Time to stop dragging feet on concussion management

ON RUGBY:A "head bin", clinical physical testing in addition to cognitive testing, and a reduction in the mandatory
three-week rest would be steps in right direction, writes GERRY THORNLEY

WHEN RUGBY historians look back on this era of the game they will hopefully cite John Fogarty and Bernard Jackman as having been saviours of a sort. That their harrowing and cautionary tales of how they and other players have lived in denial about the consequences of concussion prompted the authorities to establish medical protocols which better safeguarded future generations of players.

Failing that, it will have been due to something far worse. And that doesn’t bear thinking about.

Quite simply, all sports have a duty of care to their protagonists. Indeed, that is their first duty. All else is secondary. In talking at length with consultant neurosurgeon Prof Jack Phillips last week, who outlined the protocols which exist in boxing and horse racing, it was no surprise to learn those two sports – arguably the most dangerous sports in the world – were 20 years and counting ahead of other sports.

It’s also no surprise this debate has been raging for longer in the United States, and especially with regard to American football. A study in 2000 surveyed 1,090 former NFL players and found more than 60 per cent had suffered at least one concussion during their careers and 26 per cent had had three or more. Those who had had concussions reported more problems with memory, concentration, speech impediments, headaches and other neurological problems than those who had not, the survey found.

These and other studies led to a hearing on the issue before the House Judiciary Committee. Following this, the NFL accepted the resignations of the co-chairmen of its concussion committee and overhauled its policies toward concussion management. Players now must be cleared by brain-injury experts unaffiliated with the team, and cannot return to a game or practice in which they have shown any significant sign of concussion.

The International Rugby Board have had a working party in operation for six years or so. The IRFU held a workshop on this very issue in Dublin in September. There are good people in these and other organisations who care about this issue. Yet nothing changes with regard to the game’s protocols on concussion, and there is nothing like the same injury surveillance which exists in American Football.

But allowing for that it is clear rugby has two main issues with regard to concussed players, namely a) diagnosis and b) treatment. Prof Phillips is by no means the only member of the medical profession who can see with his own eyes that players have resumed playing when concussed, even if the player often does shake off the effects within two or three minutes. But they would be better served being off the pitch in those two or three minutes than on it, not least to avoid the risk of Second Impact Syndrome.

Rugby should enable doctors to apply an internationally-recognised psychometric test such as the Pocket Scat 2 Protocol, which was endorsed by the world’s leading sports neurologists when they held the third international conference on Concussion in Sport, in Zurich in November 2008. Their consensus statement even suggested “in some sports this may require rule change to allow an off-field medical assessment”.

Rugby simply cannot allow quick, on-field tests when the player, team-mates, coaches and supporters alike want the said player to resume the game. This is putting too much pressure on the doctor, and in these crucial moments rugby could be doing more to protect its protagonists (as well as providing a better example for the under-age game). If memory serves, the blood bin – whereby a player seeping blood has to be bandaged up while he is temporarily replaced by a substitute – was introduced as a zealous precaution against transmitting AIDS.

Extending this protocol to players with suspected concussion, thereby also allowing a temporary replacement, looks every bit as pressing a need.

If a player is still showing any signs of concussion 10 minutes later he has no business being on a rugby pitch.

Furthermore, the evidence from Fogarty and Jackman clearly raises huge question marks about the worth of cognitive testing – a simple yes/no memory test – in the days afterwards given the temptation for players to dumb down the baseline score taken in the off- or pre-season. The Zurich Consensus Statement recommends, in addition, neuropsychological (NP) testing.

Suggesting that a mandatory four-week rest period for proven cases of concussion may make for a great soundbite and even sound entirely plausible. Better to be extra safe than sorry and all that. But all the evidence suggests this would actually only worsen the problem. Players previously reluctant to risk being sidelined for three weeks are hardly going to become even more candid about their condition knowing they could be losing their place for four weeks.

There is a reason jockeys who have suffered concussion are stood down, ordinarily, for six or seven days. The ensuing week is a very important period in the recovery from concussion. According to Prof Phillips and the Zurich Conference, the player must rest and do next to nothing. He doesn’t play video games. He doesn’t get involved in drinking. He doesn’t text. He rests his brain, in every sense of the way. In this way, he is physically, emotionally and mentally rested for a week and then he is reassessed using the larger (SCAT 2) neuropsychological test.

More to the point, the Zurich Conference also concluded that in 80-90 per cent of cases of concussion people make an absolute recovery, and that they are more likely to do so in seven to 10 days if they are elite, professional athletes, whereas “the timeframe may be longer in children and adolescents”.

So, not alone might a three-week rest (never mind four weeks) be unnecessarily cautious and thus self-defeating at the elite end of the game, the sight of players shaking their heads and gingerly resuming play when clearly concussed (as many in the medical profession maintain) is also setting a terrible example for the under-age players who are more at risk.

Of course, some of these steps, such as neuropsychological testing, add financial costs, but quite why rugby has dragged its feet on this issue is puzzling in the extreme.

But the evidence suggests that a “head bin” a la a blood bin, clinical physical testing in addition to cognitive testing as part of the concussion management, and a reduction in the mandatory three-week rest would all be steps in the right direction.