Concussion issue big enough but now research links big hits with Alzheimer’s

Brain injuries expert’s published case on early onset dementia caused by rugby could effect management of head injuries

Sat, Aug 31, 2013, 12:25

Ireland’s Six Nations match against France in March of this year was compelling and curious in a number of ways, not least of all that the paths of Brian O’Driscoll and Luke Marshall crossed in the medical room as well as on the pitch.

Marshall suffered concussion, while O’Driscoll had stitches to a wound in his ear, suffered a dead leg and was also reportedly concussed.

He was bowled over by French prop Vincent Debaty and left the field before returning for the final four minutes.

Following the match Ireland winger Keith Earls enthused: “When you see a fella who doesn’t know where he is one minute and comes back on with his head all strapped up; he’s a true warrior,” said Earls. No question.

In the final Six Nations match against Italy, Marshall clashed heads with outhalf Paddy Jackson and was again forced out of the game.

Three weeks later the centre returned for Ulster’s Heineken Cup quarter-final with Saracens. He was concussed once more and subsequently ruled out for the rest of the season and not considered for Ireland’s tour to North America.

Concussion, like other issues such as drugs in sport and HawkEye, may be suffering from fatigue syndrome.

Rugby knows it’s there. They do the best they can. It’s part of contact sports and the best medical practices are followed. The IRFU, the Irish provinces and the International Rugby Board reiterate this time and again and last year the IRB council introduced guidelines on diagnosis, care and return-to-play protocols.

But the gravity of the problem was ramped up earlier this month when clinical research released by Dr Willie Stewart, consultant neuropathologist in Glasgow’s Southern General Hospital, made public what he believes to be the first confirmed case of early onset dementia caused by playing rugby.

A former player, Dr Stewart had believed for a long time there was a link but had no scientific proof. Then one day his phone rang.

“I’ve said for several years now that from what we know about American football and boxing there is absolutely no reason at all to expect rugby is immune from this disease unless they are saying that people who play rugby have a completely different brain to the rest of us,” says Dr Stewart.

“When a potential case came along my colleague was very quick to pick up the phone and call me to come and look at it.”

What he saw was a build up of abnormal proteins in brain cells, more normally connected to patients with Alzheimer’s disease. In this case, it was a deceased male in his 50s and the only link to head injury was through playing rugby.

Until the last decade, this pathology was thought only to be present in boxers. But the focus has latterly shifted to other contact sports.

“It’s the first link,” says Dr Stewart. “Colleagues of mine in Boston have looked at a youngster who played rugby but that youngster also played American football and so how much could we say?

“This individual, as far as we know it, is somebody whose exposure to head injury was purely through rugby and not through boxing or any other contact sport, so it represents the first, although I think it’s inevitable in these cases that it won’t be the last.

Alzheimer’s proteins
“We’re seeing Alzheimer’s proteins building up in the cells of these individuals and we expect to come across several more in the next few months.”

In rugby, the observable facts are that whatever kind of tackling is in vogue – high or low, single or double, hold them up, cut them down, aggressive or passive, there is no escaping the fact the head is a high risk area and the “hits” are part of the spectacle of the game that makes it appealing to both players and spectators.

Anecdotal evidence shows the players are interested in how heavy their tackles are and wear GPS monitors that can record significant amounts of material on movement, speed, distance and collisions.

After training they frequently download the readings to see how many Gs they pulled in their tackles.

In 2011, Ireland international hookers Bernard Jackman and John Fogarty retired from rugby because of repeated concussions. Jackman estimated he was concussed 20 times over three seasons.

Dr Stewart does not have the data yet to show what frequency or severity of head injury can or will lead to the build up of the dangerous proteins but in the US, researchers who have largely studied American football, put the figure at three concussions.

“We haven’t yet got to answering how many times you need to be hit,” says Dr Stewart. “However, our colleagues in America who are looking at American football suggest that three or more concussions does carry an increased risk of long term problems with cognitive brain function.

“Personally, I think that’s quite a low number. I think the number might be higher but I think it does put into context what we are talking about and that is it doesn’t take a huge number of concussions to potentially lead to long-term problems.

“We know to some extent that getting hit within a short space of time after a first hit is a more significant injury. It’s worse and will last longer.

“Whether we can say there is a frequency that people have to get hit to be at a risk, we just don’t know. You’re talking about a number and we don’t know. We believe it makes perfect sense to allow a long recovery after the first hit before exposing to the risk of another.

“At the moment they say a six or seven day turn around. I’d say that would be an absolute minimum.”

There is no data on the forces that players exposed themselves to 20 or 30 years ago, which is presumably when the 50-year-old man whose tissue was examined, was playing.

Those collisions were certainly less than the “small car crash” impacts prevalent in the modern game.

Researchers have started gathering data on the severity and frequency of hits at club level rugby.

“That data suggests you are looking at something that is not far off what you see American football, that is hard, frequent and significantly hits going in game after game,” he says.

Symptoms of dementia usually appear between 12 and 16 years after the career begins and include memory, speech and personality problems, tremors and a lack of coordination.

The rugby player examined by Dr Stewart was aged in his 50s and had early onset dementia. The number of abnormal proteins in a section of his brain was comparable to that of a young man who had suffered a “moderate to severe” head injury in an assault.

“Our American colleagues are seeing it in the majority of brains they are looking at in American football,” he says. “The figure is in the region of 60-70 per cent of the brains.

“In boxers it has been recognised for decades and is some like 15 to 20 per cent of people exposed to injury. I have no strong data but my suspicion is those figures are probably higher than in rugby.

If it were 20 per cent or 50 per cent or 80 per cent we would have known about it by now. But even if it’s low, even if it’s one per cent of people participating in rugby, by way of illustration, that’s one per cent of the players playing in a Six Nations.

“It may not seem very much but is a significant figure because that is one or two players who may go on and develop a dementia they wouldn’t otherwise have been exposed to. That is a realistic number.

“It could be less than that. It could be more than that. We are at the very early stages but I don’t think it’s as high as high as boxing and I certainly hope it is never as high as American football because that would be really frightening.”

Four minutes and 39 seconds into Australia’s third Test against the Lions this summer, 32-year-old flanker George Smith, fearfully smashed heads with Lions hooker Richard Hibbard and fell to the ground, senseless.

The flanker had to be helped to his feet and assisted from the field by two men, his left leg and left arm seemingly in spasm. Just over five minutes later, he was back on the pitch.

‘’It obviously affected me,” said Smith afterwards. “You saw me snake dancing off the field.

“I passed the (concussion) tests that were required within those five minutes and I got out there.’’

To the surprise and dismay of many watching the match.