Wednesday 20 November 2019

Heads clash over way forward

Despite rumblings, the use of bins to treat concussions in games must be developed, says Brendan Fanning

A year ago in a meeting room of a Dublin city centre hotel, the IRB held a media briefing on a range of issues ahead of the World Cup. It was all going along swimmingly until, on the issue of how concussion is treated, the question of independent medics arose.

Yes, we were told, there would be independent doctors on duty in New Zealand. Great! Would they have the power to remove a player from the field if they thought he had suffered concussion? Eh, no. Long silence.

Martin Raftery, who at that point barely had his feet under the table as the IRB's new chief medical officer, looked uncomfortable. It was like he had just signed on as sheriff only to be handed an empty gun.

Last week in the same room of the same hotel, we reconvened. Raftery looked a whole lot more content as, in the interim, a significant development has taken place: a head bin has been introduced on trial.

If a player is suspected of being concussed, he is removed for a five-minute period to undergo a pitch side concussion assessment (PSCA). If he passes the test he returns, but after the game undergoes a SCAT 2 test -- another assessment tool -- followed the next day by a neuro cognitive exam.

Head bins have a bad name because they were widely abused when tried by rugby league in the 1990s -- coaches used them tactically, not medically -- and subsequently they were abandoned, to be replaced by nothing. Which leaves that sport with dodgy laws on safety and a problem they have yet to address.

The key elements of Union's PSCA is that it takes place off the field, and that the match day doctor -- who is independent -- can make the call as well as either the team doctor or the referee. The player has no say in the matter.

Not everyone is happy however. Chief among the dissenters are doctors Mick Molloy, former, and first, chief medical officer with the IRB; and former Irish international Barry O'Driscoll. Molloy has issues with the length of time afforded to medics to assess the victim, and exactly who should make the final call on whether or not the player returns to the field.

"You can't do it in five minutes because the situation fluctuates and changes," he says of the timeframe. "They've knocked their head and they feel a bit muzzy and they're not sure. It's very hard to make a valid judgement in that period of time. If you have them for 15 minutes you've plenty of time to watch them carefully and observe them -- an experienced observer -- and then you're in a position to make some kind of judgement. But quite frankly, the moment you suspect there's been a severe impact, they should not go back on the pitch. And it's got to be an independent doctor that makes that decision, not the team doctor. That's a mistake of major proportions.

"Sometimes they [the player] sound lucid for a minute and then they go off again and suddenly they get sick. There's a whole series of events that happen in that situation. No matter how many questionnaires and how well you go through them and how carefully you structure your questions, you still have to watch them because if you repeat the questions in five minutes you might get different answers. It is a lot more complicated than people think."

Raftery would be the first to accept the complexity of the issue. However, he is adamant that the length of the consultation is not the trickiest bit.

"I respect they [Molloy and O'Driscoll] have their opinions but you've got to remember we got together an independent group who had six physicians from six different unions who all had recent team physician experience, and they felt this was appropriate," he says. "We've taken advice from independent people, we're following up every case and to date we haven't seen one case that suggested we should be extending the time."

The new protocol was trialed in the Junior World Championship and Junior World Trophy this summer, and is now up and running in a raft of competitions, including the Rugby Championship which kicked off three weeks ago. In the first two rounds of that competition both South Africa and Australia have used PSCAs. Medics from each camp emailed Raftery last week to report the following: the two players underwent PSCAs, then a SCAT test post-match, followed by a neuro cognitive test the next day. In both cases the players returned to play on the day and in both cases the subsequent tests came back clear.

The independence of the man or woman making the ultimate call is another issue. It is welcome that the match-day doctor now can make the call to get a player off, for we have long thought it unreal for team doctors, in the heat of the moment and in the glare of public attention, to reason with stubborn and confused athletes who would rather lose a limb than leave the field.

It is either naïve or disingenuous to think that medics are so robust that there is no question of them wavering under this pressure. Even though the landscape has changed now for the better, why not plough on and allow the independents to make the final decision on whether or not the player is fit to resume?

"Once again that was debated by the working group," Raftery says. "They decided to go back to what Zurich [The Zurich Consensus on Concussion in Sport, 2008] says, and that's to go with the team doctor -- he should be making the final decision because he knows the player. What we are doing is actually analysing every decision. If there is a match-day doctor there they're actually completing the form as well, and both forms are being submitted for research. So we'll be able to look back and see is there a difference.

"There's a perceived difference -- there's a perception that there's a difference between the team doctor and the match-day doctor so we're trying to prove that [one way or the other] to see if they score the test differently. Not only that -- but after the game if you've had a PSCA, whether it's positive or negative, we then do a post-game SCAT 2 which we than can compare against a baseline SCAT 2. If the team doctors are treating it more leniently we're going to see that they're sending their players back on after the PSCA, having abnormal SCAT 2s after the game because the match day doctors are there when they do the SCAT 2s as well.

"So I believe we have the checks and balances in to answer that question, rather than putting our fingers in the wind and saying: 'Oh we think that they treat them more leniently'."

The likelihood is that the only pressure on the team doctor now will be from his colleagues, not the coach or the player. Which is a significant improvement. Two issues remain: making the game safer in the first place, before we even get to how players are treated in the second. And the potential for long-term damage caused by repeated bangs in the head.

The part of the IRB initiative that has got very little airplay is the longitudinal study that will start in New Zealand this year, in conjunction with Auckland University of Technology, into potential long-term damage suffered by elite rugby players as against amateurs and elite athletes from other sports.

Rugby desperately needs hard data in this area but by the time it arrives more bells will have been rung and more players will be exposed to the threat of health problems around the corner.

The party line is that until that data is printed off we'd be unwise to infer too much from the horrendous stories tumbling out of America's NFL. Yes, it's a game with crazy laws, but rugby is so fast and powerful and has so many points of contact that it would be a whole lot more unwise to think we aren't storing up problems in the medium and long term.

Of the 20 recorded concussions from the World Cup, 11 comprised players dinged by a clash of heads when making a tackle, or simply from the impact of the tackle itself. Lowering the point of the tackle in the first place might mitigate some of the damage without unstitching the fabric of the game itself. And was that fabric not redesigned in any case with the arrival of chest high tackles courtesy of our pursuit of all things rugby league?

The head bin is a good idea. Despite the inability of Celtic Rugby to introduce it to the Pro 12, it surely will be a part of the Six Nations in February. Before we get to that point we need to determine ways of keeping people out of the bin without compromising their health.

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