Knockout Blow

The sickening sight of Luke Marshall being removed from the field in Ulster’s game against Saracens with a suspected concussion was most sobering – a young man at the beginning of his career and full of promise had suffered a third concussion in four weeks, across three consecutive games. What were the long-term implications for his health?

Without conflating the two events, when former Pittsburgh Steeler Mike Webster died at the age of 50 in 2002, the autopsy revealed his brain had been damaged a protein called tau, most commonly found in Alzheimers patients. Webster hadn’t got Alzheimers however, he had chronic traumatic encephalopathy (CTE), a degenerative brain disease caused by repeated head trauma.

The presence of the tau protein cannot be confirmed without cutting someone’s head open, so its usefulness as a diagnostic tool is limited. However, early symptoms of CTE are memory loss, confusion, impaired judgment, poor impulse control, aggression, depression, and progressive dementia. Boston University Center for the Study of Traumatic Encephalopathy posthumously identified CTE in 34 of 35 former NFL players.

So it’s clearly an issue in the NFL – should rugby be concerned? You would think so anyway – the IRB states in no uncertain terms in its concussion guidelines that CONCUSSION MUST BE TAKEN EXTREMELY SERIOUSLY (in capitals).

We aren’t medical professionals (or lawyers) so we won’t be opining on how seriously it is taken, but we will share some of the practices in both sports used to identify and report concussions.

We think the sports are comparable, both are tremendously physical and aggression is ingrained. Helmet to helmet hits are allowed in certain circumstances in NFL, but head-to-head are not in rugby, but NFL players wear more protection. A South African survey conducted in 2008 found similar concussion rates across the two sports – we haven’t found a comparable survey since then, but it’s fair to say rugby has got more physical since then, as has, to be fair, the urgency of concussion issues at the IRB.

The NFL is better than rugby for statistics – PBS tracked reported concussive or head injuries by NFL teams, and noted 170 for the year, across 256 regular season and 11 playoff games. We could not find a similar list for rugby players.

The NFL numbers are based upon injuries reported by the teams, and it is suspected it is not an exhaustive list. For example, last season, Detroit Lions wide receiver Calvin Johnson left the field following an (illegal) helmet-to-helmet hit against the Minnesota Vikings – he underwent sideline concussion tests and returned to the field. Johnson was not listed on the Lions injury list, but was quoted as saying “Yeah, he knocked me good. You could tell. It was obvious”. A month later, Johnson and the Lions issued a joint statement in which the player retracted his claims about being concussed and claims he mis-spoke. Johnson is not on the PBS list.

Now, of course, we can’t blame teams completely for this – players have admitted that they will hide symptoms to continue playing, and it’s hard not to understand why – can you imagine Brian O’Driscoll leaving the field under any circumstances whatsoever? Remember the England game in the Grand Slam year, and that huge hit from Felon Armitage?

In the NFL, players are assessed using the SCAT-2 sporting head trauma protocol. This is a series of tests, physical and cognitive, for which players are tested, and then are scored by sideline medical professionals, who then compare the score to a baseline – for example the same test done pre-season – then make a judgement about whether the player is fit to continue.

There are some questions surrounding this test:

  • The subjectivity element – there is no defined “cut-off”
  • The baseline test – is there a possibility this could be gamed?
  • The relative contributions of different tests – the ocular test is passed with a 100% score if the player spontaneously opens their eyes, whereas with the balance test it is extremely hard to fake a false pass – but both contribute equally

It should also be noted the SCAT-2 tests usually take 10-15 minutes – that’s a smaller portion of an NFL game due to advertisement breaks, change of possessions, time-outs and simply the nature of the game. In rugby 10-15 minutes is a virtual eternity. There have been suggestions to use alternative tests, such as the King-Devick test, which is used in MMA and boxing and takes only 40 seconds for a non-concussed person – someone with a concussion will struggle with this test and often cannot complete it.

Moving on to rugby, if a player has a suspected concussion or head injury, the IRB protocols are as follows:

  • Players suspected of having concussion must be removed from play and must not resume play in the match.
  • Players suspected of having concussion must be medically assessed.
  • Players suspected of having concussion or diagnosed with concussion must go through a graduated return to play protocol (GRTP).
  • Players must receive medical clearance before returning to play.

If a player has any suspected symptoms of concussion – physical, behavioural or cognitive – they are tested using the Pocket SCAT-2 protocols on the field of play – this test need not be carried out by a medical practioner. The pocket SCAT-2 is a series of five questions. If the player is unable to answer any of the five questions, they are then removed from the field of play and subjected to the full SCAT-2 tests, by a qualified medical practioner.

The five questions are as follows:

  • At what venue are we today?
  • Which half is it now?
  • Who scored last in this game?
  • Which team did you play last week/game?
  • Did your team win the last game?

This is the key difference with NFL – for all the weaknesses of a SCAT test, they are conducted by a medical professional in the event of a suspected brain injury. In rugby, the Pocket SCAT-2 questions are an interim step, not necessarily conducted by a medical practioner, and limited in scope. These questions do have the benefits of not being subjective and having no baseline, but it’s clearly less in-depth than the full SCAT-2 or other tests.

Perhaps this is appropriate, perhaps not – we would love to see the research behind the five pocket questions. But more importantly, we really hope we never see a Mike Webster in rugby, and that Luke Marshall returns a healthy and better player.

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48 Comments

  1. Shelflife68

     /  April 18, 2013

    WOC agree with you on all this. one question though, do you know if a player who is KOed suffers concussion every time they are KOed or is it only sometimes.

    For me there are far two many players allowed to return to the pitch after being knocked out by a blow to the head. The problem is if they see it allowed in the big games they will assume that its ok for Johnny at J1 level to continue playing .

    • Chogan (@Cillian_Hogan)

       /  April 18, 2013

      When Fogarty and Jackman were banging the concussion drum, (gone very quiet now) they talked about feigning another injury in an effort to buy themselves time to recover.
      If you give a boxer or anyone long enough they will be able to fight the signs showing they are concussed.
      KO’d in boxing and it’s game over, thanks for playing, better luck next time. I’d like to see the same in rugby.

    • LeftBank

       /  April 18, 2013

      Most brain injuries result from acceleration-deceleration forces. Your brain is floating around in your head and bounces against the walls of your skull and concussion is in effect bruising on your brain both from striking your skull and from shearing of small blood vessels in your brain. If you have received a blow to your head that has sufficient force to knock you out, you will have a concussion.

      We are far too lenient at letting players back in the game. Currently the IRFU charitable trust focuses primarily on those with spinal injuries. I honestly believe (and I know of a number of medical professionals who agree) that in 10-15 years one of the major areas they will be dealing with is the fallout from CTE.

      It’s simply not good enough to let players play concussed. If they have a muscle strain they don’t play as any subsequent injury could be worse. The same goes for the brain, and pitch side assessments regardless of who performs them are simply not adequate. If there is suspicion of concussion, they should be removed from the game and given a mandatory rest period (and I would like to see this at all levels of the game, from senior down to J5 and underage).

  2. Surely if the concussed player can’t walk he has concussion – no need for test or medical people! Marshall should not have played against Italy!! never mind Sarries what happened to the 5 weeks rest??

  3. Nice piece and one which the IRB (and IRFU) really needs to give more time to. Last time I was concussed it was 4 weeks off. Why is this different for professional rugby palyers? I am not sure I have faith in the cognitive tests that have been talked up and Luke Marhsall clearly drove this home.

    The NFL has been looking deeper at head trauma for a couple of years now. This fascinating National Geographic piece totally opened my eyes to the subject: http://ngm.nationalgeographic.com/2011/02/big-idea/concussions-text

    Often it’s not the big impact but the glancing hits on specific parts of the head that lead to concussions. The jury is also out on the role of headgear/helmets.

    Anyway, something the IRFU should start taking more seriously.

  4. Independent medics on hand at pro games to assess players?

    It cannot be left to the players. Luke Marshall was never going to say no either to playing against Italy or Saracens. Both selections were pretty disgraceful, but coaches want to pick their playas and players gon’ play – the only answer is to have it taken out of their hands.

    I have no faith in this improving any time soon.

  5. Laurence Rocke

     /  April 18, 2013

    There is no difference between professional American Football and professional rugby in that the tests are all carried out by some kind of medical professional, trained in the assessment of potential concussion. I am sure that the two games are also the same at amateur level, in that it would be rare for the assessor to be medically qualified.
    There can be no doubt but that there is far more knowledge and far more concern about the effects and diagnosis of concussion in rugby now compared with a few years ago and there will be further developments in the next few years. The problem is finding the right balance between providing proper protection for the player who really needs it, while allowing the game to continue more or less unchanged in terms of its physicality, or grossly over diagnosing concussion (i.e. make anyone who gets a bang on the head leave the match permanently) and emasculating the game to a fair extent. Pitchside concussion assessment is now being used as an attempt to do just that and early indications are that it works fairly well (but not yet perfectly). Work and research to improve it is continuing.
    As for Chronic Traumatic Encephalopathy and its physical effects on rugby players, I do not know any former players from 60 years of age and upwards, say, who exhibit the symptoms as listed (early symptoms of CTE are memory loss, confusion, impaired judgment, poor impulse control, aggression, depression, and progressive dementia) but those known to me may be a relatively small sample. Anyway, it seems to me that CTE is something of a side issue at present and the rugby authorities and medics are working hard to address the issues with on-field collisions.
    As far as Luke Marshall is concerned, I very much doubt that he would have been allowed to play had he not been deemed fit by the medical teams involved, at least in terms of successfully negotiating the formal testing process and graduated return to play protocol. To sustain three consecutive bangs on the head seems pretty unfortunate. He must now be given a proper period of recovery and, I assume, further testing and specialist assessment before he plays again. I suspect that may be next season.

    • LeftBank

       /  April 18, 2013

      CTE may not be an issue yet but I can almost guarantee it will be. We have a very small sample set in this country of former professionals. The oldest of these must be what, 50? This is an issue coming down the tracks. I know in your experience you have not seen any former players exhibiting signs of CTE. In my experience I unfortunately have. Not former pros but guys who would have played at a high level. We really need to be proactive now, not in 10-15 years time.

      • Leinsterlion

         /  April 19, 2013

        Look at league, professional for as long as NFL, massive incidence of “CTE”? No, “CTE” is caused by poor tackling technique in the main, or linemen smashing their heads against one another. League and Rugby dont have this problem, concussion is a minor issue at best. Fix the rest protocols and teach kids how to tackle properly=problem solved.

        • LeftBank

           /  April 19, 2013

          Do we know the incidence of chronic traumatic encephalopathy in league players? No as the study hasn’t been done yet. CTE is a real phenomenon, I don’t know why you are using inverted commas. It just happens that our knowledge of it is rapidly developing. CTE has been shown in Americans who only played football to high school level and there is concern there about other sports. As I said I have seen former rugby players exhibiting symptoms consistent with CTE.

          Concussion happens in rugby. Teaching proper tackling technique is great. Does it eliminate concussion? No. Should be be more careful about managing concussed players and return to play protocols? Absolutely.

          • Leinsterlion

             /  April 19, 2013

            You can never eliminate accidental concussions, as for deliberate concussions, rugby does not lend itself to producing those kinds of incidents. Tackling technique will make up the difference between avoidable and unavoidable concussions. The only way to guarantee zero concussions is to ban contact.
            As for CTE being proven, that is rubbish, CTE can only be proven by autopsy. You are giving to much credence to unfinished research which has an element of bias as there is an ongoing legal issue worth billions dependent on the results of the research backing up their claims. I’ll wait until the research is cloe to concluded or proven as far as possible before I jump on the concussion bandwagon.

        • Chogan (@Cillian_Hogan)

           /  April 19, 2013

          I think you may be missing the point.
          Comparing with league is more similar but the money to carry out these studies hasn’t been there in league so NFL and NHL are our starting points.

          We all accept the running around for 80mins and bouncing into each other will occasionally result in a concussion. The issue is what are the lasting effects and what are the best ways to recover as much as possible without placing a player in a position of unnecessary risk.

          We can make a reasonable guess that the likes of John Fogarty and Steve Devine have CTE and are suffering as a result. Could better screening, diagnosis and longer recovery prevented the extent of their problems? Probably, so lets find the best way to not have it happen to others.

          • Leinsterlion

             /  April 19, 2013

            But NFL and NHL are different sports, we might as well be comparing it with boxing. League is the closest we wil get,we cannot compare NFL as the collisions and concussive blows are different.
            As you say, we can make a “guess” that Fogarty is suffering with CTE, but that is just it, a guess. We don’t know, I understand the need for and support all the research into concussions, I just vehemently disagree with the conclusions and assertions at this early stage.
            As you say lets investigate and look at better screening etc, I agree with that and mentioned it in my post. All we can really do at this stage is teach proper tackling technique and fix concussion protocols. I think WOC shouldnt link concussion protocals in with CTE as it confuses the issue.
            At the stage CTE research is at, it does no good to anyone to know “repeated concussion may cause CTE”, you cannot do anything to the game on a maybe, that does nothing to help anyone. The best we can hope for and do is overhaul the protocols and hope the research comes up with something definitive in the next few years. I think the hysteria in the media about CTE needs to be directed in the right direction, the only issue is when to let the guy back out on the field, nothing else, CTE shouldnt enter the equation until the research is more complete.

          • Chogan (@Cillian_Hogan)

             /  April 19, 2013

            Agreed.

            The focus is and should be after a player suffers a concussion. That is the area that needs to be overhauled.

            I watch a lot of NHL and that like rugby it does not contain the objective whereby it aims to injure players. Pucks flying, crashing into the boards and hitting the ice are accidental factors of the game so using their studies works for me. (Fights, yes. they account for a tiny % of concussions in the game) League has never had the money to conduct a study like this but it may well should have.
            AFL are currently doing there own studies while closely looking at the information already available to them from studies in the american sports.

  6. Stevo

     /  April 18, 2013

    Gavin Cummiskey wrote an article about this in last week’s Irish Times, noting that Dr Barry O’Driscoll (uncle of Brian) had resigned in protest from the IRB medical, anti-doping and disciplinary committees as he disagrees with the new five-minute rule to treat concussion. Some of the quotes he gave from O’Driscoll are as below:

    “Rugby is trivialising concussion. They are sending these guys back on to the field and into the most brutal arena. The same player who 18 months ago was given a minimum of seven days recovery time is now given five minutes. There is no test that you can do in five minutes that will show that a player is not concussed.”

    “If a boxer cannot defend himself after 10 seconds he has to have a brain scan before he comes back. And we’re not talking 10 seconds for a rugby player, we’re talking maybe a minute that these guys are not sure what’s going on.”

    “We’re going from being stood down for three weeks to one week to five minutes with players who are showing the exact same symptoms. The five minute rule came out of the blue. I couldn’t be a part of it so I resigned.”

    I can’t help the feeling that this is a ticking time-bomb for the sport. Even the oldest former players who played for a significant amount of time in the professional era are only just reaching the age Mike Webster died at. The sport’s governing body appears to be content to ignore the warning signs rather than make the difficult decisions.

  7. don_cherrys_conscience

     /  April 18, 2013

    As a long-time season-ticket holder for a NFL team, and a former employee in the lower leagues of professional ice hockey, I can tell you that both sports have made significant rules changes over the last 10 years or so to reduce the risk of concessions. There are just as many cases of former National Hockey League ice hockey players, many under the age of 45, with permanent effects from concessions, as their are from the NFL.

    The trade-off for this safety in both sports has been that speed, not brawn, is the best attribute a potential athlete can have. Points scored have gone up all across the league in the NFL. It has gotten to a point where wide receivers own the middle of the field, because once they go there and await the arrival of a thrown pass, virtually any contact by the defense draws a 15-yard penalty under the guise of the receiver being “defenceless.”

    The NHL seems to have gotten it somewhat right…there is still enough action to retain older generations who were drawn to the bigh hits and fights…guys trying to whack a puck skating 20 mph is pretty cool to watch, especially in person.

    NFL? They are getting close to the point where it is not even football as I knew it at all. There is a rule this year where, for the first time, if an offensive player lowers their head and makes contact with a defender, it’s a 15-yard penalty. Current NFL running backs are stating already how hard it will be to change the running style that got them to the NFL.

    Most troubling, I know from my friends with kids and stories in the local media (state of Ohio), that many parents won’t allow their kids to even start playing football. The sports the kids are directed to, instead, are soccer, first and foremost, and to a smaller extent, lacrosse.

    The average footbal fan here thinks that because the NFL is multi-billion dollar business, the players should be told the truth on the risks of concussions and long-term damage, but be allowed to play and make their share of the large pile of money, if they good enough to do so. Do most rugby fans in Ireland feel the same?

    • Leinsterlion

       /  April 19, 2013

      NFL and rugby afre incomparable, in the NFL you are taught to hit the opponents head with your head. In rugby head contact is to be avoided as you will inevitably knock yourself out. Concussion is not as serious an issue as a blown knee for example. Rugby doesnt lend itself to producing the type of collisions that cause concussion, concussions if they occur are accidental rather than as a result of simply playing the game.

  8. rugbyfan1991

     /  April 18, 2013

    Hey WOC I’m a big fan of your articles and I just thought I could add something to this discussion. I work as a health professional and I have done some research in the areas of rugby injury and epidemiology. I just wanted to highlight that as far as I’m aware professional sides use a SCAT-2 throughout the season to monitor the effects of head injury. Usually at pre, mid, and end season. The majority of research into concussion is in the areas of underage rugby (over 2 seasons in Australian school boys there were 250 concussions which to an incidence of 6.9/1000 hours of game time) and the professional rugby , amateur club rugby is the main problem area in my view. I do not agree with the current IRB concussion bin and position stance on concussion because it is a well known fact that the majority of concussion symptoms resolve with in a very short time scale. I do advocate the mandatory three week break for underage players with concussion but unfortunately this guideline is ignored by the majority of pro and senior amateur teams.
    The IRB have been more pro-active then other organisations in addressing the problem of concussion and strategies have been suggested such as mandatory rest periods .The NFL franchises have been known to discount evidence of the effects of repeated concussions.
    I think it is important to highlight as well in professional teams the medical staff do not have the final say in if a player plays or not they can only advise against it. This will have to be addressed in the future. The coach and player have the final say and thankfully 95% of coaches and players follow medical advice.

  9. All – these comments are fantastic – really expanding upon the issue and adding insights and expertise we don’t have. Keep them coming – it’s extremely educational stuff

  10. JohnMurff

     /  April 18, 2013

    I speak mainly based on my own experience of concussion and also from what I’ve seen both playing and watching rugby.

    Last time I was concussed it was during the second half of an away game. I’m told that for the first 5/10 mins after the concussion, I just didn’t make any sense, couldn’t verbalise what I was trying to say and had problems walking/running. After that I’m told I seemed fine, could hold conversation and wanted to go back on. That said, I couldn’t remember how to get back to the changing rooms, couldn’t remember what team we were actually playing and couldn’t remember if I was actually going out with my girlfriend (of 18 months) when she came down to collect me…. there was an awkward kiss where I couldn’t figure out if I should have done it or not.

    There far too much willingness, certainly in pro rugby, to let the guy play on once he can get a few words out and has his balance back. Recent rules involving preseason cognitive tests and retests just don’t go far enough. Everyone knows players dumb down their preseason tests to set the bar lower. I’d also imagine that if a doctor is constantly declaring players unfit to play after head knocks, he won’t be a professional sports doctor for too long. So based on this, the power has to swing back to the referee and his assistants. If a ref sees a guy go down, not move and struggle to get up, he just shouldn’t be allowed to play on, end of.

    • Laurence Rocke

       /  April 18, 2013

      A few things, John.
      Firstly, if players deliberately do badly in their pe-season testing, then they are very stupid indeed. I do think it used to happen (a la Jackman, etc.) but I doubt if it does now. If so, it won’t be because they haven’t been warned about it by the medics.
      Secondly, it would be a very foolish sports doc who was declaring players fit to play when they were not – litigation is a big issue here, although still less then in the USA.
      Finally, your point about letting players play on when they are seen to have lost consciousness, even for a period of seconds, is well made. The issue for me with the pitch side assessment is that it may be being used on players who should simply be excluded from the match and there should be no question of them coming back into play.

      • Peat

         /  April 20, 2013

        Foolish like the Quins doc who cut Williams’ lip? The team ethos and will to win can sweep many people into doing things against their better judgement.

  11. Lads, don’t know how closely you follow the NFL (seemingly interested anyway), but it is still a large issue there, it will always be a bigger issue in the NFL as opposed to rugby, as players use it as a weapon, leading and charging with the head. For the forthcoming season, running backs will give up a 15 yard penalty should they be found to deliberately lead with the crown of their helmet. Now if you bring your head down to protect yourself, it can be construed as leading with the crown of the helmet, so the law will be tough to police.

    You’ve mentioned Webster but there’s countless more examples of NFL players (David Duerson, was diagnosed with Chromatic Trauma Encephalopathy after repeated concussions, he committed suicide and donated his brain to science in an attempt to improve understanding of the effect of repeated concussions, Junior Seau who passed away recently, committed suicide, with no prior reported concussion history, yet autopsy reports confirmed he suffered from CTE like Duerson) and I imagine as part of your research for this you came across the court cases many players are undertaking against the NFL. As stated by Don-Cherrys, fans are not exactly in favour of the players, feeling guys know the risk when they play the game, and it’s why they got/get very good money for it (not all do though). Players have come out against the rule too, Hall of Fame Running Back Marshall Faulk stated “if you think the helmet is a weapon, take it off”. That would improve safety in American football drastically, I think, but I can’t see it happening. The main problem in the NFL is guys use their bodies as weapons, launching at opponents and this often involves the helmet too.

    By and large I don’t think it is or will be as big an issue for rugby, but measures need to be taken to ensure it is better policed. The independent doctors was a good start, but it’s not perfect yet (I think Murray got left on for Munster early on in the year when he looked totally out of it) and neither is the NFL’s system.

    Good stuff and good comments from all.

  12. opersson1986

     /  April 18, 2013

    WOC I would urge you to take a look at the career of Jahvid Best, running back from the Detroit Lions to see why there should be such concern over Luke Marshall:

    http://en.wikipedia.org/wiki/Jahvid_Best#Professional_career

    Stepping aside from the safety argument (which is obviously the most important part of the whole thing) the IRFU are opening themselves up to an absolute Pandora’s box of lawsuits by treating their dignity of care to Luke Marshall in such a negligent manner – lots of details on concussion litigation in the NFL at the link below.

    http://nflconcussionlitigation.com/

  13. Good Piece, & great to see the comments coming in. Personally I feel concussion is handled far to lightly in rugby, I honestly feel sick watching players clearly concussed managing to convince the medics they’re fine & stay on the pitch. Jeremy Manning used to get concussed every other match he played when he first joined Munster purely because of his tackling technique, it took the coaches a couple of seasons to get him using the correct techniques, thankfully they seem to have resolved the same problem with Peter O’Mahony far faster.
    But there are different types of head injury and severity of concussion depending on the type of bang your head gets. A teenager from my home village slipped on ice & banged the back of his head, he got up seemed fine but was dead a couple of days later because of the unsupected brain injury. A rugby player tackled to the ground on a rock hard pitch could very easily get a similar type of bang that on initial assessment seems nothing worse than a potential bruise & headache. For that reason alone scan’s should be mandatory for any player with even the suspicion of an head injury.

    I do know the NFL is doing a lot of research on helmet design to reduce the risk of concussion for their players, my employer has been involved in providing the technical resources for the analysis so it’s been mentioned on our internal communications.
    Previously there was a habit for medics to claim a neck or shoulder injury when taking a concussed player off so that they wouldn’t be obliged to stop him playing for the required number of weeks, that wasn’t safe either. It is time for rugby to look at procedures from other sports who’ve had far longer to develop methods of dealing with high velocity/impact head injuries.

  14. Chogan (@Cillian_Hogan)

     /  April 18, 2013

    Whats the opinion on scrum-caps, especially at mini’s level?

    As far as the IRB are concerned the scrum-cap is not intended as a helmet, rather a measure of preventing surface wounds and protecting the ears.

    Personally I’ve been involved in coaching mini rugby for a decent number of years and over that time I’ve made some observations.
    1. More and more Kids are starting rugby with all the “gear” including scrum-caps.
    3. This is a measure encouraged by predominantly protective mothers
    2. The scrum-caps are often far too big in an attempt to reduce the cost of sports equipment and lengthen the life of a scrum-cap.
    4. The poor fit of a scrum-cap impairs a child’s vision and curtails his advancement of skills and safe tackle technique.
    5. Many kids that acquire a scrum-cap having not worn one before develop a “superman syndrome” where they believe that they are now invincible and can stick their head in anywhere at the expense of safe technique that is yet to be learned properly.
    6. To my knowlege, I’ve never coached/reffed a child under the age of 12 who has received a concussion from a “collision” in rugby and I’ve had two incidents of cuts where steri-strips were a minimum requirement in closing a head-wound.

    From these observations I would recommend that no scrum-caps should be worn by any player up to the age of 12. Scrum-caps are NOT helmets Learning safe and proper technique is paramount in the prevention of concussion and as a preventative measure should be done at the early rugby years.

    Here’s a video about Steve Devine’s concussions and further concussion information:

    • LeftBank

       /  April 19, 2013

      I think your intuition about protective gear is 100% right. Style of play (Paddy W and all his head injuries…) and use of protective gear (in some cases) is associated with increased levels of concussion. I only started wearing a scrum cap once I started scrummaging as a lock on a regular basis to protect my ears. They definitely aren’t helmets and play no role in protecting against your brain bouncing around in your skull.

  15. LeftBank

     /  April 18, 2013

    The American Medical Society of Sports Medicine is actually currently staging their annual meeting, I’ve been following some of the updates of the most recent concussion research. Some really interesting stuff, will try post a summary of it later on.

  16. Jason

     /  April 18, 2013

    I’m gonna keep my comments brief…fully agree with you lads. I have to say it was an absolute disgrace that Marshall took to the pitch against Italy. Absolutely no consideration shown by management or the powers that be higher up. Getting concussed three games on the bounce is surely not a coincidence.

    I think Marshall should be rested for the rest of the season. I’d even contemplate not taking him on the Americas tour. We’ll see him next preseason. Surely it just isn’t worth the risk with this precocious talent.

  17. ruckinhell

     /  April 18, 2013

    Some great contributions here and while this will cover quite a bit of what has already been posted the below is an incredibly interesting read

    http://www.newyorker.com/reporting/2011/01/31/110131fa_fact_mcgrath

    I’ve been concussed several times in my playing days and it’s not an enjoyable experience. The first time it occured I got a filthy elbow into the temple which floored me. When I got up I couldn’t see the field of play (vision very blurred) and subbed myself off. I blacked out for the next hour and then the next thing I know I’m in the clubhouse eating soup and chatting to teammates. Apparently I was conversing fine. Later that night the left side of my face went limp as if I had a stroke and my speech became very slurred. When I got home (I was a wee student at the time) my mother took one look at me and brought me straight to the hospital. I started puking out the side of the car and after an X Ray the Dr. told me if I hadn’t been wearing a gumsheild my jaw would have shattered.

    The last time I was concussed I was captain and lineout caller. I took a knee to the head in a ruck (from my own side, the feckers!) and a minute later (play continuing all the time) I ran to the sidelines and started calling a lineout! I was pulled a minute later. What I have found is that it has become progressively easier to get concussed and that I’m finding that even a big collision (not necessarily to the head) leaves me a bit dazed and seeing stars for a few seconds.

    At Junior level in Ireland, there are no adequate controls with regards to dealing with concussions that I can see and it’s up to each player to police themselves. After the above incidents, and the two or three in between, I was “able” to play the following week. I’m currently in Argentina and it’s the same here, almost all the way up to the very top domestic level leagues.

    I’m currently out of action with ligament damage but I’m seriously considering my future as a player. I’m only 28 and have never played above J2 level so it’s not serious stuff but it’s getting to the point where I’m concerned that to continue to play may have a permanent impact on the quality of my life long after I’ve hung up the boots.

    Just my two cents, thanks again for an (as usual) great read and a thought-provoking topic!

  18. Michael

     /  April 18, 2013

    Great article lads.

    I know its a serious issue, and we shouldn’t laugh, but i once played in a game when a teammate who had been knocked out went into the opponents changing room and showered with them after the match. We still give him grief about it to this day. He couldn’t remember a thing, and can only remember puking a few hours later.

    On the serious side, you do have to look at Joost vd Westhuizen, Ruben Kruger (and to a lesser extent Andre Venter) and wonder. I feel that the current crop of 33-35 year old players are the first generation of fully professional careers, and have really been test dummies as the sport went professional. Concussion is only one of a whole host of issues that are cropping up.

    The sad fact however is that its a rough game and there will always be injuries and accidents like Matt Hampson, no matter how many precautions we take. My opinion (for what its worth) is that we need to go back to the mandatory 6 weeks for a concussion, and that the players themselves need to be more proactive in ruling themselves out. Ultimately the only person fully responsible for Luke Marshall is himself.

    • Leinsterlion

       /  April 19, 2013

      Joost, Venter and Kruger have degenerative neurological disorders completely unrelated to concussions. Bringing them into the debate is wrong as their conditions have nothing to do with rugby. Look at rugby league its been professional for decades and is built for collisions, look at their incidence of concussion etc.. People are making a mountain out of a molehill, concussion isnt a serious problem, if it was we would have massive incidences of 50 year old league players turning into vegetables, we dont and we wont.
      This is just yanks trying to make money imo and bring rugby into that mess will just harm playing numbers and create unnecessary panic and mass concerned mothers hysteria.

      • Chogan (@Cillian_Hogan)

         /  April 19, 2013

        I agree about the three South Africans. That being said, having three men with neurological disorders from the one squad is statistically weird and worthy of investigation on a separate level.

        Given Dr. O’Driscoll resigned as a form of protest over the direction the IRB have moved over concussion protocol. I think it is a serious issue and one that should be fixed now before it becomes a really really big one.
        There’s no benefit in trivialising a very debilitating condition or ignoring the smalls cracks before we end up seriously damaging the game and properly scaring people away from it.

        • Leinsterlion

           /  April 19, 2013

          Wium Basson died of cancer,Chris Roussouw also had cancer, both Boks from the mid 90’s and Rueben Kruger actually died of brain cancer not neurological disorder as Michael said. Three boks from the 90’s with cancer, two dead. Should we investigate the cancer levels of that mid 90’s squad? Correlation is not Causation, I dont wish to appear to be trivializing the issue, rather put the brakes on before we rush to conclusions from young and incomplete research.
          Concussion protocols are the issue, not CTE, CTE is muddying the water.

          • Chogan (@Cillian_Hogan)

             /  April 19, 2013

            No, cancer is far too common to read anything into it. The Boks of the day were getting no more head bangs than NZ or AUS players.
            But the neurological issues raises a bell for me. I’ve know idea what but it smells fishy.

          • Michael

             /  April 19, 2013

            TBH I have no medical background so cant really debate this. The only problem with your argument on rugby league players not turning into vegetables is that there would be no obvious way to tell..!

            Generally i’m with you – concussion isn’t a problem as things stand, but given someone is concussed (Luke Marshall), the protocols at the moment probably aren’t strict enough.

            That said, if i was a current player, i’d be more concerned with other areas of my body. There are a lot of hip replacements in the post i feel…

  19. Loving the comments lads, not one bit of provincial bias…must be a first! Does getting a concussion make you more susceptible to getting further concussions?? I know most people who dislocate their shoulder end up dislocating it another four or five times and after Luke Marshall (3 concussions in 3 matches) I’m wondering is it the same thing for concussions?

    • Chogan (@Cillian_Hogan)

       /  April 19, 2013

      Yes.
      Fogarty talked of the fact that towards the end of his playing career chest high tackles and scrum engagements were having the same affect that heavy head knocks would have had at the beginning of his rugby career.

  20. LeftBank

     /  April 19, 2013

    As promised a few updates from the AMSSM for anyone who is interested in some hot-off-the-press research. They had their concussion symposium yesterday. Interestingly they don’t recommend a mandatory rest period but that return to play should be a phased process based on the individual and their clinical symptoms and cognitive function (must be symptom free at rest and activity and have a normal neurological exam). This could take days to weeks.

    -The value of baseline testing probably isn’t as good as was hoped. Anecdotal accounts of players deliberately manipulating pre-season testing have actually been backed up.

    -Use of a single pitchside assessment tool probably isn’t sufficient as sensitivity (ability to detect cases of concussion) and specificity (ability to rule out cases of concussion) are not great. Using two or more tests together increases their usefulness but can take up to 20mins to administer. Interestingly the SCAT2 still hasn’t had sensitivity and specificity determined.

    -Athletes diagnosed with concussion should not be allowed return to play or practice on the same day.

    -Early return to play is associated with a higher incidence of a subsequent concussion, probably due to impaired decision making and reaction times. A second superimposed concussion is associated with more severe metabolic changes, further cognitive impairment and may increase risk of brain swelling.

    -Complete rest is probably not the optimal management. Phased re-introduction of physical activity and escalation of physical contact over time improves symptoms.

    -There is evidence that repeated concussion has a cumulative effect. Retired professional athletes reporting 3 or more concussions during their career have five times higher rates of cognitive dysfunction in later life.

    -Not all cases of CTE reported repeated concussions. This may be due to under-reporting, but it may also be due to sub-concussive trauma having an effect. CTE manifests decades after the insult, so in the context of pro players in Ireland, it’s still a bit early to expect to see cases.

    -Females in high impact sports are at a higher risk of concussion and are more likely to report ongoing symptoms. May be due to different neck angulation and comparatively weaker neck strength.

  21. Leinsterlion

     /  April 19, 2013

    While I think it is a discussion that needs to be had, bringing in the US as a baseline or in a comparative way is utterly wrong and is skewing the debate. WOC, I would urge you to take a conservative stance and take what the US medical profession says with a pinch of salt when comparing it to rugby. Both codes as mentioned above are completely different. Look to rugby league, which has been professional for decades, it would result in a more accurate comparison.
    I would automatically be sceptical of any negative reports as regards physical contact sports as the people who produce them generally have an agenda, its well known that physicians have been calling for regulation of contact sports and even the abolishment of boxing. The lawsuit is potentially worth billions to players, doctors, and lawyers, there are too many vested interests not to be sceptical of their findings.
    You can never eliminate risk, and some unproven reports from the states shouldn’t worry anyone enough to consider stopping their children playing rugby.
    As for the lawsuit, you cant ignore that many of the players involved are broke and are looking for money and or have had drug issues. This issue is being blown up and getting a lot of publicity as that is how the media works, based on scandal, scaring mothers into wrapping their children in cotton wool.
    I think concussion protocals need to be looked at, do I think there is cause for alarm over concusssions in rugby? No, Its a media driven agenda seeping over from the states where Lawyers and former players are looking for a payday. The issue is being overblown, it reminds me of the “drug scandal that never was” over in Australia in the past few months, vested interests throwing AFL and League under the media bus to further their own agenda.

    • LeftBank

       /  April 19, 2013

      With respect, the issue is most certainly not being overblown. Why don’t we have data on rugby league? Because the studies haven’t been done yet. There is concern in Australia that this may be an issue and a couple of prominent former players have agreed to donate their brains for research. We need long term longitudinal follow up.

      You mentioned MND earlier and said it should be left out of the debate. You are wrong. Post-mortem analysis of 85 subjects with repetitive mild brain trauma showed CTE in 68. 8 of these also had MND (or 12%) far higher than the background population risk. This data was only published in the last couple of months. Doctors have nothing to gain financially from this, all research and advocacy is driven by concern for the athletes involved.

      • Leinsterlion

         /  April 19, 2013

        So money doesn’t enter the equation? All the broke former players and lawyers are not looking for a massive payout? Medical data and studies can be formed and skewed to produce whatever data they want. This is a controversial issue, there is no medical consensus on CTE. All of the medical research is just at the hypothesis stage, nothing has been proven. CTE can only be diagnosed posthumously, causation is not correlation, the study group is too small. This research is in its infancy, to make grand claims that contact sports cause degenerative neurological disorders is disingenuous, we dont know this and its utterly unproven. CTE may be a serious issue, but we dont know that for certain, as it is, it amounts to scaremongering by claiming contact sports= dementia etc.

        • LeftBank

           /  April 19, 2013

          From a physician’s perspective it has nothing to do with money. When subjects who sustained repetitive mild traumatic head injuries are compared with controls they seem to have increased degenerative disease.

          This research is in its infancy, but it has gone well beyond the hypothesis stage. Yes we need further long term, large longitudinal studies but it’s foolish to dismiss the evidence we have.

          I do think we are MUCH better off erring on the side of caution for the health of our players in how we manage concussion.

          • Leinsterlion

             /  April 19, 2013

            Absolutely, I agree entirely about managing concussion and erring on the side of caution. I just think bringing CTE into the equation is unhelpful and skewing the debate towards contact sports=brain injury, as opposed to concussion management. Not to mention the research is incomplete.

        • Laurence Rocke

           /  April 20, 2013

          I very much agree, LL. Those people found to have the postmortem brain changes they are calling CTE are a small and very high selected group. In addition, no-one, as far as I know has actually managed to link the brain changes with symptoms and signs and with the incidence of dementia in the general population. We need to keep an eye on the research but concentrate our efforts on accurate diagnosis and proper management of concussed players – and I believe that is what the IRB and National/Provincial doctors are doing.

  22. Peat

     /  April 20, 2013

    The RFU is carrying out studies of its own at the moment on the general injury front – http://www.rfu.com/news/2013/march/news-articles/200313_injuryaudit – and have found that concussion injuries rose in the 11-12 season, becoming the most common type. That is partially due to the decrease in other injuries, but it is still a worrying sign. However, is it just a sign of people taking it more seriously and reporting it better? I don’t know. But it is being monitored, and people are building data.

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