Sports Gazette

by sports journalism students at St Mary's University, London

Early Onset Dementia Lawsuits: Rugby Counts The Cost

Posted on 14 December 2020 by Xander Chevallier

Injuries in rugby are to be expected. It’s a highly physical contact sport, and players at all levels thought they knew the risks.

Until now.

The recent news that eight former players are bringing legal proceedings against the Rugby Football Union (RFU), Welsh Rugby Union (WRU) and World Rugby for negligence has sent shockwaves around the sport.

All eight former players have been diagnosed with early onset dementia, with the probable cause being chronic traumatic encephalopathy (CTE). Even more shockingly, all eight players, including 42-year-old 2003 World Cup winner Steve Thompson, are under 45 years old.

Should legal proceedings progress, this will be a landmark case for the sport. It could see the game altered forever to try and prevent early onset dementia from becoming the norm.

The Science

Although the dementia of players involved is potentially linked to CTE, the science around CTE itself is contentious. There is only one known cause of CTE that most within the scientific and academic communities agree on: repeated head collisions.

When collisions occur, the brain will move inside the skull. Usually, the fluid around the brain prevents it from making contact with the skull, but when it does, this causes chemical changes in the brain that require recovery time.

A 'healthy' brain compared to one with advanced chronic traumatic encephalopathy (CTE), which is linked to early onset dementia
A healthy brain compared to one with advanced CTE. Credit: Boston University Center for the Study of Traumatic Encephalopathy

These collisions don’t have to be large ones. Damage will often occur without a player losing consciousness. In football there is currently a similar debate around whether headers cause CTE, even though players aren’t knocked out by heading the ball.

It is also suspected that lower impact collisions, defined as sub concussions can be just as dangerous when causing CTE. Some research suggests that multiple low-impact hits have many similar effects to the brain as more obvious ones.

The best analogy of this was given by former Wales international Alix Popham, 41, who is one of the eight players bringing proceedings against rugby’s governing bodies.

Popham said: “It was described to me as a leaking tap dripping on a piece of mud. If it dripped once or twice there wouldn’t be a mark at the end of the day, but if it dripped for 14 years there’d be a big hole. That’s what’s happened during my career.”

Could the sport have done more earlier?

Rugby has been far more aware of the issues around concussions than other sports. At the 2011 World Rugby Medical Conference, concussion was identified as the number one medical risk facing rugby. As a result steps were taken to combat concussion.

Head Injury Assessments (HIA) were introduced to allow players time to be temporarily substituted so they could have a ten minute concussion assessment without the team having to make a permanent substitution, thus in theory meaning teams are less likely to keep injured players on the pitch.

The HIA consists of a series of criteria, including: answering basic questions (such as ‘Where are we?’); a five-word memory recall test; an out-loud reading by the player of the concussion symptom checklist; a tandem gait balance assessment; and a delayed memory recall of the same initial five words.

The players all do a baseline test at the start of the season (when they are not concussed) and should they fail any of the tests during the HIA, they will not be allowed to return to the field.

Pitch-side video review also takes place while the HIA is underway, and should either the club doctor or independent pitch side doctor evaluate that the player is showing symptoms or has been knocked-out, they will not be allowed to return, regardless of whether they pass all the other criteria.

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Although having the HIA is better than having nothing at all, there has been repeated criticism of it. One issue saw teams (France in particular) appeared to be repeatedly ‘cheating the system’ by using head replacements as a means to tactically substitute starting players back on after they had had a half an hour rest to recharge.

However, by far the more serious issue is the recurring claims that the HIA is not good enough at identifying concussions. Concussion symptoms can develop after the ten minute HIA, and so some have claimed that players were passing the assessment despite being concussed.

There were already concerns around the safety of the game even before the news of these legal proceedings. A fortnight ago, World Cup winner Matt Dawson said on 5 Live that he wouldn’t want his children to play the sport, due to the long term impacts on their wellbeing.

Where does rugby go from here?

Despite the steps taken to avoid concussion, regardless of their effectiveness, the news that the eight players involved are believed to have early onset dementia caused by CTE is deeply troubling.

As the evidence is suggesting, CTE is not caused exclusively by concussions. This means that the HIA alone won’t prevent more players from suffering. It appears the only true way to prevent further early onset dementia diagnoses is to reduce the number of collisions.

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Doing this could be seen by traditionalists as ripping out the core of the sport. But there are ways of making the game safer without altering it drastically.

Limiting or even abolishing contact in training would be one simple solution; it is estimated 85-90% of the collisions that professional players go through are outside match days.

Another way would be to reduce the number of substitutes. Although this may seem counterproductive, reducing the number of replacements would bring more fatigue into the game, which may create more space on the field and potentially lead to fewer collisions.

Who will win the legal battle?

Rugby has handled head injures better than the NFL did almost a decade ago. The National Football League had denied that concussion was an issue for the best part of 15 years until eventually conceding in 2009. After years in the court room, a deal was eventually struck granting more than 5,000 former players settlement payments of up to $5 million.

However, while the NFL limited the amount of full contact practices during the regular season to 14, rugby did not follow the same route. The legal battle will be tough to predict, as the eight players involved played most of their careers before steps, including the HIA, were introduced.

The verdict will be based in large part on whether it is deemed that the HIA was seen as a big enough step to reduce brain injuries at the time it was introduced.

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If and when proceedings progress, we must not allow ourselves to forget the human impact of early onset dementia

To hear Thompson say he can’t remember the 2003 World Cup that he won and that he wished he never played the game is heart-breaking. To hear Popham say he is nervous that he might become a burden to his loved ones is horrifying.

Rugby is a sport that so many throughout the world love and enjoy, but only now are the frightening costs of the sport starting to be revealed.

If you or someone you know is struggling, UK mental health charity Mind maintain a list of helplines and services.

And if you’re reading this from outside the UK, you can find a service near you at CheckPoint.Org.