From All Blacks to amateurs, the issue of concussion lurks on the sidelines of sport. It's also a key topic at the New Zealand International Science Festival in Dunedin, writes Shane Gilchrist.
It's a Saturday morning in the South. A half-dozen junior teams have turned up to the West Taieri Rugby Club at Outram. So, too, has that winter wonderboy Jack Frost, who has the upper hand in the seasonal arm-wrestle with the sun.
The low solar azimuth, further weakened by a light haze, provides scant relief for two under-10 teams. As the 10am kick-off arrives, the field on which they have been stoically warming up remains frozen.
The boys (and a couple of girls) know this only too well. In a typically free-spirited, free-running game, the first half is defined by tackling that is tentative and upright rather than technically correct. Yet, as the players' pulses rise, so too does the intensity of the occasional impact.
The final whistle goes. The teams shuffle back to their respective sidelines, where parents offer words of support and/or condolences. Typically, the chatter of children includes an inventory of minor injuries (‘‘I got three cuts,'' says one; ‘‘Someone stood on my ankle,'' says another).
Meanwhile, a dad talks to his son, who has just been named tackler of the day. And deservedly so. One particular collision on that hard-as-concrete surface left the boy in tears. Still, he wasn't knocked out.
According to the Accident Compensation Corporation's 2014-15 annual report, there were 6229 claims for sports-related concussions or head injuries. However, significantly, ACC estimates about 1000 sports-related concussions are not reported every year.
Rugby topped the list with 2214, followed by skiing/snowboarding (493), football (485), rugby league (414), cycling (358) and equestrian (296). Of those reported concussions, almost half (46%) were classified by ACC as ‘‘mild with a high risk of complications'', and 11% of claimants had multiple concussions within a two-year period.
The issue of concussion in sport will be addressed as part of the New Zealand International Science Festival in Dunedin, which opened yesterday. Three guest speakers, including journalist, author and former Australian rugby representative Peter FitzSimons, will provide different perspectives on the effects of concussion on brain health and challenge us to think about what can (or should) be done.
Dunedin parent David (surname withheld by request) knows full well the implications of a knock to the head. His son has been concussed twice in recent years while playing sport.
"The first time was in August, 2014, when he was in year 8. He hadn't taken his mouthguard or headgear to a school rugby practice. Apparently, my son tried to tackle a boy - a very big boy, who had never played rugby - and he got struck on the top of the head by this guy's knee.
"I got a call from the school when he got sent to the sickbay feeling nauseous and with a terrible headache. I took him to see a nurse, who ran through various things. He was talking normally and all that. But it was a bad concussion,'' David recalls.
"The symptoms didn't go away so we went to see an emergency doctor, who told him to rest, stay away from screens and take painkillers, but the headaches persevered for two to three months. We went to see doctors a number of times.''
Although David's son played cricket that summer, his parents kept him out of rugby for the 2015 season, by which time he had started at Otago Boys' High School.
The decision was necessary, but difficult nonetheless.
"He had been playing to get into an age-group provincial team; he'd been training very hard. But we talked it through. He was blue but he accepted it.''
Instead, his son played football in year 9. However, by the end of last year he wanted to play rugby again.
"I was wary but let him,'' David says.
"He trained really hard all summer and returned this year. He was much bigger and faster and was really getting stuck in, but in his fourth game he either put his head into a tackle the wrong way or it hit the ground...''
David didn't see the incident.
But he did notice his son sitting on the ground, gesturing to him.
"He came off in tears and said he'd been knocked out. He didn't know for how long but he had visual interference - bright colours - and felt nauseous.
"We took him to A&E, where he was checked. It was probably less severe than the first concussion. He was told to rest, take paracetamol and have some days off school.''
Following the second incident, David contacted Otago Boys' High School, which referred his son to a Dunedin concussion specialist.
He praises the school's "switched-on, supportive'' culture.
"They had a system in place to deal with it. They were very particular about it. If they know someone has concussion, they don't mess around; they just pull the kid. And that protects these kids from worse damage.''
It took David's son two or three weeks to recover from the second knock; again, fatigue and headaches were the main symptoms.
"Now, he's back at school and has no issues with his studies."
"We have removed all the emotion from the issue, well, as much as we can. If he gets a headache, we'll make sure he drinks plenty of water and takes painkillers and rests. He knows he's not playing rugby again this year, and hopefully not ever. However, he could fall off his skateboard.''
David's vigilance is rooted in his own experiences.
When he was 5, he was flipped on to his head by his brother and hospitalised. As a keen rugby player in Auckland, he suffered several concussions as a teenager.
"I've always been careful about concussion. It's a bit of a red-flag issue with me, so I have always been really strict with my son.''
That's a good thing, according to Jane Millichamp, a registered psychologist whose expertise includes helping rehabilitate people who have suffered a brain injury.
"Brain injuries are very much under-reported. People think, ‘Oh, it was just a small bump to the head; I'm all right.'
"Even if a person hasn't lost consciousness they might not be well. In some cases, the effects are far more severe than someone would expect.''
Dr Millichamp, a professional practice fellow in the Dean's Department of the Dunedin School of Medicine, says the effects of concussion include issues with balance, vision, fatigue and compromised cognitive function.
There can be psychological problems, too.
"A lot of people I have worked with have told me they thought they were going mad. They didn't attribute it to concussion. And mental illness is such a stigma that some people don't let on they might be having outbursts of irritability or that they can't concentrate.
"Some people think they are mentally ill, when in fact they might have an injury that just needs time to heal.''
Some concussions can be difficult to diagnose, too, Dr Millichamp says, further clouding reporting and treatment of such injuries.
A brain scan or ultrasound might not necessarily pick up a concussion.
As opposed to a more substantial head injury where damage is obvious, a mild concussion might not be specific to one place in the brain.
"I think people need to be more aware of the effects. For instance, if someone is still having headaches six weeks after the initial injury, they should be seeking ongoing help. Likewise, there are those other symptoms, including dizziness, irritability, fatigue, concentration and planning issues, as well as psychological effects such as depression.''
The key tip is rest, Dr Millichamp says.
"People need to give the brain time to heal and recover. This might include taking breaks to reduce fatigue when doing cognitive activities. It is important people take stock of themselves.''
Ever the raconteur, Peter Fitz-Simons, the former Wallaby turned author and journalist, fuses his passion for sport with an investigative zeal that has shed plenty of light on injured brains.
Speaking from Sydney, he recalls one of his seven international caps, Australia's first test against France in 1990 when, during a brawl early in the game, he was hit from behind and knocked out.
He got up. He played on. He reckons he's lucky he didn't suffer lasting brain damage.
"I look back upon that and think about what is termed second-impact syndrome,'' FitzSimons said.
"I played footy at a senior level for about 15 years from the age of 18 and got knocked out several times, but it never bothered me.''
Journalistically, he became interested in the subject several years ago when he did a piece for Channel 7 covering former linebackers who played in the NFL.
He says it's the most haunting story he's covered.
FitzSimons travelled to the United States, where he met Chris Nowinski, who helped establish the Concussion Legacy Foundation and its "brain bank'' at Boston University in 2008.
Studying the brains of deceased American football players, Dr Nowinski and other scientists documented a disease known as chronic traumatic encephalopathy (CTE).
The findings, published in peer-reviewed medical journals, have created a body of evidence that shows repetitive brain trauma can lead to CTE, a devastating neurodegenerative disease.
Of more than 250 brain donations, 150 have tested positive for CTE; 90 of 94 former NFL players studied have been found to be CTE-positive.
"I spoke to this man, the foremost brain expert in America, and explained to him my rugby career and the fact I'm now a journalist who writes 3000-4000 words a week and puts out one book a year,'' FitzSimons explains.
"I said to him, ‘I think I'm OK.'
"I hoped he'd say something like, ‘Of course you are.' Instead he said, ‘At 51 I wouldn't expect there to be signs of CTE. We'll see later, perhaps in a decade.'
"Well, that rocked me. I had played senior footy for over a decade, including overseas, meaning for five years I was playing 12 months a year. I asked him about the frequency of brain damage in people who had played for a similar length of time. He said, ‘100%', although the extent of damage differs.''
Dr Nowinski told FitzSimons to imagine the brain as if it was a bowl of jelly floating around in a bucket of bones.
"The natural condition of the brain is not to bang against the inside of the skull.''He says the subject is both fascinating and frightening.
"I see everything through fresh eyes. I look back on the naivety of me and my mates, who would play footy, get knocked out and shrug it off. We used to think it was only boxers who got punch drunk.''
FitzSimons now campaigns for greater awareness of concussion in sport. And it's not just an issue in rugby. He says football has its dangers, too, citing the impact of a wet ball to the head and cases in Europe involving former players suffering from dementia.
"All sports have moved forward admirably in their protocols in regards concussion tests. However, it's one thing to have protocols; it's another to observe the protocols.''
New Zealand Rugby recently announced it had entered a partnership with Statistics NZ to research whether concussion suffered while playing rugby increased the risk of dementia.
The project will compare the rates of dementia among players who played high-level rugby in New Zealand between 1950 and 1970 and those who did not.
The headlines surrounding elite players offer a recurring theme.
Take the case of one-test All Black prop Ben Afeaki, of the Chiefs, who announced his retirement last year because of continuing symptoms following a February 2014 concussion he suffered during a Super rugby match against the Crusaders.
Or the news earlier this week that Highlanders and All Black loose forward Liam Squire was returning from South Africa because of a blow to the head (this follows Squire being forced to take a six-month break from rugby last year following a series of head knocks while playing for Tasman in the NPC competition in 2014).
Yet, as FitzSimons notes, competitive fervour is not limited to those at the top levels of sport.
"It's not about protecting only the elite, it's about everybody.''
FitzSimons emphasises he is not attempting to sterilise contact sports, which have inherent risks ("I think, overall, the benefits of footy, and other sports, to individuals and communities outweigh the risks'').
However, some sporting cultures could do with a tweak, he believes.
"It's not about shutting down a sport. It's about becoming more aware, of changing the culture.
"How do we change a culture? We do exactly what you and I are doing now. We get the message out there. It's about urging people to look at the consequences.
"And it's not just the consequences to players who suffer concussions. Others have to live with them and support them.
"The mantra that needs to be drilled into all players, and parents and coaches, is, if in doubt, sit it out. Looking after your brain is not a game.''
David, the concerned dad who has had a few knocks himself, agrees: "My son is a good rugby player. But I don't care. There is a big world out there.
"I just don't want him to end up brain-dead.''
The talk
• From international level through to junior levels, concussion is one of the biggest issues facing sport today. Join one of Australia's foremost authors and speakers, Peter FitzSimons, Prof Damian Bailey (Wales) and Prof John Sullivan (Otago) as they give their different perspectives on the impact of sport on brain health.
St David Lecture Theatre Complex, St David St, Dunedin, Wednesday, July 13, 7.30pm-9.30pm. Entry: Children $5, adults $10, family (two adults, two children) $20. Bookings essential.www.scifest.org.nz
