De­fin­i­tive treat­ment for con­cus­sion still for de­bate

Sym­po­sium hears US ex­perts take issue with model ad­hered to by IRFU

The Irish Times - Monday - Sport - - Rugby - Gavin Cum­miskey

A fun­da­men­tal dis­agree­ment in how brain in­juries should be treated ex­ists be­tween lead­ing US ex­perts and what was agreed at last year’s in­ter­na­tional con­sen­sus con­fer­ence on con­cus­sion in Ber­lin, Ire­land’s sec­ond Na­tional Con­cus­sion Sym­po­sium was told on Satur­day.

The IRFU builds its ed­u­ca­tion pro­gramme for play­ers, coaches and par­ents – us­ing World Rugby guide­lines taken from Ber­lin – on four pil­lars: Stop, In­form, Rest, Re­form.

“Rest in the case of con­cus­sion can in many cases ex­ac­er­bate the prob­lem,” ex­plained Dr Micky Collins, ex­ec­u­tive di­rec­tor at Univer­sity of Pitts­burgh Med­i­cal Cen­tre (UPMC), a renowned fa­cil­ity for treat­ing sports-re­lated con­cus­sion.

“Ber­lin stated in red that ‘pa­tients can be en­cour­aged to be­come grad­u­ally and pro­gres­sively more ac­tive,’” added Dr An­thony Kon­tos, UPMC’s head of con­cus­sion re­search. “That’s new from the last time. Fi­nally, they are say­ing you can be ac­tive but then they threw in this ‘any ac­tiv­ity that brings on symp­toms’ shouldn’t be used.

Pro­vokes symp­toms

“So, ex­er­cise, be­ing ac­tive, cog­ni­tive ex­er­tion, all of that, lit­er­ally gets thrown out with the bath wa­ter, so to speak, be­cause it is ex­posed re­cov­ery, which means you have symp­toms – but isn’t that how ex­er­cise works? It pro­vokes symp­toms, tears the sys­tem down a lit­tle bit then we re­cover and build the sys­tem back up. That’s what we are do­ing with con­cus­sion therapy.

“We know rest can have neg­a­tive ef­fects on mood,” Dr Kon­tos con­tin­ued. “It can ex­ac­er­bate symp­toms. We can’t just say rest or be ac­tive – we have to see what the per­son looks like when they walk into the clinic or how they are on the side­line.

“Con­sen­sus state­ments are nice be­cause they put a tidy lit­tle box around ev­ery­thing but they are ex­tremely po­lit­i­cal and tend to be not very progressive.”

The UPMC meth­ods of treat­ing con­cus­sions has been adopted by Dr Ni­amh Lynch at Bon Se­cours hos­pi­tal in Cork and by sev­eral GAA medics work­ing with in­ter-county pan­els.

How­ever, the Ber­lin con­sen­sus state­ment and UPMC ex­perts re­main in agree­ment on the lack of sci­en­tific ev­i­dence to link the de­gen­er­a­tive brain dis­ease chronic trau­matic en­cephalopa­thy (CTE) and con­cus­sion.

This stance, de­spite Dr Ann McKee, a neu­ropathol­o­gist, re­veal­ing 110 of 111 de­ceased NFL play­ers had CTE, sparked a de­bate be­tween Dr Collins and Dr Colin Doherty, con­sul­tant neu­rol­o­gist at St James’s Hos­pi­tal, dur­ing Satur­day’s sym­po­sium in Croke Park.

Pub­lic pol­icy

Dr Doherty: “I can see there is a con­flict be­tween what Ber­lin is say­ing and what [UPMC] are say­ing. I am com­pletely on board. I work with Eu­gene Wal­lace, the re­ha­bil­i­ta­tion spe­cial­ist in James’s and we don’t rest any­one. But as a par­ent I am ask­ing you: What are you say­ing to peo­ple about CTE? If you are in­vited to de­sign pub­lic pol­icy around CTE, what would you do?”

Dr Collins: “My re­sponse is that we need to make pol­icy based on sci­ence and un­for­tu­nately the sci­ence doesn’t ex­ist yet to guide us in terms of these is­sues. This is an evolv­ing area. There is clearly some­thing wrong but we don’t know if con­cus­sion is the only vari­able in some of the scary things we are see­ing.”

Dr Doherty: “I have heard that an­swer be­fore. The prob­lem I have, as some­one who is in­volved at pub­lic pol­icy level, it’s a bit like cli­mate change. When you are deal­ing with pub­lic pol­icy you can’t wait for the worst out­come. You have to make de­ci­sions that con­sider the worst out­come is pos­si­ble. Do­ing noth­ing is just not an op­tion. Say­ing we have to wait for the re­search to be com­plete; we are 20, 25 years from know­ing ex­actly what the re­search for CTE are.”

Dr Collins: “I’m just very mind­ful of hav­ing a con­ver­sa­tion that is bal­anced on this topic. We don’t have the an­swers of what the po­ten­tial long-term ef­fects are. I do take issue with you say­ing noth­ing is be­ing done. There is a lot be­ing done. It has taken 15, 20 years of work to have a lec­ture where we are com­ing up with ac­tive treat­ments for con­cus­sion. I think we have to be care­ful about how much fear is be­ing risen in the pub­lic.”

Dr Doherty, seek­ing to dis­pel any lin­ger­ing be­lief that scrum caps are a protective mea­sure in rugby, urged any­one coach­ing young play­ers: “It doesn’t mit­i­gate any of the ef­fects of con­cus­sion, and it makes play­ers more likely to feel safer.

“My son has had two con­cus­sions with the full spec­trum of dizzi­ness, feel­ing tired, drowsy,” added Dr Doherty. “I have a lot of fear about it. He is now 14. I am get­ting into a phase now where if he said to me ‘I don’t think I am go­ing to play rugby’ I would give a sigh of relief.”

The IRFU were in­vited but did not at­tend Satur­day’s event.

Con­sen­sus state­ments are nice be­cause they put a tidy lit­tle box around ev­ery­thing but they are ex­tremely po­lit­i­cal and tend to be not very progressive.

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