Concussion has become a major issue recently after incidents involving Ireland’s British and Irish Lion Brian O’Driscoll against France and Australian flanker George Smith in the Lions series, both of whom returned to the field on after suffering concussion.
In an exclusive interview with The Scotsman last month, recently-retired Scotland internationalist Rory Lamont decided to go public with his concerns around players cheating concussion tests, the ease of passing tests while concussed and a rugby culture that isolates players who refuse to ‘play through injury’.
That brought the issue into sharp focus for rugby unions and players around the world. Dr Willie Stewart, a consultant neuropathologist at Glasgow’s Southern General Hospital, had spoken to us about startling new medical research into concussion, and while he initially wished to keep this confidential due to legal confidentiality, under the weight of enquiries in the wake of Lamont’s article, he agreed to reveal in general terms on Saturday what he had discovered.
In essence, after years of studying concussion he uncovered clear evidence related to dementia in the brain of a male in his 50s who had played rugby. These changes were typical of an individual who had suffered from repeated head trauma, though Dr Stewart confirmed that other risk factors, including lifestyle, social and familial, and the exposure to head knocks in and out of rugby were factors that required further investigation.
Dr Stewart is currently in the USA at a series of meetings with clinicians leading research on Chronic Traumatic Encephalopathy (CTE) in world sport.
The International Rugby Board’s Chief Medical Officer is Dr Martin Raftery. The 55-year-old played centre and wing in rugby league for Cronulla Sharks in the 1970s and 80s, and remembers suffering concussion, and he came into the IRB post two years ago after eight years as the Wallabies team doctor. He was a leading rugby league team medic before that and has also worked closely with famous Australian league player turned boxer Anthony Mundine.
“So I have seen a bit of concussion in my time and it’s something we must take very seriously,” he told The Scotsman from his home in Sydney.
“I read what Rory had to say and I applaud him. His decision to come out and speak about what is going on in the game is helpful and his message to players to stop cheating tests and ignoring head knocks is vital.
“I hope that we can use him as an ambassador because we need people in our sport to be honest if we are to make players, coaches, medics and parents aware of the seriousness of concussion and the importance of stopping players from playing with head knocks.”
Strong, positive words, yet the IRB and Dr Raftery have been criticised for trialling a new ‘five-minute’ test, most vividly in the resignation last year of former IRB medical adviser Dr Barry O’Driscoll in protest at the test.
In an interview with our sister paper, Scotland on Sunday, Dr O’Driscoll said: “There is no test that you can do in five minutes that will show that a player is not concussed.
“We have all seen players who have appeared fine five minutes after a concussive injury then vomiting later in the night. To have this as acceptable in rugby, what kind of message are we sending out?”
Dr Raftery launched the Pitchside Suspected Concussion Assessment (PSCA) last September to allow medics to remove players from the pitch they feared may have suffered concussion. In the past, a player could be treated quickly on the field, but if he was taken off he could not return unless he had been bleeding, leading to snap judgments on concussions.
The PSCA allows medics to take players to a quiet room inside the stadium, where they can conduct concussion tests. If the player is suspected of having concussion he must stay off. It has proven to be controversial because several players, including Smith – the PCSA was not used in the Six Nations so O’Driscoll did not pass it - have passed PCSA tests and returned when it was clear to those watching on television that they had been concussed.
“Having been a team doctor in those situations I have sympathy with the difficulties in diagnosing concussion in five minutes, even off the field,” said Dr Raftery.
“That is a key message to get across – concussion has been recognised as being the most complex sports injury to diagnose and there is no perfect diagnostic test or marker for clinicians to rely on. The science is lagging quite a bit behind the demands of doctors in the modern game.
“The PSCA test is not perfect, but nothing is, so, what do we do? Sit on our hands? Before PSCA medics had to make the call in a minute or so during the mayhem on the field and research showed around 25 percent of players confirmed as having concussion, through missing training or a game afterwards, had not been taken off in the game they suffered the head knock. In the past year, with the PSCA, research shows it now to be around 11 percent.
“It’s still not good enough, but it has to be a step in the right direction.”
Dr Raftery is finalising a report for the next step in the IRB’s battle with concussion based on that research. The PSCA will continue but with changes to reflect the research and feedback from team doctors and video analysis.
Before the PSCA doctors did not consistently assess symptoms, balance and cognition (memory), so with the introduction of the PSCA this has become standard and there will now be more standardisation with tests immediately after the game and more conducted within 36-48 hours, irrespective of whether the player returned to the field. Independent video analysts are also to watch matches and report suspicions of potential concussion, while fresh guidelines and different rules are being examined for youth players.
Dr Raftery ruled out a return to the three-week mandatory suspension of any player diagnosed with concussion, however, citing research at World Cups and community rugby level as suggesting a return would force concussion “back underground”.
Brains are vast, complicated organs so it should be no surprise that research into them is a minefield with conflicting opinions. However, as deepening research uncovers more startling evidence of the effects of concussion in later life changing the culture of ignorance in rugby now appears to be unavoidable.