Addressing the challenge of concussion in rugby is like a skirmish with the marauding All Blacks. Hazards emerge from every angle and each advancing metre is hard fought.
Leading the line is Dr Simon Kemp, chief medical officer at English rugby’s governing body the RFU and a former physician to the England squad.
With his involvement, the game has made significant progress in improving its handling of concussion in recent years, but the battle is far from won.
“Concussion is just about the most difficult sports injury to diagnose and recognise because it can present in so many different ways,” he says.
“It can lead to two or three seconds of unconsciousness with no signs or symptoms afterwards – or can present with somebody who develops a headache over the course of four to 24 hours, for example.”
Custodians of the game are working on several fronts to better prevent, manage and understand concussion at every level, from schools and grassroots to the top tier.
Like football, American football and boxing, rugby must also answer difficult questions about its long-term impact on the brain.
This follows revelations about links between football and NFL to CTE, the progressive degenerative brain disease caused by repetitive brain trauma and associated with dementia.
Long term study
Kemp (pictured above) says: “Sport in general needs to answer the question of whether there is an association between playing sports and neurocognitive decline.
“It’s a difficult question to answer because, as we age, we all see neurocognitive decline, which is one of the reasons for the limited amount of evidence around to date. We acknowledge that there may be an association [between rugby and CTE] but the reality is that the available evidence is limited and conflicting.
“Unlike some other sports, we do actually have a long-term study underway, involving 205 ex-rugby players, most of whom were England internationals. Rugby has been pretty upfront about this issue.”
The RFU is working on the study with the London School of Hygiene & Tropical Medicine and researchers from Queen Mary University of London, The Institute of Occupational Medicine, University College London and Oxford University.
It is backed by £450,000 in funding from The Drake Foundation, which supports sports concussion research. Results are expected to be published next year.
At the last count in 2015/16, concussion accounted for 25 per cent of all match injuries in the English professional game, up from 17 per cent the year before.
But the sport is not necessarily becoming more dangerous – heights and weights of players have remained stable since 2002, after an initial surge when the game turned professional in 1996.
Rather, Kemp puts rising concussion rates down to greater recognition of the condition.
“In the professional game, reported concussions have been going up dramatically over the last five years but all other contact injuries have remained stable. We think the rise is because we are much better at recognising it.”
This surge in reported concussions corresponds with the establishment of World Rugby’s Head Injury Assessment (HIA) tool, which underpins concussion management in the elite game.
It consists of a three-step process of assessment for any player suspected of sustaining a concussion.
The first stage involves 11 immediate and permanent removal criteria relating to factors such as consciousness, balance or behavioural changes.
“The player absolutely does not go back onto the pitch if any of these criteria are met,” says Kemp.
An off-field screening tool, pitch-side video review system and evaluation by an attending doctor are also involved at stage one.
Stages two and three cover tests and assessments for early signs of concussion, within three hours of the match, and delayed signs, after the player has had two night’s sleep.
The protocol was introduced in 2012 – a year in which an estimated 56 per cent of players later deemed to be concussed stayed on the field.
The latest available stats, from 2015/16, put that figure at nine per cent, with the fourth version of HIA now in play. As often happens at the intersection between much-loved sports and newly installed regulations, the HIA protocol has attracted some criticism.
And, despite its continual improvement via updated versions, it cannot protect against every concussive incident in every match.
Lessons to learn
Last year Northampton winger George North was allowed to return to the pitch at Leicester, despite having appeared to lose consciousness.
A review found there was enough evidence from footage of the incident, together with North’s history of concussion, to have kept him on the field.
It accepted that Northampton’s medical team acted in the best interests of the player, however, since it had not seen all the available video footage due to Wi-Fi problems.
Rugby’s response was swift. The Concussion Management Review Group drew up
nine recommendations, which were implemented by Premiership Rugby.
They included ensuring a pitch-side video reviewer remains in their allocated seat and has backup to make sure video feeds are monitored continually.
Various Wi-Fi protocols and a stipulation that medical rooms should have hard-wire video feeds were among other measures.
Former World Rugby medical adviser Dr Barry O’Driscoll said at the time that the episode showed: “The protocols are totally unfit for purpose. Time and again they are putting brain damaged players back on the field.”
O’Driscoll quit his role at World Rugby in 2012 in protest at the way concussion was being handled.
In the absence of a proven and objective, single pitch-side test for concussion, Kemp insists the HIA system is performing well in terms of protecting players.
Official data backs this up; in 2015/16, 98.5 per cent of head injury events in the Premiership were managed according to the protocol.
“HIA has evolved since 2012 and it really is pretty sophisticated now. The tools that we
have to identify concussion are of real value, but they are, of course, subjective.”
Should an accurate, objective pitch-side test emerge, Kemp envisages it being embedded into HIA protocols, rather than replacing them. Such a test might be based on saliva samples, if trials taking place this season in the Premiership and Championship are successful.
The study, being carried out in collaboration with the RFU, Premiership Rugby and the Rugby Players’ Association, will run throughout the 2017/18 season and is the biggest of its kind in the history of UK sport.
Birmingham University, led by neurosurgeon Professor Tony Belli, has spent the last nine years working towards a test that measures biomarkers present in the saliva and urine of players.
If validated, it could be carried out on a hand-held device, which is currently under development.
Professor Belli says: “If these biomarkers are found to be reliable, we can continue our work with industrial partners with the hope of having a device available within the next two years that will instantaneously diagnose concussion on the pitch-side with the same accuracy as in the laboratory – a major step forward for both sport and medicine.”
While rugby works towards a fast, watertight pitch-side concussion test, what other interventions might minimise the risk of brain injuries in the game? NFL or amateur boxing-style head guards are often suggested, perhaps by those uninitiated with the medical implications of contact sports.
These, says Kemp, would be pointless in relation to head injuries.
“Rugby headgear can protect against head lacerations and cauliflower ears but there aren’t any helmets in sport that have been shown to protect against concussion.
“They can prevent skull fracture, but not the rotational, acceleration and deceleration injuries that are associated with concussion.”
One safety measure which has been adopted by the professional game recently is an increase in the sanctions players receive for tackles made over shoulder level.
In January 2017, the minimum on-field sanction for a reckless (high) tackle was upgraded to a yellow card with a maximum of red, while the minimum on-field sanction for an accidental (high) tackle is now a penalty.
“We are already starting to see more penalties and yellow cards as a result, so referees are definitely implementing it.”
Time will tell whether this heightened threat of an early bath or time in the sin-bin leads to a reduction in concussion rates.
A longer-established part of rugby’s concussion prevention strategy is the
training course delivered to all players and backroom staff at every club in English rugby’s top two divisions.
The club doctor at each of the 24 clubs runs an hour-long concussion session, with mandatory attendance for every member of the playing, coaching and support staff.
Around 1,300 people have now been through the course since its launch in 2014.
“It has transformed the way players understand concussion. They are really well informed about what it looks like, what it feels like and why they need to come off.
“The course also talks them through what the potential consequences are.
“In the short term, if they stay on the field, they have an increased risk of further injury, their performance goes down and their symptoms are likely to last longer. We also talk about the potential long-term consequences.
“We don’t know exactly what they might be, which is why it is so important to get across to players why they need to be removed in order to recover and return safely.”
At amateur and age group levels of rugby, concussion education is not mandatory, but plays a crucial role in protecting players.
The RFU runs online courses and offers a wealth of resources to school and community teams through its Headcase initiative.
They include advice, assessment tools and changing room posters with the slogan “DON’T BE A HEADCASE, STOP! CHECK FOR CONCUSSION”.
Tens of thousands of people have undergone training via the scheme since it was launched in January 2013.
The grassroots campaign advises anyone involved in the game to; ‘Recognise, Remove, Recover, Return’ and Kemp says the message is hitting home.
“Evidence suggests that the simpler your message, the more likely it is to be remembered. We’ve been working hard around the Headcase resource to achieve this, including through the commissioning of a video animation which has gone down particularly well with teenage players.
“The message is getting through but it needs to reach millions of people and it hasn’t got to everybody yet. We also need to consider what is rugby’s responsibility and what is that of the departments of education and health.
“Our principle responsibility is to get the message to coaches, players and parents.
We can help in terms of getting the message out to GPs, emergency doctors and teachers but we do need support from government departments, which, in fact, we have very good relationships with.
“Also, concussion advice to teachers needs to be consistent across sport, which is why we’re working with other sports and our advice is aligned with soccer’s for example.”
Schools must adapt
An important element of the RFU’s work with schools is providing guidance on what happens after a concussion.
“If a pupil sustained a concussion on a Saturday and still had a headache on the Monday, they shouldn’t be back into a full school programme.
“We have been working with schools to help them understand that they may need to make some academic adjustments as the pupil recovers from the injury.
“This is a big task but schools are increasingly receptive. Some independent schools with big rugby programmes have even developed an approach to player recovery that looks very similar to that of professional clubs.”
In concussion prevention and management, the amateur and schools-levels of rugby take their lead from the professionals.
“Concussion is the same injury in professional, community and age group rugby. But the way it is managed varies because of the different resources you have. The principals are the same however and are consistent with the science [of concussion].
“How concussion is managed at the professional end drives how it is managed at the community end.
“So it is incredibly important in the professional game that we recognise and remove players with suspected concussion and do not leave them on the pitch. By doing so, we send a message to the community and age group levels.”
Further protection for young people comes via a lower threshold for leaving the pitch, and a slower return to play.
“Schools rugby doesn’t have video evidence, but does have the coaches, parents, teachers and other players all alert to the possibility of concussion and players coming off.”
Young players also experience a gradual increase in the level of contact permitted in their game as they get older. Full contact rugby is not played until players turn 15, a strategy which also protects players from head injuries, says Kemp.
Exercise may protect young people
New measures could further protect young players, meanwhile. Recent research from the University of Bath found that a 20-minute exercise programme for young rugby players to improve their strength and balance could help to reduce concussion injuries.
A study, involving 14 to 18-year-olds across 40 schools, found 59 per cent fewer concussions in schools that completed the exercises three times a week, compared to those that didn’t.
The exercises focused on increasing neck muscle strength, balance and movement. The RFU is rolling out the programme in schools in England this season.
Other researchers suggest the game should go even further to prevent concussion in school rugby.
A Newcastle University study, published in July in the British Journal of Sports Medicine, re-examined existing evidence on the rates and risks of injuries in sport.
It cited “strong evidence” from Canada that removing the “body check” from youth ice-hockey, where a player deliberately makes contact with an opposing player to separate them from the ice-puck, led to a 67 per cent reduction in concussion risk.
The report drew parallels with rugby and urged a ban on tackling in the youth game; although another recent study in the same journal suggested concussion risk in youth rugby is no higher than in other sports.
Kemp urges balance when considering the risks and rewards of young people playing rugby.
“You have to look at both the sport’s benefits and negative elements. The reality is, at a time when our children are becoming increasingly sedentary and heavy, the place for physical activity in sport is increasingly valued.
“One of the important points about rugby is that it’s a game for all shapes and sizes. The shorter or less mobile child who might not get a look in in soccer, may have a place on the rugby team.”
Yet, despite rugby’s obvious health benefits, is there a danger that officious head teachers might still be tempted to avoid any rugby-related risks completely?
In the US, where American football is still reeling from revelations about links to early-onset dementia, non-contact, ‘flag football’ is reportedly replacing the pigskin in some schools.
Non-contact forms of rugby are already in existence here, but Kemp sees no signs of a drop in appetite for proper rugby among young people.
“Clearly as we become more aware of injury risks, it might change how schools review individual sports, but at the moment the uptake of rugby in schools is significantly growing,” he says.
Making the shift from victim to survivor
After having a stroke two years ago at the age of 39, former international swimmer Craig Pankhurst founded the charity Stroke of Luck to support stroke survivors through activity and exercise. Jessica Brown reports.
“Stroke survivors are in one of two places – they either see themselves as a victim, with a not very positive outlook,” Pankhurst says.
“Or they see their stroke as a bump in the road, but that no one will stop them from having a fulfilled life, just one that’s different to the one they were leading before.
“We put in a halfway line to move people from the victim to survivor mentality.”
Pankhurst wanted to build the charity’s website to enable interaction between stroke survivors and experts in neuropsychology and personal trainers trained to work with special population groups.
When the coronavirus pandemic hit the UK in March, Pankhurst decided to do live sessions on social media, where he brought in guests and spoke about his experience and the charity he’s set up – and says he got good interaction with viewers.
His efforts caught the attention of the World Stroke Organisation, which partnered with Pankhurst to create videos for stroke survivors for what they can do to aid their recovery safely at home, with the help of specialist physiotherapists.
The videos are uploaded by both Stroke of Luck and the World Stroke Organisation.
“I spoke to the World Stroke Organisation over a number of weeks and we agreed to collaborate to create story-specific exercise and activity videos for stroke survivors, to start releasing over 12 weeks, to see if they get good engagement.
“Then we’ll carry on, and do some more,” he says.
The videos are now organised into a library, colour-coordinated into red, amber and green, depending on the viewer’s ability. The library also includes specific videos for carers.
The man who couldn’t see numbers
The unusual case of a man who can’t see numbers has led researchers to argue that the brain can process things without a person being aware of what they’re looking at.
Researchers from Johns Hopkins University studied a 60-year-old man known as RFS, who has a rare degenerative brain disease that prevents him from seeing numbers two to nine.
He would describe seeing one of these numbers as a tangle of black lines that changed every time he looked at it. He had otherwise normal vision, and had no problem identifying letters and other symbols.
The problem would happen before he knew which number he was looking at, which meant his brain had to at least know that numbers were in the same category before something could then go wrong; study author Mike McCloskey tells NR Times.
“It didn’t matter how we presented digits to him, they were always distorted,” says McCloskey, a researcher in the Cognitive Science Department at Johns Hopkins University.
The researchers didn’t know what they were looking for when they started working with RFS, as this specific pattern has never been recorded before. The closest recorded cases are of patients who see distorted faces.
The researchers, whose findings were published in the journal, ‘Proceedings of the National Academy of Sciences,’ also found that RFS couldn’t recognise anything placed near or on top of a number.
They recorded RFS’s brainwaves while he looked at a number with a face embedded on it, and found that his brain detected the face, even though he was unaware of it.
“In one experiment, we showed him a big digit with a face on top of it and recorded EEG signals to see how his brain responded to the face.
“Even though he couldn’t see the face at all, we could pick up a response in the brain 170 milliseconds after the face was presented.
“We saw a perfectly normal brain response to the face, which told us his brain unconsciously identified the face as a face, even though he wasn’t aware of it at all.”
In another experiment, they put words next to the numbers and told him a target word. When he saw the target word, his brain had a bigger response even though he said he couldn’t see the word. They also did tests where they placed a number in front of RFS and asked him to guess what a number was, to test implicit knowledge.
“Sometimes, blind people say they can’t see a light, but can often point to it accurately when forced to make a guess,” McCloskey says.
“We did that with him and saw absolutely no indication he had any implicit knowledge. He couldn’t tell us if numbers were the same or different, odd or even – yet the EEG showed his brain was responding.
The reason it could just be numbers that are affected, he says, is because evidence suggests the brain treats categories of things differently.
“Furniture, fruit and vegetables, for example, may be treated separately, so it’s possible for some areas to be affected and some not.”
The findings demonstrated that the complex processing needed to detect words, numbers and other visual stimuli isn’t enough to make a person aware of what they’re seeing.
“We can draw conclusions about what’s necessary for you to be aware of what you’re seeing. You’d think that, if the brain has done enough work on something to know it’s a face or a particular word, you’d be aware of it.
“These results tell us the brain can do an awful lot of processing on something you’re looking at without you being aware of it at all,” McCloskey says.
“Something else needs to happen after the brain has identified what it’s looking at before you become aware of it at all. ”
And the reason these findings apply to everyone else is because the researchers assumed RFS’s brain was the same as anyone else’s, except for this one thing that went wrong.
“In order to become aware of something, you have to do more than processing to allow you to identify what you see – we think this is true for everyone.”
As for RFS, who was a geological engineer, the story has a happy ending.
“Because RFS couldn’t see regular digits, this was a real problem for him. We created a new set of symbols for him for digits, to see if he could use those,” McCloskey says, as well as a calculator on his phone using the digits.
“He learned them very easily – we wondered if they’d get distorted for him but fortunately, they didn’t. He says he’s been using the symbols ever since – he uses them in his daily life and stayed in his job two years longer than he would’ve otherwise, because of them.”
“Assume brain injury” after domestic violence, researcher urges
Domestic violence survivors in hospital should automatically be tested for traumatic brain injury (TBI) because they, and doctors, may not be aware of the symptoms.
That is according to researcher Jonathan Lifshitz, director of the Translational Neurotrauma Research Programme at the University of Arizona’s college of medicine.
When a patient goes to the doctor with a cough, they’re tested for numerous diseases to rule them out, but with intimate partner violence (IPV), Lifshitz says, we should “flip the script”.
He tells NR Times: “If the individual doesn’t have encyclopaedic knowledge of what TBI is, they may not offer all the symptoms up to their healthcare provider.”
Similarly, the brain injury itself may prevent the patient from being able to detect their symptoms.
Instead, practitioners should suspect that victims of IPV have a head injury, so they can be tested.
“If we tested all people experiencing intimate partner violence for TBI, and are able to screen them using objective tests, we’re going to have far fewer people who experienced intimate partner violence and go untreated,” he says.
In one study, Lifshitz found that 62 per cent of people subject to IPV and diagnosed with TBI were unaware of their TBI when they sought treatment.
While it’s a challenge to determine that someone has TBI, the risk of missing something, Lifshitz says, is much greater. And while increased testing would incur more cost, due to additional testing, Lifshitz says it would save money.
“An individual may be able to hold down a job better, be less dependent on services and won’t need healthcare services as much in the long run,” he says.
Lifshitz is involved in the Maricopa County Collaboration on Concussion from Domestic Violence (MC3DV), a county-wide collaboration in Arizona. It aims to increase the suspicion of head injury by analysing health data for patterns and problems that can be targeted with a county-wide approach.
It educates police officers to recognise symptoms, social workers to better identify abusive relationships, emergency services to profile forensic evidence and clinical partners to assess and treat symptoms of TBI and concussion.
Also, prosecutors through the Maricopa Country attorney’s office are supported in being able to build their case against the assailant; while scientists and process developers also help to bring everything together.
Meanwhile, social workers and nurses are educated on the signs and symptoms of TBI, proposing an objective measure where head injury is implied.
Hospitals are a key area of focus for MC3DV, where one challenge is rebuilding trust between medical practitioners and patients who have previously suffered discrimination, and as a result have a lack of trust.
“It would be easier to implement this change in one crisis shelter or emergency department, when we have the opportunity to regulate and control the organisation we’re working with and we can put in new policies and procedures,” Lifshitz says.
“When trying to coordinate multiple systems in multiple organisations, it’s much more challenging.
“While everyone is receptive to the topic, the problem is having enough resources to do it.”
MC3DV is also hoping to replicate state-wide efforts made in 2012 to better detect evidence of strangulation.
As a result, Maricopa County prosecutors attributed the rise in domestic violence prosecution and decrease in domestic violence deaths to this change.
“Arizona recently changed the way the legal system deals with strangulation, in terms of how it sees evidence,” Lifshitz says.
“Prosecution is much more rapid and severe; it’s unburdened the legal system because many more cases are starting as guilty.”
Lifshitz hopes better testing and evidence gathering will act as a deterrent for abusers, and provide additional motivation for victims to step forward, although, he concedes, psychological, emotional and financial controls an intimate partner has over their victim complicates this scenario.
“A patient wanting to seek treatment is very different from the ability to seek treatment,” he says.
Lifshitz hopes there will be some real changes to come out of the research programme.
“I’ve always needed a bigger social driving force to keep me motivated. It’s unconscionable to know about this and not do anything about it.
“This programme helps to bridge the gap between social work, police work and biomedical research, to attack this problem from multiple angles.
“The majority of the work we do is stepping back, looking at what healthcare data we might have, and asking very specific questions.
“We sit around the table not necessarily with the smartest people, but with the most passionate people. It’s not any one person doing the work, but relying on a community of providers to support the victims and warn abusers.”
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