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Rugby in the firing line as brain damage is linked to contact sport

One of Ireland’s leading neurologists says problem remain as much societal as rugby

The recently televised documentary Head On: Rugby, Dementia and Me with former English hooker Steve Thompson was a particularly harrowing watch. At 44 Thompson cannot recall winning the World Cup in 2003 nor meeting the queen when he received his MBE, while even more sadly on certain days he can’t remember the names of his four kids.

Unemployed, he worries about the future of his family and the cost of his long-term care. Interviews with other former players such as Alix Popham relay a similarly restricted, day-to-day existence.

At the age of 41 a former Welsh captain and British & Irish Lions flanker Ryan Jones was diagnosed with early onset dementia. He told the Sunday Times in July: “I feel like my world is falling apart. I am really scared because I’ve got three children and three stepchildren, and I want to be a fantastic dad.

“I lived 15 years of my life like a superhero and I’m not. I don’t know what the future holds. I am a product of an environment that is all about process and human performance. I’m not able to perform like I could, and I just want to lead a happy, healthy normal life. I feel that’s been taken away and there’s nothing I can do.”

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Rugby is in the firing line like never before, and is faced with a time bomb that ticks ever more loudly. Thompson, Popham and Jones are among a group of more up to 250 former professional and semi-professional players who’ve suffered brain damage during their careers, including three former Irish players in David Corkery, Declan Fitzpatrick and Ben Marshall, and have launched legal action against rugby’s governing bodies. The case is the biggest class action of its kind outside the US, where the NFL has paid out more than €765 million to former players who suffered brain damage.

But how can you put a figure on compensating Thompson, Popham, Jones et al for what they are going through and will continue to do for the rest of their lives?

The mistakes from the early years of professionalism will blight the game forever. The sport has made belated strides in the use of HIAs in tandem with live video footage for medics at pitch side, and World Rugby’s recommended reduction in contact training for 15 minutes per week are also an acknowledgment of past mistakes. Yet one of Ireland’s leading neurologists says the problems remain as much societal as rugby.

Prof Tim Lynch has treated both past and current players in rugby and other contact sports, and says there is a dearth of education on the brain in Ireland generally, indeed a “neurophobia”, and a lack of data internationally. Yet he would not advocate banning rugby, nor discourage children, including his own, or adults from playing the game.

“Do I think rugby should be shut down for kids? No, I don’t think so because if it’s a sport that they enjoy doing it’s going to be good for their brain as well as muscle and heart.

“I think a clear diagnosis is critical when assessing a player, and this is where neurophobia can cause problems. The doctor needs to be able to sift through the video, a detailed history and examination to assess ‘where is the lesion?’ and ‘what is it?’ Migraine and concussion overlap greatly and the history is key here to distinguish the two.

“The similarities between migraine symptoms and concussion symptoms are striking – this is where we need to increase education about the brain across society and healthcare, and indeed need to consider a masterclass course for anyone in the business of sports medicine and players at risk of concussion.”

But, ultimately, exercise is good for the brain.

“Somebody who plays sport is at less risk of getting neurodegenerative disease than somebody who is not. Kids should be exercising and if they’re not that’s not good for them in the long-term, both from a brain level and from a fitness and cardiovascular perspective.”

Lynch is a consultant neurologist at the Mater University Hospital and clinical director of the Dublin Neurological Institute. He is also the vice-principal for Health Affairs at UCD and chief academic officer at the Ireland East Hospital Group, and is responsible for teaching, training, research and innovation across 12 hospitals.

Headlines were generated following a recent study led by consultant neuropathologist Prof Willie Stewart at the University of Glasgow looked at former Scotland internationals – from the amateur era and later professional players – and found they had more than twice the risk of a neurodegenerative disease and a 15 times higher risk of a motor neuron disease diagnosis.

“Stewart’s paper did not give actual numbers of players who developed motor neuron disease and so it is hard to interpret if there is increased risk because the number of players ultimately studied was relatively low,” says Lynch. “If two players developed motor neuron disease and only one non-player developed MND then you might find yourself saying the risk of MND is twice as much in rugby players compared to non-players – but it could just be by chance.”

Stewart has “a significant reputation and I think he’s trying to do good work, but it’s hard to interpret this”.

Having played rugby with UCD himself, he admits to a personal interest. His own son captained the Mater team to victory in last season’s Hospital Cup and he himself plays tip rugby every Sunday.

As well as Leinster, Ireland and Ulster players – and occasionally Munster and Connacht – Gaelic football and hurling players are referred to him individually. Some he has advised to retire, others he has treated and they have resumed playing.

“We have a problem in Ireland, and elsewhere, in that brain disorders in their full entity are not well understood and appreciated, nor is there interest in them, and that also applies in greater society because it’s not taught in school.

“The vast majority of the nation haven’t got a bog’s notion about mind and brain, nor do they have an interest. It particularly affects me when I’m trying to deal with civil servants and argue the point that we need resources here because they kind of look at me with blank eyes.”

There is greater understanding around cancer, heart disease and paediatric disease, but not brain disorders. Some 40 per cent of the population get Alzheimer’s disease or Parkinson’s disease by the age of 85. In the Mater his department deals with 7,000 outpatients a year. Like mice on a treadmill, he says, they can’t keep up, all of which reflects on the phobia but also the complexity and increasing therapies available.

“That’s a roundabout way of saying concussion and its assessment in general is patchy, and I think ‘what is concussion’ is an interesting question because it is not easily defined. Nor is it easy to diagnose actually.”

Lynch cites a hurling match he attended a number of years ago which highlights the confusion around concussion.

“One guy went down and ‘postured’,” which he explains is a tell-tale sign of a concussion in a player going to ground. “I went on to the pitch and said: ‘he’s off.’ Then I had the ref and the father of the player argue with me, and I wouldn’t budge.” Eventually Lynch won a five-minute argument. “That was a number of years ago and I think the GAA and other sport bodies have become more aware of protecting their players when injured,” he says.

The long-term consequences of repeated concussions, which can lead to CTE, are enormously concerning.

“There are some groups who are looking at this particularly well, such as the University of Pittsburgh, and Michael ‘Micky’ Collins was over here recently at UCD. He has an impressive approach, which is ‘what’s the evidence base?’ You’ve really got to have good evidence and science behind this, because this is a new area.

“Brain neurology disorders have got more diagnoses than the rest of medicine combined unfortunately. Not all concussion is concussion. I can see that certainly in patients who are players. About a third didn’t have concussion to start with.”

In addition to exercise, he says “intellectual activity”, sleep and diet are all critical for the brain.

“Keeping up exercise into old age is a great preventative treatment of neurodegeneration. The same seems to apply to intellectual activity (novel challenges) good diet and good sleep. The issue then is contact sport and its risk, and I think the jury is still out about many contact sports and their risk because it is still early days in the study of these newly described entities (CTE etc) and we don’t have the clean data to predict the risk or otherwise of bangs to the head over time – research such as Micky Collins and others will hopefully address some of these unanswered questions.”

Gerry Thornley

Gerry Thornley

Gerry Thornley is Rugby Correspondent of The Irish Times