Saturday 16 December 2017

The nightmare finally arrives

Concussion and how it is dealt with by the courts and doctors will be a game-changer

Ireland team physio James Allen signals to the touchline for a substitution for Mike McCarthy. Picture credit: Ramsey Cardy / SPORTSFILE
Ireland team physio James Allen signals to the touchline for a substitution for Mike McCarthy. Picture credit: Ramsey Cardy / SPORTSFILE
Neil Francis

Neil Francis

I don't think rugby jocks could ever be classed as Cure heads but I did love Robert Smith's brilliantly constructed lyrics about his recurring nightmare of being eaten alive in his bed by the Spiderman. Smith always had the consolation of the knowledge that " . . . I know that in the morning I will wake up in the shivering cold."

On candy stripe legs the Spiderman comes
Softly through the shadow of the evening sun
Stealing past the windows of the blissfully dead
Looking for the victim shivering in bed
Searching out fear in the gathering gloom and suddenly!
A movement in the corner of the room!
And there is nothing I can do
When I realise with fright
That the Spiderman is having me for dinner tonight . . .

'Lullaby' - The Cure

Last week the rugby family woke up to find that their nightmare had arrived - one where they know that there is no refuge of a blinking awakening in the morning - it is real and it will be there night and day.

On January 29, 2011, Ben Robinson died as a result of second-impact syndrome sustained in a medallion match in Carrickfergus Grammar School. Two days after sustaining head injuries in rugby the boy died in the Royal Victoria Hospital in Belfast.

An impossibly handsome boy, his world would be denied the benefit of his spirit. In the blur of adolescence he would not have the luxury of time to think about what he wanted to do in life. There were so many choices for this fledgling and then, suddenly, he was gone. The possibilities in life for this vibrant being are gone. For his parents, emptiness on a scale that is unimaginable.

The nightmare for those on the other side of the equation also began in the shape of a lawsuit which will set a precedent that could change, literally, everything in the game forever. The incident that everyone was hoping would never happen did happen and the natural sequence of events that would inevitably follow came about in the High Court in Belfast.

The coach of the school team and the referee who was in charge that fateful day are being sued by Ben Robinson's father. Carrickfergus Grammar School, Ulster Rugby, the IRFU and World Rugby are being conjoined in the action. It will be a seminal moment in sport. I plan to be there when the case is heard. I believe it will change rugby and sport in this part of the world forever.

Contact sport, by its very definition, implies an element of risk. Rugby is a dangerous sport and, on average, about 10 people per year die directly from playing it. Despite the generally-held notion that it is a dangerous game, it is still in the ha'penny place when it comes to horrendous fatalities on an annual basis in boxing, mountaineering, skiing, cycling, motor racing, motor biking and diving. These sports have tolls that run well into the hundreds per year.

The governing bodies in rugby have moved to limit damage and make the game safer - even the incidences of catastrophic spinal injuries have plateaued. They still happen, but nowhere near the levels we expected them to be, say, 20 years ago. Contact game.

Year on year, since 2012, concussion is the major injury in rugby union. Brain injuries are creeping higher and higher and there is no question that more people will die from a concussion injury in the next year or so, no matter what safeguards are implemented. More will suffer neurodegenerative syndromes later in life. It's a contact sport.

And so the race, and that is what it has become, to understand this complex and labyrinthine injury starts - and it starts from a frightfully shallow base.

The recent consensus symposium on concussion in Berlin, with 500 medical professionals in attendance, sought to do a number of things. It looked at where they were and how they had improved their understanding of concussion in sport worldwide since their first seminar in Vienna in 2001.

There have been more than 60,000 research papers on concussion published in scientific and medical journals that are available on the web. Even on a subtext there have been 3,362 medical journals written just about sideline screening. The organising and scientific committee charged their delegates to rate the strength of the research papers and assess their relevance for the purposes of the strategic values of the conference.

There are 12 groups of 10-16 people and they have to look at and analyse all of them. Sixty-thousand journals, some of them hundreds of pages long. Our game ricochets and lurches at breakneck speed through new barriers, yet our medical people are charged with research of such magnitude that it is impossible to keep up with the rate the sport changes. The research, however, to be reliable and relevant, has to be studied painstakingly slowly and methodically.

The results of this opus will be published in May 2017. It is unlikely to be a game-changer, but we are promised a big step forward in dealing with, diagnosing and rehabilitating from concussion. Another season will have gone by that stage.

World Rugby have done their own research by necessity. They have analysed 600 videos of rugby concussions at professional level over a nine-month period. Seventy-five per cent of all concussions came from the tackle and, in 75 per cent of those tackles, it was the tackler who was concussed.

The results of their findings will be difficult to collate because there were 15 different variables in how the tackles came about and how the head was moved about in its collision with another part of the body. The findings will be out after Christmas. What is in this report that will tell us something that we don't already know?

Diagnosis is another area where it has been difficult to assess. In clinical situations, blood bio markers, imaging and MRIs, there is no evidence to provide absolute proof because different parts of the brain are affected. There are different levels of effects and you are never absolutely certain what part of the brain was injured. Clinical diagnosis is in its embryonic stages.

The big breakthrough is in rehab. What the medical world is saying now is that complete rest can often do more harm than good. Symptoms can be prolonged, recovery time lengthened and you may become more prone to recurrence.

There will be changes in how rugby players who present with concussion are treated. Instead of complete rest and standard return-to-play protocols, players will be put through newer procedures. Rehab will consist of a new series of balance and co-ordination exercises which will be introduced far earlier and on a faster scale from the date of injury. Players will be put on treadmills under supervision. They will make concussion victims work to 80 per cent of their capacity to get their heart rate on a consistent basis again.

Ocular exercises are another key component where special goggles are introduced and players will have to track objects passing through the goggles, read them clearly and follow them precisely. The King-Dewick eye co-ordination test is now being trialled in the UK/Premiership.

The Santry Sports Surgery Clinic have introduced a research-based concussion passport to return safely to playing sport again. They have taken readings on about 150 schoolboy rugby players from St Michael's, Blackrock, St Andrew's, Gonzaga and St Mary's and all of these boys have a base-line which will help in assessing them should they become concussed during the season.

As these institutions are primarily educational establishments there are other parameters at play here. A boy's ability to get back to study is also an issue that can be affected. Adolescents who have had a concussion can have problems with subjects like maths. Their co-ordination, balance and reaction times are usually significantly out of kilter as well. Quite often for parents, returning to learn is higher up the priority list than returning to the rugby field. This relatively new approach has to be commended but, at this moment in time, all it is really is baby steps.

Advancements in diagnosis on and off the field, and particularly rehab, are highly welcome, but we are never going to get away from the fact that this is a contact game and prevention is more important than diagnosis and rehab.

Rugby league-style defences, body size and the ability to generate power and speed at elite level will always be a problem. This, unfortunately, is being replicated in schools. Weight restrictions must come in now and the game must be de-powered.

This must be done on the instructions of the governing body before the law courts do it for them.

What we have coming at us in 2017 will force the entire game of rugby union to change. Some of the volunteers who coach or referee will now be required to check if any one of the 30 boys on a field over 70 minutes are suffering from a bang or a knock and check to see if the same boy got another blow to the head. How many volunteers would want that onerous responsibility? They will have a duty of care far beyond just refereeing a game or ensuring the lads get a run-around with a ball after class.

By necessity, the game will have to change. The governing body is making efforts. The medics are doing their best, but there is something coming down the tracks which will change the game forever. Rugby's nightmare has arrived. It was only a matter of time.

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