How much progress are we making on concussion?

25 Feb 2016

Concussion is a hot topic at the minute, with Hollywood and Lansdowne Road the sources of the latest bout of worry. But is it as simple as saying sports are getting more dangerous?

In cinemas around the world right now – release date dependent – Will Smith is playing the lead role in a film called Concussion. You may have seen it. You may have read about it, heard about it on the radio or, quite possibly, you might know the story already.

In a nutshell, Smith plays Dr Bennet Omalu, a real-life physician from Nigeria who was the first to publish findings on chronic traumatic encephalopathy (a degenerative disease caused by multiple blows to the head) among NFL players.

He wrote his paper in 2005, with the long-term effects of concussion finally accepted by the NFL just before the end of that decade.

If concussion and American Football rings a bell, it might be to do with the death of Dave Duerson, a two-time Super Bowl champion who killed himself a few years ago by a gunshot to the chest, thus preserving his brain for science.

“Please, see that my brain is given to the NFL’s Brain Bank,” he wrote in a letter found by police upon his body’s discovery. The 50-year-old Duerson was sure he suffered from chronic traumatic encephalopathy.

Abstinence always beats protection

As it turns out, years of taking bangs to the head, even with protective equipment like helmets, shoulder pads and face guards isn’t great for the human brain.

Extrapolate that out a bit and think of other sports that see heads continually clatter into heavy forces. Hurling, boxing, mixed martial arts, horse riding, rugby, etc.

Occasional bangs to the head. Regular bangs to the head.

“If concussion continues at this rate, it’s too risky.
We need it a little safer”

But it’s okay, doctors are on the case now. Sports use more protective equipment now than ever. Players know, fans know, officials know, parents know. Or do they?

The University of Ulster recently published a report into how many concussions were logged in one season of schools rugby. In brief: more than there should be.

Earlier this month, a Leinster Schools Senior Cup match resulted in a ludicrous situation when the referee ordered a player from the field following a suspected blow to the head, with club representatives arguing the decision at the time.

Someone being ordered off the field for their own safety was argued against.

This, while a Six Nations tournament that has thrown up numerous concussion injuries already saw the topic of brain injuries dominate coverage of rugby. But is it right to lambast one sport?

Everybody is at it

A recent report in Vancouver found cycling to be the leading cause of sports-related concussion among youths. According to the American Academy of Pediatrics, concussions in kids aged eight-to-13-years-old have doubled and in teens they’ve risen 200pc in the last decade. This report looked at ice hockey, soccer, American football, baseball and basketball.

Cycling crash concussion

Two members of Team Lampre crash into a corner at Stage 4 of the 2009 Tour de France, via John Kershner/Shutterstock

The World Cup final in 2014 in Brazil saw Christoph Kramer cleaned out early on. He continued until half-time, though, asking his teammates during the game if he could play in goal, trying to swap jerseys with the referee at the break. Total disorientation.

“We know a lot more about concussion in terms of diagnosis and in terms of management,” says Ciaran Cosgrave, a consultant sports and exercise medicine physician at the Sports Surgery Clinic in Santry. “Management both in the short term and long term.”

There’s a weird culmination of forces happening at the moment, which has resulted in rugby being singled out as a barbaric sport that picks off players one by one, again and again, until one day there’s nobody left.

Rugby’s popularity in Ireland, in particular, has rocketed in the past 20 years. The sport went professional in the mid-1990s and, with Ulster landing the European Cup in 1999, and a plethora of young superstars emerging through the Irish youth ranks, crowds attending games swelled.

Peak practice

It’s at a peak now, meaning it’s garnering way more attention, way more scrutiny and, in the case of injury, way more concern.

Add to this the actual diagnosis of concussion – Cosgrave explains that “our threshold for diagnosing a concussion has massively reduced” – and you get the impression that injuries haven’t spiked, awareness has.

“Things we’re calling concussion now would never have been called concussion 10 years ago. If you’re twice as aware, you’ll have twice as many. It’s being picked up more now.”

“The doctors are ahead, the players still have to catch up. But that won’t take long.”

I ask Cosgrave if he feels a larger uptake in contact sports is something that should be of concern. “No,” he says immediately. “If you think about it, boxing, soccer, GAA, rugby and martial arts have been around for decades, always had people participating in them. The attention drawn to it has changed, though.”

So, with all that attention, and all this new information surrounding head injuries, what has a doctor’s role become? Well, far more tailored, it seems.

There’s no definitive test to tell you someone is concussed, explains Cosgrave, no blood test, no scan. That leaves people like him combining some related symptoms with clinical opinion.

“If someone is knocked out, that’s concussion by definition,” he says, but any bang to the head that causes “any accelerational, decelerational or rotational movement of the head or brain” has the ability to cause a concussion.

Doctors would look out for symptoms like headaches, dizziness, nausea or vomiting. Memory, orientation and balance tests would be undergone and, added to the medical professional’s clinical opinion, an assessment is made. The trouble here, though, is time.

Rugby World Cup 2015

The 2015 Rugby World Cup Pool D match between Ireland and Romania, via Mitch Gunn/Shutterstock

“Symptoms can develop almost immediately, some can develop hours later,” says Cosgrave. “It would be unusual for them to develop the next day, but it’s possible.”

This means that once there’s a bad knock to the head, any medical professional pitchside, courtside or whatever, is diagnosing against something that may not present symptoms anytime soon. A frightening prospect.

A risky time

“If concussion continues at this rate, it’s too risky,” says former Ireland rugby player Keith Wood. “We need it a little safer.

“There are far more clubs around nowadays, parents are bringing more kids to play. I’d like them to get the best coaching from a young age but that’s not always possible.”

Wood tells me that he thinks players were treated better in his day – he retired in 2003 – largely because, should concussion have been diagnosed, you were out of the team for three weeks.

“No question. Three weeks. I thought it was mad at the time, it was right though.”

This ignores the fact, though, that concussion in 2000 is not the same as concussion in 2016, in terms of definition.

“I’m hugely interested in all of this,” explains Wood, who works with Orreco now looking at how to use blood markers to predict injuries. “We’re getting more and more information,” he says. “We’re informed by so many more data sets.”

A traumatic experience

It’s the information that’s key. An exhibition at the Science Gallery in Trinity College, which closed last week, looked at the whole area of head injuries.

Called Trauma, one of its installations showed how various sports helmets deal with impact and how, over time, they crack and break. Beyond this, the pressure on the brain, even when the helmet holds up, is shocking.

Shocking, and making quite the impact.

“It was quite well timed,” says Jennifer Lorigan, lead mediator for Trauma. “With the Rugby World Cup and Six Nations – it’s made people a lot more aware of what rugby players and sports people put themselves through. Ticking the boxes, wearing the equipment might not be enough.”

Lorigan is particularly happy with the number of schoolkids who have seen the exhibit, and maybe now know just how risky head impacts can be. “At that age, you think you are invincible. Getting the message across, without being preachy, is really valuable.”

A changing world

Concussions used to be graded as mild, moderate or severe, explains Cosgrave, who says any knockout situation was immediately considered severe. But then, as doctors learned more, a problem emerged. Sometimes a clean knockout resulted in a faster recovery. Doesn’t sound as severe, does it?

“To treat it, we used to just rest it to get better,” says Cosgrave. “Now people think active recovery is better. Light exercise, balance exercises, manual therapy on the neck, mobility, work range and movement in the neck.

“Sometimes those that are knocked clean out recover quicker, not always, but it happens. Why? Nobody knows. We’re still learning.”


A fixture of sports helmets at the Trauma exhibit in the Science Gallery in Trinity College Dublin

One issue is the communication needed to diagnose – players need to be honest about how they’re feeling for any true assessment to be given – and another issue is that the knowledge is top down, and most sports people are at risk from the bottom up.

By that I mean the vast majority of those involved in a sport are amateurs, below the radar somewhat.

I swam competitively for a decade. Any change in rules came from the top. Any change in treatment came from the top. However, I, along with my teammates, were all at the bottom. We were the ones at risk immediately if something was up.

The same is true of rugby, GAA, soccer, etc. So even though education is better among players and coaches, it remains quite elitist.

Concussion: Players on board

“Players are more on board now, especially in the professional game,” says Cosgrave. “I find people hiding symptoms a lot less. If it does happen, it happens once. They get back too quickly and they can’t play right, feel groggy and then flag it in. They don’t make that mistake again.

“I think the pro players are almost better at calling things themselves than in the amateur game. Amateur is macho, pro guys know it’s serious. They have all the education, all the advice. The problem may be in the amateur game that they don’t have that education.”

Paul O’Connell, who spoke with Wood at an Accenture event in the lead up to the Six Nations, said medics are now ultra cautious, reacting to the slightest knock with 100pc concern. “The doctors are ahead in that regard, the players still have to catch up. But that won’t take long,” he said.

All this is playing out under the guise of rugby, the headline sport, front and centre all over the papers, TV and radio.

“One last thing,” says Cosgrave before we end our chat, “is other sports. The sports with the highest rates of concussion are equestrian sports. In horse racing, show jumping, etc, there are far higher rates of concussion than boxing or rugby. You don’t see a big campaign stopping people horse riding, though.”

It’s a fair point, and one that ties in with the narrative that we’re far more aware now, rather then more or less safe. But that’s not to say a sport that constantly pits head against head is a bastion of safety. More discussion is certainly needed throughout the whole world of sport.

And when you see the damage done to various helmets at the Trauma exhibit, it brings home just how broad this issue is. With information always increasing, though, maybe the future looks a little brighter.

Main brain MRI image via Shutterstock

Gordon Hunt was a journalist with Silicon Republic