Sport Rugby

Thursday 14 December 2017

‘Everybody’s winging it – including the doctors’ – Players and doctors tell the story of concussion in Irish rugby

Ireland's Mike McCarthy after picking up a concussion. RBS Six Nations Rugby Championship, France v Ireland. Stade de France, Saint Denis, Paris, France. Picture credit: Ramsey Cardy / SPORTSFILE
Ireland's Mike McCarthy after picking up a concussion. RBS Six Nations Rugby Championship, France v Ireland. Stade de France, Saint Denis, Paris, France. Picture credit: Ramsey Cardy / SPORTSFILE

Jack O'Toole

‘Winging it’ is never really a phrase that instills you with great confidence but it’s nevertheless acceptable in some realms of life more than others.

It’s okay to wing it when you’re off on a drive down the country and you don’t really know the directions, or when you’re trying to spoof your way through a job interview that you really have no business of being in.

They are perfectly acceptable platforms to ‘wing it’, but when those are the words that are used to describe the state of concussion in rugby, from one of the leading neurologists on the issue in Irish sport in Dr Colin Doherty, then there is some cause for concern.

Concussion is certainly not a new issue in rugby but it is certainly a topic that has been the victim of intense magnification and scrutiny over the past few years, and rightly so.

The images of Northampton winger George North lying prone on the cold turf of Welford Road last December, or the view of Mike McCarthy down on his back in the Stade de France last year, 20 metres away from play, are images that are quite difficult to erase from the mind, but they are only what we see in the public view.

What we don’t often see is former Leinster lock Ben Marshall discombobulating his speech and lapsing mentally in conversation, or his ex-Leinster teammate Kevin McLaughlin having to remove himself from a game of keepie-uppies after feeling dazed from just five headers.

We hear of former Connacht centre Dave McSharry retiring from rugby due to concussion, but we don’t often hear of his symptoms, and how he sat in a room with blackout blinds in what he worryingly likened to ‘being in a prison cell.’

Concussion is of paramount concern for World Rugby, and it’s an issue that could have a dramatic impact on the future of the sport, but for the moment, the issue of concussion in rugby is in a state of flux, in a position of the great unknown.

8 October 2016; Mr. Kevin Moran, Consultant Surgeon in Letterkenny University Hospital and Donegal GAA Team Doctor in attendance at the National Concussion Symposium at Croke Park in Dublin. Photo by Tomas Greally/Sportsfile
8 October 2016; Mr. Kevin Moran, Consultant Surgeon in Letterkenny University Hospital and Donegal GAA Team Doctor in attendance at the National Concussion Symposium at Croke Park in Dublin. Photo by Tomas Greally/Sportsfile

No one really knows this stuff

“No one really knows this stuff. It’s all a little bit up in the air,” said Dr Doherty, a consultant neurologist and Honorary Senior lecturer in neurology at St James's Hospital in Dublin.

“Like how many concussions can you have before you have to retire? Who knows that question, and I hear of people going to the doctor’s, and I know Johnny Sexton was ruled out for four months by his doctor in France, but there’s really no evidence to say that that was the right amount of time – was it too little? Too much? We just don’t know.”

What we do know is that different players respond differently to concussion. George North had five concussions in two years between 2014 and 2016, but he’ll most likely line up on the right wing this summer when the British and Irish Lions take on the All Blacks in June.

Joining him on the field could be Ireland fly-half Johnny Sexton, who has suffered a series of concussions over his career but could be the Lions starting outhalf for the first test in Auckland.

Ben Marshall (26) and Kevin McLaughlin (32) certainly won’t be joining them on the field after their careers ended prematurely due to concussion - Ben after just one concussion against the Ospreys in February 2016, while Kevin retired from rugby after a series of concussions over the course of the 2014/15 and 2015/16 seasons.

But what separates Ben from Kevin? Or Kevin from Johnny? Or all three from George North?

According to Dr. Doherty, there are a number of different factors that determine a player’s susceptibility to concussion and how their body reacts to concussion.

“I think it’s very complicated but I think it all makes sense,” added Dr. Doherty.

“I think the first thing to say is that in the external environment there’s a massive variation in velocity and torque, that whole field is what is called kinematics. The pressure exerted – is it a glancing blow, is it a full on force blow, is there a rotation involved? And we’ve a few of our research people looking at that.

“Firstly, you need very high definition video, you need about six different camera angles to determine the external pressure or in other words ‘how big the blow is.’

“If you look at 100 different tackles you’re probably going to get about 100 different types of pressure effects.

“If you examined 100 people you would get a different response from all 100 of them. A certain percentage wouldn’t get a response at all.

“A certain percentage wouldn’t feel the blow at all, they’d keep on playing and would feel no symptoms. Another percentage would get symptoms that last 30 minutes, maybe until the end of the game. And then a certain percentage would have persistent symptoms for days and months afterwards.

“They’ll receive the same blow, the same force, but they have individual factors about them that make them feel differently about the bangs. Those are very complex, genetic, structural differences about people receiving a bang.

“Age is meaningful, sex is meaningful, how well trained you are, how healthy you are. There’s 100 different variables that would make you experience a blow differently to me.

“Johnny Sexton is a brilliant example because the biggest variable for Sexton is how he plays. He tends to stand up in the tackle all the time.

14 February 2015; Jonathan Sexton, Ireland, is attended to by team doctor Dr. Eanna Falvey and referee Wayne Barnes following a blood injury during the second half. RBS Six Nations Rugby Championship, Ireland v France. Aviva Stadium, Lansdowne Road, Dublin. Picture credit: Brendan Moran / SPORTSFILE
14 February 2015; Jonathan Sexton, Ireland, is attended to by team doctor Dr. Eanna Falvey and referee Wayne Barnes following a blood injury during the second half. RBS Six Nations Rugby Championship, Ireland v France. Aviva Stadium, Lansdowne Road, Dublin. Picture credit: Brendan Moran / SPORTSFILE

“He doesn’t really do low tackles. He stands up in the tackle, he gets targeted by the big players, the wing forwards and the locks all the time, and they know that he’s vulnerable to getting symptoms easily from bangs.

“They know they can knock him off his stride, but even those factors; they’re nothing to do with him as an individual. They’re complex individual factors, external factors and every player has them.

“We’re in this sort of tackle free zone at the moment because we’re just learning what these things mean and how to quantify them.

“What we’re trying to do is to come up with a signature set of tests to give you a risk profile if you’re getting persistent symptoms. We’d then be able to give that test to a player at the beginning of the season.”

How the players feel

A recent survey by the Irish Rugby Union Players Association (IRUPA) showed that 59% of current players in Irish Rugby admitted that they are concerned about the long-term effects that concussion may have on their health.

However, 97% of these players feel that they receive adequate support in dealing with concussion, with 95% agreeing that the HIA (Head Injury Assessment) protocol is adequate.

Adequate is acceptable, but it’s not bulletproof as Marshall and McLaughlin point out.

“You rely on what a player tells you to judge the symptoms,” said McLaughlin.

“There’s no scan, there’s no blood test, there’s no electromagnetic type treatment or assessment that can allow a doctor or a neurosurgeon to understand the extent to which a person has been concussed, or the extent as to which they’ve suffered a concussive injury.”

“The HIA there is no baseline to go off,” added Marshall.

“I was passing the HIA, repeating words to them, repeating a series of numbers in reverse. Walking in a straight line I was actually okay at that time.

“But when I went to do the IMPACT afterwards, I failed the IMPACT test for a good number of weeks afterwards. It wasn’t actually relative to where I was.

“The IMPACT test lasts for about 25 to 30 minutes and it goes through reaction times, your comprehension, your recollection, symbol recollection, memory, it’s quite good.”

Quite good is quite good, but not bulletproof.

“The IMPACT test serves a purpose in that you set a benchmark score in pre-season when you’re fresh and dandy, and then during the season if you get a bang to the head they use it as a way to determine return to play protocols,” said McLaughlin.

“Rather than sticking their fingers in the air and saying 'okay three weeks', they assess your cognitive function to see if you’re back to normal.

“It’s about as good as they’ve got right now, but do I think it’s really effective? No, I think the results you get on the test can be impacted by a lot of external factors.

“Did you sleep well the night before, whether someone walked into the room when you were taking the test and you got distracted, whether you were distracted by other factors like not getting selected on the weekend, like there’s so many different variables that impact on your ability to do that test, outside of pure cognitive function.

“On top of that, we don’t even know for sure how big an impact of a concussion would have on each individual’s cognitive function, even that in itself is very subjective. I know they’re desperately searching for a way to measure concussion but they don’t have it yet unfortunately. That’s why honesty is my only answer for now.”

Honesty in rugby is a murky subject at best. As McLaughlin notes the culture in rugby is to play through pain. When players like Paul O’Connell are playing through Test matches with a broken arm, it sets a tone for everyone else and concussion, or what is brushed off by some players as feeling ‘dazed’ or ‘woozy’, is no exception.

4 September 2015; Kevin McLaughlin, Leinster. Guinness PRO12, Round 1, Edinburgh v Leinster. Meggetland, Edinburgh, Scotland. Picture credit: Stephen McCarthy / SPORTSFILE

“The culture in rugby is that you play through pain but I think with the education that is in place now players realise that concussion isn’t a case of pain and get on with it and that it will go away,” added McLaughlin.

“If a player suffers a concussive instance you need to make sure you look after your brain and that you get off the pitch.”

McLaughlin’s comments are echoed by former Leinster winger and IRUPA Operations Manager & Head of Legal Affairs Simon Keogh, who insists that there’s a changing culture in rugby towards concussion.

“Even if you look back to the 2011 Rugby World Cup, World Rugby put out stats around that time that assessments were made in just over a minute,” said Keogh.

“Now you’re getting around 10 minutes, but yeah the attitude of the players is a lot different now. You’re more likely to get a guy tap you on the shoulder and tell you you’re not right, you need to take some time out. That’s a shift in culture.

“Rather than get on with it. I think even the supporters are recognising that that when a player is concussed, and the referees are doing a very good job in that respect as well, that when a player has a head injury that they are stopping the game, and that they are looking after the player. That’s huge from our perspective because we just want to ensure that the players are looked after in the best possible way.”

But is the culture changing? Maybe among the professional ranks for some players, but not for some of the players that are trying to get there in the first place.

The Ireland U19’s returned from their two-game tour of France earlier this week, but before they left they played Japan U19’s, in which a player I spoke to told me of his insistence that he had to get up off the ground quickly after a heavy collision because he feared that if he did not show to his coaches on the sideline that he was unaffected by the blow he had just received, he could be ruled out for the French tour due to concussion, as one of his teammates had in the build-up to that game.

With doctors still objectively looking for a way to measure concussion in individuals, McLaughlin says that honesty is the only way forward but that the message won’t trickle down to younger players until the game’s best players start leading the way.

“I think in Ireland we’re shining a leading light in that Joe [Schmidt], Ciaran [Cosgrave](Ireland team doctor) and the other medics, they realise that concussion is a serious issue,” added McLaughlin.

“There have been some really high profile cases - like Ireland v the All Blacks in the Aviva last year - were there was a case where Ciaran Cosgrave, who weighs about 40 kilograms less than CJ Stander, had to literally drag him off the pitch which you would have never seen before.

“It would have always been that the doctor would have said to the player ‘are you doing okay?’ and the player would have said ‘yeah’ and the doctor would have let them play on.

“The doctors are under huge pressure now from coaches to keep them on the pitch. Even with Joe and Ciaran, and some of the leading lights in that matter, it’s going to have a massive impact on the underage and schools game and the academy structure.

“Hopefully it gets to a point where players realise it’s actually okay to come off if you get a bang in the head, even if you feel like you’re okay to play on.

“That’s the thing as well, Stander is one of the toughest players in the game and he came off.

“But the coaches and other medics in underage teams, amateur setups etc., I think that is absolutely key that the top, top players in the country are willing to admit they might have a head injury and are willing to be honest about their symptoms, and can come off if they get a head injury.

“Then everyone else will follow in their footsteps and school players watching will be able to replicate what the stars on television are doing.”

Where's it going and what is the future

Like many of us, Dr Doherty is fearful for the schoolboy, underage and club game where many teams do not have the small army of doctors, medics and support staff that is actively present at the professional level.

There have been a number of high profile schoolboy incidents over the last year, including a game between Presentation Brothers College (Cork) and St. Munchin's College (Limerick) in February which had to be abandoned due to two Munchin players suffering head injuries.

Dr. Doherty feels that the professional teams have the resources and staff to combat concussion, but that there should be some changes made at the underage level to compensate for the inequalities between the professional and schoolboy sport.

“You’ve got this game at the professional level which has become very successful as an entertainment sport, and you might say you could mitigate the risk there by increasing the medicalisation on the sidelines,” said Dr. Doherty.

“And that all makes sense but I still have problems with it, because at the same time the same game is being exported outwards to a situation where the coach is just a dad, he’s coaching an U16 game and these guys are doing the same stuff. Who’s taking the responsibility for that?

“If you’re the headmaster of a school, a coach of a club team, is it reasonable just to keep taking the lead from the professional game and keep making the amateur and the school games more and more physical?

“I don’t know whether that’s reasonable or not, but in terms of injuries that are being avoided, we’re building up a repository of information on that as well, apart from the research we’re doing, but I think the next five years is going to be very pivotal in trying to understand the game going forward.”

As well as being a consultant neurologist at St. James’, Dr. Doherty is also a leading member of The Concussion Research Interest Group based in Trinity College, which is currently conducting research into concussion in sport with an aim to provide evidence to the government to hopefully endorse national guidelines concerning concussion in Irish sport.

It is Dr. Doherty’s intention that every coach and player in the country will one day know exactly what to do, and where to go should they suffer concussion, but just like current research into concussion, it’s all a work in progress.

“We’re going to use that committee to put together this guideline on concussion. It will probably take a year to 18 months, because what we do is basically read the literature in the whole area and you try and map it on to a structure of the Irish health services, because we want to be able to tell a coach down in Lixnaw, Co. Kerry, what does he do if he sees a kid get a bang in the head and he’s concussed.

“When does he decide to send him into hospital, and if so, which hospital does he send him to?

“We don’t expect that we would solve all concussions by any means, but we know that anywhere between 20% to 30% of patients show persistent symptoms after three months. We would argue that those patients would probably need a specialist review. Most patients can be managed by their GP, or local hospital, or sports physician, or whatever, but if they have persistent symptoms they’ll need advice and specialist rehabilitation.

“That’s where we’re going to try and persuade the government, and the department of health, and the HSE, that they need to invest in services for this because for the moment we have a fairly big team but we’re all funded through research projects.

“There’s no special funding from the government for this area, as a service, and that will  need to change because the number of patients referred to occupational therapists has increased.

“We have a couple of occupational therapists at St. James’, but from 2015 the occupational therapists only got a very tiny number of referrals from the emergency room, something like seven or eight.

“By 2016 they had 170, so there’s a massive focus coming because everyone understands now that this stuff is very serious and needs to be taken seriously.”

Concussion is being taken seriously now in rugby, at all levels, by players, coaches and administrators.

But at the same time, while it is a growing area of concern and while it has received widespread media attention, it has not altered the outlook of many of those people that have been most affected by concussion, the players’ whose professional careers were cut short by it.

Marshall and McLaughlin both had their professional careers end prematurely due to concussion, but they don’t hold any animosity towards rugby and a sport, that for a brief period in their lives, provided them with an avenue to become professional athletes.

“I’m happy with how IRUPA have handled it, I’m happy with the HIA, and to see where we’ve come from six years ago to now, and where we can go from now to six years time, it definitely has come a long way and people are working on it the whole time,” said Marshall.

“I’ll be bringing my kids down on Sunday to rugby just like my dad brought me down.”

McLaughlin added: “I chose to play rugby, I chose to play a physical game, and obviously you’re always concerned that you may have decline in your brain and in your cognitive function, but who is to say you wouldn’t have had it anyway.

“There’s no one in the world right now that can assess me and tell me I will, or I won’t have any issues later in life so there’s no point in me dwelling on it or thinking about it too much.

“I think Irish players are safer today than they ever have been before. They’re in the best possible care they could be, I think between IRUPA and the IRFU they're taking concussion seriously. I think rugby now is a safer game than it’s ever been.

“You think about myself five or ten years ago, and you could be knocked out for 30 seconds and you’d just play on. I think that that is something that gets lost in the media hype is that players today are safer than they ever have been.

“The game is more physical and there are more concussions, but at least players come off the pitch now when they get concussed.”

They do come off the pitch now, but that’s not the problem, at least not for Dr. Doherty.

The problem for him is the players that don’t come off the pitch, the players who are left in there to battle away none the wiser.

“The evolutionary sense of pain is a very good protective factor,” added Dr. Doherty.

“If someone chops your arm off it’s probably a good thing that nature confirms a painful stimulant on you because it makes you retreat from whatever force has caused that.

“Similarly, if you get a bang to the head, if you get symptoms, that’s protective. What we worry about are the people that don’t get any symptoms, because they’re getting the same force but they’re continuing to play.”

And play they will continue. Rugby’s attitude towards concussion is gradually changing, but at least for the moment, players are still the same.

CJ Stander and others can set an example at a professional level, but underage players who are trying to get to where he is may not always heed the caution, despite IRUPA’s and former players best intentions.

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