Concussion in rugby… it’s not just going to go away
Not enough is being done to highlight the misconceptions of concussions in rugby, which is becoming a serious problem.
“Building Character since 1886.”
This is the motto of the IRB, world rugby’s governing body. Con Houlihan, the great Irish sportswriter, described rugby as a sport which ‘demands the total man; it is of all games the nearest to battle. It satisfies the need for glory — not glory in the sense of fame or tangible honours but in the testing of your manhood and finding it not wanting’.
The question today is whether the game has changed so fundamentally that it has moved beyond similarity to combat and become directly responsible for poor health in sporting retirement.
Rugby is a powerful and increasingly popular global sport. It is marketed intelligently and led by smart, business-minded people. It has grown exponentially over the past twenty years since the inception of professionalism, seamlessly expanding beyond the traditional upper/middle class base to include the wider, receptive general public. Viewing and participation figures increase year on year and as an entity in itself, rugby is big business.
In 2016, the IRB estimated that there were 8.85 million participants, male and female, actively involved in rugby in 121 countries worldwide. The documented strategic plan of the IRB involves protecting player welfare through the use of best practice and maximizing commercial revenue by increasing the financial sustainability of international rugby. Reasonable objectives of any organization and aims that imply that rugby is commercially lucrative, which it is.
In 2015, admittedly a World Cup year, World Rugby revealed pre-tax profits of 189 million pounds. This figure relates to World Rugby alone and has nothing to do with the finances of individual leagues, including broadcasting/sponsorship etc. For example, the French Top 14 assigned broadcasting rights to Canal+ last year for 388 million euro over a four year period, enormous money considering the relative youth of the professional game.
This incredible sporting juggernaut had been proceeding unhindered until the issues of concussion and performance-enhancing medications became problematic. Drugs have been blamed on the individual, a character stain on someone struggling to keep their job in a ruthless environment, with whispers of widespread drug abuse within teams dismissed as vitriolic gossip. Despite visual evidence of incredible muscular development that puzzles me both as a physiotherapist and doctor, there has been a relative paucity of journalistic interest in this topic.
The standard reply from the earnest player that he himself has never seen drugs in the locker-room is invariably accepted by rugby fans and writers (there seems to be very little difference in some cases). However, if PEDs are the problem of the individual, blamed on weakness of character, concussion is a fundamental issue rooted in the game itself and can no longer be ignored as it may provide a stumbling block from which the game of rugby union cannot recover.
Concussion may be defined as a clinical syndrome characterized by immediate and transient alteration in brain function and now accounts for one third of all on-pitch injuries in the professional game. The long-term implications of concussion, specifically in relation to early onset dementia, have been topical and divisive in American sports and particularly American football over the past two decades. Chronic traumatic encephalopathy is a neurodegenerative disease classically associated with boxers but there is now a growing body of evidence illustrating the link between repetitive minor traumatic brain injury in other contact sports and this fatal condition.
Through the work of neurologists and neuropathologists in Europe, there is a slow gathering of evidence in relation to the correlation between rugby and CTE. The IRB states that there is currently no link between CTE and rugby, but this may not remain the case.
The signs and symptoms of concussion have been well described and do not need to be elaborated upon but there are some misconceptions which absolutely need to be clarified. Firstly, the mechanism by which a concussion can occur. The stereotypical concussion is suffered when a player’s head collides with another player, resulting in a change in level of consciousness, headache, personality change and so on. However, it is important to stress that there does not have to be any blow to the head to suffer a concussion. A striking description of this occurrence can be found in an essay written by the ex-England international Shontayne Hape in which he describes suffering repeated concussions when tackling other players with no actual head contact. Visual evidence can be gleaned by looking at George North falling off a tackle against England the year before last, visibly unconscious before hitting the ground, with no obvious contact to the head.
A simple analogy when considering the brain and skull is to compare it to a tin of soft tomatoes. If you shake the jar vigorously, you can bruise the fruit without having to drop it to the ground. If you then consider that the average weight of a professional rugby player is now nearly one hundred kilograms and the speed at which they are colliding has increased exponentially since the advent of the professional game, the simple physics of force equaling mass x acceleration should illustrate the simple point that the impact that players are absorbing thirty to forty times per game, thirty to forty times per season has the real potential to have catastrophic consequences for the brain in both the short and long-term without a player ever having suffered an actual symptomatic concussion.
In a recent symposium on concussion in Trinity College Dublin, Dr Colin Doherty, consultant neurologist, described casually watching the 2015 World Cup final and estimated that there were at least 56 traumatic brain injuries sustained over the course of 80 minutes without one player being deemed symptomatic enough to be removed from the field of play. This is a vital point because it has been demonstrated that the only common identified risk factor in the development of chronic traumatic encephalopathy is repeated minor traumatic brain injuries.
In a fascinating paper by Dr Willie Stewart, consultant neuropathologist and concussion expert, he stated that ‘the incidence of concussion in elite level rugby union is reported as the highest in contact sport, with so-called sub-concussive head impacts occurring as frequently in rugby union as in American Football’. In the same symposium, a geneticist described a study that he has conducted on senior cup rugby players in a prominent Dublin school. The participants underwent MRI brains both pre and post-season and the scans were examined by radiologists. There was evidence found of microvascular or small vessel changes found in a significant proportion of the boys’ MRIs. Whether this is significant or not has not been proven but it is certainly an interesting finding.
The second and perhaps most important misconception to address relates to the safety and effectiveness of concussion assessment. The Head Injury Assessment (HIA) is coming under increasing scrutiny for several simple reasons. Pitch-side assessment of concussion is guided by the use of the SCAT-3 tool. This is essentially a checklist that a physician goes through when assessing a player for signs and symptoms of concussion and was compiled by a panel of experts with a background in concussion research.
Despite being experts in their fields, this does not constitute good science and constitutes the lowest level of scientific evidence. It should be explicitly stated that level 3 evidence in medicine is regarded as incredibly weak. It is intrinsically subjective and amounts to a consensus opinion. In no field of medicine would level 3 evidence be accepted when making broad recommendations, yet we seem to accept the HIA and various concussion protocols as fact. These are tests to prove that you can pass a test. It will show whether the player has retained the cognitive and physical ability to pass the test but otherwise, does not appear to have any intrinsic benefit. It is also completely reliant on the biases of the physician administering the test and has not always been shown to demonstrate significant reliability between testers.
The test may well protect the player from the immediate implications of concussion but there is no evidence to suggest that administration of this test will protect a player from future concussions or long-term complications of concussion.
In fact, some leading experts in this area, such as Dr Barry O’ Driscoll (former medical head of the IRB) and the aforementioned Dr Stewart, have stated that these tests are simply not effective in protecting their players. Indeed, Dr O’ Driscoll’s assertion is that if a player needs assessment for concussion, this implies that he is showing signs of concussion and he should be immediately removed from the field of play.
The most important point to remember after reading this piece is that there is no evidence whatsoever that any test can protect a player from the development of long-term sequalae of concussion. There is no evidence whatsoever that any test will accurately predict that the player is completely safe to return to the field of play. The next time that you hear a coach say ‘X passed all the protocols and has been judged fit to play this weekend’ your immediate thought should be ‘great, he’s no longer showing acute signs of concussion but none of us have any idea whatsoever as to the long-term implications of this concussion and repeated sub-concussive hits will have for this individual’.
I would like to be clear in stating that I admire the effort of individuals such as Ross Tucker in terms of trying to make the game safer. I am however, an advocate of safety and honesty. We demand it from sports such as cycling and scream that illegal medications are making the sport more dangerous for its participants.
My argument should be that the same rules should apply to rugby. There is no transparency from World Rugby, whose PRO informed me that the ‘science is constantly shifting and we are moving with the times’ when I asked him as to the risks associated with concussion and the effectiveness of concussion protocols. This again essentially means, we are as blind as you but at least we are being seen to try to do something. Parents should be aware that there is an inherent risk of repeated head injury when allowing their children to play rugby and that as medical professionals, we simply do not know what the long-term implications are of those injuries because quite simply, we cannot see into the future.
Head injury assessments are just that, assessments and they provide no credible long-term protection. As long as parents and individuals are aware of this, as they are in pursuits such as boxing and mixed martial arts, then the responsibility lies with the individual. This is not currently the case and hence the onus lies on the code of rugby if they wish to persist in building character among its participants.
