Collision course proves fatal
Links between sport and brain disease are too close for comfort, writes Neil Francis
Last Monday, we learned through various forms of the media that Paul Darbyshire 'had lost his battle' with Motor Neuron Disease (MND). The use of the word 'battle' evokes the notion that there was some form of contest going on. There would indeed be winners and losers as there are in every contest but these are pre-determined. There are no betting arena barkers shouting out the book in these cases -- there are no odds when it comes to this ghastly disease. It is galling too when a popular and productive member of society is taken, particularly when they leave with their life contribution unfulfilled. I wish him well in his next life.
Darbyshire's father died from the disease years before him; it left him in a minority category of 5 per cent who are genetically predisposed towards the disease. Darbyshire diagnosed himself and only presented himself clinically for confirmation. He is one of the few rugby players who had the disease where you were not inclined to ask to ask the question: is there some connection between rugby/contact sports and MND?
The disease, as we know, is a relentlessly progressive neuro-degenerative condition. Progressive paralysis and physical impairment and atrophy occur before end of life -- it is a grim exit. I knew Don Revie, the former Leeds manager, had died from it and Conor Coakley, a former team-mate and an exceptional individual, also succumbed to its malign influence. That was it as far as any relevance to my world was concerned.
The year before it surfaced again, I was in the United States and I watched a HBO production called Real Sports with the broadcaster Bryant Gumbel. This particular episode was called 'After the Hits'. The programme was about MND which is also called Lou Gehrig's Disease or ALS. Normally when you are on holiday you would prefer to watch something reasonably cheery, but this was compelling viewing.
The clinical focus centred on Dr Anne McKee of Boston University and Dr Chris Nowinski of Harvard University who, after extensive research, produced a paper that was published in the American Journal of Neuropathology and Experimental Neurology which made a connection between brain trauma and concussion suffered in contact sport (NFL) and MND.
McKee's interest was caught by the diagnosis of Wally Hilgenberg, a line backer with a long successful career with the Minnesota Vikings -- Hilgenberg was diagnosed with MND. What McKee was interested in was that he was one of several suferers on the same team. McKee's colleague Chris Nowinski, in a blackly comic moment, rang Hilgenberg's widow two days after he died and candidly asked: "May I have your husband's brain?" They also asked for his spinal cord as well. Mrs Hilgenberg agreed -- and the results of the cranial autopsy were interesting. McKee's centre for the study of Traumatic Encephalopathy came to the conclusion based on Hilgenberg and 12 other deceased NFL players -- the first firm pathological indications that brain trauma results in motor neuron degeneration. All of the brains examined had chronic traumatic encephalopathy (CTE), a progressive disease in brain tissue that results in cognitive impairment and eventually dementia.
McKee deduced that Hilgenberg, who was diagnosed with MND, might not even have had the disease, rather a similar but still lethal form of it -- the evidence apparently coming from proteins travelling down the spinal cord as a direct result of a blow to the brain. These proteins are not found in people who are formally diagnosed with MND.
Either way, CTE is a pre-cursor to all sorts of wonderful neurological impairment. The NFL has a disproportionate level compared to the general population of dementia, depression and Alzheimer's. There are many reasons for this but we know what the prime ingredient is. Suicide is also at epidemic levels among former and current players. In the NFL, though, Motor Neuron Disease is eight times the national average.
Orla Hardiman, consultant neurologist at Beaumont Hospital and clinical professor (neurology) Trinity College Dublin, is the consultant who dealt with Paul Darbyshire's early stages of MND. She points to an anomaly in Italian soccer where MND had reached levels which would draw cause for concern.
If you were a professional soccer player in Italy, you were 15 times more likely to catch the disease than the general population. Significantly, most of those diagnosed were midfielders. It's hard to extrapolate real meaning or draw conclusions but it's "not replicated in any other class". Hardiman stressed that unless there are large population-based studies, there is no evidence to support this finding.
There are further anomalies or coincidences -- these come within the rugby family. Joost van der Westhuizen was recently diagnosed with MND. His colleague Andre Venter -- a formidable proposition on the blindside flank for the same Springbok squad -- was also diagnosed with MND a year earlier. Most of the media picked up on this, but they never asked the question what were the odds on this happening? Two international rugby players in the same squad at the same time. The bookies could offer you odds on this one and they would run into the 1,000s.
Van der Westhuizen might not win too many personality competitions but you cannot fail to have sympathy with his predicament -- he was one of the greatest players of all time in his position and indeed in any position. What is remarkable about his diagnosis is that in June 2006, while playing in a Rugby Legends tournament in Durban, Van der Westhuizen suffered a serious concussion and swelling on the frontal lobe which required hospitalisation. This was one of a number of concussions he suffered throughout his career. Maybe just a coincidence.
It is significant that nearly all NFL and rugby players are diagnosed in their mid to late 30s -- sometimes much earlier (particularly in the NFL). The general population normally has to wait until the 50-70 demographic before the disease manifests.
One of the things that the IRB, through the offices of Dr Martin Raftery, their newly appointed chief medical officer, should do is to conduct a survey -- say back to the 1970s -- and find out how many rugby players (League as well) have been diagnosed with MND or indeed CTE. It would be useful to know.
In a week when Berrick Barnes, the Australian centre who would have played a part in his country's pool match against Ireland this September, was advised to take an indefinite break from rugby as a result of continuous concussions sustained on the field of play, the IRB brought in revised protocols governing concussion evaluation and what are called graduate returns to play. Sterling work lads. The programme used the 'Zurich Consensus' as a template and initiated their procedures based on its principles. The Zurich Conference took place in November 2008 -- I'm just wondering why it took two and a half years to implement.
I have always thought the term proactive was to have the capacity, foresight or vision to see something coming down the line and pre-empt or take calculated corrective action.
This latest initiative from the IRB has the sheen of reactionism about it. A legal rearguard action or a preventative move based on the realisation that a game whose force equals to mass times acceleration quite often leaves its combatants with brain injuries and they are only a year or two from following the NFL into litigation from players who are brain-damaged or worse.
It is an unfortunate situation. You still have people who smoke 40 a day suing tobacco companies for giving them lung cancer. You cannot play a high-intensity contact sport without picking up head injuries -- what these morph into in later life is a matter of chance -- at the moment all I am doing is pointing out a series of coincidences. In 50 years' time or, God willing, sooner, we will know for definite.
Sunday Indo Sport