificant number of people that end up with persistent post-concussion symptoms that can travel with them for months, if not years.

“Those people have been reaching out to us saying ‘we’re worried we’ve got CTE’. In fact, what they do have is persistent post-concussion syndrome.

“So, trying to get the proper investigations and to diagnose or exclude persistent post-concussion syndrome is very important.

“It’s important not to jump to CTE straight away. But if there are people who seem to have a progressive deterioration, it should be considered. And they should be referred to either a psychiatrist or a neurologist that has an interest and some expertise in this area.”

A/Professor Buckland said he had two visions for the future of CTE research and prevention.

“CTE is remarkable,” he said. “I don’t know of any other neurodegenerative disease which is potentially completely able to be eliminated through behavioral modification.

“It’s entirely preventable.

“If you work with radiation in the lab or your work, you carry around a dosimeter, it measures your cumulative exposure to radiation every month, and when it’s red you can’t go back in the lab for another 6 weeks, until you’ve got that cumulative level down.

“We need something like that in all contact sports, something that measures cumulative exposure to head impacts and G-forces. That should be monitored throughout a player’s lifetime and if that goes over a threshold, it may be that player has to sit out, do non-contact activity for a year.

“Every sporting organisation should have not only a concussion policy, but a CTE policy. And that CTE policy should be founded on two basic principles: reducing lifetime exposure to repetitive head injuries and delaying the onset of exposure to repetitive head injury.

“I don’t think there should be contact sports for children under the age of 14 years. They should be playing modified games.”

Also online first at

Research letter: Same‐day inguinal hernia repair in Australia, 2000–19
Mills et al; doi: 10.5694/mja2.51410FREE ACCESS permanently


Contact sports should be prohibited for children under 14 years of age
  • Strongly agree (46%, 27 Votes)
  • Agree (17%, 10 Votes)
  • Neutral (14%, 8 Votes)
  • Strongly disagree (14%, 8 Votes)
  • Disagree (10%, 6 Votes)

Total Voters: 59

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7 thoughts on “Concussion and CTE: sport guidelines “manifestly inadequate”

  1. David Cartwright says:

    ‘it may be that player has to sit out, do non-contact activity for a year’. My comment is that I don’t think that we know that that will improve anything. It seems that the recommendations to sit it out for a longer period of time are all opinion-based, no prospective studies. From the nature of the lesions seen on MRI, one would think that these lesions don’t actually ‘get better’. Some swelling may subside, clinically headaches may become less frequent, but neuronal damage has occurred, and neuronal regeneration won’t occur, scarring might. The condition is not hidden until post-mortem, as one respondent above suggests, there are many long-term behavioural signs and symptoms that have been described, some unfortunately culminating in suicide. I suspect that prevention is the only effective ‘treatment’.

  2. Tony B says:

    While I am sure that we should be considering CTE for the football codes I agree that we cannot ignore boxing and we should be advocating stongly for the elimination of the “sport”. It is hard to condone a sport where one certain way of winning is to cause brain injury to your opponent (a knockout).

  3. Dr Greg Caddy says:

    GPs are not even given access to an easily obtainable formal definition of concussion with strict diagnostic criteria/ severity rating and a recommendation of how long different sports should be abstained from . All the articles are academic and not clinically helpful .
    I am cynically concerned that the sports medicine specialists are ” protecting their patches” .
    Every time I read an article on this it is singularly unhelpful.

  4. Lachlan Doughty says:

    If you can only identify this condition, CTE, at postmortem, ie there are no associated behavioural changes/symptoms, is it reasonable to apply further restrictions to contact sports?

    What data supports 12months as the appropriate length of time to abstain from contact sport?

    Your POLL question is too vague to answer meaningfully. Ie Definition of “contact sport” as identified by Ian Cormack. Further the meaning of prohibited – is this an absolute ban? Why choose 14yrs when we appreciate neuronal development continues into late teens early 20s?

  5. Alan Mackenzie says:

    I find it really strange to the degree of conspiracy that none of the CTE “experts” ever mention boxing or try to get it banned or modified

  6. Anonymous says:

    The moderate to severe cases not infrequently have conventional imaging biomarkers/findings of a recent closed head injury (e.g. a microhaemorrhage or evidence of limited axonal injury). We should be looking for these and those patients with positive findings need to be on the sidelines for longer. CT negative, MR (quality 3T MRI reported by a neuroradiologist) positive cases in “concussion” is not infrequently seen (if you look for it).

  7. Ian Cormack says:

    1) Re the poll, I missed the definition of “contact sport”.. Ballroom dancing? can be disastrous. Death has happened in cricket, football (unrelated to contact), swimming, bull riding – etc. Images from competitions in skate-boarding, ski-jumping, where control appears minimal and landing is variable and a long way down bring on my foot-tingling.
    Some sports can be made safer, but banning is not the answer.

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