Debilitating symptoms from brain injuries can emerge well after the initial incident. This presents challenges for insurers.
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People in countries around the world passionately support high-impact sports such as soccer, rugby, and football. But these sports and others like them produce some incredibly violent contact, and only now are the consequences on competitors’ brains starting to become clear.
One of those consequences is chronic traumatic encephalopathy (CTE), a degenerative disease whose symptoms include behavioral problems and mood dysregulation that often gets worse over time and can result in dementia.
In this article, rugby union supporter Carmel Twist and Dr. Pramodh Nathaniel, RGA Australia and New Zealand’s Chief Medical Officer, discuss potential long-term brain injuries.
A common misconception is that concussion requires a person to become unconscious. This happens in only a minority of situations. Concussions can be graded as mild, moderate, and severe, though there are various classification systems used to grade the severity. Serious neurological symptoms can arise after one is concussed, including:
Symptoms after a mild traumatic brain injury, however, can be more subtle. Symptoms include headaches, difficulties with concentration, sensation of a fog or pressure in the head, fatigue, irritability, and drowsiness.
Not only are repeated concussive episodes felt to be significant, repeated sub-concussive episodes are also believed to be relevant. These events can arise in a variety of ways, from elite sports and community sports to repeated whiplashes, in those with epilepsy, or, sadly, in cases of domestic violence.
The only way right now to confirm CTE is by autopsy. We are, however, beginning to understand that the first symptoms of the disease appear years after a head impact. Different classification systems help define the symptoms associated with other conditions related to repetitive head injuries, such as Post-Concussion Syndrome and Traumatic Encephalopathy Syndrome. These can help flag those at potential risk of CTE while the individual is still alive.
Symptoms resolve within one to two weeks for 90% of people with concussions. However, 10% might have persistent symptoms, and an unknown number of people develop even more severe complications.
At this point in time, insurance medicine doesn’t understand the high-risk population very well. We don’t have clarity yet on what places them at higher risk, nor which individuals within these high-risk populations are going to experience a more limited future due to repetitive mild traumatic brain injuries.
There is a bit of uncertainty in clinical medicine when it comes to understanding the implications of high-impact activities. Typically, applications for life insurance will ask whether an applicant currently engages in any form of high-impact activity. But what we are talking about is the accurate recollection of repetitive mild traumatic brain injuries in the past, how they persist, and if they are likely to result in future significant neurological issues.
Recurrent concussive episodes can be associated with more significant traumatic and complicated conditions, such as CTE. The challenge is that we don’t understand the pathology, natural history, or even how many episodes of repetitive head injuries place a person at risk of future complications. This makes an insurance risk assessment extremely challenging.
Currently, there is no evidence to show that one single concussive episode with resolved symptoms leads to or is associated with CTE. We do know that there is a very rare syndrome called Second Impact Syndrome. If someone gets a second concussive episode while still having symptoms from the first, it could potentially threaten their life.
The first step is to use conventional CTs and MRIs to exclude structural damage and bleeding. Following that, there are more specialized forms of imaging, such as Functional MRIs, which look to be very important. These detect the changes in blood oxygenation and blood flow in response to neural activity.
Another MRI-based neuroimaging technique is Diffusion Tensor Imaging. This method measures how water moves along the nerves. This technique enables a visualization of neural pathways and connectivity that is invisible to standard CT or MRI scans.
We are only now starting to understand which option is best and what the outcomes are when used together. At this point, imaging remains an aid rather than a diagnostic tool for concussions. The trouble with mild repetitive concussive injuries is that people don’t usually present a need for any sort of imaging. It’s only when symptoms are established that we move to the management stage.
Absolutely. The symptoms remain the established way to understand what is happening. The persistence of symptomatology is the key to understanding whether there is an ongoing problem. For those with concussions, the 10% that go on beyond two weeks are the ones who need more assessment.
For more significant injuries, a neuropsychological test can be regularly performed to try to understand changes in cognition. This is routinely done for elite sports professionals, but it is also available to the general population after symptoms develop. At the start of an athlete’s sports season, the medical staff perform a cognitive test of some sort. This testing is repeated on a regular basis and after the season ends so the medical staff can track potential cognitive effects of concussive episodes with far more precision.
A lot of medical professionals looking at the new rules support talk about the tenor of the game changing. I don’t think what has been appreciated fully is that there is a potentially existential threat to contact sports if this becomes something considered an occupationally acquired illness. If that happens, we start to bring in a whole range of potential regulatory mechanisms for health and safety.
We could potentially destroy a sport because we don’t understand the link between repetitive traumatic brain injuries and the eventual outcomes. This is a dangerous point for a lot of these sports, and I think the administrators of those sports understand that this is more than just a short-term legal liability with financial consequences.
Helmets reduce the force of injury, but there’s no prospective clinical trials that address whether helmets prevent long-term brain damage. And, again, we’re talking about hundreds of repetitive hits and mild traumatic brain injury.
These are the immense challenges we face. The answer comes down to where on a continuum the person’s symptoms lie, how best they can be managed, and to what degree the damage is permanent.
Symptoms remain the hallmark of assessment, and neuropsychological testing helps to identify areas of difficulty for rehabilitation. It is intensive, time consuming, and requires discipline and substantial resources. It also relies on compliance from a very unwell person to adhere to treatment. We need to determine if the person can even get back to gainful employment.
Given the lack of understanding, there is not a preventive aspect to claims, and there is no way to predict which cases are going to get worse. There have been people who have gotten better, yes, but those with prolonged or persistent concussive symptoms are the ones who are unlikely to return to work, unlikely to get substantially better, and more likely to be disabled at a very young age.
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