Staying ahead of the concussion curve

By Pete Fairbairn, 23.09.15

With Rugby World Cup (“RWC”) underway the eyes of the world are on our sport. One of the most topical debates across all contact sports is the issue of concussion management.

All stakeholders will be looking forward to a RWC in which players, medical personnel and team support staff play their part in managing this important aspect of player welfare. Rugby is making significant progress in the detection and management of concussion and it will be important that other professional rugby competitions move to adopt the standards set for RWC 2015. Rugby should not see the management of concussion as a risk at RWC, but an opportunity to demonstrate how far the game has come in recent times.

The International Rugby Players Association (“IRPA”) is constantly thinking about what more can be done to further improve the games ability to manage the issues associated with concussion.

Effective from 1st August 2015 after a successful global trial period at elite level, World Rugby has now formally introduced a temporary substitution rule. This applies to any player who is removed from the field of play to undertake a Head Injury Assessment (HIA) when it is unclear if that player has a suspected concussion.

Having the ability to remove a player from the action and from the cauldron of a packed stadium, to undertake a thorough clinical assessment and video review of an incident, in a private controlled environment, makes good practical sense. Previously players in this situation would often go untreated, or be checked over briefly on field using questionable methods.

World Rugby and other key stakeholders are leading a real culture shift amongst professional players, coaches and medical personnel in relation to peer pressure to play. Recent statistics back this up. Research has underpinned the HIA process throughout. Prior to the temporary substitution trial, 56 per cent of players with a confirmed concussion remained on the field following their injury. Now that figure is less than 12 per cent (British Journal of Sports Medicine, 2014) and the hope is that following continued refinement of the HIA process we will see further improvement in 2015 and beyond.

A key point lost on many but one that IRPA believes is fundamental to a conservative management approach is that a player is now removed once the attending medics confirm a diagnosis of suspected concussion. This takes the pressure off trying to make a definitive diagnosis of concussion during a high-pressured game. That does mean players will be removed who have not suffered a concussion, but better the conservative approach.

Thankfully the message is getting through and along with World Rugby’s #RecogniseAndRemove campaign, the games stakeholders are realising that it is not just the player’s responsibility but its coaches, referees, and team support staffs obligation to step in if they suspect a concussion has occurred.

Whilst IRPA see this as a positive step, it is one that needs to be continually developed and filtered down to the community game where awareness and education on the subject is not yet at the same level.

At the elite level, advancements in digital technology has most definitely assisted in the assessment of a potential concussion incident. The systems that will be in place for the RWC are rigorous. They include

Compulsory education for all teams via online modules;
Video replays for medical teams;
Digitalisation of the respective HIA testing procedures and results;
An independent doctor at every match who has the final say on whether a player should be removed from the pitch or be able to return to the game;
A regulated return to play protocol that must be adhered to; and
Medical specialist in concussion monitoring individual cases.
Additionally, IRPA is very supportive and engaged on the work that is being undertaken on the laws of the game to ensure the risks of on-field instances that result in serious injury, including concussive events, are minimised.

There is much conjecture on if rugby, and concussions sustained playing the game, lead to long-term cognitive health issues. From a player’s perspective IRPA does not want that debate to be a distraction from making sure the right thing is done by the players now. IRPA believes that the game should be doing all it can to ensure the welfare and health of the player is an ongoing priority.

So what of the future and in particular the debate of using new technologies to take human error out of the equation? One such advancement that may justify further research and refinement is the use of sensors to help aide team doctors with real-time data. It could provide insight into accelerations and forces that they may not have seen first-hand particularly where the player has either not recognised a head knock, chosen not to seek medical assistance or suffered signs and symptoms post game. The sensor does not diagnose a concussion but rather provides accurate previously unavailable live information which combined with testing (HIA) and baseline data can aid in a clinical diagnosis. In the same way team support staff use other data like heart rates and GPS data, the sensor can provide data to assist medical personnel make informed decisions regarding concussion management.

From a player welfare perspective, IRPA believes the pressure put on players to return to play to preserve their contracts and the rehabilitative support provided to players recovering from a concussion are areas that should be looked at further.

Ensuring a players contractual terms and conditions are supportive during times of serious injury is fundamental. It allows the player the opportunity to fully recover without the added pressure or threat of having his or her salary or match payments stopped, or worse, the contract terminated. In this respect physical injuries are more obvious and certain, concussion in its very nature is obscure and invisible. Currently there are no set guidelines around minimum standards for players’ contractual terms and conditions. IRPA feels that the time is right to address this, not just because of the issues around concussion, but to maintain the integrity and reputation of the game.

For those players who endure concussion complications either as part of their return to play process, or following a decision to stop playing, there seems little available to aide recovery beyond rest and time – which for an active professional athlete can be a very uncertain and sometimes depressing experience. IRPA would support more research into identifying rehabilitation techniques and programs to help in the resilience building and recovery process, and to ensure they are readily understood and available throughout the game.

World leading player welfare standards are a priority in building the legacy of our sport. It is fundamental to the integrity of the game and to those who participate in it. IRPA is looking forward to continuing to work with World Rugby to bring about the culture change and to enhance the education and regulatory framework that ensures rugby leads the way on concussion management globally.

Pete Fairbairn
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