Definitive treatment for concussion still up for debate

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.

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“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.