I AM sitting in the staff canteen of Glasgow’s Southern General waiting for the consultant neuropathologist, Dr Willie Stewart, to appear when I receive an online press release from the Pro12 informing me that Cardiff Blues flanker Rory Watts-Jones has had to retire after suffering multiple concussions. His family reportedly noticed changes in his behaviour. He is 26 years old. The timing is horribly apt because Dr Stewart is the go-to guy on this very topic.
Sport measures its concussions by incidents per 1,000 player hours and last week the Aviva Premiership stats showed an increase from 6.7 per 1,000 hours in season 2012-13 to 10.5 per 1,000 in 2013-14. For reasons of comparison, American football’s NFL is around five per 1,000 hours, boxing 17 and horse racing, the highest of all, comes in at 25. In the opening two rounds of the Six Nations, some way short of a statistically meaningful survey, the incidence of concussion is running at 25 or 29 per 1,000 player hours, depending upon whether six or seven players were concussed.
In truth the numbers are far higher, Dr Stewart cautions. Following research done at the amateur level in rugby, for every one concussion that is diagnosed there are four of five that will be missed.
World Rugby (formally the International Rugby Board) appointed an independent advisory panel on the subject that includes Robert Cantu (an American expert who wrote the book on the subject), the Australian Caroline Finch, South African Jon Patricios and our own Dr Stewart. The softly spoken Scot is a ubiquitous voice on the dangers of concussion and has been critical of World Rugby in the past. Now inside the tent, his barbs are a little less pointed, insisting that rugby’s governing body is “streets ahead of anyone else”.
Why such a scare about concussion in the game and why now? The answer lies across the Atlantic where the Americans are streets ahead of us in their understanding of the problem thanks to the way money focuses the attention of the guardians of the game.
The NFL initially settled a class action brought by 4,500 former players for $765 million, proper money even for a league with annual revenues of around $10 billion, although the pay out may yet rise. The reason is chronic traumatic encephalopathy (CTE), a form of dementia which is the result of repeated head trauma. It can only be diagnosed in post mortem examinations and clinically CTE looks much like any other dementia, which is why it has remained under the radar for so long.
“My worry is that if you look at American football there are more and more cases,” says Dr Stewart. “In American football, the first case of CTE was diagnosed in 2005, the second case was in 2007 and the third, fourth and fifth cases were in 2009. Now there is an archive in Boston with 150-200 cases but it is growing all the time and never mind all the people that are surviving. In rugby the first case of CTE was diagnosed in 2013, the second case in 2014, so already we are ahead of the NFL, and I predict that in the next year we will see the third, fourth and fifth cases. The numbers are there.”
Remember that the concussions per 1,000 player hours in American football at five are approximately half that of the Aviva Premiership at 10.5 and that rugby players probably suffer more head knocks (sub-concussive incidents) than American footballers, all of which contribute to future problems. So although horse racing is more likely to cause concussion (25 per 1,000 hours) it is probably less dangerous than boxing (17 per 1,000) simply because in between falling off his thoroughbred the jockey is sitting pretty in the saddle. In between being laid flat on his back, a boxer is still getting his brain pummelled every few seconds. Rugby sits somewhere in between the two.
According to Dr Stewart, the literature suggests that 15-20 per cent of former boxers will suffer brain issues in later life but he rules out any comparison with rugby on that score because of the above. However, he does draw parallels elsewhere.
“The latest Rugby Football Union data suggests that there is one concussion every 2.5 matches at [Aviva] league level and what we are seeing at international level is one per match,” he explains. “I think you get to the point when you start to wonder, is the level of brain injury in the sport worth the risk. That is the sort of threshold boxing crossed some years ago. In the sport of boxing, it became clear that you set out to cause brain injury because that’s how you won your match and it was no longer acceptable to society and there have been calls for bans on boxing.
“If you look at the level of brain injury in rugby it’s not far behind [boxing] and you begin to wonder at which point do you tackle that. What I don’t want is for rugby to go the way of being banned, of seeing schools giving up on rugby, I’d like to see rugby grow and grow and have all the benefits of playing but get rid of the negatives of the game.
“All along we have said that we need better awareness, better understanding, better management of injury and, if and when we have done that we can still see a problem with injury – and I think we have got there now – we have to look at the game closely and see what needs to change. I just wonder at what point do we need to start acting fairly quickly?”
There were numerous head knocks in the opening two rounds of the Championship – Wales wing George North was only the most obvious – and Dr Stewart thinks the furore over his dual concussion against England will help in the long term (though obviously not North). Highlighting such a howler makes Dr Stewart’s advice that medics be privy to the video replays far more likely to be acted upon, although a change in regulations means it won’t become official for some time.
Samson Lee, Scott Spedding, Sam Hidaglo-Clyne, Gordon Reid, Rory Best and Wesley Fofana all suffered head impacts of various severity, with England’s Mike Brown completely sparko. Johnny Sexton has only just returned to action after a mandatory 12-week stand-down following four concussions in 12 months and he, too, suffered a cut above the eye on his comeback. The issue isn’t going away.
“I want to be proven wrong about exposure to head injury increasing the risk of dementia, and overall the numbers are small,” says Dr Stewart to anyone who may suspect that he is scaremongering. “People say we need a longitudinal study which will follow rugby players for 20 years. My problem with that is that if we wait 20 years and I’m right, we will have had 20 years’ worth of exposure. If we get to 20 years from now and I am wrong and [CTE] is a very rare thing, that’s fine. I’m not bothered.
“In the interim we have kept the game of rugby alive and we have taken away the risks of immediate death, because that is the other thing that concussion can do, even if it is rare.”
More of a whippet than a bulldog these days thanks to a daily diet of cycling, Dr Stewart used to play prop for Cambuslang at age grade level. Did he suffer from concussion in his playing days?
“I used to see stars so big that I wouldn’t have been able to see your face from here.” We are sitting perhaps four feet apart. “When I was 14, 15, 16, I thought that was just normal after you played rugby because I didn’t know any better. I had a constant ringing in my ears the following day. I thought everyone did.”
Is he worried about the long-term implications to his own health?
“Yeah,” he replies, holding my gaze, “yeah. They say that three or more concussions and your risk of permanent damage is increased and I suffered multiples of that, 10, 12, 15… I don’t know? There is nothing that I can do about it now but it would be nice if I could prevent it from happening to someone else.”
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