Sport Rugby

Wednesday 13 December 2017

Comment: Theory not being put into practice for head injuries - HIA is in tatters

Murray episode shows up flaws in process of dealing with suspected cases of concussion

Munster’s Conor Murray is assessed after suffering a head knock against Glasgow in the Champions Cup in January. Photo: Stephen McCarthy
Munster’s Conor Murray is assessed after suffering a head knock against Glasgow in the Champions Cup in January. Photo: Stephen McCarthy
Brendan Fanning

Brendan Fanning

If you spotted the written judgment last week on the Conor Murray concussion case - if we might call it that - then it was only because you knew where to look. Buried under the blizzard of news and opinion surrounding the announcement of the Ireland side to play Wales yesterday, it merited not a line on the rugby pages of the nation's daily newspapers. Which, we imagine, was the point of the exercise.

The report is a crock: a badly-written account of a flawed process. It contains no testimony from a handful of people who were first on the scene when Murray was flattened by Glasgow's Tim Swinson.

The report prompted a withering response from Dr Willie Stewart, a consultant neuropathologist, and a leading expert on the issue of head injuries in sport. Stewart is one of four on World Rugby's Independent Concussion Advisory Group, but is considering his position there now.

"The Head Injury Assessment, and particularly this review process, is in tatters," he says. "Serial reviews that have continued to find no fault in the process, and no fault in the application of the process, just don't hold water."

The review process in question is rugby's way of backtracking to clear up injury-related incidents that raise alarm bells. When competition organisers like Premiership Rugby or EPCR signed up to the HIA journey, part of the package was that they follow the signposts. And reviewing dodgy-looking incidents is on that road.

So when George North was knocked out playing for Northampton Saints against Wasps last December, the (English) RFU convened a panel to review how it was handled. And when a few weeks later Sale flanker TJ Ioane was left on the field against Harlequins, despite showing concussive symptoms, they did the same again. The hat-trick was completed when EPCR convened a three-man panel to review the Murray incident in the Glasgow versus Munster Champions Cup tie just a week after the Ioane injury. It was a busy time.

All three reviews concluded something different, yet the same. For North they said Saints got it wrong in returning him to play. With Ioane they concluded that while other doctors would have wanted a HIA, Sale's doctor made a clinical judgment call, so that was fine. And with Murray a HIA did eventually take place, so that was fine too. No action was taken against any of the clubs. It took the review group seven weeks to follow up their initial judgment on Munster with the written version, which crept out last week. When you read it you wonder what could possibly have taken so long to wrap it all up.

The incident occurred in the 63rd minute of the game when Murray went to tackle Swinson, and hit the deck like a stone. The reactions of those nearest were swift and obvious. Munster's Andrew Conway immediately moved in gesticulating that something was wrong. No testimony from him. Next, Glasgow scrum-half Ali Price started tapping Murray and looking at the ref in order to indicate something serious. No testimony from him either. Referee Luke Pearce blew his whistle no fewer than seven times, reflecting the urgency of the situation, and immediately signalled for medical assistance. Not a word.

All three, plus a couple of others, might have had useful information on whether or not Murray was, as the pictures suggested, knocked out by the force of the blow. The HIA protocol lists the criteria for suspecting loss of consciousness. It includes "co-player concern".

Then there was the ready acceptance of Munster's version of events. Their description of the footage is that it shows Murray "completing the tackle" before being unable to move his legs "as players are lying on top of him".

It is hard to agree with the first claim. And impossible to fathom the second: Glasgow hooker Fraser Brown goes in to clean and, when he goes off his feet, leaves a leg trailing over Murray. If the hooker had produced a rattlesnake from his pocket we suspect Murray would have been able to move fairly sharpish. Well, he would have had he been conscious. The best bit however, comes with Munster's description of how they treated the injured player:

"After assessing his cervical spine and clearing him of any significant cervical spine injury he was further assessed for any possible head injury. He answered all his Maddocks questions correctly . . ."

What? Maddocks questions are asked only in assessing a possible concussion. They are a fundamental part of the HIA process. According to the SCAT3 concussion assessment tool: "The Memory Function (Maddocks Questions) should not be used to clear a player who has a suspected concussion." One of the chief selling points of the HIA was that it takes the assessment off the field, affording the medics some time and space.

"There is no place in rugby at any level for the Maddocks questions on the field," Willie Stewart says. "World Rugby has been very clear on that from the outset. If you ask Maddocks questions on the field you're already beginning the process of establishing if the player is orientated, and if his brain is functioning ok. If you're asking then it's because you think the player has been involved in a head collision that may have injured the brain. That's a Head Injury Assessment, and the player needs to be off the field."

Maddocks questions were also asked in the North case. Remarkably, there seems to be confusion in World Rugby about whether or not this should be carried out on or off the field.

So Murray was allowed to continue. The game restarted with a Glasgow scrum, off the back of which Josh Strauss attacked and promptly bounced Murray out of his way. The scrum-half, decked again, was slow to get back in the game. There is no mention of this in the report.

Two-and-a-half minutes had elapsed between play restarting and Murray being called ashore - by that stage the medical staff had reviewed the video footage via their Myplayxplay, a video analysis tool that allows for rapid rewind and review on the hoof. Much was made in Munster's testimony of having invested in this technology. Yet the Swinson biff left Murray on the ground for nearly three minutes, plus another two-and-a-half before they got him off. What's the point in having all the bells and whistles if you can't make a sound? Were they short-staffed? And having added it all up, how did they let him back on the field to complete the game?

Murray passed the HIA when he came off. And the one that followed after the game. And the third one in the days immediately post-match. Great. This may tell us more about the HIA than whether or not Murray was concussed.

World Rugby already know that their HIA is not an accurate diagnostic aid, rather it identifies a suspected concussion. Its value is in contributing to the awareness that it is not ok to continue when your brain has been injured. It is inarguable that the culture surrounding this issue has changed for the better, and WR's work has allowed the removal of far more players whom, in the old days, would have staggered on regardless. Moreover, players' treatment post-injury now is unrecognisable from what obtained previously.

The problem is that no identification via HIA does not mean no concussion. And when you have some medics believing that the HIA is for off-field only, and others thinking it's good to crack on straight away with the player on the deck, it illustrates a shocking lack of clarity.

Moreover, what WR have become acutely aware of, through the findings of these review groups - over which they have no control - is that getting the people who matter on the same page is like herding cats.

"That's what we're looking to change and looking to get consensus on standardising, and getting better outcomes from it," World Rugby chief medical officer Martin Raftery says. "That's ongoing. It's not going to come out of one meeting and we're speaking with a number of different levels of the game to make that better."

In case you thought we were already past this point, we're not. And until we are, more players who should be withdrawn from battle will be left in the line of fire. Murray was one of them.

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