Concussions in sport are a taboo subject. ETC or chronic traumatic encephalopathy, the possible consequence of concussions, is even more so. If this pathology is better and better known, it is still rare on the scale of a country. But the damage of concussions on the brain, and the sequelae that ensue, are clearly visible.
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Jean Chazal, neurosurgeon in Clermont-Ferrand, one of the first to have alerted to the danger of the violence of shocks in sport and author of the book This rugby that kills (Solar editions) returned for franceinfo: sport on this disease, its consequences and the way sports bodies take it into account.
Franceinfo: sport: What is chronic traumatic encephalopathy, also called ETC?
Jean Chazal: It is a disease that is the most dreadful consequence of repeated concussions. Concussion is the result of head trauma, which leads to brain dysfunction. During this trauma, the brain is shaken inside the cranial box. Imagine the brain as gelatin. If you shake the box containing it, it will split, and in the extreme dislocate. It is the same for the brain.
“The brain is under construction until the age of 25”
Jean Chazal, neurosurgeonfrance info: sports
The ETC is subject to a threshold effect. You can have three, four, five concussions, without any clinical problem or very transient. After an intellectual and physical rest, the patient recovers and one fine day, after a new concussion, he no longer recovers. But the ETC can also occur ten or fifteen years after one or more concussions, without trouble at the time, and which, one day, become symptomatic. An evolution towards a demented or pseudo-demented state is possible. It’s unpredictable.
The symptoms of ETC are very diverse: headaches, fatigue, hypersensitivity to noise and light, insomnia, mood disorder, concentration, balance, sleep, memory loss, depression. .. The diagnosis can therefore be complex to make.
Yes, because some patients will have more or less proven memory problems, will be very irritable for example. These symptoms may interfere with your daily life, but not enough to be taken seriously.
Doctors will generally put this down to age, character, lifestyle or another pathology. And it is also often the relatives who challenge them by saying: “I no longer recognize him”. It’s very fine, and that’s what makes expertise difficult. Diagnosing ETC requires extensive experience.
If the ETC is recognized in France by the scientific community, it is however poorly known to doctors. Not to mention that it is complex to detect.
Yes, in the sporting field in particular, it is potentially a judicial time bomb. The problem is expertise. There are many doctors and experts who do not necessarily have a good experience of this pathology, its causes and its mechanisms. To conclude an expertise in the field of cranial traumatology, three years of hindsight can be justified.
“At the bend of the first concussion, the imaging may not reveal any abnormality”
Jean Chazal, neurosurgeonfrance info: sports
After a head trauma that leaves sequelae, there is a first expertise at T0, then at 6 months, at 1 year and a last at 3 years. During this period, examinations are carried out, in particular neuro-psychological tests and control MRIs. They must then be compared with the previous examinations carried out since the appearance of the first symptoms. At the turn of the first concussion, the imaging may not reveal any significant abnormality.
The ideal would be to be able to carry out particular MRI sequences using software, and revealing microlesions, such as tractography. This process is able to show the multiple bundles that allow neural traffic (an electrical current) to pass from one part of the brain to another. Following one or more concussions, a rupture of one or more of these bundles may be observed. It is obviously an important anomaly, a true cerebral lesion explaining the dysfunction of the brain and therefore certain symptoms.
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But it’s almost research, and so far there aren’t enough systematic studies or enough case studies to draw conclusions. However, with advancing age, for example around 40 or 50, the cerebral atrophy finally caused by repeated concussions is very well distinguished on conventional MRI. It is therefore a very long-term and very detailed work. And it is unfortunately not done systematically.
What is this due to?
I myself am an expert, and I can clearly see that the files are often incomplete, that the expert reports are only three or four pages long. They were written by doctors who are not completely competent and aware of everything we have just talked about. In their defense, the files are sometimes insufficiently documented and informed. I have already heard experts, doctors, Social Security for example say: “everything that this player suffers from (insomnia, mood disorder etc.), I have no proof, so I will not incapacitate”. Even though he suffered concussions.
My intention is not to criticize the colleagues, but to say that training must be reinforced, insisting on raising awareness of the problem, by having recourse in difficult cases to a college of several experts. It is a serious subject, of public health and sports, and I think we should go much further.
“The problem is actually the sport business”
Jean Chazal, neurosurgeonfrance info: sports
Do you also want to say that ETC is taboo in France?
There is a form of denial and omerta in some clubs for financial reasons. Beyond the fact that few doctors have the right training, they can come under pressure from club presidents or national and international rugby governing bodies.
I was an expert in the Rugby League. In 2017-2018, I participated in the National Observatory of the Health of Rugby Players at the federation, after which I was no longer invited. Why ? Because I spoke too much about the dangers of this sport and I wrote a book following this mission, which is called This rugby that kills (Solar editions), where I detail everything I have just explained to you. I also relate the death of four players in the immediate aftermath of a match, during which they had suffered too violent a trauma. So I was told: ‘it’s no longer worth coming, and you must no longer express yourself on the subject’. But I don’t put myself on the back burner, I continue to say what I think.
In this book, I talk about the ETC, this judicial time bomb. The problem is actually sports business. If the ETC is recognized without reservation, many players will seek redress, and this will have a financial cost. I believe club presidents know this, and they are not the ones in charge, because they operate their club on a voluntary basis, sometimes even at a professional level. They are not doctors. Those responsible are the governing bodies, the national federations and World rugby. And I think that the Ministry of Sports and the Ministry of Solidarity and Health should look into the subject more attentively and precisely.
Precisely, do you have any leads to limit concussions and therefore cases of ETC in athletes?
I don’t have a radical solution. The one thing I can say forcefully is that the only real cure is prevention. So, people will tell me that these sports have always existed and that there have always been concussions. Yes, but the difference is that the players were much lighter and less powerful than today, and did not have hypertrophied muscles (abnormal increase in the volume here of a tissue) like today. In amateur times, they ran at 25 km/h whereas today, we have already timed professional players clocking in at 36 km/h.
“We put 500 horsepower engines on 4L chassis”
Jean Chazal, neurosurgeonfrance info: sports
Imagine a player over 100 kg (and it’s common these days) colliding with an opponent who weighs twenty less. At this speed, the forces deployed and sustained are considerable and the damage can be appalling. We put 500 horsepower motors (in other words hypertrophied muscles) on 4L frames (bones, tendons and joints remain the same without hypertrophy). The brain also remains the same, and has no more protection to withstand such trauma.
However, World Rugby implemented concussion protocols at the start of the 2014-2015 season precisely to protect players.
Yes, World Rugby and the FFR have set up diagnostic protocols. When a player is the victim of a head trauma, he is examined on the pitch, at H+6, H+48. If the concussion is confirmed, he is put on total rest. Once cured of all symptoms, and this is a normally unavoidable condition, he will be able to return to the field.
The problem is that you can make heads in football all year round, or suffer seemingly minor head injuries all year round in rugby, without any symptoms. These are called sub-concussive states. Today, we know that these “well-supported” traumas cause microlesions which accumulate and one day, these individuals develop a dementia or pseudo-dementia syndrome, in the multiple forms already listed.
“When the brain has been weakened between the ages of 20 and 30, it ages prematurely”
Jean Chazal, neurosurgeonfrance info: sports
Why ?
When the brain has been weakened between the ages of 20 and 30, it ages prematurely. He has accumulated microlesions with no obvious or troublesome symptoms. With the cessation of sport, tobacco and alcohol possibly consumed, overweight, arterial hypertension, adding to the microlesions, physiological aging accelerates abnormally.
It has been perfectly demonstrated by the medical scientific literature that the incidence of degenerative diseases, such as Alzheimer’s and Parkinson’s, is significantly greater in top athletes who have suffered head trauma. Today, it is also accepted that after practicing boxing, 15% of boxers suffer, at the end of their life, from disorders similar to early dementia.
It is accepted that in current professional rugby, a player can suffer up to three or four concussions between the ages of 20 and 30. It is considered that on average, there are ten concussions per 1000 players per hour, which represents a concussion every three or four rugby matches. In a Top 14 weekend, that means there are at least three or four concussions. It’s a lot.
We know that for some, this will end with an ETC, without being able to make case-by-case forecasts with certainty. Some players will escape it, without knowing the exact, scientifically proven reasons. We know, however, that the risk exists, that it is far from negligible, and that when the symptoms appear, the life of the player, and of his family, changes dramatically.