Playing with their hearts, and their heads

Lead
The NFL learnt an expensive and devastating lesson from concussion, but in rugby the same mistakes are being made and an horrific epidemic is coming down the tracks, writes Ewan MacKenna. 

Kevin McLaughlin is one of the lucky ones. He may not feel it this week as, at just 31, he’s lost his job, career and passion following another concussion in Leinster’s season opener, but his exiting of the stage was a case of medical experts telling his brain and body enough. Twenty years into the pro era of rugby, often built on players used as expendable parts thrown out when they no longer work, too often it’s the other way around. All in all, McLaughlin got out because he could, not because he no longer could.

Others weren’t so lucky. Back in February, Cardiff wing Rory Watts-Jones went for tests after both his family and girlfriend noticed worrying behavioral changes that are believed to have been brought about by repeated head trauma. At 26, he was forced to retire but to what kind of future? This summer, after 17 seasons with Gloucester, Andy Hazell could take no more after admitting that he’d “see stars” in training and that “I’d be standing at the back of the line-out thinking this is like I’m actually dreaming”. And just this month former Wales international Jonathan Thomas had to quit after developing epilepsy. Yet despite the evidence, there are those playing on.

Indeed last weekend, Jamie Cudmore lined out for Canada against Ireland. This, after a summer spent on his sofa in pain and in worry. “I had all kinds of symptoms: headaches, being very irritable, tired when you shouldn’t be tired, then being really tired and not being able to sleep,” he noted. “That was really bizarre, just lying down and closing your eyes and not being able to sleep. It was very scary.”

Dr Barry O’Driscoll, a second cousin of Brian, tried to warn this would happen. But having been a member of the medical committee of the International Rugby Board (IRB), he quit in 2012 over the introduction of the five-minute rule whereby doctors had just 300 seconds to test for concussion. That has now changed to a 10-minute rule – although many argue you get transient symptoms which settle down and the most common time of presentation after that is between 10 minutes and four hours. Meanwhile independent doctors now check players away from pitchside – crucial as studies show occupational health doctors subconsciously tend to veer towards the company no matter their ethics. But O’Driscoll is adamant nowhere near enough is being done.

Toulouse

“I’ve spent a long time on it now, and nothing has happened over the time since to confirm anything other what I felt back then. While we’ve exceptions like Thomas and Hazell developing issues early, a crucial point is are we going to wait before we act? There will be a reservoir of players from the last 20 years whose symptoms aren’t going to appear for another 10 years. Do we wait for that to happen and let players play in the present with no real changes or do something now?”

For the moment, it seems world rugby made up its mind on that and we’ll have to wait to see some of today’s heroes degenerate into tomorrow’s inconvenience as if war veterans in the wilderness. That’s because of what the sport is still allowing to happen. It was just last year that New Zealand lock Craig Clarke had his career ended at Connacht but only after his 10th concussion in less than two years. George North stayed on after being knocked unconscious against England in the last Six Nations, bringing his total to four head blows in five months. Meanwhile Johnny Sexton, Mike Brown and Kieran Read have had to sit out extended periods.

Little wonder that, after a long career of being a crash-test dummy as well as a genius, when asked if he was worried how his son Brian would be in 20 years, GP Frank O’Driscoll responded, “Absolutely. It’s horrible to watch. The time against France [in 2012] when he talked his way back on to the pitch… that was outrageous, it was nonsense.” Even less wonder that Professor John Fairclough and Wales legend JPR Williams — both orthopedic surgeons — issued dire warnings for top players.

Willie Stewart, a consultant neuropathologist at Glasgow’s Southern General Hospital and an expert in head trauma, has closely studied the effects of Chronic Traumatic Encephalopathy (CTE), once and perhaps more strikingly known as punch-drunk syndrome. “In the past concussion was thought of as your brain misfiring and then going back to normal but it’s clear at a cellular level your brain has been damaged,” he explains. “It’s not the kind of damage that would show up on a brain scan but it is the damage that, if I get a person’s brain, I can see it down a microscope. The fine fibres, or cables, that connect all the parts of your brain and let messages flow freely become stretched and damaged.

Drico

“They no longer pass a message as quickly as they should. So your brain is trying to get you to stand but the message isn’t getting to your legs. Or you’re trying to remember but just can’t. And the brain isn’t a good organ for healing. Cumulatively if you’ve several of these injuries on top of each other, it’s not just permanent damage. It’s damage that gets worse so your brain degenerates and that leads to memory loss, headaches, personality change. What we don’t know is how many might be affected by that.”

On Monday night, Stewart was seen on BBC’s Panorama investigation into the issue. He expected it would make waves but when he got to his computer on Tuesday and checked his emails, there was a tsunami from former players who’d never never understood what might be wrong with them and presumed it was personal rather than sport related. But the sport should know better after what’s happened its cousin across the Atlantic. In Boston, founder of the Concussion Legacy Foundation Chris Nowinski had access to the brains of 91 deceased NFL players. Of those, 87 were diagnosed with CTE. The league spent years denying any link but the NFL now expects 6,000 of its near-20,000 retired players to suffer from Alzheimer’s or moderate dementia.

The individual cases show the reality behind such numbers. Cases like Jovan Belcher who killed his girlfriend before going to the Kansas City training facility and shooting himself after suffering CTE. Cases like Junior Seau who put a bullet in his chest after suffering the same chronic brain damage following a hall-of-fame career mostly with San Diego. Yet in July, world rugby released findings from a long-term study of 485 men including 131 professionals claiming no definitive link between the sport and long-term cognitive health problems. The study’s lead researcher, Professor Patria Hume, said such a claim “irresponsible”.

Very irresponsible when you consider Hayden Smith, a tight end for New York Jets before joining Saracens, said the collisions in the two sports feel “similar”. And that research has shown that not only do NFL players play less – with the regular season lasting just 16 games – but there’s a higher incidence of concussion in rugby matches too. As Stewart notes, American football sees a three-to-four fold increase in the chances of dementia and he expects rugby to be similar.

NFL

“Have they acted fast enough?” he asks. “I’m not sure. They’re talking about possible rule changes after a review of injuries some time after the World Cup. American football, faced with a similar situation, introduced rule changes and could see a reduction in the problem. I’m not sure it takes months of inquiry to spot what we already know. Now I see players that clearly have symptoms of concussion and should be got out, they are being taken off, tested and returned. That player has got a brain injury! His brain is injured! But the subjectivity of tests makes it pretty weak. The sport is hoping it’ll turn out to be nothing but I’ve seen the cases, I know it’s very real and at a reasonably high level.”

As of now that test, known as the head injury assessment (HIA), involves a symptom checklist, a cognitive assessment an a balance evaluation. Yet in Ireland’s World Cup warm-up game against England, Conor Murray was knocked out and according to Joe Schmidt passed the HIA even though Irish medics stopped him returning to the field. But there’s an even more troubling issue. They keep it quiet but according to the IRB’s own set of protocols anyone suspected of concussion must come off and stay off with no test carried out. But if you need to take a person off for a test, then there’s surely already suspicion. This is contradiction involving people’s health and puts doctors in a dangerous grey area.

So with reported concussions doubling in five years and one UK expert claiming that, on average, one player at every Six Nations match suffered a brain injury, what can or must rugby do?

“Firstly you’ve got to keep a guy off if there’s concussion and you’ve to go rigidly with that,” says Barry O’Driscoll. “Secondly, they are talking about tweaking the tackle, maybe below the nipple line but it will only marginally help. The problem is rugby is a huge commercial entity and if you dominate physically you usually win. And a big part of the attraction is the huge hits and there’s not a lot they can do without seriously affecting the attraction. Thirdly, you’ve to cut contact in training and, on that, players are playing too much but again cutting that has commercial implications. That’s the worry, factors other than player welfare are undoubtedly in play.

“But crucially they’ve to keep players fully informed and also, as this isn’t just an elite game, they’ve to keep parents fully informed about what can happen to a small percentage. We don’t know that percentage but we need to say kids will in future years develop, due to multiple concussions, anxiety, depression, cognitive defects, memory loss, epilepsy and early degenerative disease of the brain. There’s huge research in America but still so many unknowns. And in the meantime, children with mild concussions, they are physically fatigued, memory function is hugely affected for weeks, maybe months, and they are taking exams in school and so on. We have to let everyone know. The NFL hid it but we’ve to be open and say ‘Here are the facts and risks, now you go and choose.’”

Otherwise there may be a huge price to pay for world rugby. But not as big as the price already being paid by many of its exponents and the price far more will pay long into the future.

Sunday Business Post
25 September, 2015

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