Meet the Solutionists, with Mark Scott

Whether it’s watching your kids play their local club fixtures or gathering around the telly for the grand final, sport brings Australians together more than almost anything else. But there’s a hidden – and potentially deadly – cost.

Associate Professor Michael Buckland studies the brain, and through the Australian Sports Brain Bank, he examines the brains of athletes who’ve passed away. He’s worried by just how many brains come into the bank and are revealed to have CTE, or chronic traumatic encephalopathy. 

It’s a degenerative brain disease caused by repeated head impacts over a long period of time. In other words, the kind of thing that might happen if you’ve been playing collision sports since you were a kid. 

Michael explains how our understanding of CTE has changed in recent years, its causes, and most importantly, how we can mitigate the risk of CTE for all athletes, of all ages. 

NOTE: This episode contains a reference to suicide. If you need support, please contact Lifeline on 13 11 44 or Beyond Blue on 1300 224 636. For listeners outside Australia, please seek services in your region.

Mark Scott  00:01

This podcast is recorded at the University of Sydney's Camperdown campus on the land of the Gadigal people of the Eora nation. They've been discovering and sharing knowledge here for 10s of 1000s of years. I pay my respects to elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander people.

Lydia  00:24

Something that I really started experiencing after a lot of the concussions was migraines. I'd have migraines nearly daily. I'd have visual disturbances, I'd be nauseous.

Mark Scott  00:36

This is Lydia. She's a 30-year-old retired athlete. A series of head knocks forced her from the field.

Lydia  00:46

Ultimately, I wanted to play professionally, plain and simple.

Mark Scott  00:50

Like most athletes, Lydia prided herself on her toughness, her tenacity.

Lydia  00:58

So my first game, we were 60 points up to who we were playing, and it was about the last five minutes of the game. I was playing in forward, I took a diving mark. Obviously, somebody has come in at the same time, knee to the head, knocked out. There was no reason to take that mark.  

Mark Scott  01:26

Australians love their sport, especially the hard-hitting collision kind. It's part of who we are. Families watch it most weekends of the year, and kids grow up playing it weekend after weekend. But research suggests that repeated blows to the head, even ones that don't cause concussion, might be linked to CTE, and it raises a difficult question; how do we reconcile a national pastime with a potentially serious public health threat, and more importantly, how do we change the culture so our children can play safely? This is The Solutionists, and I'm Mark Scott. Michael Buckland is a neuropathologist, a doctor specialising in the diagnosis of nervous tissue disorders. He is head of neuropathology at the Royal Prince Alfred Hospital, founder of the Australian Sports Brain Bank and clinical Associate Professor at the University of Sydney. Michael's exploring the science, the risks and what's at stake for the next generation of players. Hi Michael, what is CTE?

Michael Buckland  02:31

Hi Mark, well, CTE stands for chronic traumatic encephalopathy, and it's a degenerative brain disease which is linked to exposure to repeated head impacts.

Mark Scott  02:44

It once had another name, though, right?

Michael Buckland  02:46

It's had a few names over the years, initially described as punch drunk syndrome, and that was sort of the clinical picture of CTE. That was about 100 years ago, and it was described in boxers that had taken a lot of hits to their head, and they often had slurred speech, problems with their thinking, problems with their emotions and problems with walking. Hence, drunk, punch drunk. It then changed to dementia pugilistica, certainly when I was a young medical student here at the University of Sydney, we all learned about dementia pugilistica, but it was at the end of the Alzheimer's disease topic, and certainly I and many others walked away thinking it was just a historical oddity that used to happen a lot when there was a lot of boxing, but wasn't really relevant to modern society.

Mark Scott  03:41

So what's changed our thinking and our understanding about CTE?

Michael Buckland  03:46

Certainly one of the seminal moments was the identification of CTE in Mike Webster, an ex-NFL player, a player of American football. He died and had his brain examined after experiencing many years of quite disabling symptoms, and Bennett Omalu then published what he said was the first case of CTE in a professional contact sports player.

Mark Scott  04:11

So you've looked at a lot of brains, Michael and you'll see healthy brains, but ones affected by CTE aren't healthy. How do you know they're not healthy? What are you seeing when you look at those postmortems?

Michael Buckland  04:23

So in young people, when you look at the brain macroscopically or with the naked eye, it looks completely normal. And it's only when you get the slides under the microscope that you start to see this buildup of this abnormal tau protein. Typically, the tau protein will start to build up in the frontal cortex and the temporal cortex, areas that are important in emotional control, planning, memory. And in a normal 35-year-old, there should be no tau there, absolutely none. And so even seeing some, it's a concern, and obviously when you see that the definitive CTE lesion, you have a diagnosis, and then the tau spreads. So we know tau accumulates, not only in CTE, but in other brain diseases such as Alzheimer's disease and some of the frontotemporal dementias, but it's a specific sort of tau that builds up in CTE. And we know that all the tau isoforms from all those diseases have the ability to spread through the brain. And in CTE, it moves from the cortex, the area where you do your thinking and planning and impulse control, and it moves down to your memory centres, and that's when you're sort of in the later stages of CTE, and then that's when it starts to look clinically that person often has problems with memory and can resemble Alzheimer's disease.

Mark Scott  05:51

So you see it tragically after the person has died. But you've been seeing often patterns of behaviour or symptoms leading up to the death of the person. What are you seeing in them that is afterwards validated by the autopsy?

Michael Buckland  06:11

There are some core clinical features described in CTE. Unlike a lot of other degenerative brain diseases, it can declare itself in very young people, people in their 20s or 30s or 40s, those people typically present with symptoms that very much resemble mental health symptoms. So depression, anxiety, poor impulse control, there might be drug and alcohol use, suicidal thoughts and actions, disinhibition, aggression, all those things which none of those are particularly specific to CTE and can be found commonly in the population. It then changes if something and we don't know why, but in some people, the disease doesn't declare itself until they're in their 60s or 70s, and then it often will present, much like Alzheimer's disease with difficulties in thinking and memory and planning.

Mark Scott  07:05

You said that we can only really conclusively diagnose it after death. That sounds tough and almost surprising. Do you expect that that will change over time, and do you think there'll be ways for clinicians to get a more precise diagnosis whilst the person is alive and demonstrating the symptoms; and if, in fact, you did get that diagnosis, would there be any, what would the practical benefit of that earlier insight be?

Michael Buckland  07:32

I should say that, in fact, most neurodegenerative diseases, including Alzheimer's disease, can't be accurately diagnosed during life. Even though your doctor might tell you you have Alzheimer's disease, we know from autopsy studies, both in Australia and overseas, that up to 30% of clinical diagnoses of dementia or Alzheimer's disease are incorrect or incomplete. So CTE is not alone in that space where it's sort of hard to get very accurate diagnosis during life. We are now standing on the cusp of biomarkers for Alzheimer's disease diagnosis. So we have some very good PET scans and blood and CSF biomarkers that when you add those to the classic clinical picture, can really increase your confidence in diagnosing Alzheimer's disease. And I expect in the next 10 or 15 years, we'll see the same with CTE. But yes, the big question is, what are we going to do about it, even if we do have a diagnosis? I think the most important thing is that if we're able to diagnose during life, we can then start trialling treatments, because currently, there's no known effective treatment for CTE. But we can't trial it in the living at the moment, because we can't get a diagnosis.

Lydia  08:53

Yeah, so in quite a short period, within three, say a four-year period, I had about seven, eight. My first year I had, I think it was about three or four. They were pretty significant, but I think I missed maybe one week from them. I was really sort of starting to struggle towards the end of the year. I got one in finals and that the next game that we sort of played in that final series, I was completely just not I was at the other end of the field when I should have been at the other sort of thing, and didn't really second guess or think it. And, you know, had a really strong couple of weeks and start to the season, and then sort of in training again. Yeah, pretty serious one sort of happened in training, along with a pretty significant and serious neck injury at the same time. I think my concussion in that sort of episode definitely got overlooked because we were so concerned about, you know, what was going on with my neck and that injury there.

Mark Scott  10:00

Lydia can't know for certain that she has CTE. As Michael explains, it can only be definitively diagnosed after death. But after a series of head injuries, she is now living with concerning symptoms.

Lydia  10:14

I had to have six months off, but I found from that moment coming back, I was just not the same outside of I guess outside of footy, I was definitely not the same person with a lot of things.

Mark Scott  10:28

In the hopes of better understanding what she and other athletes are experiencing, Lydia has pledged to one day donate her brain to the Australian Sports Brain Bank.

Lydia  10:38

When I decided to go back, people thought I was nuts for going back, but I did. I really started to notice I was not the same, like I could not track the ball as well. My reaction times were off. I couldn't understand what we were doing at training, which is just wild, like I just couldn't grasp the game. I was off the pace. I was just struggling so much. I was tired as soon as I would do like a lap of the oval, you know, you warmup, I was like, I am so fatigued. And for me, I was just, like, trying to put it down to everything else. But it was never really, oh, well, okay, this could be because of concussion, XYZ sort of thing. We never sort of assessed it that way.

Mark Scott  11:19

Michael, let's talk about how your interest developed in CTE. Let's go back to 2018 and then you got through your research to look at the brain of an ex-rugby league player. Can you tell us how that came about and what you discovered when you were doing your research?

Michael Buckland  11:37

Well? So yes, I mean, my job is the diagnosis of disease through examination of the brain and spinal cord. So I see a lot of brains under the microscope, lot of brains removed at autopsy, as well as brain biopsies. And I had been following the literature coming out of the US describing this quite remarkable pathology associated with CTE and thinking, gee, I've never seen that before. Never seen that. And certainly at that stage, there were many sporting doctors that said Australian sports are very different to American football. It's not here. We don't have a problem. And I thought, I bet you no one's actually really looke. So I was very keen to start looking at people that would have been at high risk, and I was lucky enough to, in 2018 look at the brain of an ex professional rugby league player. And the first slide I put under the microscope, there it was. That's how hard it was to find. First patient, first slide, CTE, that really kicked off something in me, I think, where, which made me determined to try and get to the bottom of the disease. Hence, we launched the Australian Sports brain bank.

Mark Scott  12:51

And tell us about the brain bank. What have you got and what do you do?

Michael Buckland  12:56

So the brain bank is a way for people to either sign up during life to donate their brain after death, or for families to donate their loved one's brain at the time of death. The coroner system in Australia is such in it's very difficult to do brain examinations if they're not directly related to cause or manner of death. And so we've set up a mechanism where anyone across the country is able to reach out to us and request the brain examination. So far, we've collected 155 brains. We finished analysis on about 120 and we're just about to publish results of our first 100 brains collected. Our CT diagnosis rate is sitting just under 50% and of those around 45% of those with CTE came to us because they died from suicide. As I said, the earliest person is in their 20s. We would have a dozen people under the age of 40, most of them profoundly affected by so-called mental health symptoms, many of whom took their own life. And then also, we have a significant collection of people in their 60s, 70s and 80s with CTE. And interestingly, in that older population, they are the hardest brains I've ever seen. You don't it's not just they have CTE, it will be they have CTE, plus a bit of Alzheimer's disease, plus a bit of Parkinson's disease, plus a bit of Frontotemporal dementia. The pathology is remarkable, and I suspect that whatever goes wrong in the brain, the cause of CTE after all those head impacts, I think there's something fundamental to that mechanism which is actually going to give us great insights into all these degenerative brain diseases that, you know, are becoming the greatest health burden on the Australian economy,

Lydia  14:50

Something that I really started experiencing after a lot of the concussions, was migraines. I'd have migraines nearly daily. I'd have pressure in my head. I'd have visual disturbances. I'd be nauseous. My memory was the biggest thing. I couldn't tell you what I had for breakfast. My speech even went like, I always sort of describe it to some people, of like, it's like a slow Wi Fi connection, trying to load. Like, I know what I'm trying to say, but it's not coming out properly. And there'll be a delay in response to things. You know, I'd be like, Okay, I'm going to the shops and then I get shops, and I’ll be like, Why am I here? Being at the traffic lights and going, okay, Lydia green means go. Like, having to sort of talk yourself through things. Personality changes, just everything you know, irritable. I became light sensitive. I became noise sensitive. You know, every aspect of my life probably was affected in some way, shape or form.

Mark Scott  15:58

What's your association with the sports particularly, I suppose the major footballing codes that have so many players playing, attract such big crowds, attract such significant revenue from broadcasting rights and the like. I mean, this is clearly a very significant issue for them and the wellbeing of their current and former players. But I imagine it's a message they really don't want to hear too much or engage too much in as well.

Michael Buckland  16:26

Yes, I can't say we've been welcomed with open arms by any of the large sporting codes. I think they do see it as a threat. And personally, I think it is an existential threat to all the codes if they don't do anything about it, I would like to see them sort of embrace the issue and try and fix it and prevent it, because we know that CTE is a disease of exposure. So there should be all those clever footy people that understand the intricacies of the game trying to work out, how do we reduce exposure to head impacts without wrecking the game. And if they don't do that soon, then I think we're going to see reducing numbers of children playing, and then we're going to see lawsuits coming, because they should know now, in 2025, there's enough evidence out there that they should be doing something.

Mark Scott  17:17

And it's a duty of care question, fundamentally.

Michael Buckland  17:19

Oh, absolutely, absolutely. I don't see a problem with people doing risky things. I mean, there are definitely risky jobs, but usually if you take on a risky job, one, you understand it’s risky and you get financially compensated for taking that risk. And two, you go into the job knowing that your employer has done everything they can to mitigate the risk. And then if you decide to do it, the employer's done that. That's fine. I mean, we're all adults, but to date, today, I don't think any player playing understands the risk. 

Mark Scott  17:56

It strikes me, as someone who watches the sport that you have this kind of conflict here, the players seem bigger and stronger than ever. The clashes are more confrontational than ever, on the one hand, but there does seem to be a lot of engagement around concussion management and players being taken from the field and having to have a game off. What do you think about the interventions that are taking place at the moment, and how effective are they in managing risk here.

Michael Buckland  18:26

Often, when we have come out with announcements about the certain ex player had CTE, the codes will say, Well, we have the best concussion protocols in the world. But CTE is not an issue of concussion. There is no evidence that accurate diagnosis or accurate management of concussion does anything to that person's CTE risk. CTE risk is driven by exposure to repeated head impacts, the vast majority of which don't cause any signs or symptoms, don't give you a concussion, but it's those many, many hundreds, if not many 1000s of those over a person's playing career that determines their risk. So while the diagnosis and management of concussion is very important in and of itself, because concussions are serious, that's not enough, and that does not address the problem of CTE.

Mark Scott  19:24

So what would you be advising the CEOs of the big sporting codes that what are the things that they should be putting in place now to more effectively manage the risk of this?

Michael Buckland  19:34

Every code needs to have a CTE prevention protocol to sit alongside a concussion protocol and a CTE prevention protocol should be based on two fundamental principles. One is reducing cumulative exposure to head impacts, and two, increasing the age of first exposure to head impacts. How that is implemented in individual codes would be up to the people that understand the intricacies of the game. But I do know that in American football, they now have 15 minutes full contact training per week, and no more. So by reducing it from full contact training, they're actually essentially halving that person's overall exposure to head impacts without changing a single rule of the game. So that would be an obvious first move to take to reduce the player's risk.

Mark Scott  20:34

And what do you think will happen if the professional codes don't keep up with the research on CTE?

Michael Buckland  20:40

Oh, look, I think it is an existential threat to all of them. I certainly get the feeling that most pronouncements from the codes come through their lawyers about this issue. There are rumours of class actions looming. I don't know how valid they are at the moment, but what I do know is that in 2025 we have enough evidence that if someone playing today ends up with CTE, then I think the codes are running a risk that they will be liable in any class action.

Mark Scott  21:16

And to parents who might be listening and for those who are involved in children's sport, would you fundamentally change the rules of engagement for children in light of the evidence and the research that you've seen so far?

Michael Buckland  21:29

Yes, absolutely, absolutely. So certainly, the Brain Bank, as well as our sister organisation, the Concussion Legacy Foundation, very much advocate for modified, low or no contact versions of the game for every child under the age of 14. First of all, if you're enrolling your child in a risky activity, they're not consenting. What are they going to say when they're 30 and they've got terrible depression or so forth? So I think it's very important by increasing that age of first exposure, even if that person plays till they're, say, 30, if you've actually, they're only got to have 16 years of exposure, rather maybe 25 years, if they started tackling when they were six or so. So I think that's very important, and that position has recently been backed up by the Royal College of Pathologists of Australia, who have also called for the same thing. 

Mark Scott  22:27

I'm curious where you think we're at as far as public awareness and the public response from sports fans. The biggest shows on Australian TV this year will be major sporting events, including collision sports. It's just such an ingrained part of life in this country. But do you think there's a growing concern among spectators for the price these players might be paying?

Michael Buckland  22:59

I don't know about the spectators. A lot of them love the big hits. I often because I'm in sort of embroiled in the world of CTE, I often think that the awareness is very great in the community. And then I get people saying, I've never heard what's this. I've never heard of it. And so I do get a bit of a reality check quite regularly that, in fact, the awareness, we need to have much more awareness. The problem is, it's, yeah, it's not just a medical problem. It's a sociological problem. Often people's weekends revolve around the footy and their social lives in the local footy club, and all that sort of stuff is good. It's just trying to change some behaviours around it, without people getting their backs up and saying, Well, you're trying to ruin the game and so forth. And I think, you know, I suspect it will take a generational change before people are really taking it seriously. I think, much like smoking, you probably like me, remember when you were young, getting on a bus was always full of smoke, the train was full of smoke, or restaurants were full of smoke.

Mark Scott  23:34

Ads on the television.

Michael Buckland  23:36 

Yes, advertising on the television. I couldn't imagine my 21-year-old son now tolerating any of that. And I would imagine that if you were seen smoking in the car with your kids in the back, you'd probably be arrested. But often it takes that generational change for those sort of behaviours to become ingrained and become normal, and that's certainly what, what gives me hope.

Mark Scott  24:28

Well, thanks for doing the important research, and thanks for increasing our education about CTE today, Michael. That's Associate Professor Michael Buckland, the head of the department of neuropathology at the Royal Prince Alfred Hospital in Sydney, and the founder of the Australian Sports Brain Bank. You also heard from Lydia, a retired athlete from Queensland. And if this has you thinking about the health and rights of Australian children, you might be interested in our episode about early childhood education and care. Philosophy professor Luara Ferracioli argues all Australian kids have the right to an excellent, equitable education.

Luara Ferracioli  24:51

If we don't provide universal ECC in Australia, we end up with a situation where not all children are well placed to start their formal education journey, and that's incredibly unfair. 

Mark Scott  25:27

You can listen to that episode of the solutionists right now and make sure you're following the show so you don't miss an episode. The Solutionists is a podcast from the University of Sydney produced by Deadset Studios.

The Solutionists is podcast from the University of Sydney, produced by Deadset Studios. Keep up to date with The Solutionists by following @sydney_uni on Twitter, Facebook, and Instagram.

This episode was produced by Liam Riordan with sound design by Jeremy Wilmot. Supervising producer is Sarah Dabro. Executive editors are Kellie Riordan, Jen Peterson-Ward, and Mark Scott. Strategist is Ann Chesterman.

This podcast was recorded on the land of the Gadigal people of the Eora nation. For thousands of years, across innumerable generations, knowledge has been taught, shared and exchanged here. We pay respect to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander people.