On a rugby field in France, two ex-All Blacks are squaring off against one another. Anthony Tuitavake receives a pass and squares his shoulders as he plunges towards the defensive line. Waiting to meet him, Ma’a Nonu steadies himself and launches into a tackle. The two massive men meet, and Nonu is thrown backwards, his head colliding flush with the lowered shoulder of his countryman. He falls to the ground, tipping over like a felled tree, and lies prone on the turf, his arms and legs jutting out, stiff and loose at the same time, in a way we only ever see in concussed individuals and young partygoers who just had their first tab at a concert. The commentators, experts on the game, quickly point out that this collision was “a pure accident, a rugby accident”. Nonu tries to get up, to shrug it off, but even the effort of raising his head a few centimetres off the ground seems too much for him. He nestles back into the grass as concerned players, referees and medical staff converge upon him. The medics stabilise his head and neck, while teammates and opponents alike mill around in solidarity. The camera zooms in on Nonu, and we see him cringe and squint. A surge of relief rushes through the viewers as we see that Nonu has regained consciousness.
As the broadcast continues, we get an obligatory slow-motion replay of the collision (then another, and another, and another five after that. Clearly broadcasters think we get off to this sort of thing). The replay shows in painful clarity the moment when Tuitavake’s shoulder slammed into Nonu’s cheek, and the split second later when his brain rattled around inside his skull with such force that it temporarily shut down; the neural connections that make up his memories, personality, knowledge and skills shredding as they are ripped past breaking point. After the final replay of the collision, the broadcast cuts back to the field, as Nonu slowly rises to his feet, and groggily leaves the pitch on his own two feet. The crowd cheers, and one of the commentators describes him as a “hard man,” while the other says, “it’s great to see, isn’t it, after the worry of what happened, him walking off. Sometimes you have the old jelly legs when you’ve been knocked out, but he is A-OK now.” Reassuring words, but, as he meanders off the pitch and struggles up the stairs to the locker room, I wonder aloud (to the bemused stares of my flatmates), “A-OK? Is that really true?”
“If your child plays [rugby], even for one season, there is a 100 percent risk of permanent brain damage.” This statement was given during a recent interview by Dr Bennett Omalu, the guy whose accent Will Smith butchered in the movie Concussion.
Wherever you look, the sport seems under siege as damning evidence piles up against it from the media, popular science, and even the rugby institution itself. Quotes like the one by Omalu are everywhere. Given this level of scrutiny, it must be just a matter of time before all but the most obstinate of us realise the risks of playing a sport that inflicts concussions so readily.
Rugby players have gotten swole as the game has professionalised, and the pace and physicality of play has reached new levels of intensity. In the past decade, players have put on an extra 20 kilograms of muscle, and, as a consequence, the England Professional Rugby Injury Surveillance Project found that on average every five games of rugby a team plays, two players will be diagnosed with a concussion. The only sports with higher rates are boxing and horse riding. Rugby and concussions seem as inseparable as those nauseating young couples you see on park benches, and they aren’t breaking up anytime soon.
Research implicating concussions in accelerated age-related mental degradation, and ex-players have come out of the woodwork to share their stories of suffering after concussion-filled careers. Former All Blacks like Leon McDonald and Steve Devine pulled the plug on their careers due to concerns over what concussions were doing to their brains. Shontayne Hape suffered literally more concussions than he could count. At the time he said that he suffered constant migraines, depression, irritability and memory loss to the point that he couldn’t remember his pin number. Doctors blamed his condition on his concussions, and reportedly found his brain function had been compromised.
Older players tell similar stories. Former All Black Neil Wolfe said in an interview, “I guess I have a little bit of dementia now, and I suppose it relates back to the time that I was playing rugby and did get knocked out”. This may be classic Kiwi understatement. The article this quote was taken from also stated that Wolfe didn’t remember that he had agreed to be interviewed, nor did he always remember which day it was. He is suffering, and he thinks that rugby is to blame. Nor is this an isolated experience. From a single team Wolfe played on, four others now suffer from dementia, all relatively early in life.
Two studies conducted recently in Auckland back up Wolfe; both concluded that people who suffered concussions had greater cognitive limitations and worse mental wellbeing than those who had not.
In American football, the NFL professionalised a generation before rugby in New Zealand, so the troubles it faces now could very well be ours too in the future. There has been research on chronic traumatic encephalopathy (CTE), a condition similar to dementia supposedly caused by frequent head collisions. A 2017 study published in the Journal of the American Medical Association found that amongst brains donated by those that played American football, 87 percent had CTE present, and 110 out of the 111 brains donated by NFL members did. Since we know that rugby players get concussed about twice as often as American footballers, CTE could be another horror waiting in the wings for New Zealand.
It isn’t just the aging that concussions seem to affect. A young man died in May this year on a field in Wellington after being taken off for a concussion presumed to have happened earlier in the game. Rugby almost certainly killed him. As evidence mounts showing how bad concussions are, and how regularly rugby players suffer them, it can seem as though the game is about to be squeezed out of society.
But there is more to this story. A 2016 study lead by AUT’s Dr Alice Theadom said: “there was not enough research to date to show the long term effects on the brain of athletes in contact sports.” Playing rugby might result in long-term brain damage, but the verdict is still out, despite what Omalu says. For instance, while rates of dementia are skyrocketing worldwide, probably most of this has been caused by “increased life expectancy and, it’s probably better diagnosis as well," according to Dr Chris Murray of the University of Washington. Data from the World Health Organisation shows early onset dementia, which is what concussions supposedly cause, only makes up between 6-8 percent of dementia cases around the globe. Rates of early onset dementia are virtually identical in developed and developing countries, despite vast differences in sporting pastimes. The stories of ex-players developing dementia early in life are heart-breaking, but they are currently isolated anecdotes. They don’t predict the fate of all ex-rugby players.
Scientists studying the effects of rugby concussions will generally advertise for ex-athletes to take part in a study on brain health. One such research group currently looking for participants is advertising itself as, “the biggest research project ever undertaken into the possible long-term effects of head-injuries sustained in sports”. By mentioning that they will be testing mental function, they skew their sample group. Ex-players who are concerned about their mental health are more likely to respond to such an advertisement than those with concerns. The conclusions of these studies are drawn from non-random samples, which makes their findings questionable.
People who play rugby are also more likely to take risks with their health, given that they willingly play a sport that endangers it. This will heighten their risk of concussion outside of sport, and probably also affect how well they follow instructions for post-concussion recovery.
Research on CTE also has a tendency for bias, because CTE can only be investigated after death. People who donate their brains to science are often those who think that their brain is betraying them, and these are the only brains that can be examined for CTE.
The brains that researchers have access to in CTE studies are just as likely to be riddled with CTE because their owners were depressed or suffered from dementia, rather than because they played in the NFL. Furthermore, we don’t know if the presence of CTE affects mental functioning. The University of Otago’s Dr Hamish Osborne compared it to arthritis, pointing out that if you looked in almost any elderly person’s knee, you would find it filled with arthritic growth. However, only a few of these people will actually suffer the pain associated with arthritis. CTE could be the same. It may be that only a portion of people with CTE suffer negative consequences from it.
Osborne believes there is no strong evidence showing that suffering concussions, followed by appropriate rest, will compromise long-term health. He argues that concussions will cause short-term symptoms, and they should be avoided, but the problems they cause should fade. Osborne said that “a rugby player is just as likely to have [their] career end after their first concussion as their tenth,” and went on to say that the “good evidence [on concussions] just isn’t in yet”.
So, were the people from my earlier anecdotes just unlucky? Research might provide an answer to that too. While playing rugby obviously carries risk, most famous cases of post-concussion problems happened to players who continued to play rugby during the recovery period when their brains were susceptible to reinjury. Shontayne Hape suffered concussions in consecutive weeks, flaunting the standard recovery protocol due to alleged team pressure to do so. Older ex-players like Neil Wolfe all played rugby in the bad old days when concussions were considered ‘no big deal’, and athletes played through knocks, no questions asked. Even the young man who died was removed from the game after looking concussed during a stoppage in play. The actual concussion must have occurred earlier in the game. He may have suffered more concussive knocks to the head between then and when he went off the field. Perhaps it was those subsequent knocks that took his life, rather than the first one.
These anecdotes, normally used to illustrate how dangerous concussions are, may actually indicate the importance of post-concussion recovery. After a concussion the brain is tender, and further knocks can create a downward spiral in mental functioning. This is how you get to the horror stories of Shontayne Hape, Neil Wolfe, and his team mates.
There are sports with higher rates of concussion than rugby. Ex-boxers are notoriously beset with malfunctioning brains, such Muhammad Ali, who suffered with Parkinson’s disease for decades. Meanwhile, there is no such consensus for ex-jockeys, despite horse riding being the most concussion-prone sport. This could be due to the way they get concussed. When a jockey comes off their horse, their race is over, and they have a chance to rest before they get back in the saddle. Recovery is built into the sport. Meanwhile, boxers get slugged in the head for nearly an hour if they go the distance, almost guaranteeing the sort of repetitive concussive impacts that are most dangerous.
It seems clear that concussion recovery is vital, which is concerning, given how the most widely-cited studies on the long-term effects of concussions fail to account for it. Without recording whether or not their participants suffered concussions on top of concussions, and whether they followed appropriate recovery procedures, it is extremely hard to figure out whether concussions themselves cause long-term harm, or if it is the specific impact of repeated knocks during recovery. Without this, we cannot determine if rugby is intrinsically tied to significant long-term brain damage (since playing it makes you much more likely to be concussed), or whether better recovery precautions are all that are required.
This sentiment was echoed at the Fifth International Consensus Conference on Concussion in Sport, the world authority on sport-related concussions, held in Germany this year. The conference attempts to consolidate concussion research from around the world to develop a scientific consensus. The most recent report cited a lack of evidence between sports concussions themselves and serious later life complications, while making recommendations on the best practice for concussion recovery as a potential solution to the terrible short-term consequences of concussion. The emphasis placed on improving concussion recovery shows this is where researchers think the biggest gains can be made in mitigating the risks of concussive brain injury.
Concussions certainly aren’t good for your brain, and contact sports will never be fully safe. However, the scientific consensus, for the time being, is simply that there isn’t one yet. Not enough studies have been conducted, and those that have were too limited to provide an answer. This shouldn’t be taken to mean that rugby is safe. Future Kiwis may know that rugby is a game that exacts a heavy toll. But at the moment that is not the case. Without evidence of harm it isn’t fair to swoop in and make the decision for others. We let people drink, skydive and do a million other crazy things, despite the potential for harm, because our society values giving everyone the option to take reasonable risks to get their kicks. To try to take that away, because of anecdotes and inconclusive science, would be wrong.