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Leaders from the Concussion Legacy Foundation (CLF) visited New Zealand this week to announce that the University of Auckland has joined the CLF Global Brain Bank, a network of academic research centers that collaborate with CLF to study Chronic Traumatic Encephalopathy (CTE) and other effects of sports-related brain trauma.
The newly launched New Zealand Sports Human Brain Bank Initiative will be part of the University of Auckland’s Centre for Brain Research, led by internationally recognized neuroscientist, Distinguished Professor Sir Richard Faull.
“We are thrilled that Dr. Faull and the impressive team at the University of Auckland Center for Brain Research are joining the fight against CTE,” said Chris Nowinski, Ph.D., co-founder and CEO of the Concussion Legacy Foundation. “It is fast becoming clear CTE is a global problem, and CLF is committed to recruiting top scientists to collaborate for a cure.”
The Centre for Brain Research was established in 2009 and is home to New Zealand’s only human brain bank. The new extension to the brain bank will collect from donors who have played contact sports like rugby, boxing, soccer, and others, whether or not they have experienced a concussion or traumatic brain injury (TBI), to scientifically research how head impacts in sports influence brain health and brain disease.
“With a large focus on contact sports in our culture, it’s important that New Zealand is part of this global conversation and that our sports people are included and have access to relevant research results,” said Sir Richard Faull.
The CLF Global Brain Bank was launched in March 2018 with the Australian Sports Brain Bank at the University of Sydney’s Brain and Mind Centre and Royal Prince Alfred Hospital. In October 2018, the University of São Paulo Biobank for Aging Studies became the CLF Global Brain Bank’s exclusive collaborator in Brazil.
The mission of the CLF Global Brain Bank is to accelerate research by activating the global scientific and sports communities in the fight to understand, prevent, treat, and eventually cure CTE and other trauma-related brain diseases. The CLF Global Brain Bank is modeled off the success of CLF’s collaboration in the United States (US) with Boston University (BU) and the US Department of Veterans Affairs (VA), which has become the world’s largest CTE brain bank. The VA-BU-CLF Brain Bank research team, led by Dr. Ann McKee, has diagnosed more than 400 cases of CTE in the U.S.
Members of the CLF Global Brain Bank commit to collaborative research, including using common study methods, common data elements, and sharing data. Brain tissue will be stored and made available to outside researchers.
“The Australian Sports Brain Bank looks forward to collaborating with our New Zealand colleagues at the New Zealand Sports Human Brain Bank Initiative,” said Dr. Michael Buckland, director of the Australian Sports Brain Bank, who was also in New Zealand for the announcement. “I hope that by working together we can make a uniquely Antipodean contribution to international collaborative efforts to understand, treat and prevent CTE”.
Dr. Buckland announced this week that more than 200 people have pledged their brain to the Australian Sports Brain Bank, which has now received nine brain donations and completed analysis on four cases.
Rugby players from Aviva Premiership Rugby and Greene King IPA Championship are to take part in a major study led by the University of Birmingham as part of its work to develop a ground-breaking pitch-side test to diagnose concussion and brain injury.
The study, being carried out in collaboration with the Rugby Football Union (RFU), Premiership Rugby and the Rugby Players’ Association, will run throughout the 2017/18 rugby season and is the biggest of its kind to take place in the history of UK sport. It is a key element in the University of Birmingham’s research programme to create a test that can be performed rapidly pitch-side and will determine whether a player has been concussed. The study is part of the University of Birmingham’s REpetitive COncussion in Sport (RECOS) project.
The test also has the potential to assist in return to play decisions and could be used across sports, from grassroots to professional level. It is hoped it could also be used more widely by frontline medics in the NHS and military to improve diagnosis and treatment within the first critical hour after brain trauma.
The team at the University’s College of Medical and Dental Sciences, led by neurosurgeon Professor Tony Belli, has spent the last nine years carrying out research which has led to the development of a test that measures biomarkers present in the saliva and urine of players. The test, if validated, could be done on a hand-held device, which is currently under development.
Professor Belli said: “Early and accurate diagnosis of concussion is one of the biggest challenges we face clinically and is particularly a major concern in the sporting world.
“The University of Birmingham recently made a significant breakthrough after identifying molecules, which can be found in saliva and act as biomarkers to indicate whether the brain has suffered injury.
“In this exciting next study with the RFU, Premiership Rugby and the Rugby Players’ Association, we will collect players’ saliva and urine pre and post-injury, which we will then test in the laboratory in order to assess the reliability of these biomarkers.
“If these biomarkers are found reliable, we can continue our work with industrial partners with the hope to have a device available within the next two years that will instantaneously diagnose concussion on the pitch-side with the same accuracy as in the laboratory – a major step forward for both sport and medicine.”
Dr Simon Kemp, RFU Chief Medical Officer, explained: “This is an important addition to the breadth of research we are undertaking into concussion and player welfare more broadly. There is currently no reliable or proven biomarker or objective test for the diagnosis of concussion and this lack of objectivity is the biggest challenge facing medical professionals in dealing with this type of injury.
“While very much an exploratory piece of research, this is a project that has the potential to make a very significant impact on the diagnosis and management of players following concussion.”
Premiership Rugby Head of Elite Performance and Player Development Corin Palmer said: “Premiership Rugby is committed to putting our clubs and players at the front and centre of what we do, and player welfare is our number one priority. This research has the potential to impact positively on the way in which we assess and manage concussion and as such we are keen to give it our full support.
“All Premiership Rugby clubs and players are already taking part in the preparatory stages of the research ahead of the new season, and we look forward to seeing the results of Professor Belli’s work.”
The Rugby Players’ Association’s Rugby Director Richard Bryan said: “The RPA Players’ Board has given its full support to this vital research study which we hope will be a significant development for the future of concussion diagnosis.
“This forms part of the RPA’s ongoing commitment to work collaboratively with the RFU and Premiership Rugby to ensure that the game continues to make advances in concussion education, research and management for the wellbeing of all players.”
Players participating in the study will provide saliva and urine samples to act as a base-line benchmark. During a match, players with confirmed or suspected concussion will provide saliva samples immediately following injury. Players will also provide follow-up saliva samples, as well as urine samples, as they go through the return to play protocol. These will be compared to the baseline benchmarks, plus those from players from the same game who did not suffer head injury, and those who had other injuries. If there are no Head Injury Assessments (HIAs) or confirmed concussions in a match, then no samples will be collected.
The study will be carried out during all Aviva Premiership and Greene King IPA Championship club competitions where the HIA is in operation and will run alongside the existing HIA off field screen that will be for a fixed period of ten minutes. This study replaces the King-Devick research project that was conducted last season. The King-Devick results are currently being analysed and the aim is to publish the findings following scientific peer review.
(Editor’s note: the following was written by Iseult Cody and initially published in www.nflconcussionlitigation.com)
A wet October morning. A field outside Roscrea, an unremarkable town in the midlands of Ireland, a rugby heartland, where men are men and pride in a jersey comes before all else. Thirty men on a field chasing an oval ball with maybe the same number again on the side-lines watching.
Supporters of a certain size and gender dare not get too close to the team manager for fear that if a substitute is needed they could be drafted in. There is no stand, no television cameras, no TV match official just the players, the officials and the supporters, maybe 60 sets of eyes follow the ball as it slips from muddy hand to hand weaving through the players. The jerseys are faded, the lines on the field are smudged but the passion is evident with every run, every tackle, and every kick.
Everything will be left on the field, they will give it everything they have and for no reward, there is no cup, they won’t be paid, they won’t get recognition save for from the small assembled crowd or a by-line in a local newspaper or tweet from a supporter. This is a religion in itself and this scene is repeated across the country every weekend throughout the season.
Suddenly a shoulder collides with a head, a man drops to the ground, he touches his hand to his head, and the team doctor who incidentally doubles up as the kit man runs on, glancing over his shoulder to see who is on the side-line potentially ready to enter the field of play if needed. He asks the right questions but is reassured by the player that he is fine. The doctor scurries back to relative warmth of the side-line the game continues on.
This is amateur rugby. This is the heartbeat of the game. This is the reality.
A different picture unfolds before our eyes. The scene is set, it is the 6 July 2013 at the ANZ stadium in Sydney. Eighty-three-thousand-seven-hundred-and-four sets of eyes will watch every movement, will feel every hit from their seats, will discuss every blow, will follow every movement as fifteen Lions take to the field with the intention of mauling, both literally and figuratively, the Australian Wallabies. Millions of eyes across the world will follow the ball on their TV screens, watching not only the live action but the replays.
Four minutes in and pulses are already racing, Wallabies legend George Smith (who incidentally returned from retirement for the game) has the ball in hand and collides with 250 pounds of Welshman in the form of Richard Hibbard. The initial hit almost has the effect of bringing time to a standstill, every viewer almost feels the reverberation as Smith’s head bounces of Hibbard’s shoulder before landing to the ground with a thud unable to prevent his own fall.
The medics race on, the spectators hold their collective breath, on the side-line Michael Hooper throws off his training top and races onto the field as the replacement.
The supporters are still discussing how sad an end to his career it is for Smith and hoping his injuries are minor when he emerges from the tunnel before running back onto the field.
One could be forgiven for questioning whether the team doctor had himself suffered a blow to the head in allowing Smith back on. This is professional rugby. This is the elite. The is with the eyes of the rugby supporting world watching.
In the wake of the game Smith himself acknowledged the severity of his injury, World Rugby, in its former guise the IRB, stood up and took notice. The rules changed, safeguarding player welfare became the headline issue, excuse the pun.
The “6 Rs” – recognise, remove, refer, rest, recover, return – should be the mantra when we witnessed a potential concussion, it should be instilled in our memories and in every participant, every coach, every official, every parent. Rugby would not fall into the pitfalls of NFL in seeking to distance themselves from concussion or shirk their responsibility.
In the wake, Rugby would protect its players from themselves. In a sport where physicality is inevitable, and indeed a requirement of the playing of the game, to protect players you have to take an almost parental approach and make the decisions for the players as to what is in their best interest. Rugby would change, rugby would adapt and rugby would protect their biggest asset, their players.
Fast forward three years and despite the rule changes, the negative publicity, the experiences of litigation in other jurisdictions and other codes and the awareness of the potential long term effects of successive repeated blow to the head, on 3rd December 2016, Northampton’s George North flies through the air as he collides with Leicester’s Adam Thompstone before landing directly on his head, apparently knocked clean out.
North, who has suffered a number of concussions throughout his career, departs the field of play only to return within minutes having undergone the HIA (Head Injury Assessment) protocols.
The sense of déjà vu was frightening to the scene witnessed in the ANZ stadium and indeed to the countless other instances in the intervening years of players receiving blows to the head and yet remaining on the field of play or leaving only to return.
The sceptic amongst the rugby fraternity may suggest nothing has changed but we (the rugby supporters and players) are now more educated, more aware, more sensitised so there is an immediate investigation into the conduct of the club in allowing Smith’s return to the field undertaken by Premiership Rugby and the RFU, and they issue guidelines but no sanctions are taken.
The complaints at the lack of action reverberate throughout the rugby community like North’s head against the turf, so World Rugby takes action and a strongly worded statement issues emphasising how seriously head injuries must be taken, that the protocols must be adhered to but yet again there is no sanction.
The situation posed a new question, if the procedures were followed and North was still deemed fit to return to the field of play then perhaps the question is are the protocols fit for purpose? What is to prevent a player dismissing the team doctor’s queries, he is the professional, the valuable commodity to the team, what if the team is losing and this is the “star” player; who is to say the doctor doesn’t look the other way or doesn’t see the signs that another doctor may?
Doctors differ and patients die but at the end of the day it is accepted that the HIA isn’t the only assessment of potential concussion, a player may satisfy a doctor conducting the HIA but still have suffered a concussion. The time may be approaching where a clear injury sustained to the head should have the effect of removing a player from the field for the remainder of the game with the HIA conducted to determine what further period of exclusion a player should have prior to their return to play.
Rugby related litigation to date has been largely focused on injuries sustained in scrums whereby players have suffered serious injuries as a result of collapsed scrums including players rendered tetraplegic however matters seem to be, pardon the pun, coming to a head now particularly with three sets of proceedings which look to shake rugby to its very core.
The first set of proceedings were instigated in Manchester by former Sale Shark Cillian Willis. Willis’ proceedings claim that his premature retirement from the game resulted from his taking two separate blows to the head during the course of a game. After the first blow the medics deemed Willis fit to continue but the second blow would see him crossing the side-line for the last time as a player.
The second case is being taken by Jamie Cudmore against his former club Clermont Auvergne. Cudmore’s case which cites his former employer’s negligence in exposing him to potential further injury in allowing him to play on, is particularly remarkable given that after this incident he went on to continue his career and indeed is still playing with French side Oyonnax. Cudmore may face an uphill battle in showing the injury or damage caused if his case were to go before the courts, but many commentators would expect this matter to be settled prior to that possibility. Cudmore himself is quite frank in his comments on contact sport and his comments on the matter illustrate a player’s perspective of the matter.
The third case which may prove to be the catalyst for the biggest change to head injury protocols or indeed for underage sports in general is the tragic death of Benjamin Robinson.
Benjamin holds a unique accolade, one that no one would want and one that has broken the hearts of his family, friends and teammate’s alike: he is the first person in the United Kingdom to die as a result of Second Impact Syndrome playing rugby, as determined by the coroner.
At 14 years of age Benjamin took not one, not two but three blows to the head during the course of a schoolboy’s rugby game. Benjamin collapsed and was treated on the field as his helpless parents looked on. Benjamin would later die in hospital with the coroner noting three separate brain injuries which in all likelihood represent the three blows sustained in that fateful game.
In the wake of his death his parents became aware that one of the opposition had recorded the match and suddenly they were faced with the harrowing prospect of reliving their son’s death on camera but also having the opportunity to dispel any notion of his death being a tragic freakish accident.
His death had to bring a positive legacy, it had to be the catalyst for change and could not be allowed to be in vain. Benjamin’s parents have now launched proceedings against various defendants including the school, the IRFU (governing national body for rugby in Ireland) and World Rugby. The case is one which they acknowledge won’t bring back their son but it may protect another family from suffering the loss they have had to endure.
For those of us who love the game of rugby, Benjamin’s smiling face pictured in his jersey is a poignant reminder of why rugby has to change, Rugby has to protect the future of the game, the participants who can’t be expected to protect themselves. Benjamin’s face should remind us of what is at stake.
The reality is players are getting bigger, hits are getting harder but the brain doesn’t and can’t protect itself any more now than it could yesterday. Two opponents collide, they both are stronger than their counterparts 10 years ago but their brain hasn’t changed, that strength doesn’t afford it any more protection or safeguard it from injury.
In our first tort class we learn the “eggshell skull” rule whereby the defendant will be responsible for the consequence of their actions no matter how remote or unforeseeable they may be; it is hardly that unforeseeable to picture the result of repeated blows to the head incurred during the course of rugby being chronic traumatic encephalopathy (“CTE”), as seen in the NFL.
The game has changed from so many perspectives, the physicality, the professionalism, the regulations but the biggest change needs to now be how World Rugby deals with head injuries or instances of suspected head injuries, not just to protect itself but to protect every participant and to ensure no family has to endure what the Robinsons have had to. Rugby for many is not just a sport, it is a way of life but no life should be lost in the pursuit of sport.
Iseult Cody is a practising lawyer in Dublin, Ireland with Eoghan P Clear Solicitors where she specialises in Property and Probate Law. As an avid sports enthusiast she has recently completed the first Sports Law Diploma course through the Law Society of Ireland and hopes to further expand her practice into Sports Law related matters.