Tuesday 24 April 2018

On collision course with tragedy

Not everyone believes that rugby is doing enough to counter the threat of concussion, says Brendan Fanning

George Smith
George Smith
Brendan Fanning

Brendan Fanning

The scene is pre-match, on an American football pitch on the south side of Chicago. The game's equivalent of baseball's Little League. The coach is addressing his players, firmly cast as the underdogs. Across the way are the favourites. All combatants look like they're about eight or nine years of age, but the tonnage on the far side of the field seems industrial by comparison. Everyone is suited and booted and, to varying degrees, ready for action. Time to ramp it up.

"Hard work!" the coach shouts. "Hard work!" the kids echo. "Dedication!" he roars. "Dedication!" they respond. Then he reaches for a parable. "I didn't tell y'all this little story guys about David and Goliath. The big ol' giant and little ol' David. That big ol' giant was The Hurricanes, the ones that was always beatin' up on everybody 'cos they was good and big. Right? But it was this little ol' guy named David, that's y'all. Little ol' bitty guy. Plenty courage. He believed in his self. You know what David did? He got a little ol' rock, a smooth rock, this yo rock -- this helmet (taps the head of one of the kids) and he ran into that big ol' giant. And BOOM!"

These are the opening frames from the documentary Head Games -- The Global Concussion Crisis. It may not be coming to a cinema near you, but you'll be able to access it early enough in the New Year via the internet. If you or someone close to you is involved in physical sport, anywhere from basketball at the lower end of the scale to rugby at the top, then watch it.

Some of it you will be familiar with already. The theme is simple enough: getting banged in the head repeatedly is bad for your health. So bad in fact that your brain may well rot, leaving you to live out the last years of your shortened life with dementia. If you are lucky then none of this will come to your neighbourhood, let alone your front door. If you are less fortunate then it may arrive and ring your bell, and stay a while before moving on. Or worse.

Three years ago in these pages we told the story of Leinster hooker John Fogarty. He was earliest out of the concussion closet in this part of the world, the first man to throw some light on the darkness that can dominate those whose career has featured too many dings.

It caused a flurry of interest at the time. In his autobiography Blue Blood, Bernard Jackman, Fogarty's colleague and rival, had revealed how concussions in his career had been like toll booths for a long-distance lorry driver. For Fogarty, however, the price would be higher: he would have to disembark altogether. The pains in his head were, as he said at the time, affecting every facet of his life.

"It takes from you," he said. "I'm a different person when this is bad."

These days thankfully he is still attached to the game he loves, working for Leinster as a scrum coach, and forwards coach to the 'A' side who were playing in Wales this weekend. Health-wise he is in a much better place than when he sat down with us three years ago.

Head Games -- The Global Concussion Crisis deals with more dramatic cases than John Fogarty's. It tells of former NFL stars whose lives were shortened by their own hand, or simply diminished by avoidable brain disease. The killer in both cases was a condition known as CTE (Chronic Traumatic Encephalopathy).

Chris Nowinski is the poster boy of the concussion world, the Harvard graduate who played Ivy League football before embarking on a five-year career in the makey-up, but dangerous, game of professional wrestling -- WWE. He is the co-founder of the Sports Legacy Institute which is dedicated to solving the concussion crisis.

That battle has brought Nowinski into direct conflict with the NFL who, like the tobacco industry in its day when denying the connection between smoking and lung cancer, claimed that there was no evidential link between head dings and dementia. Then they caved in and opened their wallets. They are still paying, and will be for years to come.

Nowinski sees some similarities between rugby's reluctance to engage with the increasingly obvious and the NFL's ostrich impressions.

"Yes, I think I've heard many of the same comments from leaders in rugby as I did in (American) football regarding casting doubt, demanding more evidence, claims of having it under control when clearly not all the right policies are being put in place or just very recent," he said last week. "But that's their job. The job of the spokesmen for these organisations is to claim everything's fine. I don't begrudge them for it -- they're just doing their job -- but it's not necessarily in the best interests of everyone playing sports."

When asked two days ago what was the position of the IRB on the claims of Nowinski, and the foremost authority in the world on this issue, Dr Robert Cantu, on the relationship between repeated head trauma and CTE, a spokesman said he recognised the "proposed link (sic)."

"However, the IRB has been proactive in focusing on evidence-based recommended steps to mitigate risk to ensure that our athletes are protected -- education; reduce deliberate hits to the head; implementation of graduated return to play; and research," the spokesman added.

The flagship of the IRB in this area has been the Pitch Side Concussion Assessment, a trial measure introduced by the board over a year ago and now in its second phase. It has been hugely divisive.

The PSCA allows for players to be removed from the pitch for a five-minute period so medics can assess suspected concussion. On Friday in Lansdowne Road, Acquired Brain Injury Ireland followed up their premiere of the previous night with a conference on brain injury and sport. In a wide-ranging and interesting day, the PSCA was like a cork bobbing on the waves, refusing to go down.

Its chief detractor is Dr Barry O'Driscoll. The Manchester medic resigned after 15 years as IRB chief medical officer when he lost the fight to keep out the PSCA.

"They actually brought this trial in first with teenagers," he says. "Now I can't as a doctor -- and we know that a teenager's brain is probably more susceptible and a second injury can kill -- and they brought it in at a World under 20 Championship in South Africa? That was the dividing line for me. I'm sad to be gone but I'm very glad I've made the right decision."

The IRB see O'Driscoll as a maverick. They consulted a range of medics in coming up with the PSCA, and when it was combined with the introduction of independent doctors on match days, to support the team doctors, we thought it was a useful development -- one that would take the heat from both team doctors and players alike.

What happened in Australia five months ago, however, tore the backside out of that one. Five minutes into the Third Test of the Lions series, the veteran George Smith, playing his first international in four years, had an almighty head clash with Lions hooker Richard Hibbard. Smith was all over the place and literally had to be propped up walking from the field. Incredibly, he returned to play. It was a mortifying moment, and hugely damaging to the IRB's claim to be on top of the game.

It didn't need a PSCA to tell you Smith's bell had been rung so hard it could he heard in the next parish. What concerns Barry O'Driscoll specifically though is the grey area which is more common than that scene in Sydney.

"The knowledge at the moment is that all you can do is suspect there is a concussion," O'Driscoll says. "Now, when the doctor goes on the field, if he wants to take the player to the dressing room then he suspects that there is a concussion -- if he wants to take him for a PSCA he already suspects it. The IRFU, the IRB and every sports body in the world says that if you suspect concussion then the player must stay off and not return. We all know about the guys getting ill that night, getting headaches that night -- that five minutes (PSCA) can show nothing! You already suspect it. Now if it was a question of diagnosis then fair enough, but diagnosis doesn't come into it because there is no empirical test."

The IRFU's new head of medical services, Rod McLoughlin, at least agrees with O'Driscoll that the PSCA is not a diagnostic tool. Rather he says it is another window through which medics can look to see if they need to examine the situation more closely. You may think we're into semantics here but that's where the medics are at. "We're using it as part of many other views to decide if I have a suspicion," McLoughlin says. "This tool is not about making a diagnosis. It's a case of: 'Do I have any suspicion?' And if I have any suspicion they're off."

Moreover he maintains that the information gathered in the quiet of the changing room, rather than in a fraction of the time under pressure on the pitch, is useful to add to the body of evidence.

In which case a solution presents itself. We know players lie about their condition if their brains are not so scrambled as to allow them to do that. And we know that team doctors by virtue of their links to the team are compromised. So continue with the PSCA, except make it a one-way system: if there is a need to subject a player to the protocol then there is enough suspicion to remove him, period; and in the course of that examination the medics might learn something they wouldn't have if they had to carry out the same process on the field with the clock ticking in the background.

This seems like a productive way of keeping dodgy cases out of the firing line. Three years ago in these pages we wrote about the dangers of second-impact syndrome, when one ding was followed by another in quick succession. In January 2011, a 14-year-old Carrickfergus player, Ben Robinson, died in just those circumstances, having played on after being concussed in a schools game.

If that seemed almost inevitable then so too is it only a matter of time before a deceased rugby union player fetches up on the CTE charts. Chris Nowinski reckons that technology is advancing so fast that soon enough we will be able to identify the condition other than through a neuropathologist.

"It will probably be PET scan technologies but I know of a multiple that are in early studies and showing they are probably going to be very effective," he says. "So we could know in a year or two who has CTE and who doesn't. It would be a huge advance."

The closing scene from the film is the endgame from Chicago, with li'l ol' David chasing big ol' Goliath. The final play sees one of David's crew -- they fought back to turn a hammering into a close-run thing -- being tossed aside like a rag doll. He landed, appropriately enough, on the crown of his head.

Irish Independent

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