School of hard knocks for football players

TAKING the big hits - and dishing them out - is part of football. But are players putting themselves in the firing line for long-term brain damage?

THE rugby union gods were smiling on the NSW Waratahs at Sydney Football Stadium on May 21 this year - their opening assault on South Africa's visiting Lions was so blistering that the scoreboard read 29-5 at half-time, prompting a standing ovation from the 14,000-strong crowd.

But in the game’s second half, the Waratahs’ star five-eighth, Berrick Barnes, began acting oddly. His normally fluid gait became clumsy; his focus seemed to slip; as he ran up the field, the 24-year-old Queenslander appeared to be favouring the right side of his body. Ten minutes before the end of the game, a trainer ran on to the pitch and led Barnes off.

Watching from the stands, the neurologist John Watson hurried down to the Waratahs dressing room. A professor of medicine at Sydney University, Watson had been treating Barnes over the preceding months for what appeared to be recurring concussion injuries that had forced him to miss many games this season. When Watson reached the change rooms he found his patient sitting on a bench with a look of bemused vacancy on his boyish face. Barnes reported only vague physical symptoms – the beginnings of a headache; a neck-ache on his left side – but he could not remember the name of the team he had just been playing. As Watson and the Waratahs’ physiotherapist fired more questions at Barnes – when had he become engaged to his fiancée? which team had he played for in 2010? – they grew more alarmed. Entire swathes of memory seemed to have been erased, going back years.

“It was really scary, for everyone,” recalls Watson. “But as a neurologist it was a rare opportunity. Normally patients tell you what happened to them weeks afterwards. In this case I got to see it in the heat of the moment, and observe the effects directly.” Watson realised he was seeing effects akin to a stroke: Barnes was weak on one side of his body, for instance. “And then in front of our eyes this extraordinary memory gap faded to almost nothing in the space of less than an hour. He remembered that he was flying to South Africa the following day; he knew he had his bag packed at home. He could even remember parts of the game he’d just played.”

In the sports pages the next day, Barnes’s injury was listed as “concussion”, but when Watson watched a video replay of the game he couldn’t see any major head-impact. After assessing Barnes, he diagnosed a condition called “footballer’s migraine” and cleared his patient to resume playing with the Waratahs two weeks later. On June 11, however, Barnes was again led from the field in a state of woozy confusion 33 minutes into a game against the Highlanders at Sydney Football Stadium. Two days later he announced an indefinite break from playing. The Kingaroy wunderkind who’d been named vice-captain of the Wallabies at 23 had joined a growing list of footballers – including AFL players Daniel Bell and Daniel Gilmore, and rugby players Elton Flatley and Reece Williams – whose careers have been interrupted or ended in recent years because of fears of long-term brain damage.

In an earlier era any one of these players might have chosen to battle on through the headaches and blurry vision – surviving the hard knocks is, after all, a badge of honour in football. But the notion that concussion is a minor injury has been turned on its head in recent years as doctors in the US began examining the brains of living and dead gridiron players. What they found – early-onset dementia and Parkinson’s disease, along with extensive brain damage which may cause depression and impulsive violence – has left football administrators around the world scrambling to rewrite their rules on head injury.

The problem is that “mild traumatic brain injury”, as it’s called, remains a mystery even to neurologists such as John Watson. What concussion does to the brain, and how to diagnose it, is such a source of dispute among the experts that Watson freely admits his diagnosis of Berrick Barnes could be challenged by other neurologists. The term “footballer’s migraine” was coined in the 1970s to describe the headaches, nausea and optical distortions experienced by some soccer players, but many of its symptoms mirror concussion. “My cynical senior colleagues might say, ‘Well, it’s concussion, you idiot – he’s had a bump on the head and he’s confused’,” acknowledges Watson.

On a recent Saturday afternoon, the neurologist was on hand at Sydney University’s main oval to watch Barnes playing in the university rugby team, the fourth game of his tentative comeback in the minor leagues. Here under a wintery sun, with a scattering of families lounging on the grass while a police brass band pumps out the Star Wars theme, it’s a long way from the heady excitement of Barnes’s debut for the Wallabies in the 2007 World Cup. Yet nothing in Barnes’s demeanour betrays the slightest disappointment: on the field his quicksilver passes set up two tries and he converts five of his six set-kicks; after the game he happily signs autographs and poses for photographs with kids and female admirers. “I feel good,” he says, flashing the smile that’s helped him launch a sideline modelling career. “Haven’t had any dramas.”

Barnes’s policy of openly discussing his problems – and permitting his neurologist to speak equally freely – is courageous, given how any perceived weakness is targeted out on the field. “Mate, I lost a lot of confidence,” he says candidly. “It was the first time I had ever been a little bit fearful going into a tackle. I thought, ‘This isn’t good.’” The wooziness that caused him to leave the field, he recalls, was like seasickness. “I got pains in my neck; on the field I’d get tunnel vision. You’re playing on autopilot. You don’t know where you are. It’s a weird sensation.”

Barnes was first concussed at 15, playing for Ipswich Grammar. Asked how many times he has been concussed since then, he doesn’t hazard a guess, although a YouTube clip of England’s Matt Banahan slamming him into the turf of Gosford oval last year gives a pretty good measure of the brain-rattling impacts that have been part-and-parcel of his career. Perplexingly, however, Barnes’s migraine-like symptoms haven’t always been caused by heavy knocks. At the May 21 game against the Lions, a relatively minor bump seemed to trigger his massive amnesia.

“Berrick is a special case,” says John Watson. “He has had concussions, but on many occasions the severity of his symptoms was out of proportion to the hits he took.” Watson points out that there is well-documented condition called Acute Confusional Migraine in which a minor bump to the head triggers amnesia and disorientation. Why that happens is unclear, migraine being another enduring mystery for neurologists. The “footballers’ migraines” Barnes suffers are similar and Watson doesn’t believe there are long-term dangers to his resuming play. But as he looks across the Sydney University oval at his nine-year-old son kicking a football, the neurologist voices the secret fear of every parent. “The real worry is, what would you do with a kid? What would I do if my nine-year-old were badly concussed? I have to say I would take him off for the rest of the season. And if it happened a second time to any young kid I would probably say, ‘You’d better find another sport.’”

 The human brain is a very fragile organ inside a very hard shell. At high velocity, an impact to the head can cause the brain to slam against the rough inner surface of the skull so violently, and with such twisting force, that its fragile membranes are torn apart, causing massive structural damage. That is apparently what happened to Halley Appleby, the University of Queensland rugby player who died in hospital on July 18, two days after being flattened by a tackle in a game at a suburban Brisbane oval. Concussion injury, however, is smaller in magnitude and more mysterious in nature, producing no bleeding or detectable tissue damage which might explain the dizziness, headaches, loss of consciousness and visual distortions it causes.

Ever since neurologists began studying the brains of deceased “punch-drunk” boxers in the 1970s it has been known that even relatively minor head-blows can cause brain damage. Floyd Patterson, the former US heavyweight champion stricken by Alzheimer’s in his early 60s, became a symbol of the affliction known as dementia pugilistica. The name reflected a belief that fighters, who suffer repeated blows over many years, were uniquely susceptible. In the 1990s, however, some retired soccer players began reporting early-onset dementia, prompting speculation that even repeatedly heading a soccer ball could cause long-term brain ¬damage. Then, in 2002, doctors in the US performed an autopsy on the body of former Pittsburgh Steelers gridiron player Mike Webster and made a discovery that has since thrown sports medicine into turmoil.

Webster was only 50 years old when he died, after suffering dementia and depression of increasing severity. A study of his brain showed severe degenerative damage of the type seen previously in boxers, a condition known today as chronic traumatic encephalopathy (CTE). The finding led to speculation that CTE might have caused the mental instability and violent deaths of several former gridiron players, including Terry Long, another Pittsburgh Steelers player who killed himself by drinking anti-freeze. When a Boston University doctor, Ann McKee, performed autopsies on 11 former gridiron players she found CTE in all of them, prompting her to appear before Congress in 2008 and demand “radical steps” to change the way the game is played. Since then the sport’s national body has modified its playing rules and set up research projects to look into brain damage and early dementia in its players.

In Australia, team doctors in the the Australian Football League and National Rugby League initially resisted changes to their concussion rules, which until recently permitted concussed players to resume playing if they passed a cognition test. (In rugby union the International Rugby Board requires concussed players to rest for three games unless cleared to play by a neurological specialist.) At Sydney Cricket Ground in May last year, the Sydney Swans’ Jude Bolton was concussed twice in one game but played on regardless, despite later admitting he could barely remember the game. Swans team-doctor Nathan Gibbs defended his decision to let Bolton keep playing, saying that “concussion has no obvious short-term consequences for health or performance”. His judgment was backed by Dr Hugh Hazard, former chief medical officer of National Rugby League, who said there was a “global consensus” that if players pass a standardised concussion test, they are fine to play on.

But that global consensus shifted radically only four months later when doctors released the results of an autopsy on a Pennsylvania gridiron player named Owen Thomas, who had committed suicide after a sudden depressive spiral. The autopsy again revealed chronic traumatic encephalopathy, but two details about the case caused headlines worldwide: Owen Thomas was only 21 when he died, and had no record of concussion. The finding has major implications for all contact sports, says Gina Geffen, emeritus professor of psychology at the University of Queensland and a long-time researcher on sports concussion. “The real concern about the reports on American footballers is the fact that you do not need actual contact head injury,” she notes. “It’s basically successive impacts of body on body.”

It’s possible, of course, that Owen Thomas suffered concussions he never reported to team doctors. And many Australian football officials question whether gridiron can be compared to our football codes. Hugh Hazard points out that gridiron players, who wear helmets and heavy body-padding, essentially use their heads as battering rams. (Indeed, the introduction of helmets to gridiron is thought to have encouraged the kind of car-crash impacts that cause chronic brain damage.)

But Geffen, who spent eight years studying concussion injury among rugby league and AFL players, sees fundamental similarities. “The severity of impacts does vary between the football codes,” she says, “but the same principle applies to all of them, which is that repeated impacts – with or without head contact – cause the brain to be shaken within the skull. In rugby league, particularly, you have enormously large guys running into each other and colliding as hard as they can. They can sustain 20 tackles of that kind in a game. You only have to watch them to perceive the force of the impact being transmitted to their brains.”

Earlier this year, both the AFL and NRL changed their rules to forbid concussed players from playing on, and since June rugby union players must pass a seven-step test before they can return to play. But the financial implications of this issue became clear in March this year when former AFL player Daniel Bell revealed he is seeking compensation for cognitive problems linked to the multiple concussions he suffered while playing 66 games for Melbourne. Bell, who is only 26, was delisted last year after suffering a number of injuries. Club doctors referred him to a neuropsychologist after he admitted he had been suffering persistent fogginess and memory loss for two years but kept it secret in order to retain his place in the team. Widespread reports that Bell has suffered brain damage are incorrect, according to Melbourne Football Club, which says he has cognitive problems and is gradually improving. But his revelation brought a number of other cases to light: former West Coast Eagles player Dean Kemp has revealed he still gets post-concussive symptoms such as dizziness a decade after he retired, and the Fremantle Dockers confirmed that their former ruckman Daniel Gilmore is pursuing a claim for persistent concussion-related problems. In rugby league, 35-year-old former Cowboys forward Shaun Valentine has said he still suffers dizziness, nausea and memory loss since retiring nine years ago.

The football codes are now conducting surveys to get a measure of how many players and ex-players might be suffering the same problems. But as John Watson points out, on any given weekend in Australia the vast majority of footballers aren’t playing in professional teams with doctors, physiotherapists and video replays at their disposal – they’re young blokes slugging it out in amateur sub-division games, or teenagers playing on thousands of school footy ovals.

“At that level you often aren’t going to pick up these concussion injuries,” Watson says. “You might have a situation where the parents aren’t at the game, the player wants to go back on, the coach wants him to go back on and there’s only a first-aid person on hand. What protections do we have in place to pick the younger players who might be susceptible and deal with them?”

Matt Psaltis, a flanker for his Sydney high-school rugby team, believed he was about to score the try of his life two years ago at Boronia Park oval. A pass from a team-mate landed the ball in his hands as the field opened up before him and the 12-year-old took off, aiming his slim frame at the distant try-line where glory awaited. “I was running down the sideline,” he recalls of that heroic moment, “and then I woke up in the ambulance.” What happened in the 20 minutes between is erased forever from young Matt’s mind, although team-mates later told him that the biggest player on the opposition team crash-tackled him sideways so hard that he hurtled over the sideline and slammed his head into the turf. When his mother, Sue, rushed to the scene she found her son out cold and a crowd around him. As he came to he started shouting, “What’s happening?!” in a panic-stricken voice, calling out to his mother with open eyes that apparently saw nothing. Matt himself doesn’t remember that bit, although he does recall the aftermath: “Really dizzy, and sick. I was vomiting. Nervous. It lasted all that night. Then I got headaches for the whole week.”

It was Matt’s first concussion, of the classic knocked-out-cold variety. In May this year he was in a scrum when a team-mate’s knee slammed into the side of his head, leaving him with blurred vision and dizziness. Three days later he still had blinding headaches and tunnel vision – another concussion, but of a type that often gets overlooked or dismissed as just a knock. On the advice of Associate Professor Gary Browne, a concussion specialist at the Children’s Hospital at Westmead, Matt stopped playing. But last month he returned to the field after being symptom-free for more than three months and passing a raft of cognitive tests.

For Sue and Ed Psaltis, the decision to let their son play again was a classic parental dilemma, a tussle between the unknowable long-term dangers of another concussion and the tangible benefits of playing sport for his school. “I played rugby between the ages of eight and 26 and had some of the best times of my life,” says Ed Psaltis. “The social life, the teamwork… We didn’t want him to miss out on all that.”

Matt Psaltis’s story is a familiar one to Browne, who has seen a growing number of concussed children – particularly teenage football players – pass through the Children’s Hospital in Sydney’s western suburbs over the past decade. From 2000 to 2009, admissions to the emergency department for sports-related concussion increased from 797 to 1214 a year. In Victoria, hospitals have reported a 32 per cent increase in sports-related concussions involving kids over the same period, according to Monash University’s Injury Surveillance Unit.

Why that’s happening is unclear, but Ed and Sue Psaltis remark on the sheer hulk of some players taking the field. At 61kg and 165cm, their son is the second-smallest player on his team, an almost diminutive figure next to the Pacific Islander and Maori boys who weigh in at the top of the scale. Reluctant as he is to create undue alarm, Ed Psaltis acknowledges that even he is concerned about the disparity.

“I have no complaints about the way the school handled this,” he says. “When I played rugby it was a badge of honour if you got concussed – you were almost a hero of the team, which is silly when you think about it. The fact that Matt wasn’t allowed to play for three months shows that it is being taken much more seriously. But my concern is that the players today, even along the backline, are huge compared to the general size of players in my day. You look at a photo of the Wallabies 20 years ago and they are minuscule compared to the current team.”

That the dangers of concussion have become greater as footballers across all codes have become bigger and faster is one plausible theory. Changes to the rules, particularly in AFL, may also have made high-speed collisions more common. But concussion has been such a low-priority injury in sport that precious little empirical data is available. The NRL has set up a program of measuring and weighing junior players and plans a trial competition next year of teams based on size rather than age. At the AFL, the medical officers association’s Dr Hugh Seward is this month convening a meeting of medical officers and team doctors from across the codes to discuss the implications of the US research.

One issue that will doubtless cause plenty of discussion at that conference is a survey conducted by the National Football League in the US which found that retired gridiron players aged 50 and over suffer “dementia-related conditions” at five times the rate of the general population.

In Australia, the various football governing bodies and their player organisations say they haven’t seen evidence of significant problems among retired players. But Dr George Stathers, a senior geriatric consultant in Sydney’s southwestern suburbs, wonders if he is seeing the first signs of the phenomenon. “It became quite apparent to me a couple of years ago that I was starting to see very eminent ex-rugby league footballers, men in their 60s and in some cases their late 50s, presenting with early onset of dementia symptoms and Parkinson’s disease,” Stathers says. “These are men who had been forwards playing in the scrum, and they’re presenting 10 years before the majority of the people I see, with the kind of damage I have seen in boxers.”

Stathers estimates he has seen a dozen such men in the past three years and says he has a growing conviction that their brain damage can be traced back to their days on the field. “It’s anecdotal, and I don’t want to overstate things,” he says. “But it does mirror what the Americans are seeing.”

For John Peard, a legendary league player of the 1970s, that’s a familiar story. Peard often visits ailing and elderly ex-footballers as part of a support program run by the Men of League Foundation, and he wonders about the number with early-onset dementia. Peard himself suffered a stroke at 57; today he’s in his mid-60s, and as we talk over the telephone he apologises for the rattling sound created by his shaking hands. “I’ve got a little bit of Parkinson’s,” he explains.

In his heyday Peard suffered many concussions – five in one season alone – and as we talk he admits to wondering if he might be paying a price for those past glories. “I did get quite a few knocks,” he says ruefully. “I don’t think it’s going to be very pretty later on.”

Hardcore rugby union fans have been less than kind to Berrick Barnes in recent months, with phrases such as “too soft” and “habitual choker” thrown around liberally on online blogs. Capitulation to a mere headache is still seen as unforgivable among the “bring back the biff” crowd. The jibes point to the fundamental tension in all contact sports between exciting the crowd and safeguarding the players. Aussie Rules commentator Robert Walls remarked recently that the pace of the modern game was now so frenetic that a player might one day be killed on the ground. In rugby, such incidents already occur. For players, the temptation to defy such risks grows in tandem with the financial rewards on offer. For team doctors and officials, often caught up in the fever-pitch hysteria of a game in progress, the line between acceptable risk and unacceptable danger can become a very fine one.

Former AFL player Chad Rintoul, who lived on painkillers and sleeping tablets to endure the concussion headaches of his final year at Collingwood in 2002, said last year that club doctors tend to “work for the coach”, not asking hard questions of players who might be disguising their symptoms. That may well be changing, but the problem at an amateur level may be even more endemic. When Australian researchers followed nearly 2000 community and junior rugby union players for a number of seasons, they found that almost 90 per cent of them returned to play the following week, despite International Rugby Board guidelines that recommend three weeks off.

Padded helmets of the kind Berrick Barnes wears have long been touted as a solution, although research on them is mixed – whether they limit concussion significantly is unclear, and the US experience suggests that players wearing helmets take greater risks. Even the seemingly tougher concussion guidelines of the AFL and NRL have not been universally praised. Nathan Gibbs, team doctor for the AFL’s Sydney Swans, says a player who is dazed by a blow to the head but recovers quickly can be categorised as non-concussed even though his symptoms suggest concussion. The temptation, he believes, will be for team doctors to classify mildly concussed players as non-concussed, jeopardising the AFL’s ability to collect accurate data on the causes and frequency of the problem.

“Sporting bodies who run contact sports don’t want concussion to be highlighted,” Gibbs says. “That’s not good for the sport, long term. So a lot of the information we’re trying to find and research is stuff the sporting organisations don’t necessarily want to hear about.” Gibbs acknowledges that in the past he has allowed probably 75 per cent of concussed Swans to play on, but says that is safe if proper tests are performed.

Dr Hugh Seward of the AFL acknowledges there is a grey area involving near-concussions but says the league is collecting data on such incidents to determine whether the guidelines are working – one of a dozen research projects on concussion which the league is conducting or planning. “Nathan’s views are not held by the majority of doctors,” says Seward. “We are certainly not trying to sweep it under the carpet and we’re trying to get a better understanding of what it means for those players who have near-concussion.”

For Berrick Barnes, the confusion runs deeper: is his “footballer’s migraine” just concussion injury by another name? And if not, just what is it that triggers these strange episodes? “I don’t know whether it was fatigue at a certain point in the game, over-anxiousness… yeah, I don’t know,” he confesses. “You don’t want to be saying to some poor kid, ‘Aw, it’s just footballer’s migraine, it’ll be fine’. You want people to take proper precautions. I’m just trying to encourage understanding from some of the players, the coaches and clubs when it comes to properly supporting players. There’s a lot of money tied up in certain players and their value is on the field, but precaution has to be taken with head injury in the same way as a knee or shoulder injury.”

Has he read the research from the US about dementia among gridiron players? “Yeah, I read that stuff, I’d be lying if I said it didn’t concern me. It’s hard to know, isn’t it – whether 30 years down the track you’re going to find out you’ve been affected.”

The day after we spoke, Barnes was named in the Wallabies team for the World Cup. He was back in the game, and back in the firing line.