Concussion

1st December 2017

In a recent blog on the Glasgow Warriors-Leinster game in the European Rugby Champions Cup (A Tough Pool”, 23rd October 2017), I noted that, during the course of the match, four players left the field for Head Injury Assessments (HIAs). One of these – the Glasgow captain, Ryan Wilson – departed the scene under some protest and had to be restrained by the medical staff from rejoining the action. Even for a non-expert such as me looking on from a distance, it was clear that he was not fully aware of his circumstances and was suffering from some form of concussion.

Events within the last fortnight or so seem to have confirmed that most high-profile rugby matches – of both codes – include similar incidents. In the Rugby League World Cup quarter-final between England and Papua New Guinea in Melbourne, the latter’s star player, David Mead, received a heavy blow to the head after only a couple of minutes and took no further part in the match. England’s Kevin Brown similarly received a head injury a few minutes before half-time; he was allowed to continue until the interval – during which time he moved sluggishly on to a pass and dropped the ball – but did not re-appear for the second half. On the same day, in the rugby union international at Murrayfield, the Scotland prop forward Zander Fagerson was concussed against New Zealand and obliged to miss the following week’s match against Australia. In last Saturday’s Wales-New Zealand game, it was clear from the television coverage that the Welsh scrum-half Rhys Webb had been dazed after being tackled and hitting his head on the turf; play continued for some time afterwards, with Webb apparently recovering his wits and participating again in the Welsh attack, before he was taken from the field at the next stoppage of play. In the same match, the New Zealand centre, Ryan Crotty, went off for a HIA after 20 minutes and did not return. And so on…

It is widely agreed that these incidents are important not only because of the immediate injuries incurred by players, but because of the possible long-term implications for health and well-being. Indeed, such links are becoming part of the conventional wisdom: The Scotsman’s obituary of David Shedden, who died in October at the age of 73 after a decade-long battle against an aggressive form of early-onset dementia, noted that, in addition to his 15 Scottish rugby caps in the 1970s, he had suffered from no fewer than a dozen concussions on the field of play.

In the period since the Glasgow-Leinster encounter, I have read Truth Doesn’t Have a Side: My Alarming Discovery about the Danger of Contact Sports (2017)by Bennet Omalu.

Dr Omalu was the neuropathologist with the Allegheny County Medical Examiner’s office in Pennsylvania who conducted an autopsy on Mike Webster, a former American Football player with the Pittsburgh Steelers, who had died in September 2002 at the age of 50. He became aware of Webster’s post-career history of mental illness, memory loss, depression, disorientation and spontaneous anger episodes, but, initially, could not find the evidence of blunt force trauma on the brain that he had expected to see with the naked eye. Nor was the deterioration of Webster’s brain consistent with the dementia pugilistica that is seen in punch-drunk boxers. Instead, “many [brain cells] had died and disappeared and many appeared like ghost cells… [There were] spaces in the substance of the brain… like a partially demolished building stripped of its windows”.

Eventually, Dr Omalu concluded Webster’s decline and demise were the result of the brain disease Chronic Traumatic Encephalopathy (CTE) and brought about by the repeated blows to the head (concussive and sub-concussive) that Webster had incurred playing his sport. The wearing of a helmet had been irrelevant, in Dr Omalu’s view, because it had not prevented the brain bouncing around inside the player’s skull and suffering impact on the skull’s inner surfaces.

The fascination of Dr Omalu’s book is not only in the medical detective story that he presents – with its references to tau tangles and amyloid plaques – but in the broader circumstances in which he conducted his research and then presented his findings. He was born in Biafra at the height of the civil war in 1960s Nigeria and had made his way to the USA on a medical scholarship. After publishing his conclusions on CTE, he was widely attacked as an outsider seeking to undermine the sport that plays a central role in defining American society and culture. Perhaps naively, he was shocked by the counter-response, notably by some of the NFL franchises and the National Football League itself.

A feature film of Dr Omalu’s story, starring Will Smith, was released in 2015. Ironically, its title – Concussion – cuts across one of his central findings: that damage to the brain is done by repeated incidents of “mild” trauma as well as obvious concussions in which a player temporarily loses consciousness: “the fundamental issue is not concussions, but repeated blows to the head without or without concussions”. And once that damage is done, it is permanent and irreparable: “the human brain does not have any reasonable capacity to regenerate itself”.

I was interested in what the author had to say about rugby. Not surprisingly, he did not differentiate between the union and league codes, so one assumes that it is the former with which he is the more familiar. The references in the book are relatively brief, but still very clear: participation in other “high impact, high contact” sports, in which repeated blows to the head are prevalent, also increases the risks of CTE. Rugby is included in this list.

It is not only American Football and rugby, of course. With regard to soccer, there has been much media comment in the UK following the recent broadcast of the very good BBC documentary – Alan Shearer: Dementia, Football and Me. The medical researchers interviewed in that programme echoed an important point made by Dr Omalu: there is the potential for brain damage from repeated heading of the ball – as Shearer reckoned he used to do about 100 times a day in training – as well as from the clashes of players’ heads. A poignant episode in the programme was Shearer’s interview with his first manager, Chris Nichol – a robust and committed centre-half in his own 20-year playing career – who bravely admitted that his memory was “in trouble” and, on occasion, that he forgot where he lived.

It is clear that, across many sports involving physical contact, the authorities are increasingly conscious – if you’ll pardon the pun – of the potential long-term dangers of head injury. In rugby union, the HIAs procedures have been tightened up, though many medical experts would argue that they do not go far enough. The Football Association announced last month (jointly with the Professional Footballers Association, PFA) that experts at the University of Glasgow had been commissioned to conduct research on the incidence of degenerative neurocognitive disease in ex-professional footballers. In the USA, in 2015, heading a ball was removed from the soccer played by under 11s and heading practice limited for 11-13 year olds. (Dr Omalu would extend this ban to under 18s, given that the brain is still maturing to that age). The NFL has banned helmet-first tackling and has established new protocols for dealing with concussed players.

Although these developments suggest that a clear direction of travel is evident, it is also the case that there is far from unanimity about the linkages between sport-related blows to the head and the long-term health of the brain. (Part of the problem faced by researchers is that, currently, CTE cannot be diagnosed until after death). The counter-argument was made, in a soccer context, in another interesting recent documentary – Sky Sports’ Concussion: The Impact of Sport – in which it was noted that modern footballs are much lighter than the heavy rain-sodden leather balls of old and that, in any case, “there don’t seem to be hundreds of Jeff Astle cases out there”: a reference to the former West Bromwich Albion and England centre-forward, whose death in 2002 at the age of 59 was judged by the coroner to have been due to an industrial disease i.e. football-related. In turn, the short answer to that is that we simply don’t know how may “Jeff Astle cases” there are – a point acknowledged by the PFA chief executive, Gordon Taylor, in the Shearer documentary. An important aim of the FA/PFA-commissioned research will be to determine whether the incidence of long-term brain disease amongst ex-professionals is statistically different to that within a control population on non-players.

Where do we go from here? I find it very difficult to forecast what the sports of rugby and football (soccer) might look like in 10 or 20 years time. However, I think we can be reasonably confident of a number of things. First, there will be continued further lobbying for significant rule changes in many sports by some branches of the medical profession. In addition, parents will continue to pay close attention to activities that affect the well-being of their children (and, in large numbers, will prevent participation in sports that they judge to be too risky). We can also be sure that the lawyers will be painstakingly examining whether sports authorities and clubs are meeting their duty of care towards the participants of those sports.

And, finally, we can be certain that – irrespective of the perceived risks – many people will wish to continue playing “high impact, high contact” sports.

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