Concussion. Brain. Injury. A frightening combination of words, one that for many triggers an almost visceral reaction. Muscle tears, ligament ruptures, even broken bones are all part of the sports injury landscape, but there’s something about a brain injury that provokes a deeper concern. The potential for long-term and permanent changes to our personalities and very beings is a big part of the fear, making these injuries more than “just another injury”.
Sport has to face this challenge. The contact and combat sports in particular are facing scrutiny at unparalleled levels and their response to both preventing and managing concussions may significantly impact their futures. In the 2011 Rugby World Cup, incoming World Rugby chief medical officer Martin Raftery conducted a basic experiment.
He timed how long a team doctor would have to run on to the field, assess a player who had gone down injured and then make his way off again before he became an obstacle to the ongoing match. The answer? 64 seconds. A shade over a minute is all the time that a medical professional was afforded to make an assessment about whether that player could continue or should come off.
When that injury is a potential concussion, the implications of staying on may be far more serious than a muscle or tendon problem. Concussions are often transient. They are short-lived. A blow to the head may cause the player to see stars, become dizzy or nauseous, lose their balance, maybe even lose consciousness.
Often, within 20 seconds, they have “recovered”. But they remain concussed. So it is imperative, for the health of the player, that they be removed, assessed and cleared of a concussion before being allowed to continue. The risk of remaining on the field includes potentially fatal second blow to the head, the so-called “second impact syndrome”. Alternatively this may aggravate the original injury and end up suffering from debilitating long-term symptoms caused by structural damage to the brain.
Given the 64-second window for the doctor to make their assessment, it’s not surprising to learn that in that World Cup, 56% of the players who would later be diagnosed as concussed (after the match) stayed on the field at the time of the head injury. That is alarming. More than half of concussed players were only diagnosed after continuing to play for as long as 70 minutes.
A call to action
Those numbers – 64 seconds and 56% – represented a call to action for rugby. It was a call that had already been heard across the Atlantic as a result of the same growth in concussion awareness in the National Football League (NFL). There, some American football players who had suffered multiple concussions during their careers were developing early-onset dementia and other personality changes that often, tragically, led to suicide.
Now immortalised by Will Smith in Hollywood’s Concussion, Bennet Omalu, a neuropathologist in Pittsburgh, examined the brain of Hall of Fame linebacker Mike Webster after his death in 2002 and described a condition called chronic traumatic encephalopathy (CTE). This is a neurodegenerative disease where the brain wastes away and proteins accumulate in neural cells. The debate rages on over the exact link between concussions and CTE, but the NFL found itself facing a hefty lawsuit that was settled in 2017 and may surpass $1 billion (about R14.75 billion) in damages.
American football and rugby aren’t the only sports facing this issue. Football, too, has concerns. As far back as 2002, England’s Jeff Astle choked to death aged 59 and his autopsy concluded that repeated minor traumas from heading a heavy, rain-soaked leather football had contributed to his death. A verdict of “death by industrial injury” was recorded, putting Astle’s death in the same bracket as say, asbestos inhalation and lung disease in construction workers.
While ball technology has improved significantly, the sport still experiences concussions. Liverpool’s Mohamed Salah and Tottenham Hotspur’s Jan Vertonghen sustained concussions in last season’s Uefa Champions League, and Liverpool goalkeeper Loris Karius was infamously concussed during the 2018 final.
Hockey, ice hockey, surfing and, of course, boxing, where the objective is to concuss the opponent with blows to the head sufficient to knock them out, all face the same challenges.
Rugby’s response after 2011 was immediate. First, the ability of doctors to identify and diagnose concussion had to improve. This was achieved through two things, time and knowledge.
Time was provided by creating temporary substitutions. A player suspected of having a concussion after a blow to the head could now be removed for assessment while a replacement took their place. Their stand-in could also stay on the field should the injured player “fail” the assessment.
The simple act of removing the player was a huge first step. It’s far easier for a doctor to keep a player off permanently once they’ve been taken from the field, than it is to remove them in the first place. Temporary substitutions lowered the threshold for diagnosis. Before, only the very obvious cases were removed. Now, the more subtle types could be diagnosed because teams were not being punished.
Allied to this was knowledge, a “toolkit” to guide and assist the diagnosis of injury in the form of the Head Injury Assessment (HIA) screening. Initially called the Pitch Side Concussion Assessment and lasting five minutes, it is now a 10-minute screening tool that assesses various functions that can be affected by head injury.
Doctors conduct a memory test, a test of orientation – Where are we today? Who scored last? Which half are we in? and so forth – two balance assessments, a symptom checklist, a cognitive function challenge and a delayed memory test. This wide range of tests reflects the complex nature of concussions, because injury to different areas of the brain impairs different functions.
The sideline screen is not the only tool in the process. Before the player reaches that point, they are assessed at the time of injury and if they show any clear or obvious signs of concussion – loss of consciousness, convulsions, confusion or the tonic or abnormal posturing that can precede a seizure – they are removed immediately without undergoing the screen.
There is a follow-up test to the HIA three hours after the match, and a third and final test 36 to 48 hours after the game. These are aimed at detecting how symptoms evolve and ultimately help support the diagnosis of a concussion.
This multistage approach has had a significant effect on how many concussions are identified in professional rugby. That earlier figure of 56% of players who play on but are later diagnosed as concussed has dropped to 7%. The culture is also changing. That players frequently report their own symptoms and remove themselves after head impacts is a further sign of progress.
But progress will only be complete when concussions can be prevented. It’s all good and well to diagnose and then manage them once they’ve occurred, but in the words of Hippocrates, “prevention is better than cure”. Since 2015, the focus has been firmly on understanding how concussions happen so that high-risk situations can be targeted and their occurrence reduced.
To do this, a risk assessment was first conducted from a large study that identified high-speed active shoulder tackles, front-on tackles and higher contact tackles as the main risk factors for concussion. When tacklers are upright, rather than bent at the waist, the risk of concussion is 50% higher and head to head or head to shoulder contact was four times more likely to concuss than head contact below the sternum.
The name of the game, then, is to change tackle technique. This is being achieved partly by changing and reinforcing the law.
Using the data from the study, World Rugby convened a high-powered group of coaches, referees and current and former players. Their mandate was to change the behaviour of players by using the current law to punish what had been recognised as being higher in risk. High tackles are being singled out more harshly than ever, including using a new decision-making framework for high tackles in an attempt to get the message through to players to tackle lower.
Not low to the point of going at the knees, but rather a “nudge” lower of about 10cm to 15cm. This is so that the heads of two players do not “share airspace” but rather that the tackler’s head is near the trunk or upper body of the ball carrier. There are concerted drives to communicate safer and more effective techniques, and an education process around “high-risk” tackles where the tackler is upright and head contact occurs.
This will undoubtedly increase the numbers of penalties and cards. But hopefully players and coaches will take the technique changes on board and adapt, to avoid being awarded too many cards. It’s difficult to envision a situation where teams would choose to accept more cards over reduced brain injuries. Can rugby – or indeed any sport – afford not to react, given the social and medical pressures, threats of litigation and possibly even threats to the survival of sports that do not reduce risk?
The goal is not zero risk, contact sports will always carry some. The physicality of the sport is part of its appeal. But minimum risk and maximum awareness? Those are the objectives and all sports are surely obliged to pursue them with full commitment.