The words land with a slap. “There is no scientific evidence that sustaining several concussions over a sporting career will necessarily result in permanent damage.” They are from a December 2001 editorial in the British Journal of Sports Medicine, called “When to retire after concussion?”
It goes on to say that it is “neuromythology” that a player ought to retire after suffering multiple brain injuries. “The unstated fear behind this approach is that an athlete suffering repeated concussions will suffer a gradual cognitive decline similar to the so called punch-drunk syndrome or Chronic Traumatic Encephalopathy seen in boxers. Based on published evidence this fear is unfounded.”
“When to retire after concussion?” must have been a reassuring read for athletes and the medics treating them unless, that is, they were already suffering from the problems it dismissed as myths. The BJSM is supposed to be one of the leading journals in sports medicine and yet here was a flagship editorial arguing that the issue had been “confused” by the “media and lay-press” and that post-concussive syndrome is actually “exceedingly rare in sports”.
If anything, the editorial explained, doctors who advised players to retire after suffering multiple concussions would leave themselves open to “medicolegal challenge” because they were going against the science.
Twenty years later, when it comes to the science it feels like reading one of those 1930s adverts that recommend cigarettes for your health. It is bad enough that the editorial was published at all in that form and that is before you know that the man who wrote it, Dr Paul McCrory, was the journal’s editor-in-chief and went on to become one of the most influential figures in this field. McCrory was the lead author of four concussion consensus papers. His work has shaped concussion policy across global sport for the past 20 years.
This week the British Journal of Sports Medicine retracted McCrory’s 2001 editorial, along with eight more of his articles. It has attached an “expression of concern” to another 38. “The scientific record relies on trust,” the publisher explained in a statement, “and BMJ’s [the British Medical Journal, publisher of the BJSM] trust in McCrory’s work – specifically the articles that he has published as a single author – is broken.” Five of the nine were retracted because they had been partially plagiarised and three more because they were redundant publishing. That leaves the ninth, and most interesting, case, the editorial titled: “When to retire after concussion?”
The editorial argues that the concussion procedures used by many sports at the time were “arbitrary” and ought to be replaced. This was an argument McCrory pursued through the 2000s. He explored it in another important paper, “A prospective study of postconcussive outcomes after return to play in Australian football”, which he coauthored in 2009. He then helped to enshrine these ideas in the Zurich concussion consensus, published in 2009, which laid out a new six-day return-to-play programme for concussed athletes.
That consensus was funded and endorsed by Fifa, the IOC and the IRB (which is now World Rugby). The IRB then rewrote its own concussion protocols to bring them into line with the return-to-play procedure laid out in the Zurich consensus. Until then a concussed rugby union player was given a mandatory three-week stand down. After the IRB’s medical conference in 2011, that was changed to a six-day graduated return to play.
It sounded good in theory – there was an idea that the prospect of a three-week standdown was stopping players from reporting concussions – but in practice a six-day return-to-play meant it was possible for a player to be concussed one weekend and, if he passed the tests, play again the next. As Rob Nichol, who was on the IRB’s concussion working group, explained at the time the new procedure had “been developed off the consensus document that was developed in Zurich a few years ago by all the world leading experts in concussion”. There were other researchers, doctors and scientists involved in the process, but McCrory was undoubtedly a key figure. He had been working for the IRB at the time, as a member of its Rugby Injury Consensus Group. And now one of the editorials that underpinned his argument has been retracted.
As Dr Stephen Casper and Adam Finkel explain in an essay published in BJSM this week, in “When to retire after concussion?” McCrory “changed and weakened” a key quote from Dr Augustus Thorndike. This misquotation had the effect of undermining the argument in favour of the kind of three-week standdown period used by rugby union at the time, and bolstering the argument for the new six-day protocol McCrory believed it should be replaced with.
As Casper and Finkel say: “It’s possible that this misquotation was also used to represent Thorndike’s views in internal discussions by sports organisations regarding concussion science. In such a case, it would have also misled those sports organisations, their chief medical officers and other important office-holders who owe a duty of care to the sportspeople within and served by those organisations.”
World Rugby finally changed that six-day return to play rule this summer. Its decision to switch to using it in 2011 and to stick with it through the last decade is likely to be one of the key arguments in the legal action being brought against them by the players suffering with the effects of brain damage in retirement. So the BMJ is not the only body which is going to have to confront its past relationship with McCrory.
The Concussion in Sport Group, which authors the concussion consensus, is going to have its own reckoning. And some day soon so is World Rugby.