The Australian Football League has released its updated guidelines for the elite game and strategic plan for sport-related concussion in Australian football.
The Guidelines for the Management of Sport-Related Concussion – AFL & AFLW, which are continually modified and enhanced in line with evolving scientific evidence, provide best-practice information for the diagnosis and management of concussion in the AFL, to protect the short and long-term welfare of all AFL/AFLW players. Revised community guidelines for all other levels of Australian football will be released soon.
In following the elite game guidelines, the earliest that a player can return to play after a concussion is on the 12th day after the day on which the concussion was sustained and provided that the player has safely progressed through each phase of the 11-step return-to-play program.
The 11-step return-to-play program consists of three distinct stages – rest, recovery and graded return to training and play. The updated guidelines insist on a minimum period of 24 hours (or longer) for each Step of the progression and, if any symptoms recur during the graded return to training and play stage, the player athlete must go back to the previous symptom-free Step.
The guidelines also insist on a more conservative approach in cases with “modifying” factors, including young players, where there is a history of learning disorders or mood disturbance, or a history of multiple concussions, particularly those with prolonged recovery, and previous concussion/s in the same season and where there is a high symptom burden in the first few days after injury. In these cases, the graduated loading program should be conducted over a longer period of time (e.g. by extending the number of days between progressions, or increasing the number of days held at each Stage/Step of the graded return-to-play).
The player must have medical assessment prior to being cleared to return to full contact training with the group and then a further medical assessment before being cleared to return to play.
The updated 17-page guidelines also make clear that there are computerised screening cognitive tests (e.g. Cognigram, ImPACT) that have been validated for use following sport-related concussion, which are readily available and are a practical method to assist with the assessment of cognitive recovery. The guidelines also insist that neuropsychological testing is only one component of assessment and does not replace the need for a full history and clinical/neurological examination.
The AFL has also released its Strategic Plan for Sport-Related Concussion in Australian Football, covering the current period to 2026, which formalises a guiding framework for the football industry’s approach to sport-related concussion and affirms the AFL’s commitment to the prioritisation of the health and safety of players at all levels while maintaining the fabric of our game.
The plan sets out the AFL’s ambition and its pathway in continuing to make our game safer and outlines the AFL’s planned integrated framework for managing the potential impacts of sport-related concussion.
At its core, the plan aims to pursue excellence in each strategic objective: Education, Prevention, Detection, Recovery, Support and Innovation. The AFL convenes a steering group which has five separate Working Groups to guide the work and ensure the successful implementation of the five-year plan and each of the strategic objectives.
The strategic plan was formulated and finalised last year and is now able to be publicly released after the conclusion of the independent review led by senior barrister Bernard Quinn KC, Professor of Neuroscience at the University of Queensland and Royal Brisbane and Women’s Hospital Michael O’Sullivan and Jane Lindgren of Counsel into the work undertaken by former AFL concussion consultant, Associate Professor Paul McCrory. The independent panel’s 260-page detailed report reviewed the Strategic Plan as part of its investigation. The AFL will shortly release its action items in response to the findings and recommendations of the report.
The plan includes key priorities within each of the strategic objectives to guide how the AFL will evolve its concussion management and research activities over the next five years including in:
- Educate – Enhance sport-related concussion expertise across the industry, including healthcare practitioners, players, umpires, coaches, teachers, parents, media and fans
- Prevent – Promote a culture of safety which encourages behaviours to protect the brain health of teammates and opponents
- Detect – Diagnose sport-related concussion quickly and accurately using best practice clinical standards, supported by detection technologies
- Recover – Facilitate recovery through holistic, evidence based and individualised approach to care
- Support – Enable access to support across the entire lifespan of players recovering from sport-related concussion
- Innovate – Collaborate widely to identify, integrate and deploy world-leading solutions in sport-related concussion
The release of the plan comes as the AFL continues to make changes to improve the safety of the game and increase education and awareness of concussion at both the elite and community levels.
Important steps taken in 2022 include:
- AFL Brain Health Initiative (Longitudinal Research Program): Further development of the design of the longitudinal brain health study – to be known as the AFL Brain Health Initiative – on which further detailed preparatory work is underway in 2023. Another key appointment has recently been made to assist with that program, Dr Jonathan Reyes, neuropsychologist who is the AFL’s Concussion Research Lead. Dr Reyes works alongside the Head of Concussion Research and Innovation Adjunct Associate Professor Catherine Willmott, Chief Medical Officer Dr Michael Makdissi and Head of Concussion and Healthcare Governance Rachel Elliott.
- New AFL concussion governance structure: The AFL has completed its first year of operation of its new concussion governance structure directed towards more consultative, transparent and accountable operations overseen by the AFL Concussion Steering Group and Working Groups, working closely with the AFL Concussion Scientific Committee that is constituted by some of the world’s leading concussion and head trauma specialists.
- AFL and AFLW player support and education: The AFL presented in-person, doctor-led concussion education to the AFL and AFLW teams in 2022. The presentation covered areas such as identification of concussion, risks associated with concussion and head trauma, and the AFL concussion management approach. In 2023, the education session has been broadened to include football staff. In addition, for the first time, webinars on concussion for our Indigenous players and officials were conducted and led by an Indigenous doctor.
- Community football support and education: In 2022, the AFL delivered six concussion education webinars for community football leagues, clubs and participants, with between 800 and 2,000 registrations nationally per webinar. A program of further webinar and education events is planned for 2023, with a range of new concussion education and information materials shortly to be made available via afl.com.au.
- Using technology to aid players: The CSx App utilises sophisticated app-based technology to document concussion injuries and monitor recovery, and has been used successfully in AFL and AFLW competitions for several years, with a trial conducted at a State League level (i.e. VFL) in 2022 with an expanded trial encompassing VFL Women’s to be undertaken in 2023. The AFL-approved HeadCheck technology is an app that assists first aiders/trainers, coaches and parents to recognise and manage recovery from concussion in children.
- Proposed expanded financial assistance scheme: The AFL is working closely with Gordon Legal to consider options for the introduction of an expanded financial assistance scheme for former AFL and AFLW players who suffered a serious injury with long-term consequences and financial need.
The release of the AFL’s strategic plan comes after the AFL wrote to all Victorian-based AFL clubs in late 2022 to inform them that WorkSafe Victoria’s investigations into complaints as to concussion management referred to it by an individual had all been completed and that WorkSafe has informed the AFL that it has determined to take no further action and close its file. The AFL anticipates the WorkSafe Victoria has made this determination on the basis that the concussion management by the AFL and Victorian-based AFL clubs meets or exceeds the relevant workplace safety obligations.
The steps taken in 2022 come in addition to a number of other important initiatives undertaken by the AFL since 2021, as part of its approach to concussion management. These include:
- Mandatory minimum recovery: In 2021, the concussion management guidelines introduced an 11-step, minimum 12-day post-concussion recovery and rehabilitation period to complement the existing conservative return-to-play protocol for all levels of Australian football that focuses on individualised assessment and management, which involves a brief period of relative rest, a period of recovery and a graded return to full contact.
- Medical substitutes introduced for AFL where a player medically unfit to continue can be replaced from an additional interchange player, noting that in 2023 AFL clubs will continue to have access to a substitute player and although they can now activate that substitute for any reason, it will continue to be an important measure in the assessment and management of injured players.
- Release of independent report: Independent panel have compiled a 260-page report into the concussion-related work undertaken by Associate Professor Paul McCrory. The panel made numerous recommendations to improve the structure and workings of the AFL’s new concussion management and research governance model. The AFL immediately commenced a process of consideration and response to all of those recommendations.
- Participation in the International Consensus Conference on Concussion in Sport: The AFL sent a delegation to the 6th International Consensus Conference on Concussion in Sport, held in Amsterdam from 27-28 October 2022. The delegation was led by the AFL’s Chief Medical Officer, Dr Michael Makdissi, who was joined by Head of Concussion Research and Innovation, Adjunct Associate Professor Catherine Wilmott, and Head of Concussion and Healthcare, Rachel Elliott. The expert panel from the Conference is in the process of drafting a consensus statement, which is expected to be delivered sometime in mid-2023 and the AFL will use it to inform further work into concussion management.
For the AFL, the safety and health of the game’s players - former, current and future at all levels of the game - is of paramount importance and is the foundation of the Strategic Plan. While some risk of head impacts is an inherent feature of contact sports, the AFL is committed to mitigating that risk across the game.
A range of concussion-related initiatives are in development for 2023, including:
- Recruitment of initial participants in the AFL Brain Health Initiative (Longitudinal Research Program)
- A model for an expanded financial assistance scheme for former elite players suffering serious injury and experiencing financial need
- Review into the elite player disability and/or trauma insurance policy
- Re-launch of a concussion information portal on afl.com.au - a central repository of information and resources for stakeholders involved at all levels of the game
- Trial of a telephone support service for community football, to be conducted in conjunction with the Victorian Amateur Football Association and Monash University
- Continuation of education opportunities and briefings nationally for AFL and AFLW players, as well as community football representatives and key stakeholders, including media
AFL Executive General Manager Football and General Counsel, Andrew Dillon, said: “Overall, this past year represents significant progress in the area of concussion management with the adoption of a new governance structure, the development and release of the strategic plan and the release of updated concussion guidelines.
“These actions demonstrate the AFL’s ongoing commitment to continuous improvement, increased transparency and diverse consultation, in the prioritisation of health and safety of all Australian football participants across all levels of the game.
“There have been significant enhancements in both the resources devoted to the area of concussion management within the AFL and the lines of accountability since the period of 2014-19, which was the focus of the internally-commissioned independent review.
“The AFL acknowledged and accepted criticism of it in the recently released independent review and is taking steps to address recommendations in the report, including that the AFL improves clinical care aspects for past players. The AFL apologised to past players who were let down by the manner in which some of the research and clinical programs were at times conducted in the past.
“The AFL has made more than 30 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 accordance with current and evolving science and we will continue to work to strengthen protocols and increase the education to clubs and players.
“The AFL thanks those who have been involved in development of the strategic plan and other important work around concussion, including the AFL Players Association and members of the AFL Concussion Steering Group.
“The AFL will continue to review its elite and community football concussion guidelines with the benefit of the research insights that will be presented in 2023 as an output from the recent Concussion in Sport Group’s conference in Amsterdam in October.”
AFL Chief Medical Officer, Dr Michael Makdissi, said: “Concussion and repeated head trauma continue to be an extremely important issue across our industry. The updated guidelines and strategy reinforce our commitment to continuing to improve healthcare education, recognition and management of head injuries, and prevention of concussion and head trauma at all levels of competition.
"The guidelines reinforce the importance of players passing through each of the steps safely (i.e. rest, recovery and a graded return), without a recurrence of symptoms, rather than simply progressing through a schedule.
“The health and wellbeing of all players who choose to play our game, at all levels from grassroots through to the elite game, remains a priority.”
- Click here to view the updated ‘Guidelines for the Management of Sport-Related Concussion – AFLW & AFLW’
- Click here to view the AFL's Strategic Plan for Sport-Related Concussion in Australian Football current-2026
- Click here or on the graphic below to view the AFL's Concussion Management Return-to-Play flow chart (PDF version - for media outlets to link to)