Scotland & Lions doctor: Concussion action needed

Dr James Robson leads Scotland's Chris Cusiter from the field in a 2009 Test match. Picture: Ian Rutherford

Ben Robinson was an outside centre, and stood out as the best player in the schools cup match in Carrickfergus, Country Antrim in January, 2011. A willing tackler, he took a few hard knocks and was checked for concussion more than once during the game, but passed the coach’s basic tests. Two days later, he died in hospital with a brain injury that doctors later compared to that witnessed in victims of a car accident.

It sent shockwaves through Irish sport, for collisions and concussion are not restricted to the 15-a-side game, and the inquest comes at a time when concussion has attracted worldwide headlines. Australia’s mistaken decision to allow their star flanker George Smith to return to play against the British and Irish Lions in July, having needed two men to hold him up on leaving the pitch because his legs resembled jelly, was another shocking incident. Fortunately, Smith showed no ill-effects, yet.

Rory Lamont, the former Scotland full-back, spoke out in these columns last month of risks he knows players to be taking in the game through deliberately trying to beat concussion tests to allow them to return to the field quicker than is medically advisable. And we spoke to Dr Willie Stewart, the consultant neuropathologist at Glasgow’s Southern General Hospital, about his discoveries of a potential link between repetitive concussion in rugby and early onset dementia in later life.

Dr James Robson, Scottish rugby’s leading medic, has now urged everyone involved in rugby to stop and ask themselves whether they are fully briefed and confident in dealing with concussion. Over 10,000 new “snap-cards” are to be issued by the SRU to schools and clubs across Scotland in the next fortnight and adults urged to take the online training available through the International Rugby Board.

Robinson’s father Peter, who now lives in Scotland, will go further at next week’s inquest and demand that rugby follows examples in the USA, where teachers and coaches must undertake mandatory training in concussion before being permitted to work with children.

“As the sport develops we are seeing different issues being raised in rugby,” said Dr Robson, “and while we had a major problem with spinal injuries in Scottish rugby a few years ago, and have worked hard to develop our knowledge and care in that area, the issue of concussion is now attracting a lot of attention, and I’m delighted with that.

“It has been a concern to me for some time that people in rugby do not take it seriously enough. Years ago concussion was a laughing matter to some people in sport.

“Thankfully, that is changing, but we are aware that it is still not being taken seriously enough across the game.”

Lamont’s comments raised the ire of some initially, but Dr Martin Raftery, the IRB’s chief medical officer, welcomed the player’s contribution to the debate and Dr Robson has followed suit.

The SRU’s Head of Medical Services has been at the forefront of injury studies in world rugby, leading various working parties, and has received wide praise for his approach to player welfare, most memorably after his treatment of Will Greenwood on the British and Irish Lions tour in 1997 and Scotland wing Thom Evans against Wales in 2010, credited with having saved Greenwood’s life and Evans from paralysis.

But, such elite level of medical expertise is not always available, certainly not at club and schools rugby matches.

“That is why we need everyone to understand that there are ways for players to be protected, through simple education and understanding.

“We do not yet know everything there is to know about concussion. We know that when you get a concussion you get a knock to the brain, but we’re still not sure of the science of what that does, because if you do the most detailed of scans you still don’t see any structural damage.

“But we need people to understand that concussion as a clinical entity has to be taken seriously. In rugby, we really take it seriously, as can be seen by the changes in the treatment in the past five or six years, but this is across sport. The worst head injury I’ve seen recently was in a schools hockey match when a girl was struck with the ball square in the face.”

This is a wider issue than merely rugby, but the oval ball sport is now leading on changing a culture that encouraged players to “shake it off”. The IRB has moved from a three-week mandatory period of suspension for a player diagnosed with concussion to a more scientific approach to determining when a player is able to return to the field, whether that is after one week or five. Medics in pro rugby now use the “return-to-play” protocol, which tests players each day on their ability to take part in moderate, non-contact exercise and steps it up to full-contact if they show no ill-effects.

The SRU have a good brains trust to draw on. As well as Dr Robson, his predecessor, Professor Donald Macleod, is back at Murrayfield as the union’s new president. He spent 26 years as Scotland’s chief medic, took part in Lions tours and led early IRB progress on player welfare. The retired surgeon also spends much of his time now watching local club and schools matches, and so understands the peculiar difficulties at grassroots level.

“Suspected concussion is managed in a totally different way in pro and international rugby to club and schools rugby,” Dr Macleod said. “There, the 21-day protocol is still the basis of concussion management.

“Most clubs and schools don’t have access to medics who can test players each day, so we have to have a different philosophy. If they do have an experienced doctor who can manage the concussion and look after the player appropriately, then in theory they can pass a player fit sooner, but the principle is that it’s three weeks with graduated return to play and that is also after return-to-play in the third week.

“Sometimes players will not be ready after three weeks and it could be longer, which has to be recognised too.

“But this is where the George Smith incident has actually done us some good. People just could not believe that this guy got back on the field, and we have spoken to coaches at different levels recently who admit they are now more aware of the risk as a result of the publicity.”

Dr Robson remembers vividly the day he got it wrong, when Scotland winger Simon Webster suffered concussion in an international match at Murrayfield and, after convincing Dr Robson he was recovered, stayed on for another 15 minutes. He then became dizzy and Dr Robson withdrew him immediately, cursing that he had missed the early symptoms.

“I speak about that case with Simon’s permission because it showed how diagnosing concussion is not easy; no test is perfect. People ask me how I missed it, and at the pitchside angle I was at I missed it.

“We can all learn which was why I welcomed Rory’s comments on how he felt about his own pressures because, ultimately, players know how they feel better than anyone. And sometimes, we have to speak out for things to change. The IRB annual conference [on player welfare] in 2009 stemmed from us speaking publicly about what we perceived to be dangerous aspects of the game and we have to not pay lip service to player welfare but really move it on, and concerns we expressed about the World Cup schedule led to a fairer timetable that now ensures the smaller nations aren’t playing every four days, when they actually have less resource, fewer players and less robust players. Having players recognise the importance of being honest about injury is vital.”

Rugby remains a popular sport and neither doctors quoted in this article have concerns about relatives of theirs playing the game. Robinson will also allow his younger son, currently enjoying football, to make his own choice on whether he plays. They are confident that if the training exists and is followed, concussion will be effectively dealt with long before the tragic outcome that befell Ben.

Sadly, those managing Ben have revealed that they were not aware of the IRB concussion guidance, with the traditional, outdated test of holding up fingers for the player to count being used. Rugby and sport in general has to work harder to ensure that that is not repeated.

• For more information on concussion, tests and online courses, go to: www.irbplayerwelfare.com and www.scottishrugby.org