The Fragile Mind
MINDGAMES HOW WE STOP CONTACT SPORT FROM STRIKING A FATAL BLOW
As we learn more about the link between head trauma and brain damage, contact sports have returned to the spotlight. Those crash tackles, headers and right hooks could be putting people in more danger than previously acknowledged. And while competitors’ physiques are growing more powerful, our brains remain as vulnerable as ever. Are we playing games with our lives?
Around the world, a network of laboratories is stockpiling and studying the brains of dead athletes. There are thousands of them: some were donated in wills, a small number in suicide notes and many more by bereaved families searching for answers. In life, these brains belonged to footballers, boxers and NFL stars; cyclists, martial artists and rugby players. In death, they are pieces in a puzzle.
The neurologists who scan and dissect these brains are looking for damage and abnormalities that may have been caused by head impacts in sport. They want to know how prevalent these injuries are, and how a collision on the field of play can lead to lifechanging symptoms in the short term, or a neurodegenerative disease over time.
On one level, it’s a question of simple physics. The battle of brain and brawn isn’t a fair contest, at least not on the sports field. You can make your muscles bigger and stronger, so they can better withstand the artillery of modern contact sports. You can’t do that with your grey matter. The more physical athletes become, the greater the forces they’re able to exert on themselves and their opponents. The punches are harder, the tackles are heavier – but the brain is as fragile as it ever was.
What causes problems isn’t necessarily the blunt force in itself, but how it causes your brain to move inside your head. Each impact has the potential to rattle your skull and cause a physical injury that’s as visceral as a torn hamstring. Rotational forces can warp your white matter. Your neurons twist and stretch and shear.
At a microscopic level, your brain tissue can come apart at the seams, and damaged blood vessels spill proteins that can be toxic when they gather in the wrong places. Most of us know the catch-all term “concussion”, but neurologists prefer TBI, or “traumatic brain injury”.
Growing Concerns
“I have a bit of a problem with [the word] ‘concussion’,” says Dr Willie Stewart, a neuropathologist who runs the Glasgow Brain Injury Research Group, one of the labs that examine the brains of ex-athletes. “It’s used by some quarters as a kind of soft and cosy word that belies the seriousness of the issue. We’re talking about people whose brains have been injured.”
A decade after the NFL squared up to a head-injury crisis in American football, British sport is having its own reckoning with concussion. Football and both codes of rugby are under pressure to bring in reforms that better protect players from long-term brain disorders, as well as catastrophic short-term injuries. Though the chorus of concerned voices is getting louder, some think that the governing bodies are still in denial.
The numbers should be a wake-up call. Stewart’s research into Scottish ex-footballers found that they are three and a half times more likely to die from dementia than the general population. It’s arguably worse in rugby. More than one in five professionals in England will be concussed this season, the legacy of a sport that has become significantly more physical since rugby union went pro in the 1990s. In the past 30 years, the number of tackles made per game has more than doubled. A group of former players is currently taking legal action against the game’s governing bodies for the post-concussive symptoms they now live with, including early-onset dementia. One of them, former England international Steve Thompson, can’t remember winning the World Cup in 2003.
“More and more players in different sports are coming forward,” says Luke Griggs, deputy chief executive of Headway, the brain injury charity.
“We are potentially seeing the tip of the iceberg here. Everyone involved in sport needs to fully understand the short- and long-term risks associated with head injuries, particularly at grass-roots level.”
It’s not just World Cup competitors who are in danger. Every weekend
(pre-COVID, at least), millions of amateur sportspeople pull on their boots. They trade punches, compete for headers and wrestle each other to the ground. Neurologists warn that you can’t extrapolate what happens in the elite game and apply it to amateur sport, but it’s also true that there are perils on a soggy community sports field that don’t trouble athletes at the country’s biggest stadiums.
Refereeing standards, for example, are generally lower at the amateur level. There may be no professional linesmen. And contact sports can be more brutal when there aren’t TV cameras or a TMO (television match official) to keep players honest. Tackling or heading technique may not be as good, either.
Head injury protocols do exist at the amateur level – indeed, they’re far more stringent than those for professionals – but whether they’re properly applied is disputed. Small squad sizes can lead to players returning from injury sooner than they should, or playing through pain because there isn’t a substitute to take their place. Then there’s the lack of pitch-side medical support: maybe a St John’s ambulance, if you’re lucky.
Collision Course
Another problem – at all levels – is an athletes’ bloody-minded will to compete. Their enthusiasm to place their bodies on the line in the pursuit of sporting glory and peak performance puts their brains at risk of becoming collateral damage.
“Sometimes, what we see is that players go through all of the return-toplay protocols [without issue]. Then they get to the next match and, after the first contact, they come to the sidelines and say they feel terrible,” says Dr Richard Sylvester, a consultant neurologist at the Institute of Sport Exercise and Health, in partnership with HCA Healthcare UK. “It turns out that they haven’t been feeling great all week but haven’t been reporting their symptoms.”
Sylvester sees the fallout in specialised concussion clinics that he runs for athletes. He has scanned the brains of more than 500 rugby players and has noticed the same symptoms in both professional and amateur athletes. “The difference is that, at the professional level, they have access to medical care with expertise from day one. At the grass-roots level, I probably see people a bit later,” he says.
Symptoms vary depending on the severity of the injury. The majority of people who have small, one-off concussions recover pretty quickly. “People get very confused, their behaviour is altered, they feel slowed down and drowsy,” Sylvester says. “Usually, those symptoms settle down within days to a week or two.”
Players with more severe injuries may suffer a collection of additional symptoms, which are loosely grouped together as post-concussion syndrome. There is more confusion, dizziness and migraines. Speech may become slurred and short-term memory affected. Patients often suffer migraines, anxiety and sensitivity to bright lights. Their families might notice mood and behavioural changes.
There are more than 50 symptoms of concussion to look out for, but it’s notoriously difficult to diagnose. A mild brain injury and a severe one can look indistinguishable, and players may not exhibit any symptoms until hours after an injury. Some estimates even suggest that sports concussions are chronically under-reported, with five brain injuries sustained for every one that is reported and treated.
“People get very confused, they feel drowsy, and their behaviour is altered”
Lasting Impact
It’s not just the trauma of a single lightsout impact, or several. Researchers such as Stewart believe that sub-concussive hits can also cause lasting damage to the brain. The effects of every header, every jab that evades your guard, or every crash of hitting a ruck – all the little knocks that sportsmen take on the chin – can accumulate in the brain and increase your risk of neurodegenerative disorders such as Parkinson’s, dementia and CTE.
The last of these – chronic traumatic encephalopathy – is a disease that is
specifically associated with repeated head impacts. It’s found in war veterans who have sustained multiple blast injuries and psychiatric patients who bang their heads against the wall. Once, it was found in the brain of a clown who had repeatedly been fired out of a cannon.
And neuropathologists keep finding it in athletes who played contact sports for a prolonged period. Long observed in the brains of boxers, it was recognised in NFL veterans around the turn of this century. More recently, it has been discovered in the brains of hockey players, mixed martial artists, rugby players and footballers – always post-mortem, in labs such as Willie Stewart’s in Glasgow.
Before death, CTE causes many of the same issues as other progressive brain diseases – for example, memory loss, confusion, impaired learning ability and poor judgement. It increases your risk of dementia by two to four times, and there are also reports of significant changes to behaviour. As with other disorders, it can also alter your sense of who you are.
Research by the charity Headway found that 70% of brain injury survivors consider themselves a completely different person afterwards. In CTE specifically, erratic behaviour and aggression are not uncommon. Depression and suicidal thoughts can stalk victims. Contentious but widely publicised cases have even linked CTE to tragedy and violence.
Dr Chris Nowinski is a former WWE wrestler who retired with post-concussion syndrome in 2003. Today, he is the CEO of the Concussion Legacy Foundation and co-founder of the Boston University CTE Center.
“The third brain I ever procured for research was my colleague Chris Benoit from the WWE, whom I’d known for five years before he killed his wife and son and then himself. He’d confided in me that he’d had more concussions than he could count,” Nowinski says. “He had severe CTE.”
The brain of former NFL star Aaron Hernandez was studied at the same laboratory in Boston. Like Benoit’s, it had severe CTE. And, like Benoit, Hernandez killed himself and others. He was found dead in his prison cell in 2017 while serving a life sentence for the murder of a semi-professional American footballer.
The idea that CTE can drive somebody to homicide or suicide is speculative and extremely controversial. However, Nowinski says, cases keep appearing. “I spoke yesterday to a man whose father had – at my age,
42 – killed his wife and himself. We were discussing whether or not he had CTE, because he was a long-time contact sport athlete.”
Risk Assessment
So, it seems a lot to risk – not just the personality changes but all of it. The headaches and memory loss, the mental health issues, the spectre of dementia. Every sportsman accepts that when they hang up their boots, there will be aching muscles and niggling injuries – but most of us assume that these will take the form of dodgy knees and sore shoulders, not malfunctioning brains.
But risk is a difficult thing to judge. It’s important to remember that, for all the noise around concussion, researchers believe that it will just be a significant minority who suffer the worst consequences. They also believe that professionals are at a greater risk
than amateurs, who generally don’t train as often or play for as many years.
Think of it in terms of dosage. Perhaps concussions are like cigarettes, and the more you have, the worse the outcome. “The hope is that because amateurs are likely to have other jobs and so on, they won’t be exposing themselves to as much risk, or as many impacts during the week,” Stewart says. “It’s just the weekend game-day exposures. We hope that’s what we’re dealing with.”
The dose effect is also the rationale behind calls for reform in football and other sports. If you ban heading in children’s football, you remove a significant portion of the head impacts that each player will take in a lifetime. If you limit the amount of contact training in rugby, you cut out a large number of concussive and sub-concussive hits, just like they did in the NFL a decade ago.
Some argue that it’s not just the rules of contact sports that have to change, but also the culture around them that glorifies brutal tackles and savage knockouts. This is what cheers players on as they crash head-first through one collision after another. It’s what wills a boxer to stagger to his feet, beat a 10 count and battle on when he lacks the basic motor skills to raise his gloves.
There’s a line somewhere between celebrating toughness and unwittingly fetishising brain injuries. Are we sure where that line is? Or are we going too far the other way, attempting to sanitise sports that nobody wants to be genteel?
Professor Mike Loosemore is a consultant in sport and exercise