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Heads up on injuries

Whatever doesn’t kill me makes me stronger” first appeared in Nietzsche’s 1889 anthology Twilight of the Idols. Although popularly assumed that syphilis plagued the philosopher —a diagnosis that has been recently challenged — the headaches, attacks of blindness and dementia that he suffered from conferred weakness not strength.

Nietzsche’s still-popular maxim may stalk the psyches of some sportspeople who shrug off medical evidence showing that concussion makes you weaker, and can sometimes make you dead.

Thus, when O’Connell and Molloy (2015) considered ‘Concussion in rugby: knowledge and attitudes of players’ in the Irish Journal of Medical Science, they found that 90.8 per cent of 76 male and female rugby players in Ireland knew they shouldn’t continue playing when concussed, yet 75 per cent said they would continue an important game even if concussed. This is cognitive dissonance on a grand scale, similar to that displayed by many healthcare professionals who assume metaphorical poses of dead horses while being flogged with repeated studies showing that hand-washing prevents infection.

Perhaps many rugby players — and other sportspeople — resent what they perceive as interfering medical diktats and consider that “… medicine is becoming a major institution of social control incorporating the more traditional institutions of religion and law”.

This was a view aired by Irving Zola in his essay Healthism and Disabling Medicalisation (1977), and I guess that those sympathetic with Zola’s analysis might cite as an example of medicine’s attempt to exert social control a recent open letter from academics and health professionals urging the UK and Irish Governments to ban tackling in school rugby.

Calderwood et al present an alternative point of view, summed up in the title of their paper in the British Journal of Sports Medicine (online 24 September 2015): ‘Turning people into couch potatoes is not the cure for sports concussion’. A similarly robust argument against throwing out the physically active baby with the risk-averse bathwater is offered by Prof Chris Oliver, cyclist, Consultant Orthopaedic Surgeon and Professor of Physical Activity for Health at the University of Edinburgh. On the issue of whether cycling helmets should be compulsory, Prof Oliver is clear that there is no justification for helmet laws or promotional campaigns that portray cycling as a particularly “dangerous” activity, or that make unfounded claims about the effectiveness of helmets: “Cycling,” he says, “has very substantial health and other benefits, whereas the risks of cycling are not especially high. By reducing cycle use even slightly, helmet laws or promotion campaigns are almost bound to cause a significant net disbenefit to public health, regardless of the effectiveness or otherwise of helmets.”

And in amateur boxing, the removal of head guards has seen fewer stoppages as a result of boxers receiving blows to the head. In a recent study in the Clinical Journal of Sport Medicine, Loosemore et al report on the ‘Use of head guards in AIBA boxing tournaments — A cross-sectional observational study’. Following up on the implementation of a ruling by the International Boxing Association to remove head guards from its competitions, the study found a “notable increase in cuts” following the removal of head guards, but fewer stoppages for head blows. The authors concluded: “Removing head guards may reduce the already small risk of acute brain injury in amateur boxing.”

I have watched a few fast, furious and — yes — exhilarating hurling games from the touchline, and once exchanged an involuntary air-kiss with a speeding sliotar as it whistled past my mouth. So I recommend the compulsory introduction of suits of armour, and that’s just for spectators. But in the real world of hurling, the compulsory introduction of helmets and faceguards in 2005 has seen the almost complete eradication of head and face injuries, which were once endemic in the game.

Yet, as consultant eye surgeon Mr David Kent makes clear in ‘Eye safety in hurling: a few remaining blind spots?’ published in the Irish Journal of Medical Science (first online 19 April 2015): “Despite the compulsory use of faceguards in hurling, serious and sight-threatening eye injuries are still occurring.” Of the five cases described by Mr Kent, one was a goalkeeper who was struck on the face, although he had worn both a helmet and faceguard. But he had modified the faceguard “… to improve his field of vision”. And Joyce and Kelly report in Injury (2015, 46:2,520-2,522) ‘An unusual penetrating hand injury from a hurling helmet’, describing a 16 year-old boy who, while trying to catch the sliotar, had his arm parried towards his face by an opponent. It is unclear if the metal protector grille was broken before or during the match.

When sane individuals participate in dangerous sports, they know that at some time they will get hurt. It should be up to sporting bodies and individuals — with advisory input from medics — to determine the extent to which protective equipment should be deployed. But when medicine turns from providing advice to proposing coercion, it raises the bleak prospect of becoming, as Irving Zola remarked, “… the new repository of truth, the place where absolute and often final judgments are made by supposedly morally neutral and objective experts”.

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