Kirsten McLeod was on her way home from a VFLW game at Morwell, approximately 150 kilometres south-east of Melbourne.
Driving on the highway at 110 kilometres per hour, the onset of symptoms was sudden.
"I just lost all my vision," she tells ABC Sport.
With cars hurtling past her, McLeod did her best to blindly navigate her way from the right-hand lane to the emergency lane on the left.
"I was like, I've just got to try and wing it," McLeod recalls.
"It was honestly the weirdest, scariest thing.
Earlier, in the game against Collingwood, McLeod had landed on her head and neck.
Despite the feeling that something wasn't right, she managed to get through the rest of the game.
"It wasn't until I was driving home that my symptoms really started," she says.
Drafted by the Western Bulldogs at pick number 28 in the inaugural AFLW draft, McLeod is one of the league's most durable players.
An AFLW premiership player in 2018, she has played consecutive seasons of football for the past 17 years.
She is also a club favourite. In the year her team clinched the premiership, she won the coaches' award, while in 2020 she was the Bulldogs' most improved.
But 2021 was a difficult season for the forward, sustaining what she describes as "four or five head knocks" in the preseason.
"I [often] had to go and sit on the sidelines at training, because I was dizzy, had a headache, was feeling nauseous and all that stuff."
Despite the severity of her symptoms, however, McLeod was reluctant to report them to the club's medical team.
This includes the day she lost all vision on the freeway from Gippsland to Melbourne.
"Me being me, I didn't tell the doctors. I didn't tell anyone," she says now.
McLeod was particularly hesitant to disclose, she adds, because of the short nature of the AFLW season.
"We don't have a lot [of games] to play. We only have a limited time. Our seasons aren't long. So I was just like 'Man, I'm not saying anything.'"
Diagnosis of concussion relies on self-reporting
Shreya McLeod is a physiotherapist, PhD candidate at the University of Newcastle and lecturer at Australian Catholic University researching sport-related concussion.
Defining concussion, she says, is more complicated than might be assumed, and differs depending on the context.
Sport-related concussion is considered distinct from other forms of concussion, with the definition updated approximately every four years.
The current medical consensus is that sport-related concussion is a "mild traumatic brain injury... caused by a direct blow to the head, or an indirect blow to the body, which then transmits a force through to the head".
Perhaps contrary to common perception, it is only associated with a loss of consciousness in a minority of cases.
A big part of the problem with concussion, McLeod says, is that there is no "objective" way to diagnose it, with findings on CT and MRI typically normal.
This means that diagnosing concussion relies on athletes self-reporting symptoms, which presents several problems.
Firstly, athletes must be honest about what they're experiencing.
"Athletes may under-report their symptoms to not let their teammates down and risk missing games," she says.
McLeod, whose PhD involves video analysis of concussions sustained in the NRLW, adds that in this context, women in sport may downplay their symptoms.
This is further complicated by the fact that research suggests there are sex and gender differences in the types and severity of concussion symptoms.
Overall, says McLeod, women report more symptoms, for longer periods of time, with increased severity.
As she explains it, athletes of all genders report symptoms such as headaches, mental fatigue, concentration difficulties and mood swings, amongst others.
Men, however, report amnesia and disorientation more frequently, whereas women report symptoms such as migraine-like headaches and photosensitivity (sensitivity to light).
"But it's important to frame this in the context of women in the general population also having up to five times more likelihood of having a migraine-type headache," McLeod says.
"So in preseason testing, we would find that women who may have reported that they have migraine headaches often have greater symptoms post-concussion, if they're exposed to contact sport."
'It started to click … I don't think this is right'
In this context, Kirsten McLeod presents a textbook case.
Prior to sustaining in-game concussions, the Bulldog forward experienced a range of migraine-like headaches.
Afterwards, however, the migraines became more intense and frequent and would come on regularly while she exercised. She also experienced vertigo while running and would vomit after higher intensity sessions.
"It was really hard to figure out what was going on … [the club and I] were trying to sort out if it was my migraines, an issue with my neck muscles, or something to do with concussion," Kristin McLeod says.
"I think it started to click more [that it was concussion-related] when I was asking for Nurofen and Panadol before a game because I knew I was going to get a headache while I was running.
"I realised, 'I don't think that this is right'."
For McLeod, this was the turning point in her accessing the care she needed.
After presenting to a physiotherapist who specialised in migraines, she was eventually referred to see a neurologist, neurophysiologist and neuropsychologist.
At first, she tried incremental increases in the time and intensity of exercise, before graduating from non-contact to contact drills. But her symptoms persisted, and she returned to see the neurologist with a club doctor.
To McLeod's shock, the specialist recommended 12 months off contact sport.
"He did say to me that it was up to me what I did and he put it in a really good way," she says.
Nonetheless, McLeod decided she would give it one last shot at participating in the 2022 season.
"Me being me, I was like, 'I'll be fine. I'll get the tick off [to play] mid-season, I'll be sweet'," she says.
Also factored into her decision was the fact her contract was up at the end of the season.
"That's why I made the decision, I was just like 'no, I want to play, I've got to earn a new contract.'"
As a result, McLeod — who, like many of her teammates, caught COVID soon after her consult and spent two weeks in isolation — fronted up to training earlier this year in the hope of recovering in time.
After three weeks of training, however, and just before the first round of the AFLW season, a letter arrived from the neurologist to the club. It contained his advice that she take 12 months off contact sport.
"Because it was in writing, [the club] wouldn't ignore the recommendation," McLeod says.
"They need to do what's best for me, which is completely the right decision.
"And I have the full support of everyone as well, all the way from the top, from Ameet Bains [club chief executive] down. You don't realise how much support you have until you actually have something like this happen."
Nonetheless, McLeod was left shattered by the need to take the year off football — her first in 18 years.
"I experienced a lot of emotions that I probably hadn't before. I think I was shocked because the first time I saw the letter [from the specialist] was when it was placed in front of me," she says.
"Thinking about it now, it still upsets me obviously. But, yeah, it was like, I don't have to worry about putting my body on the line at the moment."
'Hard to separate the biological and political'
McLeod's ongoing problems with concussion place her into the approximately 10-30 per cent of athletes who experience ongoing and persistent symptoms.
In general, most adults will recover from a concussion in seven to 10 days, while evidence suggests that women can on average take six to 20 days longer than men to recover.
Any delay in presenting to a specialist can also significantly extend the time taken to recover.
However, as is too often the case in medicine, research on women's experience of concussion is sorely lacking.
This is what motivated Katherine Snedaker to found Pink Concussions, a not-for-profit organisation based out of the United States, which focuses on education and care for women and girls with brain injuries, including those sustained in sport.
She notes that while there is healthy debate about contributing factors, there are observable gendered differences in frequency of concussions and length of recovery.
"While we see gendered differences in most sports, it's most striking when the rules of the sport are the same, such as in soccer," says Snedaker.
"In those situations, you generally see two to three times the frequency of concussions for women."
The literature describes a range of possible physiological contributors, such as women's shorter and narrower necks, smaller head mass and differences in the corpus callosum (the large bundle of nerve fibres that separate the two hemispheres of the brain).
Shreya McLeod, however, provides a word of caution about drawing causal conclusions about differences between sexes.
"We don't really have the capacity to do a direct gendered comparison, because the rules may be different, even in the same sport," she says.
On this point, Snedaker agrees.
"The problem in sport is that women don't have access to the medical care that the men do," she says.
"When they walk off, is there a physio there? Is there someone to report it to? How long does it take to get to a doctor?
While both AFLW and NRLW have physios and doctors who watch out for players who may have been concussed, that is, resourcing is not equal across the men's and women's competitions.
For example, at AFL men's games played at larger stadiums, there are a greater number of cameras set up at grounds — including those available in the AFL's Score Review Centre (ARC) — giving clubs access to higher quality vision that can be used to diagnose and review possible concussions.
Another key difference is in the AFL men's and women's soft caps. The so-called 'soft cap' refers to the money available to clubs to spend on football department staff, including medical and fitness staff.
The larger soft cap available to men's teams means they can employ a greater number of staff and offer them full-time as opposed to part-time or casual positions.
"There's a huge gap [in men's and women's sport]," says McLeod.
In a written statement provided to the ABC, an AFL spokesperson said the "health and safety of all players, across all levels of football continues to be an absolute priority for the AFL".
"The AFL continues to commit investment into concussion research and management, including the official AFL/AFLW concussion guidelines which sees players sidelined for a minimum 12 days if they suffer a concussion," the statement says.
“At AFLW matches team doctors have access to Hawkeye technology to assist with reviewing of vision if required on collisions.
"There is [also] an independent doctor at every AFLW match that is funded by the AFL whose role is to support both medical teams as required, but particularly spotting concussion signs and supporting with management.”
Long-term concussion effects linger off the field
Having been moved to her club's inactive list for season 2022, Kirsten McLeod is in the unfamiliar situation of being able to focus on one of her two jobs: as a project coordinator for a plumbing business.
Her company, she says, has been supportive of her attending appointments to aid her recovery, even though her concussions have affected her ability to work.
"My boss sat me down, and was like, 'You need to sort this out,'" says McLeod.
"He said, 'I can tell the difference in you pre- and post-concussion.'
The impact on her work, says McLeod, has made her reflect on the difference between being a professional and part-time athlete.
"I was talking to [former AFL player] Jack Fitzpatrick the other day, because he was our midfield coach, and we talked about the differences between the AFL men's players and us. The men, that's their full-time job, so they get a concussion and they don't have to go to work. They don't have to worry about that.
"He said, 'You can't just say, 'I'm taking two weeks off [work], because they'd probably be like, OK don't come back.'"
Shreya McLeod says such impacts are typical of women in sport who have prolonged concussion symptoms.
"Many report overwhelming fatigue, exhaustion and difficulty coping with the demands of home, work, career and/or children," she says.
As a result, both Shreya McLeod and Snedakar would like to see specific guidelines drawn up to support women in sport to better recover from concussion.
"Until recently, most of the research has been focused on the male domain," says McLeod.
Guidelines that have been drawn up specifically for men, she says, have then been applied to women's programs.
"We can no longer rely on male data that's generalised to the female population.
McLeod adds that athletes of all genders need support with education about the long-term impacts of concussion and the importance of prioritising their health.
"They have to be brave, to be willing to tell us and that's important. That's the message we want to give them, that we are looking out for their best interests," she says.
In sharing her story, Kirsten McLeod hopes other players will take concussion more seriously.
At the Western Bulldogs, she has led the push for further education about the impacts of concussion, including presenting to her teammates.
"I said to them, 'Being honest is going to be the best thing for you'," she says.
"As much as it sucks if you miss a game … identifying that you're not OK, you don't feel right, and telling someone about it could be all the difference."
