‘It’s traumatic brain injury, not concussion’

This past week the concussion conversation zeroed in around the acronym HIA. Two medical experts – Dr Barry O'Driscoll and Dr Willie Stewart – believe that will inevitably change to CTE.

This has already occurred in American sports, primarily the NFL. The film Concussion, starring Will Smith, about Dr Bennet Omalu, who discovered and so named Chronic Traumatic Encephalopathy, following autopsies of a number of deceased American football players, is released in Ireland next month. Expect some shocking revelations about brain injuries from the viewpoint of a forensic pathologist's slab.

Dr Stewart, a leading expert in forensic neuropathology and traumatic brain injury (TBI), was asked whether he has come across any examples of CTE from deceased rugby players.

“Yes,” Dr Stewart replied. “Undoubtedly we will see more. And undoubtedly there have been many already, just not diagnosed in life or after death. And undoubtedly there are many more currently living with a diagnosis of dementia of another type, but who have CTE.”

Both Dr Stewart and Dr O’Driscoll, the former Ireland international who retired from World Rugby’s medical board in 2014 due to his dissatisfaction with its approach to concussion, believe the horrors experienced by NFL players and their families will eventually visit rugby players.

What has further muddied the waters about concussive blows in rugby is the Head Injury Assessment (HIA). If a player passes HIA 1, a series of questions pitch-side or in the changing-room in those immediate minutes after sustaining a blow to the head or suffering a potential concussion, they do not have to follow World Rugby’s return to play protocols. They can also return to the field of play immediately.

This is not about Johnny Sexton but unfortunately he is, yet again, the catalyst for a deeper conversation about concussion in rugby following his HIA, which he passed, during Leinster’s defeat to Wasps last weekend.

‘Ready to go’

Ireland coach Joe Schmidt has reiterated that the 30-year-old did not sustain a concussion – despite a clash of heads with Wasps centre Brendan Macken.

“Johnny’s fully fit and ready to go,” said Schmidt on Wednesday. “He’s done HIA 1, 2 and 3, and passed all three. That’s the protocol. It was this time last year that the problem really arose and he had the [12-week] break. Since that time he hasn’t really had too many problems. He’s had a few injuries, not head injuries at all. As far as we are concerned and as far as Johnny is concerned he is very keen to be ready to go in 11 days time [against Wales].

“All we can do is go on the best medical opinion and he had two of the best guys that are around make some decisions for him last year and have followed up since then. When they give him the all-clear then we have a lot of trust in them.”

1. Despite recent education and new protocols introduced by World Rugby, is rugby inevitably going to face a full-blown crisis with concussion?

BOD: Yes. However, the crisis may not manifest itself for some years to come. They have not been honest with their professional players, and this has reverberated through the game. Some of the experiments at the elite level (part of the new protocols referred to) have been misleading and dishonest. The reassurance that World Rugby gave to their players, stating that the pitch-side suspected concussion tool was safe and world-best practice, was simply not true. This may well come back to haunt them.

WS: All sport is facing the same issue, changing a mindset of concussion being a trivial injury to acknowledging concussion is anything but trivial, and for some it can have lifelong consequences. Rugby is under particular attention as the concussion incidence is recognised as high in comparison to most other sports, higher even than American football. Undoubtedly, if rugby is to avoid the crisis faced in American football, and before that boxing, then it has to act to reduce concussion incidence.

2. Does the brain, following a head clash, whether it is termed a concussive blow or not, have the capacity to heal itself?

BOD: In the majority of cases yes it does, but not all. The functional change to the brain caused by interference with oxygen, glucose and electrolyte metabolism, as far as we know is temporary. However, it now also seems extremely likely that there can be structural damage, ie change to the actual nerve tissue, which will not regenerate. What we do not know is which individuals will be affected and for how long.

WS: It depends on the definition of "heal". If you mean repair, the answer is no, to any great extent anyway. If you mean "recover", so get back to normal (or near normal) function, the answer is yes, but the capacity of the brain to recover may be limited, so cumulative injuries may eventually overwhelm this recovery and lead to permanent impairment.

At issue is, what is concussion? Popular definitions talk of a “functional” disturbance in the brain, implying or stating there is no physical damage to the brain. This is incorrect. The brain is damaged in concussion in a number of ways, perhaps the most significant injury being to the fine “wires” or axons coursing through the white matter of the brain.

3. The current Head Injury Assessment (HIA) of a player happens three times – pitch-side, same day and within 36 hours of the suspected injury – and if a player passes each one he avoids the return to play protocols. Is this a flaw in the system?

BOD: The Head Injury Assessment is totally flawed. It is designed for players who have no signs, no symptoms or no suspicion of concussion. Who are these players? The reason they go off for this test is by definition that there must be a suspicion. If there is a sign, symptom or suspicion, the regulation is that the player does not have a HIA. He stays off and goes through the graded return to play (RTP) procedure. This ridiculous situation is putting doctors under huge pressure and at risk. World Rugby has already threatened the doctors with disciplinary action. For what? Not being able to distinguish between possible and suspect.

WS: No. If anything it is a flaw in the way concussion is diagnosed. Still, in the 21st century, diagnosis of this brain injury rests on largely subjective assessments. In other words it is an opinion-based "diagnosis", and in any one player, one doctor's opinion could be quite different to another's despite running the same tests. This is equivalent to winding the clock back before blood tests and tracings for heart attacks and basing diagnosis of myocardial infarction on a story of chest pain and a doctors opinion only. But we haven't been that backward in managing heart attacks for decades. There are promising objective tests on the horizon to make decision making in concussion less subjective and opinion based. Rugby (and all other sports) need to work to see these developed and into practice.

4. What is the difference between a head injury and a concussion?

BOD: A head injury may be a laceration which may not necessarily lead to suspected concussion. A concussion does not necessarily have to be caused by a head injury; it can for example just be caused by a tackle. Concussion may be caused either by a direct blow to the neck or face or elsewhere on the body with an impulsive force that is transmitted to the head. This is because concussion is due to the acceleration, deceleration and rotational forces on the brain – a soft mass surrounded by fluid inside a rigid casing (the sponge in a bucket effect).

WS: In common, they are both unhelpful terms. And neither tells the story of the diagnosis. A bit like the chest pain analogy above. Chest pain could be anything from insignificant indigestion to life threatening myocardial infarction. We need to move away from "concussion" to what it is: "traumatic brain injury".

5. Are rugby’s return to play protocols effective enough to protect a concussed player?

BOD: The minimum six-day RTP is probably as good as we can do at the moment. However, I believe that with the ever-increasing research knowledge, this may well need to be extended.

WS: If we're honest, current return to play protocols at elite level (back in six days) are not adequate in any sport. Here we are back to the problem of opinion over science. Current opinion in sport is that most players more or less cope with that protocol, so it should be okay to run them all through it. And, as an aside, on that basis it is no surprise the "graduated return to play" protocols has players back inside the typical turnaround for next game day. However, there is no sound science to back that up. And what data there are looking at evidence of injury and recovery would seem to support this being too short a time. When we are talking injured brains, which we each only get one of and can't replace, what's the rush?

6. Would you suggest another approach?

BOD: At the moment we have no definitive HIA which rules out concussion. If you are concerned enough to perform a HIA, the player should stay off and enter the RTP protocol. Again, this will have to be assessed at frequent intervals to improve the safe approach.

WS: Be more scientific. Look at current and emerging research data on TBI recovery. And treat each player individually.

7. Should “concussion,” as a term in sport, be replaced by “brain injury”?

BOD: Yes – because that is what it is.

WS: Concussion is a vague and uninformative term that, in my view, is popular with certain sectors as it sounds like nothing too much to worry about. What we are talking about is an injured, damaged brain.

8.Do you see rugby players suffering the same mental and physical issues experienced by retired NFL players?

BOD: Yes.

WS: Yes. And to presume otherwise would be to repeat the mistake of assuming you had to be a boxer to get CTE. We've moved on from that. Exposure to brain injury increases risk, no matter the sport or circumstance of the injury.

9. In your opinion, are the head blows in rugby comparable to American Football?

BOD: Absolutely, and a higher incidence in rugby than in American Football.

WS: They arrive with as high, if not higher frequency, over a career as long, if not longer, and with a concussion incidence higher in rugby than American football – so yes. And while the brain is clever, a brain injury in rugby is no different to a brain injury in American football, or boxing, or hockey, or netball. Popular excuses as to why American football might be different to rugby such as helmets, padding, tackle style etc are smoke and mirrors. And, again, none of this alters the injury.