Tom English: Rugby concussion rule causes alarm
As a respected doctor (whose son was team doctor for Ireland and the Lions in the recent past) with a background as an international full-back he became an important figure on the International Rugby Board where for 15 years he held positions on the medical, anti-doping and disciplinary committees. Until late last summer, when he resigned.
In giving an example of why he left the game’s governing body he tells you of the events of 9 March this year, when Ireland played France in the Six Nations and when his nephew, Brian, got concussed on the field. What happened next was Barry O’Driscoll’s issue in microcosm. After one collision too many that day Brian O’Driscoll lost his bearings, was clearly unsteady on his feet and had to be helped from the field, like a boxer assisted from the ring. You did not need experience in pathology to know that the great man was out of it for a moment in time. Yet a few minutes later he was back on the pitch, supposedly as bright as a button and fully recovered.
Regulation 10 of the IRB code says that any player suspected of concussion must be taken off and not allowed back on to the field. There is an accompanying rule now – still on trial – and it states that if a player with suspected concussion can pass a series of tests lasting five minutes then he can be allowed back into the fray: the Pitch Side Concussion Assessment (PSCA) – or the five-minute rule. The Six Nations did not have this rule in place for this season’s championship, so you have to ask, why was O’Driscoll, above, allowed back on?
His uncle is asking further questions. The five-minute rule is one that Barry O’Driscoll suspects will be introduced across all elite rugby in the near future and it troubles him deeply. It was the introduction of the rule that sparked his resignation from the governing body.
“Rugby is trivialising concussion,” he says. “They are sending these guys back on to the field and into the most brutal arena. It’s ferocious out there. 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. It is accepted the world over. 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?
“If a boxer cannot defend himself after ten seconds he has to have a brain scan before he comes back. And we’re not talking ten seconds for a rugby player, we’re talking maybe a minute that these guys are not sure what’s going on. They don’t have to have a brain scan, they have to have five minutes where they have to stand up straight without falling over four times, they have a basic memory test – ‘What’s the score? Who are you playing against? Which half did it happen in? And do you have any symptoms?’
“These questions should serve as a landmark for when you examine them six hours later to see if they’re getting worse or if they’re bleeding into their brain. That’s why you ask them, not to see if they can go back on. They are already concussed at that point. You don’t need to ask questions to find that out. If six hours later their responses are worse than they were earlier you say ‘Wait a minute, this shouldn’t be the case, is this guy going to bleed?’ That’s why you ask the questions and so it has always been. But we’re going in the other direction now. We’re going from being stood down for three weeks to one week to five minutes with players who are showing exactly the same symptoms. The five-minute rule came out of the blue. I couldn’t be a part of it so I resigned from the IRB. It saddened me, but I couldn’t have my name attached to that decision.”
Yesterday, the IRB responded. “The IRB and its member unions take all areas of player welfare, including concussion, extremely seriously and have engaged with relevant experts and the playing community to design and implement policies and protocols that put the player first. The Rugby approach has been endorsed by the world’s leading forum on concussion management in sport and while we always strive to do more, the PSCA approach in elite rugby is having a positive impact.
“It was developed by an international independent working group consisting of six Union doctors [five of the six had recent national team physician experience], the players’ association (IRPA) and two independent subject experts [a French neurosurgeon and an Australian sports physician who has a PhD in concussion]. As chief medical officer of the IRB, Martin Raftery facilitated the working group.”
There is clearly a divide between O’Driscoll (and others) and Raftery, who said last year that “evidence supporting the theory that collision sports have a negative effect on cognitive function has been questioned by many scientists.” Raftery pointed out, however, that studies are being undertaken by the IRB to broaden its understanding of concussion.
On the same day that Ireland played France, three men sat together at Murrayfield watching Scotland play Wales: Steve James, an award-winning American film-maker, Chris Nowinski, a former American footballer turned wrestler turned leading expert on the subject of concussion and Willie Stewart, a consultant neuropathologist from Glasgow’s Southern General Hospital.
The three were there as part of research for a film that will be released later in the year, a remake of an earlier James documentary called Head Games, an exploration of head trauma in sport. The original Head Games dealt largely with American sport, but in the new version rugby will feature prominently.
“I couldn’t believe the physicality of that Scotland versus Wales game,” says Nowinski. “Then I watched the Ireland versus France game on television where there were two very obvious concussions (Luke Marshall being the other) and only one player was removed. The other was allowed to continue in such a state that if it happened in the States there would be an outcry. The fact that Brian was allowed to continue, that would not be accepted in the US any more. If they can’t walk they can’t play. We have to protect the players, we have to respect the fact that the player has a brain injury. It’s exploitation for a concussed player to be allowed back on the field. It’s like you giving a drunk the keys to his car because he tells you he’s fine.”
Nowinski, a Harvard graduate, suffered many concussions in his own career. That is what brought him to write about it in a book and then immerse himself in research. It was Dr Robert Cantu, clinical professor of neurosurgery at the Boston University School of Medicine – the so-called Boston Brain Bank – who helped diagnose Nowinski after he started to suffer from terrible headaches. Cantu opened Nowinski’s eyes to the existence of Chronic Traumatic Encephalopathy (CTE), a degenerative brain disease that is caused by repeated blows to the head. CTE manifests itself in memory loss and difficulties with concentration, mood swings, aggression and depression. In the worst cases it can lead to dementia.
The Boston research group has examined up to 100 brains of ex-athletes who suffered these symptoms and the vast majority of them recorded levels of CTE. Currently, about 4,000 ex-American footballers and about 2,000 spouses and family members of footballers have filed a class action law suit against the NFL, the most recent case being the family of Junior Seau, the former star linebacker with the San Diego Chargers, the Miami Dolphins and the New England Patriots. Seau retired in 2009 and committed suicide in May last year. Studies of his brain showed that he suffered from CTE, as have other former NFL players who have taken their own lives in recent years. Their families allege that the NFL knew the dangers and did nothing about it.
Nowinski and Cantu and the rest of the research team in Boston have changed American football forever. “It was a big battle with the NFL,” says Nowinski. “We had years of trying to convince them that concussion and CTE was something they needed to take seriously. And now the NFL are completely on board and are very forceful in trying to change the way the game is played. They have contributed over $130 million to research over the next ten years. They were in denial, but not now.”
CTE, or the danger of it, is what brought Nowinski to Murrayfield to meet Willie Stewart. Nobody is suggesting that rugby would ever produce the same numbers of CTE cases as they are finding in Boston, but they believe the sport needs its eyes opened to what has gone on in America these past few years. They don’t want to overstate the danger, but they want to draw attention to it because they feel that the rugby authorities are not doing enough on that front.
In November 2011 I wrote about this subject on these pages. There was testimony from the former Ireland internationals, Bernard Jackman and John Fogarty, about their many concussions and the difficulties they had in life in trying to deal with them. At that time Cantu said that the rugby authorities were not listening to the likes of Jackman and Fogarty.
Cantu said that rugby was not taking head trauma seriously enough. The IRB disputed this, then less than a year later it brought in the controversial five-minute rule, trialling it at the world Under-20 championship, a fact that incensed Barry O’Driscoll. “Everybody knows that concussion in the teenager can be a much bigger problem than in adults so why did they introduce this rule in the U20s?”
In November 2011, Cantu called on rugby players to commit to donating their brain upon death to help the research. John Beattie, the former Scotland international and Lion, made a documentary on BBC Radio Scotland about the issue and committed to doing just that.
“From the CTE side, the idea that rugby wouldn’t have it is silly,” says Nowinski. “Rugby’s physicality is extraordinary. Also, the five-minute rule doesn’t make sense to me. It’s ludicrous. It’s simply a matter of time before CTE is found in a rugby player.”
The IRB say they are not blind to what is happening in America and that last year they enlisted the rugby unions of New Zealand and Australia to lead a study into the possible long-term effects of head knocks in rugby involving 200 ex-elite level players and 200 ex-community players. There is no data that the IRB can provide at this point.
Stewart outlines the problem. “America has moved on but in the UK and internationally there is talk about concussion but there is also denial about it. James Robson of the Scottish Rugby Union is different in that he is fully on top of the situation, but elsewhere there seems to be an attitude that this is not a problem for the game and that worries me. There is nothing different about an American brain compared to a British or Irish brain. If somebody is out of it, you get them off the park and don’t let them on again. You don’t put them back in to expose them to further risk. That goes against everything.Brian O’Driscoll was held on the field for a few minutes and was supported off with his legs giving way under him and a few minutes later he was back on again.
“Chris Nowinski’s view is that the way rugby is behaving now is the way American football was five or six years ago. Instead of taking fewer risks, rugby seems prepared to take even more risks by saying it can assess somebody in five minutes.”
Barry O’Driscoll’s testimony in all of this is powerful in that for a decade and a half he was part of the establishment in the IRB. Now he is one of the IRB’s chief critics. “The IRB said to me when I wrote to them about the lessons of American football, they said it’s a different game, that you can’t compare, they wear helmets, they have (or used to have) head on head collisions, but concussion is concussion is concussion. To say that we cannot take any of the facts that they’ve discovered in America because it’s a different game is head in the sand.
“I have no reason to doubt that we are going to get cases of CTE in rugby. They got them in the NFL so there is no reason to think we won’t get some in rugby. We don’t know because the research hasn’t been done, but it is our responsibility to learn from what is happening in America and act on that. We have to presume that it can happen in rugby or else we might have a very big debt to pay years from now.”