Time to get the head around a serious issue
RUGBY: Rugby has a blood-bin but after talking to the medical experts GERRY THORNLEYbelieves it's time for a head-bin and proper testing for concussion
IT HAS been described variously in recent times as a time bomb and the elephant in the room. The issue of concussion in rugby has come to the fore in Ireland especially in recent weeks thanks to the harrowing accounts of two recently-retired Leinster hookers, John Fogarty and Bernard Jackman, and profound concerns within the game and the medical profession that the sport is not as on top of this issue as it could be.
Both the IRB and the IRFU need to come up with stricter guidelines and protocols to both reduce the number of concussions in the game and more accurate diagnoses and ways of dealing with concussion as a matter of urgency. Players need to be protected from themselves, that much has been made even clearer by the honest admissions of both Fogarty and Jackman that they lived in denial about this issue. And they are hardly alone.
In a recent interview, Fogarty – the well-travelled ex-Munster, Connacht and Leinster hooker who won his first cap on the summer tour at 32 but had to retire because of repeated concussions – admitted he had no idea of how many times he had suffered what he called “bangs on the head” during his career.
Now, Fogarty also revealed, he is suffering the consequences, be it blinding headaches, days on end in darkened rooms, fatigue and mood swings, and is resigned to having these symptoms for years.
“I had eight concussions last season alone,” writes Jackman in his autobiography Blue Blood. “It’s not something I ever admitted to the Leinster coaches and definitely not to our medical team. Like most of the other frontline forwards, I keep this information to myself as much as possible.”
In rugby, when a player is examined in the days after suspected concussion, it is done through a cognitive test – a simple yes/no memory test – which is compared to a baseline score taken in the off- or pre-season. As Jackman admits, dumbing down the baseline test is tempting.
“There is no incentive to get a high score in the off-season because it could count against you down the line. If I’d had a knock I’d try to put it off until the Thursday before taking the cog test. You don’t want someone else to take your place, so players will find any loopholes they can.”
IN THE CIRCUMSTANCES of this vexed debate, it seemed instructive to hear the views of consultant neurosurgeon Jack Phillips. Prof Phillips graduated from University College Cork in 1971 with a degree in medicine and then trained as a general surgeon initially. He completed the FRCS in general surgery in 1974, went to Massachusetts General Hospital (MGH) and from there to the Radcliffe Infirmary in Oxford and on to Addenbrooks Hospital in Cambridge, thereby completing his training as a neurosurgeon.
He has written on head injuries and is co-author of the Phillips Report, which investigated 2,000 head injuries in the Republic of Ireland that were admitted to Beaumont Hospital and to CUH in Cork. That report was presented to Minister of Health Mary Harney in the Department of Health last year and is now the definitive study of head injuries in the Republic of Ireland.
Why all the brouhaha about concussion of late?
This is partly due to concussion being difficult to diagnose, be it through X-rays, scans and/or MRIs. The abnormality in concussion does not manifest itself in terms of a blood clot or bruising of the brain. Hence, clinical assessment and neuropsychological assessment are so important.
“Furthermore, there is a syndrome of a vulnerable brain,” explains Phillips. “It may be genetic. You might only find it out when a teenager is concussed more regularly than another teenager. Structurally there is no difference in the brain that we can see. It is comparable to people who are vulnerable to epilepsy after a minor head injury.”
That concussion has become a bigger issue in rugby is also due to the way the game has changed. “If you look at the Ireland team of 30 years ago they look like college boys,” says Phillips. “Compare that to the game that was played in the Aviva the other day! It’s a high-impact, high-velocity game and participants are in danger of being concussed more readily. It’s a tribute to their skill and their strength and their athleticism that they are not being concussed more regularly.”
Fully 25 years ago, the late Justice Hamilton, who was president of the Boxing Union of Ireland (BUI), along with Nicholas Moore and Mel Christle, chairman of the Boxing Union, approached Phillips with a view to offering the best protection possible for its licensed professionals. They were, according to Phillips, ahead of their time and ahead of their British and American counterparts.
“So I joined them and we made a decision that in every professional fight at the ringside there would be a general practitioner who would assess the boxer before the fight, and with him would be an anaesthetist or an accident and emergency surgeon, and a neurosurgeon. Thereby we have a doctor capable of doing the intubation and resuscitation, and the neurosurgeon there to decide if the person was concussed and whether the fight should stop.
“Evolving from all of that we had helicopters on standby in Millstreet when Stephen Collins was fighting. When Bernard Dunne was knocked out he was brought to Beaumont Hospital and was scanned. We have never had a brain-injured boxer in Ireland within the professional ranks, and that includes journeymen on the under-card. Those protocols have been in place for over 20 years and they have paid excellent dividends.”
The BUI have protocols in place whereby every boxer starts his career with a neurological assessment and an MRI scan. “Most commonly these guys come to boxing from a young age and it is very rare to find anything wrong with them,” says Phillips. “Most are very fit and there is no evidence of neuro-psychological deficit before they fight.
“There may be some minor congenital abnormalities which don’t put them at risk,” says Phillips, “but we’ve had some boxers who have large cysts in their brain or unusual congenital blood vessel and they are advised of potential risks.
“In my 30 years as a neurosurgeon in Dublin no amateur boxer has been brought to either the Richmond or Beaumont Hospital. Amateur boxers who fight with the headgear, three short rounds, who are fit, don’t get into trouble.”
PHILLIPS HAS ALSO been involved with the Turf Club and the Medical Equestrian Association. Again about 20 years ago, Dr Walter Hally, then the chief medical officer to the Turf Club, was behind the measures put in place for horse racing.
Along with Dr Michael Turner, the chief medical officer of the British Racing Board, they put in place the protocols for that sport which, according to Phillips, are a template for managing concussion in people who have head injuries in sport.
Dr Adrian McGoldrick, current chief medical officer of the Turf Club, has refined and implemented these protocols.
In horse racing, says Phillips, “in the last two or three years neuropsychological testing has become recognised as being necessary and it is now formally done. There are dangers in terms of its abuse and failure to interpret, and indeed it can be over-zealous. But it is part of the protocol of managing jockeys who have been injured and probably will become part of the protocol of managing rugby players who are concussed. I think it’s unavoidable.”
It is clear most doctors would agree that rugby players are occasionally concussed and that something needs to be done about it. The dilemma begins at a young age. Under-18, non-elite rugby players, and all athletes have to be protected more than elite athletes who are highly trained. It is they, the under-age, non-elite rugby players for whom the mandatory three-week rest for concussion should be applied.
The world’s leading sports neurologists held the third international conference on Concussion in Sport, in Zurich in November 2008. They included Dr Paul McCrory, the Australian sports medicine neurologist who is widely regarded as one of the leaders in this field and who implemented Cogsport, the commercial neuropsychological testing tool used in horse racing throughout the world, including Ireland and Britain.
Their conclusions incorporate descriptions of concussion, symptoms, classifications of concussion, return to play guidelines, etc. In their consensus statement on concussion in sport, the panel “unanimously retained the concept that the majority (80-90 per cent) of concussions resolve in a short (seven to 10 day) period, although the recovery time frame may be longer in children and adolescents”.
The mandatory three-week rest for rugby players who have been concussed has also probably backfired in the sense that players have increasingly striven to avoid being sidelined. There certainly appears to have been far fewer instances of mandatory three-week rests in the last few seasons although neither the IRB nor individual unions have any statistical evidence to show whether this is true.
In Prof Phillips’ view, rugby does not have to apply an unwieldy protocol, merely precautions “that will recognise whether a player is concussed and who, 10 minutes later is still on the field and is still concussed. That’s where a second-impact syndrome is now a reality.”
An improved protocol, without ruining the flow of the game, would also help doctors to make decisions when under the most intense pressure.
Doctors have to be empowered by an objective way of assessing whether a patient is concussed, by procedures which are applied sensibly and are recognised as guidelines.
This could simply be done with what is described as a Pocket Scat 2 Protocol, which the consensus group endorses. “That is the simplest new psychometric test,” stresses Phillips. “You recognise the symptoms, you ask the important questions and you test his balance. It might take a minute and if the player passes it he continues. If he doesn’t pass remove him from play and repeat the test. Here is where the doctor can be granted some flexibility, but if after 10 minutes the player cannot answer the basic questions, is unsure where he is or is unsteady he does not return to play and is substituted.”
It is striking that rugby has a “blood-bin” which allows for a temporary replacement, but doesn’t have a “head-bin” or a “brain-bin”. A player may be seeping blood from a relatively harmless wound and is obliged to leave the field until it is repaired, yet a player suffering from concussion might well carry on playing, with all the risks which that entails, such as a secondary impact to the head.
Phillips’ view is supported by Dr Michael Power, an intensive care consultant in Beaumont Hospital. “I would support Dr Phillips’ view that a player who has suffered an obvious concussion should be taken off the pitch by an agreed independent observer and that there should be an interval assessment in the time frame he suggested, up to 10 minutes later. Then, if he correctly answers a small list of appropriate questions, he can return to play but if he cannot, then he should not return to play that day and for the following week, at a minimum.
“Continuing to play, while concussed, also increases the risk of second-impact syndrome,” adds Power.
“Concussion precautions are provided by sports medicine across all sports. It’s important to note second-impact syndrome exists across all contact sports.”
To regular viewers of the game it is clear the three-week concussion rule is not being adhered to or enforced. It is also clear the cognitive testing procedure is open to potential abuse. And perhaps in the future, when a player lies prostrate on the ground, it will require more than a cursory shake to rouse him and send him back to combat. Allowing for temporary replacements in these instances appears both logical and overdue.
The players and the doctors involved within the professional game have to realise they are providing an example to both under-age players and indeed players at all levels of the game with regard to concussion.
THE IRFU VIEW DR CONOR McCARTHY
DR CONOR McCARTHY, chief medical officer with the IRFU, states that in accordance with the IRB, the union adheres to the mandatory three-week rest for players with concussion, though he concedes “this is not a medical rule, it’s an IRB rule. It’s based on regulation more than medical science. We need to be cognisant that a longer period of time may be necessary to keep someone out of the game.
“The IRB, through Mick Molloy, signed up to the Zurich Concussion Consensus Statement for all the sports,” confirms McCarthy, admitting: “It doesn’t refer to any three-week rule in that document, so there’s a slight anomaly there. But I do believe that the three-week rule might mean if anything, that we don’t know enough about concussion because players are reluctant to admit to it.”
As to whether cognitive testing works, McCarthy says: “We had an IRFU concussion workshop on September 16th and we had Mark Lovell who runs the concussion programme for the NFL who spoke at our conference and he designed this impact test, and he assures me that you can’t cheat the system, that if someone doesn’t react in a normative range and if someone is trying to fool the system, the system should pick that up.”
Do doctors have sufficient time to assess whether a player is concussed during a match? “It may depend on the game and the circumstances, but I think it’s an extremely difficult assessment in the middle of a game of rugby with a big crowd. I think that’s a very difficult assessment for anybody to do.
“The NFL are looking at having independent neurologists on the sideline. That’s a big step up. That may be the way to go but that’s a big step up from where we’re at now.”
– GERRY THORNLEY
THE GAA VIEW DR PAT DUGGAN
THE GAA’S original chairman of the medical, scientific and welfare committee is Dr Pat Duggan, a specialist in sports medicine who still serves on this committee. Regarding the protocols which the GAA have in place, Duggan points you to their website and how the association have adopted the Prague Convention on Concussion in Sport, since updated in 2007, as their template.
A recent debate on this issue on Setanta, in which two GAA panellists were not aware of the association’s protocol, left Duggan furious and embarrassed. “What was embarrassing about the debate on Setanta was that the two GAA guys didn’t know anything about this. So the outline of international best practice is outlined in that paper, and that is that you treat concussion on an individual basis, and it also goes through Return to Play criteria.
“I’ve always felt that the IRFU were way behind the international best practice in this and now I think it’s causing them huge problems, because many years ago they brought in the convention, which to some extent we all lived with then, namely that once a player was concussed he was out for three weeks. And of course in the era of the professional athlete this has caused huge problems because the professional athlete knows that if he admits to any form of concussion he’ll be sidelined for three weeks.”
Duggan agrees with the view put forward in the accompanying article regarding a “concussion bin” and says this is something which is under consideration in the GAA. “That would certainly be a very intelligent way forward. We have a blood sub rule, which is actually of minimal risk to anybody, so we should bring in a concussion sub rule, thereby giving the doctor up to 10 minutes to decide.”
– GERRY THORNLEY