Neurologist: Sports defenders will accuse me of ‘scaremongering’. But head injury risks remain real

I grew up in the 1970s and remember watching rugby on terrestrial Irish television with groups of slightly overweight forwards manoeuvring around a patch of mud only to be interrupted by darting runs of skinny backs who managed more to evade than collide. I remember in 1995, the year the sport turned professional, first seeing Jonah Lomu playing in the backs, but built like a forward. His storming runs were a window on the future of contact sport.

Cut to Ireland’s two-match series in South Africa 18 months ago. If you are concerned about the future of the sport, as I and others are, you would do well to consider the language on display: The Irish victory in the second test was due to “intense physicality”, there was “blood” and “broken bones” everywhere; “bodies were put on the line” and this was all discussed with a fierce pride. The eye-wincing collisions on display in this year’s Six Nations were no different.

So what are we to do now? Is that it? This now fully glorified gladiatorial contest is what rugby has become. Fierce and unrelenting physicality is now what the modern game requires, simple as!

Well, we who care about the brains of young men and women must speak up now. We must reclaim the narrative and it will not be easy.

About 10 years ago, the New Yorker writer and critic, turned podcaster, Malcolm Gladwell, released a potentially incendiary episode of his hit show, Revisionist History. The story was about college footballer Owen Thomas from Pennsylvania State University. Within a year of joining the team, his friends and family noticed a change in his behaviour – he was explosively irritable and often depressed and angry. As the season continued, his condition deteriorated. He died aged 23, by his own hand.

His brain was examined by a neuropathologist who diagnosed him with Chronic Traumatic Encephalopathy (CTE). Suddenly, CTE was no longer something that affected NFL players, rugby and soccer players in their 60s. This was a child, as far as I was concerned. Gladwell’s prescription for the game was banning it outright, but this is where he lost the dressingroom, so to speak, especially in football-loving Penn State.

But, for me, there was something in this story that is worth considering further. First, there are examples of similar behavioural deteriorations that have not been proven to be due to CTE, but for which all the evidence points towards it. Siobhan Cattigan, a young Scottish international rugby player, killed herself in 2021 after an inexplicable deterioration in mental health. Much of the controversy around Cattigan’s death surrounded the failure of rugby authorities in Scotland to afford her the mental help she needed, but, for me, the question of CTE is uppermost. Furthermore, in 2023, the Neuropathology lab at Boston University, led by Anne McKee, published a series of brain autopsy results in 130 deceased athletes under 30; the most common cause of death was suicide and up to 40 per cent had evidence of CTE.

Of course, the chorus of contact sport defenders will now arise and accuse me of “scaremongering” and “failing to see the important mental and physical benefits of sport”.

So let me deal with these charges.

[ How women’s concussions differ biologically from men’sOpens in new window ]

Simply suggesting that some youth suicide might be linked to repeated concussive or subconcussive blows is alarming and requires careful examination. If very young individuals are developing CTE, genetic susceptibility is likely involved, as many players live long lives without it. This is like smoking and lung cancer: not everyone is affected, but the risk remains real. Although genetic factors for CTE are still unknown, the potential danger cannot be ignored. So, is the young brain at risk from repeated blows in ways that could lead to severe mental health problems or even suicide in a minority? The answer must be yes, but understanding that risk demands serious research and attention.

Even a casual understanding of population health will show that team sport, and exercise in general, have significant benefits for mental and physical wellbeing. Even in those who have suspected head injury-related dementia, have been shown to be healthier from a cardiovascular point of view. The charge that people like me are out to ban the sport is like saying that understanding that driving kills a high number of people every year logically leads to the conclusion that driving must be banned.

This is patently ridiculous and yet the driving analogy is a very useful one.

In the mid 1970s, the average number of road deaths in the State was about 600. Think of that, 600 families grieving over lost lives nearly every year of that decade. In the 1980s, the numbers began to come down to where, in 2022, there were still a shockingly high number of 155 road deaths. And this reduction must be measured taking into account the big increase in the population and drivers.

What happened was a remarkable milestone in public health intervention and investment, wielding a multi-agency public and private corporate response. Yes, the car manufacturers used advances in technology to make cars safer (airbags, crumple zones, etc), but the State played a bigger role in redesigning roads, insisting on seat belts, penalty points for speeding, and a big all-society push to raise the stigma of drink-driving.

At present, the public health response to recurrent brain injury in sport is to say, “but my children play sports and we all enjoy it” and “the codes should do all they can to make the games safer”. It’s like the State in the 1970s asking the car manufacturers to take all the responsibility to make driving safer.

[ Ex-rugby international Kathryn Dane: ‘I got exposed to concussions from a pretty young age’Opens in new window ]

The evidence for recurrent, especially subconcussive, brain injury leading to early brain health dysfunction is now uncontroversial. Our research group at Trinity recently published a study showing that the brains of elite players have ongoing inflammation years after a career of contact sport. Dementia in susceptible individuals is well documented and trauma now carries 10-15 per cent of the burden of dementia.

Sports such as mixed martial arts and power slapping are only gaining in popularity. As a parent of young men, I must ask: What the hell is going on? What madness of corporate greed is allowing this toxic mix of physicality and gladiatorial pride to ignore all common sense in what a sport should be, not a glorified fight?

Is it possible that, as the evidence emerges for the development of CTE in very young brains, we may finally start to do the kind of research needed to inform parents of who exactly is at risk?

It is now past time for a broad public health response to the brain injury crisis. People who feel like me, who enjoy the game and would like to see it thrive for all the right reasons need to be listened to and the toxicity of the ‘intense physicality’ agenda needs to be balanced with a series of initiatives to make the game safer, starting with a proper independently funded research programme on mechanisms and risk, a multistakeholder guidance group should be set up to include doctors, parents, players, coaches policymakers and scientists to help develop; injury registries, dose reduction plans, rule changes and risk profiles.

Mandating all coaches at all levels to undergo training in concussion awareness and sanctions for clubs and countries that violate rest rules must be enforced. Mandatory brain health and risk screening for all players should begin immediately, starting with assessing family history of neurodegeneration in players, and having yearly, independently assessed brain imaging and blood testing in those who choose to play.

Far from wanting to ban the sport, I simply want to make it safer.

In 1905, then US president Teddy Roosevelt called for a pause in American Football due to what was called the “death harvest” of that year’s season; by some accounts, 25 players had died and 168 were seriously injured due to the accepted violence of the game. He brought the stakeholders together and it was the beginning of the player welfare movement and the game returned the following year.

I believe that in 50 years, a neurologist reflecting on the history of brain injury in sport will be pointing to the craziness of our current situation in the same way as we look at the 600 annual deaths in the 1970s on Irish roads.

We need to start to make progress: when will we just get off our arses and do it?

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