Professor Eric Anderson gave a persuasive talk at ICMI20, Adding Brain Trauma to the Men’s Human Rights Agenda. The focus of his talk was on compulsory contact sports for schoolboys, and rugby in particular. A piece in today’s Times:
Ann McKee is the foremost expert on sports-related brain injury in the world; she has studied the brains of more dead athletes than any other scientist working in this field.
In this frank interview with The Times, Dr McKee explains that the brains of rugby players she has examined carry the same disease as boxers and American football players, and that a head injury in rugby is not a danger limited to professional players but is a threat to children too.
“Rugby is just another sport waiting to explode,” she says. “I think it will crack open. There is a lot more to this than we know right now.
“It poses the same dangers as American football and I would encourage kids not to play. It’s a sport that has a lot of inherent risks with head contact and, like American football, I see no reason for a kid to be playing it. I understand that someone who is passionate about rugby might want to play it, but I would definitely delay that age of playing until teenage years or later.”
McKee, 68, is a professor of neurology and pathology at Boston University, where she is director of the CTE Centre and the Boston Brain Bank. Her knowledge is considered so pre-eminent on this hugely sensitive subject that she was named in Time magazine’s 100 most influential people of 2018.
CTE is the acronym for chronic traumatic encephalopathy, the disease that her groundbreaking work with military veterans and athletes from contact sports helped to identify. The Brain Bank is her evidence: it contains more than 1,000 brains of which she has examined at least 600.
“We have about a dozen rugby brains, some with very severe CTE, all the classic features,” she says. “We don’t have an idea of the prevalence, of course. We have fewer brains from rugby than American football and boxing, but all the indications of the disease itself look identical to what happened to American football players — the same constellation of pathological findings, very similar symptoms.”
Rugby, as a sport, is still coming to terms with the news that broke a month ago that Steve Thompson, the 2003 England World Cup winner, and a group of other former professional players under the age of 45 are suffering from early-onset dementia. The nine men have launched legal proceedings against the game’s authorities for failing to protect them from the risks of concussion. The news was shocking to the game, but for McKee it was no surprise: if rugby players are receiving blows to the head like American footballers and boxers, why should their long-term health be affected any differently?
Where her knowledge will disturb rugby is that she says the science is such a concern for amateur and junior players too.
“We have players who only played at amateur level, certainly college players,” she says. “We’ve also seen CTE in high school and younger players. It isn’t so severe but we definitely see it. We have over 100 individuals who have died under the age of 34 and about 50 per cent of those have CTE.
“You don’t have to be a professional player to get this disease. In fact, with kids starting young and playing through high school, they could have 12 years or longer of exposure to the sport, so that is a significant risk.”
The issue, she explains, is sub-concussive blows. The science and understanding of sport and brain trauma is still young and fast-changing. Only a few years ago, the belief was that concussions — knockout blows — were the issue and scientists tried to establish how many of these a player could sustain before reaching the danger zone. The growing acceptance now is that every little blow contributes to an accumulative toll. That is why heading a football is regarded as a minor hit to which children should not be exposed.
“The sub-concussive hits which are asymptomatic, the type of hit that a player thinks is a ding on the head that doesn’t give them any overt symptoms — those head impacts accumulate over time to increase risk to CTE,” she says. “It’s been shown in active players — they’ve looked at soccer, at American football, at players who’ve never had a concussion during the season, and at the end of the season they have changes in their neuro-psych performance.”
Contact in rugby is allowed for children in the UK only from the age of nine. The idea, then, that rugby for kids in those early years thereafter is just a glorified version of rolling around in the mud is one that she is keen to dispel. Those small, apparently irrelevant, blows can make an impact on young brains.
“There is really a very clear dose-risk ratio,” she says. “We know with American football that the age you start playing the sport has repercussions in later life in terms of your resilience to the pathology. Symptoms of CTE come on about 13 years later if you start football after the age of 12, so I suspect there are parallels in rugby — the later you start playing, the more mature your brain so when you expose it to head trauma, the lesser the effect.”
McKee is by no means anti-sport. “Certainly we want our kids to be playing sport,” she says. “It’s important for their physical and mental wellbeing.” She just wants, as far as possible, for the head to be removed from the action.
“We pay more attention to knees and shoulders and ankles than we do to the brain,” she says. “They are easier to diagnose and also those injuries keep players out of the game. They can still get in the game and play even if their brains are damaged.”
She was brought up an NFL fan and was “very disappointed” when her son chose soccer rather than American football. “So I’ve come round 360 on that,” she says.
The work of the Boston Brain Bank has been a huge influence on changes that have been adopted to make the NFL safer. However, McKee says, she is not particularly welcomed. “I haven’t been met with a lot of open arms from any sports leagues. It would be novel if they were receptive. This is a devastating disease, and it’s like climate change. There is so much denial. It’s just obvious. NFL have a very long way to go in terms of making it safe for the players.”
Rugby has paid some attention to McKee. A visit was made to the Boston Brain Bank by Martin Raftery as World Rugby’s chief medical officer. The study of the work of McKee and her colleague, Robert Cantu, was then quoted as a key influence in a paper by Raftery in the British Journal of Sports Medicine, published in 2014, which outlined World Rugby’s position and its response to the dangers of head injury. Whether rugby has gone far enough is now the question. McKee’s answer is clear.
Of course, there is a hugely important element to the debate that is missing here: the level of risk. McKee’s work may show the link between contact sport and CTE, but it does not tell us: if you, or your child, steps on the field, what are the chances?
She does not know. She cannot know. At one point, she had examined 111 NFL brains and 110 of them showed CTE. Yet that is not a representative sample. Only players or families of players with concerns about neurological deterioration are likely to donate their brains.
McKee’s findings, however, tell a strong-enough story. “The brain is the most important thing you’ve got,” she says. “By ignoring the issue and not looking for it [CTE], you are never going to get on top of it. Until we address it as a significant problem in the sport, it won’t get better for the players.”
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