The second part of our collaborative series on concussion looks at the issue of repeated head knocks and how they may affect longer term health.
MEDICAL OPINION IS DIVIDED AS TO WHETHER THERE ARE GENUINE LINKS BETWEEN REPEATED CONCUSSION AND LONGER TERM HEALTH EFFECTS. GREGOR PAUL WONDERS WHETHER CONSENSUS WILL EVER BE REACHED.
Concussion may become a little bit like smoking. Some time in the future it may be almost laughable that there was ever dispute about the potential long term effects of repeated concussions.
That’s a scenario that is likely, but not definitely going to play out. If nothing else, logic, gut feel, common sense... call it what you will, points towards consensus being reached in the medical fraternity about the effects of repeated concussion.
There will be different views about the potential severity and probability of associated effects occurring such as depression, mood swings, lethargy or early on- set dementia, but there will be general agreement that anyone who suffers multiple blows to the head playing rugby, is most likely going to endure some kind of ongoing health consequences.
That time is still a bit down the track. And it is down the track, largely because there isn’t enough empirical data to be definitive. It may be that there never is – that there will always be research to divide opinion: that there will be a study capable of proving or disproving any school of thought.
Those inclined to downplay the link between repeat concussions and likely mental health problems and other medical conditions later in life, are rightly protective of the game. Rugby’s enduring
beauty is its ability be a microcosm of life. The core skills learned in rugby can be applied to any facet of life.
Rugby fosters teamwork, planning, selflessness, humility and cohesion. It demands players to challenge their inner fears, to push beyond their physical parameters to sacrifice personal ambition for the greater good of the team and it helps participants forge a phenomenal sense of belonging.
It is a game that requires strategy and physicality and what makes it all worthwhile is the element of risk that it carries.
There is no truer act of comradeship than risking injury to protect a teammate or to contribute to the bigger cause. History’s great moments always involve heroic figures who have been willing to sacrifice themselves.
But no one wants to think that the sacrifice will be much more than some bruising, torn muscles or the occasional broken bone. No one wants to think that the sacrifice may be a post- career of depression, memory loss, unexplained anger and extreme fatigue. No one wants legions of people put off playing rugby because the sports administrators focus too hard on the possible link between debilitating mental health and repeated head knocks.
There is a fine line to tread between making participants cognisant of the true extent of the risks related to repeat concussions and encouraging them to play hard and fair.
All Black doctor Tony Page rightly points out that rest homes in New Zealand are not full of former rugby players prematurely forced there because they have a variety of mental disorders linked to concussion.
Perspective is hugely important: players have to be safe but at the same time, there has to be players. There have to be people willing to evaluate the risks sensibly and still conclude rugby is not overly dangerous.
A great game could be ruined if a generation of mothers pull their kids out for fear of what might happen to their children when they get older.
Right now, the balance isn’t quite right. No one is advocating scaremongering, but, even in the absence of overwhelmingly conclusive research, few medics closely involved with the game doubt the probability of there being a link.
“Why is the brain different from the other organs..? I don’t think it is,” says Blues medic Dr Steve Kara. “But we don’t have the evidence where we can firmly stand there and say it [ long term damage] definitely happens. We think it happens but we need the research in rugby to be able to definitely say.
“But look, I think all of us are moving towards the point where we are pretty sure it does have an impact in the future and our management has to be with that in mind knowing that the evidence hasn’t really caught up in rugby yet.”
There are former, elite players in New Zealand who have suffered or who are continuing to suffer from symptoms that could be linked to them having endured multiple concussions.
It seems straightforward – the likes of former All Black Steve Devine, former Chiefs captain Craig Clarke and former Taranaki prop Shane Cleaver were all forced to retire early due to concussion and all have or at times continue to have episodes of poor health.
Their respective stories have a thread of similarity – much like that of former Kiwi and England centre Shontayne Hape.
The big picture is that all of them spiralled into a progressively worse condition as a result of repeated concussions. It appeared to take them longer to recover from head knocks and it also appeared that they would suffer concussion symptoms more readily. If it could be put this way – their heads became more fragile in that they didn’t necessarily have to be clouted all that hard for symptoms to take hold. Cleaver ended up telling the New
Zealand Herald: “From my experience it takes less of a knock to give more deterioration. In my experience that is true. I can’t think of an example where it is not. The risk of longer- term difficulties increases with each impact. You’re a few trees short of a forest and when you get older and the trees are naturally falling out, how many have you got left?”
It can’t, surely, be coincidence that players who suffer repeat concussions often present with similar long term complaints? The likes of Cleaver, Devine and Clarke have all suffered from headaches, nausea and sensitivity to light. They have all said they felt foggy, unnaturally tired and irritable at times.
It’s right to wonder how other factors such as genetics, lifestyle, alcohol and drug use may also have affected their health, but the consistency of their accounts and suffering is such that it’s hard not to assume it is the concussions they suffered that are the root cause of their medical problems now.
Player testimony is strong and convincing. But on its own, not enough to qualify as definitive evidence of a longer term link. It will take scientific research for the medical fraternity to form a more consistent view. And really, it will take specific research into rugby for opinion to converge.
In 2012 when some unexpected findings came out of Scotland, there was the usual divide: for those medics who feel there simply must be a consequence of repeated head knocks, Dr Willie Stewart’s findings were welcomed. For those less willing to see a path between rugby to longer term mental problems, the research was kept at arm’s length. Not dismissed as such but cautioned against being used to extrapolate wider conclusions.
Glasgow- based neuropathologist Stewart revealed he’d found evidence of a former rugby player suffering from early on- set dementia.
“We have known that in boxing for instance repeatedly injuring your brain can lead to a syndrome, punch drunk syndrome, and you can imagine what that is,” he said to the BBC.
“The pathology of that is better classified as dementia pugilistica and we kind of assumed it was only boxing related and you had to be exposed to a lot of concussive injuries. But what we’re seeing here and in America is that it’s happening in other sports where athletes are exposed to head injury in high levels.
“Those sports include American football, ice hockey and now I’ve seen a case in a person whose exposure was rugby.”
Those advising caution about reading too much into this one case, have a valid point. Dr Stewart’s discovery is not enough in itself to change opinions, but it is enough to highlight the need for more research. One thing for sure is that rugby can’t be reactive in finding out more about concussion.
Giant strides have been made in educating players, coaches and parents about the dangers of playing with concussion. Huge efforts are being made all the time to promote good practice in returning players with concussion to the field. The next stage of this journey to be safer is to have a better handle on the longer term consequences of concussion. As was revealed in the first part of this series, the number of concussions recorded in the professional game is increasing.
More players are being concussed and therefore the game has a duty of care obligation to find out what that could mean in time.
That research will be invaluable if correctly used. Players have the right to know what could happen to them.
In all probability, the true extent of players suffering from long- term, debilitating effects from repeated concussions may be minuscule in comparison with the number of people playing the game. The risks may be real, but it’s also likely that the chances of players being affected is remote.
The truth may be rugby’s greatest ally – a stick with which to beat the speculation that tends to over- hype the state of play.
There is also the example of the NFL as a salient lesson of what not to do from an administrative point of view. Almost 5000 former players have successfully taken a class action claiming they were kept in the dark about the long- term effects of concussion and poorly managing players who were affected.
Some of the plaintiffs have suffered early on- set of dementia; some have Lou Gehrig’s disease while more tragically there have been suicides of former players, linked to depression caused by repeated concussions.
If rugby doesn’t at least give the impression it is doing what it can to provide answers to the longer term questions, it could find itself in a similar pickle – something IRB boss Brett Gosper acknowledges.
“I believe that the class action in the NFL is based on two elements,” says Gosper. “The players don’t believe the NFL has created laws and infrastructure that are in the players’ interests: to protect the players and their heads in particular. The players can use their heads as weapons. “Secondly I believe from what I am reading that the other basis for the law suits is that things were kept from players as to the dangers of concussion. In both of those areas we do everything we can to ensure that our laws protect players and make sacrosanct everything to do with the head.
“The second area is education, education, education. We do our own research we make everything we know about the dangers of concussion as obvious and as visible to our players as we can. That is our role and our job and on that basis we believe we are doing the right thing in both of those areas. We don’t feel we are as vulnerable to a class action as the NFL are.”
They are probably not, but still, Conrad Smith, a qualified lawyer and victim of several nasty concussions, said last year in regard to a class action against rugby: “I could see it. I don’t know whether it would ever get as long as far as it did over there. We have the whole ACC thing so I don’t know how that would effect it.
“But it is obviously an area where a lot of work will be done. I don’t think it will go away in a hurry and nor should it. There is a lot to be found about it for all contact sports – not just rugby. I don’t think this will go away for a decade or so.”
Rugby can’t be accused of not taking concussion seriously – either in respect to managing current players or trying to determine what might be in store for those who used to play.
The IRB commissioned AUT to research the longer term health effects of playing rugby with specific focus on mental well- being and the findings were due to be released shortly after this issue went to print.
Professor of human performance at AUT, Patria Hume, led the research team and she says she is hopeful the project will further highlight the need for more studies to be done.
“Sir John Kirwan has raised the profile of depression per se. Mental health and depression is one of the potential side effects of concussion and that hasn’t had so much acknowledgement so there is a need for more investment in some research projects.”
But this raises two questions. The first is how much research will be required for firm views to be formed? How much evidence needs to be on the table before there is consensus that repeated head knocks do potentially lead to related mental health problems? New Zealand Rugby Union medical director Dr Ian Murphy says the difficulty of conducting research is significant given the variables that may contribute to longer- term conditions.
“Is there any other factor that contributes to this [ long- term effects of concussions]? We don’t know: there might be issues such as binge drinking, or performance enhancing drugs or underlying mental health issues.
“I think a definitive answer is a holy grail. The more I learn about the science of medicine as opposed to the art of medicine, the more I believe it is not so much about delivering black and white. It is about making the grey more white or more black. I am in no doubt that my role is to help us provide answers. We need to be cognisant of this issue and do everything we can to find meaningful science.”
The second question is related to the first – and if consensus is ever reached, what then? What will the game’s administrators do? Rugby is already doing what it can to appropriately manage current players. There are strict protocols and best management practice is largely applied in the elite game.
Ultimately players will make up their own minds about whether they are willing to keep playing if the research indicates a link to longer term health problems. All the rugby fraternity can do is make players aware – be honest, keep the risks in perspective and arm everyone with all the information that is available.
Freedom of choice is imperative but so too is choice with all the facts. It’s hard to know – but would someone such as Devine have retired from rugby earlier had there been powerful evidence to suggest he was endangering his longer term health?
All he can say is: “I have treatment now and if I look after myself I am 100 per cent,” he says. “I have endured an extensive amount of testing and my results are looking as good as they ever were and I’m now a full- time professional fire- fighter. I’m a very fit, competent individual but as to what my future holds... no one knows.
“I have concerns. There are reports that say it [ multiple concussions] will be all good and other reports saying they won’t be good. I’m not sitting around crying about it. but all I know it is too late for me. I don’t get caught up in it.”