The fifth International Consensus Conference on Concussion in Sport will be held in Berlin at the end of this month and it is clear that rugby will be under considerable scrutiny, and specifically, the adequacy of the pitch-side HIAs (head injury assessment) and the return-to-play protocols.
This follows the second case of a player recently taking legal action against his club for medical negligence. Jamie Cudmore has instigated legal action against Clermont Auvergne for what he claims were breaches of the HIA which resulted in him returning to play despite failing a concussion test.
The 38-year-old Canadian lock, who played over 200 games in his 11 seasons with Clermont and is now with Oyonnax, claims team doctors at Clermont allowed him to resume playing after he suffered a head injury in the 2014-15 European Champions Cup semi-final against Saracens in St Etienne, which Clermont won 13-9.
Cudmore then started the final against Toulon in Twickenham two weeks later, when he was knocked unconscious within the first three minutes, and vomited in the dressing-room before being allowed to return to the field again.
In a statement, Cudmore said: “We believe Clermont’s medical team failed in their duty of care to me as a player and did not have my best interests at heart. Winning games took precedence over the health, both short and long term, of players and a line needs to be drawn in the sand to ensure this kind of thing does not happen again. Players need to be protected, especially in these big games when the result seems to be more important than people’s health.”
Clermont maintain they took every care in their treatment of Cudmore, and expressed their complete confidence in their medical staff. Citing how they have been developing initiatives that go beyond those advised by World Rugby, the club also said: “Following the matches referred to and in line with the correct protocols, Jamie also saw other specialists before obtaining the green light to take part in the RWC [Rugby World Cup] with the agreement of our club and his union. These independent specialists also confirmed that correct protocols and procedures had been respected.”
, the former Leinster, Ulster and Connacht scrumhalf, had previously accused Sale Sharks of “clinical negligence”, claiming that Sale and two doctors incorrectly treated two head injuries he sustained while playing against Saracens in the LV Cup on March 10th, 2013. Willis received treatment on the field in each half and was cleared to play on both times, but subsequently claims he was concussed. He retired soon after at 28, never playing again.
In the light of all this, the Sale director of rugby Steve Diamond made a rather ill-judged and ill-timed criticism of rugby's concussion protocols by claiming "all you need is a slap on the head" to be taken off after the Sale outhalf Dan Mugford was taken off the pitch in their win against Gloucester for a HIA. The former Munster and Irish flanker Alan Quinlan described Diamond's comments as "horrendous, ill-informed and dangerous".
As a sport, rugby will be watching both cases with alarm.
In America, the NFL agreed a $1 billion (€892m) settlement to 31 former players with dementia in 2013, but recently a second petition has been filed asking the US Supreme Court to reject that $1 billion settlement of NFL concussion lawsuits because of how it treats current brain injuries versus future ones.
Premiership Rugby, in conjunction with the RFU and the department of health at the University of Bath, conducted a study over two seasons (2012-2014) which investigated diagnosed match concussions in incidents involving 810 professional players.
Significantly, over 50 per cent of concussive incidents during matches occurred “in the tackle”, while players who returned to play in the same season after a diagnosed concussion had a 60 per cent greater risk of additional time-loss injury than players without concussion.
The study also concluded that the findings “pave the way for trials of more conservative and comprehensive graduated return-to-play protocols, with a greater focus on active rehabilitation”.
World Rugby also conducted a study in conjunction with the Auckland Technological Institute comparing the cognitive function between former rugby players (at elite and community levels) and former players from non-contact sport, and assessed the association between concussion history and cognitive function, in the cases of 366 former players from October 2012 to April 2014.
The elite-rugby group performed worse on tests of complex attention, processing speed, executive functioning and cognitive flexibility than the non-contact-sport group, and worse than the community-rugby group on complex attention. The average number of concussions recalled per player was greater for elite rugby and community rugby than non-contact sport.
This data follows on from the latest Irish rugby player to announce his enforced retirement due to concussion issues, namely Nathan White, after Kevin McLaughlin and Dave McSharry earlier this season.
Aside from the legal implications of the cases being taken by Willis and Cudmore, neither of which is likely to be heard for at least 18 months, they could also impact on the use of doctors at pitchside, especially as below international level so many doctors give their time on a part-time basis or even voluntarily.
Dr Martin Raftery, the chief medical officer with World Rugby, is one of those on the organising committee at the upcoming Consensus Conference, which will "bring together world leading scientists and clinical experts to review the latest scientific evidence on sport concussion and to develop a statement that provides clinicians with a practical summary of current knowledge".
While the HIAs and return-to-play protocols were welcome if belated initiatives by World Rugby, it now seems valid to ask if the HIAs provide sufficient evidence to diagnose concussion, and whether players diagnosed with concussion are being permitted to return to play too quickly.