A UK biomarker study shows that 23% of elite adult rugby players had abnormalities in brain structure, and half showed an unexpected change in brain volume, writes MedicalBrief. Although a small study, it adds pressure on world sports bodies to act to minimise concussion, after last week’s release of a British parliamentary report that is scathing of the failure of football and rugby authorities to address the issue.
As reported in MedicalBrief, in December 2021 a UK group class action for negligence was launched, following diagnoses of early onset dementia among retired players. The initial legal action, now involving around 175 British players, was started by nine rugby internationals who have been diagnosed with early onset dementia and probable Chronic Traumatic Encephalopathy (CTE).
Their lawyers say they already represent more than 100 players. It was speculated that similar actions might follow in other rugby-playing countries like South Africa, Australia and New Zealand, and that this has implications also for football.
Damning UK parliamentary report
It comes also on the heels of what The Guardian describes as “a damning new parliamentary report into the management of brain injuries in sport”, released last week. The report, based on a four-month inquiry by the digital, culture, media and sport select committee, calls for “urgent action by the government to address a long-term failure to reduce the risk of brain injuries in sport”. It is strongly critical of both the Football Association and the Professional Footballers’ Association for “failing to fight hard enough or publicly enough to address the issue of concussion” and recommends an urgent overhaul of concussion management across all grassroots and elite sport in the UK.
“What is astounding is that when it comes to reducing the risks of brain injury, sport has been allowed to mark its own homework,” said the committee chair, Julian Knight MP. “The Health and Safety Executive is responsible by law, however risk management appears to have been delegated to the national governing bodies, such as the FA. “That is a dereliction of duty which must change. The failure by these sporting organisations to address the issue of acquired brain injury is compounded by a lack of action by government. Too often it has failed to take action on player welfare and instead relied on unaccountable sporting bodies.”
The former England scrum-half Kyran Bracken, speaking on behalf of the Progressive Rugby group, said: “I truly hope the committee’s findings will be a watershed in the approach to the management and research of concussion in sport and expect to see sporting bodies being held accountable for the duty of care their employees have a right to expect.” Progressive Rugby also called on World Rugby to “urgently address the current elite return to play protocols, which we maintain are not fit for purpose”.
At the elite level the parliamentary report criticised UK Sport for running a system in which there is “no overall responsibility to mandate minimum standards for concussion and head trauma” and which “allows sports to be funded as long as their protocols look good on paper”. It also criticised the FA for not taking a stronger, sustained interest in the issue after the coroner’s verdict on the death of Jeff Astle from industrial disease in 2002, and the PFA for not pressuring the FA to do it. At the grassroots level, it criticised NHS England for failing to keep full records on concussion injuries, and for failing to ensure clinicians have the most up-to-date training.
Among its key recommendations are that the government should establish a UK-wide minimum standard definition for concussion as well as a new set of concussion protocols that all sports must use, and that the Health and Safety Executive should work with national governing bodies of all sports to establish a national framework for the reporting of sporting injuries.
It also called for UK Sport to be mandated to take a governance role in assuring that all the sports it funds raise awareness on the dangers of concussion effectively, and for UK Sport to pay for a medical officer with responsibility to ensure the safety of participants at every major sporting event.
Overall, the report recommends a move away from the conservative approach towards research into the issue advocated by the international Concussion in Sport Group, which currently underpins most UK policy, towards a more precautionary approach. It suggests the government convenes its own specialist concussion group every four years to review the existing evidence into the long-term risks of concussion, and also recommends that the government should establish a single fund to co-ordinate and pay for research.
The most recent study, part of the Drake Rugby Biomarker Study, was led by Imperial College London and published in the journal Brain Communications this week.
The Drake Foundation funds research early onset dementia among retired players allegedly caused by repeated blows to the head. Foundation founder James Drake said: “Since rugby was professionalised in the 1990s, the game has changed beyond all recognition. Players are now generally bigger and more powerful, so we have to be mindful of all the ramifications that increased impacts will have on their bodies.
“Seeing younger players suffer with the consequences of that – remember that for the ninth season in a row concussion was the most commonly reported match injury in professional rugby union – I am not convinced that the game is safer now than it was when I started the Foundation in 2014. More must be done to protect players, and without delay.”
As far back as 2017, British experts called for UN Rights of the Child intervention to remove the tackle from rugby. Experts from Newcastle University warned that steps needed to be taken to ensure children's safety when they play rugby, the call following their research that showed serious injuries – including concussion – were most likely to be caused by rugby tackling and should be removed from school sport. They called on governments to protect children under the UN Convention on the Rights of the Child by removing this avoidable harm.
According to the Imperial College article by Kate Wighton, the latest research found a significant proportion of the rugby players had signs of abnormalities to the white matter, in addition to abnormal changes in white matter volume over time.
White matter is the ‘wiring’ of the brain, and helps brain cells communicate with each other. The research team say more work is now needed to investigate the long-term effects of professional rugby on brain health.
Professor David Sharp, senior author from Imperial’s Department of Brain Sciences, said: “Despite relatively high rates of head injury and an increasing focus on prevention, there has been relatively little research investigating the long-term effects of rugby participation. More objective measures of the effects of sporting head injuries on the brain are needed to assist with the assessment and management of individual players.
“Our research using advanced magnetic resonance imaging suggests that professional rugby participation can be associated with structural changes in the brain that may be missed using conventional brain scans. What is not clear at this stage is the long-term clinical impact of these changes. Further research is needed to understand the long-term implications of repeated head injuries experienced during a rugby career and to provide more accurate ways to assess risk for an individual.”
The work, in collaboration with University College London, was funded and instigated by The Drake Foundation, which brought together academia and sport for this pioneering study, and was additionally supported by the National Institute for Health Imperial Biomedical Research Centre, the UK Dementia Research Institute and the Rugby Football Union.
Lauren Pulling, The Drake Foundation’s CEO, said: “The Drake Foundation would like to thank the RFU, rugby clubs and research team for their support in this vital study. At present, the long-term consequences of these brain structure abnormalities are unknown and require further research. However, taken with existing evidence across different sports, as well as recent cases of rugby players being diagnosed with brain diseases in their 40s, they are painting a concerning picture when it comes to players’ long-term brain health.”
The study, which took place between July 2017 and September 2019, assessed 41 male players, and three female. All underwent an MRI brain scan, and around half then had a second MRI scan a year later. The study used two advanced types of MRI called susceptibility weighted imaging and diffusion tensor imaging. This allowed them to look at the structure of blood vessels and the white matter.
The study is the first to assess long-term changes in MRI images of professional rugby players, who were compared with athletes in non-collision sports, as well as individuals who were not athletes. Among the group of rugby players, 21 were assessed shortly after sustaining a mild head injury, called a mild traumatic brain injury.
In professional rugby union in England, these types of head injuries, which often cause concussions, are the most common reported match injury – accounting for one in five injuries.
The scientists analysed the brain scans for changes in the white matter of the brain, and compared these to the athletes in non-collision sports, and the non-athletes.
The results revealed that 23% of all of the rugby players showed abnormalities to their cell axons (the ‘wires’ of brain cells), or small tears in blood vessels. These tears cause small leaks in the brain, called microbleeds. These changes were seen in both players with and without a recent head injury.
In addition, the scans provide evidence for unexpected changes in white matter volume across the whole group of rugby players. These could indicate a longer-term effect of these abnormalities to connections in the brain. However, further research is needed to understand the significance of these changes in brain structure.
The research team also asked the players to complete assessments, such as memory tests, to analyse their brain function. The results revealed players with abnormalities in their brain structures did not perform worse than players without abnormalities.
The study team added that long-term studies were needed to investigate the long-term effects on brain health and that other health benefits of sports participation must also be taken into account when assessing impact on the brain health.
Karl Zimmerman, lead author of the research, from Imperial’s Department of Brain Sciences, said: “The implications on an individual level of the brain changes associated with elite rugby participation are unclear, although obviously it is concerning to see these changes in some of the players’ brains. It is important to note that our results in adult professional rugby union and league players are not directly comparable to those who play at local or youth levels. The overall health benefits of participating in sports and physical exercise have been well established, including the reduction in mortality and chronic diseases such as dementia. Long-term studies are now needed of both active and retired rugby players to investigate the effect of participation on long-term brain health.”
Dr Simon Kemp, Medical Services Director at the Rugby Football Union (RFU) added: “The RFU is fully committed to advancing our understanding of the short, medium and long term consequences of head impacts and concussions so that we can ensure we can make continued improvements in player welfare. We welcome any research that helps to advance our knowledge, which is why we actively collaborated with the academic institutions on the Drake Foundation Rugby Biomarker Study from its inception, particularly to promote the recruitment of players.
“While it is unclear from that research what the individual long-term implications are regarding the brain changes seen in these advanced imaging techniques, it is clearly a priority to investigate this further. To further develop our understanding the RFU, in partnership with Premiership Rugby and independent experts, will be providing a specialist clinical service for the assessment and management of retired elite male and female rugby players between the ages of 30 and 55 to individually assess their brain health.
“An integrated research programme will review the risk, causes, assessment and management of brain problems for those who have participated in elite rugby.”
The study was carried out in collaboration with UCL researchers Dr Etienne Laverse and Professor Huw Morris from the Department of Clinical and Movement Neuroscience, UCL Queen Square Institute of Neurology.
Morris said: “We have more to learn about the mechanisms and consequences of head injury, and the best approaches to player assessment. This Imperial/UCL collaborative study has brought together expertise from brain sciences across London. The Drake Foundation has pioneered work in this field in the UK and we are very grateful for the support of the Foundation, players, medical teams, clubs and the RFU in carrying out this work. We hope that this work, and understanding the long-term implications will ultimately improve safety across contact sports.”
Worse odds than Roman gladiators
Rylands Law’s Richard Boardman, who is representing the former professional players with brain injuries who are taking legal action against rugby’s governing bodies, said the results from the study were “shocking”. “Gladiators in ancient Rome wouldn’t be happy with (the numbers in the study),” Boardman said.
“Does that mean potentially half of the British & Irish Lions team playing … have brain dysfunction? If so, they didn’t sign up for that. Secondly, that those tested — the mean age was 25 years old — were so young. In fact, we firmly believe that the percentage of older, retired rugby players with brain damage is likely to be higher still.”
“Hopefully, the reckless, muscular-Christian, ‘survival of the fittest,’ approach to contact sports in the UK, that’s been in place since the 19th century, is coming to an end,” Boardman added.
“A significant evidential burden”
Writing for Law in Sport website, Samuel Cuthbert and Michael Rawlinson QC argue that there are “a number of significant hurdles which the Rugby claim will have to overcome if it is to succeed”. “The Claimants will need to establish they were owed a duty of care and that duty was breached. They will need to prove that said breach was causative of their injuries, and that the Defendants had knowledge of the link between concussions and CTE/EOD. There will likely be limitation disputes, and also disputes in respect defences such as volenti non-fit injuria (voluntary assumption of risk).
They conclude: “Amidst the media speculation about the veracity of the allegations likely to form the basis of the Rugby claim, the fact remains that the Claimants have a very difficult case to make out. In short, they will need to demonstrate that:
- concussions/mild TBIs can cause EOD/CTE,
- concussions did so in the case of the Claimants in the group whilst under the care of the Defendants;
- the Defendants knew or ought to have known of the potential for (i) to cause (ii), and
- the Defendants’ processes failed to take appropriate steps to protect the Claimants in light of that knowledge.
The Claimants will find themselves under the weight of a significant evidential burden, with no obvious route to discharging it.”
White matter abnormalities in active elite adult rugby players
Karl A Zimmerman, Etienne Laverse, Ravjeet Samra, Maria Yanez Lopez, Amy E Jolly, Niall J Bourke, Neil S N Graham, Maneesh C Patel, John Hardy, Simon Kemp, Huw R Morris, David J Sharp
Published in Brain Communications, 22 July 2021, Volume 3, Issue 3,
The recognition, diagnosis and management of mild traumatic brain injuries are difficult and confusing. It is unclear how the severity and number of injuries sustained relate to brain injuries, such as diffuse axonal injury, diffuse vascular injury and progressive neurodegeneration. Advances in neuroimaging techniques enable the investigation of neuropathologies associated with acute and long-term effects of injury.
Head injuries are the most commonly reported injury seen during professional rugby. There is increased vigilance for the immediate effects of these injuries in matches, but there has been surprisingly little research investigating the longer-term effects of rugby participation. Here, we present a longitudinal observational study investigating the relationship of exposure to rugby participation and sub-acute head injuries in professional adult male and female rugby union and league players using advanced MRI. Diffusion tensor imaging and susceptibility weighted imaging was used to assess white matter structure and evidence of axonal and diffuse vascular injury.
We also studied changes in brain structure over time using Jacobian Determinant statistics extracted from serial volumetric imaging. We tested 41 male and 3 female adult elite rugby players, of whom 21 attended study visits after a head injury, alongside 32 non-sporting controls, 15 non-collision-sport athletic controls and 16 longitudinally assessed controls. Eighteen rugby players participated in the longitudinal arm of the study, with a second visit at least 6 months after their first scan. Neuroimaging evidence of either axonal injury or diffuse vascular injury was present in 23% (10/44) of players. In the non-acutely injured group of rugby players, abnormalities of fractional anisotropy and other diffusion measures were seen.
In contrast, non-collision-sport athletic controls were not classified as showing abnormalities. A group level contrast also showed evidence of sub-acute injury using diffusion tensor imaging in rugby players. Examination of longitudinal imaging revealed unexpected reductions in white matter volume in the elite rugby players studied.
These changes were not related to self-reported head injury history or neuropsychological test scores and might indicate excess neurodegeneration in white matter tracts affected by injury. Taken together, our findings suggest an association of participation in elite adult rugby with changes in brain structure.
Further well-designed large-scale studies are needed to understand the impact of both repeated sports-related head impacts and head injuries on brain structure, and to clarify whether the abnormalities we have observed are related to an increased risk of neurodegenerative disease and impaired neurocognitive function following elite rugby participation.
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