When parents send their kids out to play sport, they ensure they've got a hat and sunscreen on to protect them from the sun's long-term damage — but experts say we should be taking similar preventative measures for brain injuries.
While most people associate the devastating brain disease chronic traumatic encephalopathy (CTE) with bad concussions in heavy contact sports such as the rugby codes and Aussie Rules, researchers from the Australian Sports Brain Bank say the problem can be minor bumps compounded over time.
They say sports-mad Australia needs to completely overhaul the way it thinks about CTE and what we should be doing to protect young athletes.
"CTE is a disease of exposure," Dr Alan Pearce from La Trobe University said.
"We have a lot of players who might have had one or two concussions, but they're likely to have had probably 20,000 or 30,000 smaller hits.
"That's not just in football, or rugby, but you know it's in other sports as well. It's in the military, we've even got concerns about domestic violence.
"It's not just an elite athlete issue, with a lot of our research has shown similar outcomes in club level and community level athletes so no-one is really immune, and the brain doesn't discriminate what level of sport or activity you're playing at."
'My life has completely changed
Lydia Pingel only started playing Aussie Rules five years ago but within three seasons she needed to retire.
A series of neurological tests led specialists to the conclusion that repeated head knocks affected how the otherwise healthy 30-year-old went about her everyday life.
"I can go to the shops and I'd have no idea why I've gone to the shops," she said.
"Just the simplest of tasks, like I wouldn't know how to get to work or places I'd been several times before.
"I've had a headache everyday for the last three years. Headaches, nausea, vertigo, memory issues.
"My life has completely changed."
While CTE disease can only be diagnosed after death, Ms Pingel fears it may be what's affecting her.
'Once it's done, it's done'
An avid sports lover growing up, she played everything as a kid, before trying to make the AFLW through Bond University's program.
She was picked in the team, for her fearlessness and courage.
In the mark she took, which secured her spot, she sustained her first serious head knock which she believes would ultimately trigger the start of her brain deterioration.
"My first head knocks were pretty bad, but by the end they were just quite innocuous, just a little bump and that was enough to set off symptoms and that disorientation," she said.
Each time though, she went straight back onto the field.
"You can't see it, you don't have blood rushing from somewhere, you don't have a limp or anything like that, so it was quite easy to mask the ability to go back on.
"I didn't really notice the effects too much at first and sort of played it off, as you do being that there's not a lot of education around it, it's about that courage … it was just move on, get ready for next week sort of thing."
Eventually, her everyday life was impacted.
"I wasn't getting a lot of help from medical professionals because through no fault of their own [head knocks] aren't something that's so well researched and to find someone that has an interest in it is quite niche."
That's when she found Professor Pearce. Testing at his labs found her brain had suffered serious impairment.
"If you don't take it seriously, you don't get a second brain," she said.
"You can have knee reconstruction, you can't have a brain reconstruction.
"Once it's done, it's done. There's no reversing it, there's ways of obviously coping with it.
"If you don't take care of [your brain], you don't take it seriously … it can really creep up on you."
Sporting codes need to 'strike a balance'
Experts want parents to show the same care and attention to head safety as they do to protecting children from the sun or ensuring they have a mouthguard.
"We [researchers] have never been about anti-sport or anti-football or rugby or soccer … the message we are trying to get across is that we want to have a safer sport," Professor Pearce said.
"We can still enjoy our sports as they are but we just need to be able to think about this from a smarter perspective.
"For example, in the UK, they're limiting heading the ball in soccer for children up to the age of 12. In rugby, they're limiting the amount of contact in training for physical contact to 15 minutes per week.
"So that kind of trying to strike a balance between allowing the sports to still do what they do and continue as they are, but also putting in place, some mechanisms that can help protect the brain as well."
He said it was about time society addressed the harms of brain injury in sport after rugby league coach Paul Green died by suicide in August.
The 49-year-old's brain was donated to the Australian Sports Brain Bank, with an autopsy finding the former NRL and State of Origin player had CTE.
"We actually have to be brave enough to admit that this is something that we need to address and if we can address it, then we can actually put in cultural changes, we can modify sports and keep the sports going."
The brain bank was launched in 2018 – with 51 brains donated since then.
Studies from the United States in recent decades prompted Australian experts to take action, but neuropathologist Professor Michael Buckland said the notoriously sports-loving nation remained about 10 to 15 years behind in tackling the issue.
"The NFL and the American football professional league, did admit in a Senate enquiry that playing football caused CTE and they have subsequently set up a [concussion] compensation fund for ex-players, which is almost a billion dollars," he said.
"We're yet to see any sport recognition of the problem so publicly in Australia, but we hope that work with all the major sporting codes drives recognition and addresses it properly."
Potential of CTE plays on minds of former players
James Graham retired from professional rugby league in 2020 after playing 423 club games.
He said officially he sustained 20 to 30 concussions during his career, but under current standards he would put that figure at more than 100.
The former forward said he's looking for solutions, in light of Green's death.
He believes rugby league in particular needed to do more for retired athletes.
"Medically, the way you're treated while you're playing it's first class, but you're not prepared for the real world when you retire," he said.
"We're trying to advocate for an annual brain, body and mind check-up. And I think it could have some magnificent results, some of the results will be invisible but it'd be a great way to honour the past.
"Just to help these former players become the best version of themselves post-career, we know the struggles that they go through."
He said the potential for CTE plays on the mind of retired athletes.
"I wouldn't say it's a fear … but in some capacity, [the possibility of having CTE] is on the mind of everyone that's played the game.
"And the important thing to remember is that we can do something about it, it doesn't need to become a self-fulfilling prophecy of 'I'm doomed'.
"Experts say to monitor your alcohol, look after your mental health, remain physically active, look after your diet, remain socially engaged, challenge the brain."
