The words strike with force. There is no scientific evidence that sustaining multiple concussions over a career in sports will inevitably cause permanent damage. They are from an editorial published in the British Journal of Sports Medicine in December 2001 entitled “When to resign after a concussion?”
Further, it is stated that it is “neuropathology” that a player should quit after several brain injuries. “The unstated worry behind this strategy is that an athlete who suffers multiple concussions may experience a slow cognitive loss similar to the so-called punch-drunk condition or Chronic Traumatic Encephalopathy saw in boxers. According to published information, this concern is unwarranted.
“When to Retire After a Concussion?” must have been a reassuring read for sportsmen and the medical professionals treating them, unless, that is, they were already experiencing the mythical ailments it rejected. The BJSM is supposed to be one of the major sports medicine publications, yet its editorial argues that the subject has been “muddled” by the “media and lay press” and that post-concussion syndrome is “very uncommon in sports.
The editorial highlighted that doctors who advised players to retire after suffering several concussions would be subject to a “medicolegal challenge” because they were going against the scientific consensus.
When it comes to science 20 years later, it feels like reading one of those 1930s advertisements recommending smoking for health. It is bad enough that the editorial was published in that way, let alone by Dr. Paul McCrory, the journal’s editor-in-chief and one of the most influential experts in this field. McCrory was the primary author of four consensus publications on concussions. His work has influenced concussion policies in international sports for the past two decades.
This week, the British Journal of Sports Medicine revoked McCrory’s editorial from 2001, as well as eight of his other papers. It has added a “statement of concern” to 38 more. “The scientific record relies on trust,” the publisher noted in a statement. “BMJ’s [the British Medical Journal, publisher of the BJSM] trust in McCrory’s work – specifically the publications he has published as a single author – has been broken.” Five of the nine were retracted due to partial plagiarism, and three more were removed due to duplicated publication. The eighth and most intriguing case is the editorial entitled “When to Retire After Concussion?”
The editorial contends that the concussion methods utilized by numerous sports at the time were “arbitrary” and should have been replaced. McCrory pushed this argument throughout the 2000s. In 2009, he co-authored an important report entitled “A prospective study of postconcussive outcomes after return to play in Australian football” in which he examined this phenomenon. Then, he contributed to the 2009 publication of the Zurich concussion consensus, which outlined a new six-day return-to-play protocol for concussed sportsmen.
This consensus was funded by Fifa, the IOC, and the IRB, who also backed it (which is now World Rugby). The IRB subsequently revised its concussion guidelines to align them with the return-to-play method outlined in the Zurich agreement. Before that, a concussed rugby union player was required to sit out for three weeks. After the 2011 IRB medical conference, a six-day gradual return to play was implemented.
There was a belief that the possibility of a three-week standdown discouraged players from reporting concussions, but in actuality, a six-day return-to-play meant that a player could be concussed one weekend and, if he passed the tests, play again the following weekend. Rob Nichol, a member of the IRB’s concussion working group, noted at the time that the new method was “based on a consensus document published in Zurich a few years ago by the world’s foremost concussion experts.”
There were other researchers, doctors, and scientists participating, but McCrory was without a question the most influential. At the time, he was employed by the IRB as a member of its Rugby Injury Consensus Group. Now, one of the editorials on which his reasoning was based has been retracted.
As Dr. Stephen Casper and Adam Finkel explain in their recent BJSM article, “When to Retire After Concussion? McCrory “altered and weakened” an important quotation by Dr. Augustus Thorndike. This misquotation undermined the argument in favor of the type of three-week standdown period utilized by rugby union at the time and bolstered the argument for the new six-day policy that McCrory believed should replace it.
According to Casper and Finkel: “Probably, this misquote was also used to represent Thorndike’s views in internal sports organization talks regarding concussion science. In such a circumstance, it would have also misled sports organizations, their chief medical officers, and other key officeholders who owe a duty of care to the athletes inside and served by those organizations.
This summer, World Rugby modified the six-day return to play regulation. Its choice to switch to it in 2011 and to continue using it throughout the last decade is expected to be one of the primary points in the legal action brought against them by retired players with brain injuries. Therefore, the BMJ will not be the only organization that must examine its prior relationship with McCrory.
The Concussion in Sport Group, whose members authored the concussion consensus, will do their accounting. And eventually so will World Rugby.
