The NFL Have Shown Rugby How Not To Handle Concussion

Last week, it was announced that the NFL had reached a $765m settlement with former players and their families, who claim that the body neither addressed the dangers of concussion in the sport, nor fully revealed the extent to which it understood the problem. In the world of American Football, the tentative agreement has brought about a decidedly mixed response. Perhaps unsurprisingly so given the governing body’s poor reputation for the way in which it looks after and supports its participants of yesteryear. For rugby union, it should serve as another blatant warning of the potential for concussion, and the failure of those in positions of power to deal with it, to result in catastrophe.

The events of this summer have seen concussion brought to the fore within sport in an unprecedented manner. In the rugby world, the IRB’s latest protocols to tackle head knocks and player welfare (the Pitchside Concussion Assessment or PCSA) have been met with widespread criticism and debate, even sparking the resignation of one senior medical official. There were prominent incidents on the international stage, particularly involving Australian flanker George Smith, and scathing comments from ex-Scotland full-back Rory Lamont on the game’s attitude to concussion and player welfare. As if this was not enough cause for concern, research providing what is believed to be the first direct link between playing rugby and early-onset dementia was made public barely a month ago.

With concussion now well and truly in the limelight, the IRB should look to the stellar and on-going example set by the NFL of how not to handle to the problem. Firstly, and crucially for the American body, the settlement reached last Thursday does not hold them accountable for the medical conditions suffered by so many of their former players. Nor must they concede that the injuries themselves were caused by the sport, or indeed, expose files that may betray the true extent of their knowledge of the threat posed by concussion. In fact, the sum itself is arguably mere chicken feed in relative terms, when one considers that the NFL – last year alone – recorded a profit of some $9bn.

The class action filed by the former players and their families totalled around 4,500 plaintiffs. There are cases of early onset dementia, Alzheimer’s disease, Parkinson’s disease, and Chronic Traumatic Encephalopathy among others. Several ex-pros took their own lives while enduring life-altering and debilitating brain conditions, most notably former line-backer Junior Seau. That the NFL has effectively seized the opportunity to stall and silence those who spoke up against them is, at best, morally questionable. That it has done so without admitting fault, or being forced to fully address the issue, is nothing short of tragic.

The problem of concussion in American Football is hardly a recent development, and it is testament to the governing body’s suppressive, suffocating “hush-hush” attitude and evasive tactics that it has taken this long to come to a head. The settlement comes just days after it emerged the NFL had pressured broadcasters ESPN into withdrawing from their fifteen-month partnership with PBS’s Frontline in producing a documentary on head injuries in the sport.

The public, fans, officials, and – most importantly – players and their families deserve to know just how dangerous a game they are presently playing. How high the risks are that they may go on to develop brain damage or a serious neurological condition. How American Football may be altered to help improve and tackle concussions and player welfare. The settlement answers none of these questions. Instead, it shows the continuation of a thoroughly backwards and downright dangerous stance on an issue that can – as has been seen – spiral well out of control.

This chain of events that followed the PCSA’s introduction has merged into something of a “perfect storm” for the IRB. Parallels can certainly be drawn between the way the NFL has remained vehemently secretive on the problem, and the “shrug it off” macho attitude traditionally adopted in the sport of rugby, even in the modern era.

This, then, must be the time for the IRB to act decisively. If the sport’s governing body required a further wake-up call as to the dangers of concussion, then it received roughly 765 million of them last week. This is not an issue that can be conveniently swept under the carpet, particularly in an age where the physical attributes of players have escalated so markedly in comparison with those of just a decade ago.

There are encouraging noises from within the IRB, though, that positive steps are being taken. The PCSA’s continued implementation was unanimously backed by a panel of experts just weeks ago, and the body can cite data that points to a welcome reduction in the number of concussed players remaining on or returning to the field of play since its introduction this spring.

Whether the trial regulation will prove to hold the answer to rugby’s growing concussion problem is highly debatable. On the evidence thus far, it requires much work yet in order to be successful and significantly improve player welfare. That should hopefully come with further review and evaluation from the governing body’s top medical men, but major concerns linger over its effectiveness as a barrier to concussed individuals at elite level.

The IRB must realise that the problem is far too great and too serious to be treated in the same manner as their transatlantic counterparts. Awareness undoubtedly seems to be at an all-time high thanks to the high-profile incidents of the past few months, and the body is now under heavy scrutiny – it simply cannot afford to get this one wrong. Certainly, if rugby’s head honchos are seeking a blueprint for the disgraceful mismanagement of such a dangerous health problem, they need look no further than the unsavoury path taken by the NFL.

By Jamie Lyall (@JLyall93)

Photo by: Patrick Khachfe / Onside Images

14 thoughts on “The NFL Have Shown Rugby How Not To Handle Concussion

  1. when the PSCA first came in, I thought it was a good move. It stopped players pushing themselves to stay on the pitch without receiving any sort of real assessment and they were putting themselves in a lot of danger and medics were allowing them. However, the assessment procedure they introduced seemingly, rather than allowing players to get a real assessment has given them enough time to look like they’re fine. George Smith was a huge example of how the assessment has failed players. He couldn’t walk, he clearly was non compus mentus and needed to go to hospital for a real checkup.

    Now some of this is on the referees frankly. They have the power of veto. They aren’t medically trained but they are two things, impartial and not complete idiots. You’d hope. Any referee looking at the state of George Smith being carried off the pitch unaware of his surroundings should be saying, you’re not coming back. Yet there’s a worse example of refereeing. A Super XV game last year saw Gio Aplon (below) knocked clean out. The referee guilty on one count of not stopping play soon enough even though the incident was clear and in front of him, but then he’s guilty of allowing a player to play on who was knocked out (that is the easiest indication that he has suffered a concussion).

    The idea of the assessment is good, but it needs to be done independently and they really need to make it more cheat proof and use a bit of common sense. They also need to retrain referees to spot the early signs of a concussion as they’re often early to the scene. They certainly used to train refs the basics

  2. Rugby is a contact sport, if you don’t like it, don’t play it. We all know the risks. After a player takes a bad head knock, a pitch-side assessment should be all that is necessary. Anything further should be down to how the player feels and what the manager thinks.

    1. Of course, rugby is a contact sport, but shouldn’t we seek to safeguard the welfare of those who do play it?

      A ps assessment should be all that’s necessary? You can certainly make the case for that point, but there are serious questions over the current PCSA’s effectiveness – particularly given the high-profile case of George Smith.

      Further decisions down to players and managers? That does not work, as has been proven in the past. I have personally spoken to several elite players who maintain that the nature of pro sport is such that guys almost always want to continue despite injury. There are plenty of other quotes out there too to back this up, particularly from the likes of Rory Lamont.

      With regards to the coaches/managers, again, previous concussion laws (a mandatory 3 week lay-off for any player suffering concussion) meant that they were tempted to deny the player had suffered a concussion rather than risk losing that player for 3 weeks.

      I’m not convinced that “we all know the risks” as you claim, either. Up until recently, concussion was an issue of which there was relatively poor awareness, and one that was not particularly well-policed by the IRB. It is only this year that the topic has really come into the limelight.

      The PCSA certainly has its positives – I feel that the removal of a player from the field itself helps prevent the “snap” on-pitch decisions that can be called incorrectly even by top test-match doctors. In addition, it helps to standardise the concussion protocols across the board, and ensures consistency in that respect.

      However, I would argue that it requires a good deal more improvement and evaluation in order to be successful. Concussion is a very difficult condition to manage, but the regulation has certainly come under fire from some very well-respected medical figures.

  3. I fully agree with liam and people need to stop badmouthing a great sport like rugby, there are far greater risks in equesterian and boxing and motorsports but rugby seems to get all the bad publicity. Parkinson’s ans even alzeimher’s are by and large hereditery problems and claiming that rugby is a real cause of these disease’s is actually dishonest.

    1. Johne, I’m not sure if your points are general or specifically in response to things I’ve said in the article. I will respond here nonetheless.

      I fully recognise that the risk presented by concussion in relation to future neurological problems is relatively low in comparison to other sports. I have researched and written at length on this topic elsewhere online, and the prevalence of these brain conditions in NFL is not expected to be matched in any way by rugby. That is an important point to acknowledge.

      Dr Stewart, the neuropathologist whose research is believed to have uncovered the first direct link between playing rugby and early onset dementia, estimates that roughly 1% of current elite players may go on to develop these problems. Low figure, yes, but not low enough for me.

      With regards to your comments re badmouthing the sport/bad publicity, I do not agree. The publicity received in relation to rugby has been generated in recent months thanks to some pretty shocking incidents at elite level, and very high-profile comments from Rory Lamont.

      I don’t see where I have personally “badmouthed” the sport itself at all in the article. Nor have I claimed that Parkinson’s/Alzheimer’s are linked to rugby as you seem to think. Again, though, I’m not sure if you are referring to my article specifically or just making a general remark.

  4. Parkinson’s and Alzheimer’s are not “largely hereditary”. There are genetic components, but in Alzheimer’s disease you’re talking about 0,1% ofsufferers have a purely genetic disease. With Parkinson’s, approximately 15% of sufferers have a family member who also suffered with the disease. The concerning thing about these diseases are they are what we term sporadic, that is that they occur for a number of reasons that may appear random but generally are down to environment. There are definitely genetic components but they are more down to making an individual more prone not giving them the disease. Screening for this does not exist.

    It is long known that head injuries, including concussion when mounted up can lead to neurological disorders. Dementia pugilistica or “punch drunk syndrome” is a famous example from boxing about how cumulative concussions can result in serious brain damage and neurological disorders. At the professional level especially, governing bodies have a duty of care to ensure that these issues are monitored and players are protected as well as they can be. We can’t wrap them up in cotton wool on the pitch, and prevent concussions, but they damn well need to ensure that they’re not going out there with concussion. Repetitive concussive and subconcussive blows in a short space of time can lead to serious damage and each one in a short space of time increases the likelihood of ruptured blood vessels, a subdural haematoma which – never mind permanent damage – can leave you taking a body off the pitch, not a player. The increasing strength/weight/speed of players in the professional game have increased the risk and number of concussions.

    It is simply never down to a player to tell you he feels fine. Funny thing about concussion, it often effects your short term memory. You don’t remember the collision being that bad because really, you don’t remember the collision. The last concussion I suffered I remember the number 8 running at me and lining up my tackle perfectly. Then I was on the floor and the ref and physio were around me and the ref insisted I went off. Then I was fine and 15 minutes later I puked and passed out and I wasn’t quite right for days. Players do not know. The problem with the PSCA is that it allows players 5 minutes to recover and think they’re okay. Under old systems, George Smith would have looked dreadful and not been allowed back on the pitch.

    As far as team medics are concerned, they are the people directly responsible. A problem comes however in that they themselves are conflicted. While I recognise that they are usually the best to spot a concussion, they are emotionally conflicted, but they’re also more likely to say “he never remembers the score” (the score being one of the components of the PSCA) and pass off a number of the assessment procedures as idiosynchracies. The addition of an independent assessor to confirm the findings is crucial. The other problem with the PSCA is the pressure on medics, on teams and on players for their stars to be out there. If the player is not okay, he’s off the pitch when he needs to be out there impressing, the medic isn’t doing his job well enough to ensure he’s available and the coach is without his star. It’s a cycle of pressure in professional sports and players/medics/coaches connected with the team are under that pressure to make it work.

    As for the “rugby is a contact sport, bla de bla” a phrase I increasingly associate with people thinking you’re a whimp if you don’t want to be spear tackled or generally assaulted in an illegal manner from people who haven’t suffered horrific injuries. Yes, it is and we are taking a risk playing it. The higher the level, the greater the risk, but also the more a governing body is making out of your appearances and the risks you take. Any serious injuries associated with elite sport failing to fix a problem that has been identified instantly become their responsibility. If they don’t fix those things they risk several scenarios. 1. they get the crap sued out of them by every player who suffers an injury as a direct response to their inaction. 2. an increase in mothers saying the sport isn’t safe results in a huge player drain at lower levels and the sport shrivels and dies. 3. medical organisations begin campaigning against the sport as they have done with boxing for decades.

    We want the sport to continue and we want the competition to remain physical. However, it is up to governing bodies to work out how to retain the physicality and we all expect injuries. We’re not talking whimps here. A typical Premiership player by the end of his career has probably undergone at least 25 surgeries on injuries sustained playing rugby. Their bodies have been sacrificed enough for the sport, and it’s about helping keep good players in the game and not destroying their future at the age of 24

    1. There is at least one medic out there that is probably strong willed enough to stand up to both the player and the coaching staff. And that’s Dr James Robson.

      I remember a Calcutta Cup match at Murrayfield where he was doing his usual prowling the touch line keeping up with play when he ran onto the pitch before the ref stopped played to pull players out of a ruck to get to Ugo Moyne (I think) who was out cold at the bottom of it.

      As the Scottish team doctor yes he looks after his team but in crunch situations he doesn’t care which shirt a player is wearing. His quick actions have in the past been lauded by Messers Greenwood & T Evans as saving their lives.

      Dr James Robson has possibly set the standard for the IRB & Unions to follow.

      1. I’m not attacking team medics really, there are plenty of good team doctors, and a lot will get on and treat anyone who is injured, it’s what being a medic is about. however, I do believe that medics under situations such as concussion assessments are conflicted and it’s not a criticism of them, it’s the way the rules governing player safety work and it puts extra pressure on the medics to make sure their player is okay and make sure he can play if he’s capable.

        The problem as I mention is that concussion is difficult to diagnose. There’s the initial incident and your immediate response to it. Then, you’ll appear fine, or at least fine enough and this period is difficult. If you continue to play or exercise, you will often lose some of your faculties, forget plays and become absent minded and you can become a liability to yourself and others. The formal assessment comes during your lucid period.

        Where I will criticise medics is incidents like George Smith. He was clearly unsteady and clearly unaware. You should not perform an assessment under those circumstances, he’s already shown the clear signs of a concussion. Shame on the referee too because he should be able to recognise that the player was not fit to continue as referees are trained the basics in concussion assessment and has the final power of veto to deny the player.

  5. As a former player of the sport in the military it’s not just suffering a concussion (suspected or not) where the individual is the least qualified to make the decision of carrying on or playing next week. Most soldiers I knew at one point or other have either played a sport or carried out tough operational work either carrying a niggling injury or have returned too quickly from injury so as not to let down their boss, team mates or the team. This has in some cases led to long term damage. From a personal point of view I ignored or masked or manned up a knee injury which eventually led to several surgeries and the end of my rugby playing days and less effective as a soldier.

    Now a knee injury is a fairly simple thing to spot and possibly patch up with braces and tape. Brain injuries not so much so fair greater care must be taken to protect the players. Even if it means erring on the side of caution.

    I have spoken to several friends (and possibly posted/tweeted) that I believe to ensure player welfare that any hint of a possible concussion should be judged, like boxing, by an independent medical team with access to the same video as the TMO. With access to the video any player knocked out during the game or having a wobble (or in one famous case going the wrong defensive line) will be easily spotted and assessed.

    No one likes to let the team down but the team should not let any player down either.

  6. I am the step father of Benjamin Robinson, the 14 year old boy who died from second impact syndrome, as a result of several successive concussive blows he sustained during a schools match in January 2011.
    I have played the sport to a high level for many years and only gave up at the age of forty two, four months prior to Benjamin’s death. I played extremely physically and loved the physicality of the game, as did Benjamin, who played in the centre.
    I have to agree with Barry, that pressure to not let peers down is only natural, but this can often be to the detriment of players’ welfare. Rugby is a physical game, and there are risks as many rightly point out. However the responsibility of educating players to the associated risks, including concussion recognition, falls with the IRB and then down to the respective unions. It would be hard for anyone to argue to the contrary.
    At the minute it would appear the IRB and respective unions are talking the talk, but not walking the walk. I do not make this comment subjectively, but completely objectively. Consider this; The IRB talks as far back as 2008 about the importance of educating coaches, referees, players and parents in the importance of basic concussion recognition. Again it is hard to argue with this logic, but how incongruous is this statement when one considers that 4 of Benjamin’s young team mates gave evidence that Benjamin was displaying signs of concussion, i.e confusion, appearing dazed and an inability to remember the score in a match that ended 6 – 3. It would be hard not to argue that had Benjamin’s team mates known of the potential consequences of playing with concussion that they would have brought their concerns to the coaches.
    It is yet more alarming that at inquest proceedings in September 2012 and only last week that these pupils, now seventeen and some eighteen years old still had not received any formal instruction in concussion recognition, that the IRB had discussed in 2008, a full five years ago. What’s the delay? We all know that when the IRB puts up ticket prices that information does not take five years to be disseminated.

  7. Completely agree that concussion is a very serious issue and needs addressing. I have stopped play now at only 22 due to recurring concussions (and a back problem too; yes I’m that guy who is always injured). But on a serious note, I had no idea how serious concussions were for years. In one season aged 17, I was knocked out six times throughout the year, and missed one match through it. I was not looked after properly, and nobody ever really explained to me how serious it was. It was only when I was having week long headaches and dizziness that I began to consider my safety and was advised to stop playing. I do not know the exact number, but I would guess I was knocked out around 12 or 13 times in four years including that season, and some of those times I returned to the pitch; why? Because I felt I was letting the team down. Most of those times I was sick after playing, and felt dizzy/ had headaches for days.

    Bare in mind this is at a far lower level that elite, but it happens and needs to be looked at more closely.

    To be fair to rugby, this is a stream of stolen tweets from Charlie Morgan which shows impressive results from last seasons PCA. Not perfect, but good:

    “Former England doctor Simon Kemp went over results of last season’s Pitchside Concussion Assessment trial yesterday at Twickenham. In the Premiership alone, 33 players were brought from the field – 23 went back on and 10 were removed permanently. Of the 23 who returned only two were found to be concussed after monitoring. Of 10 removed, nine were concussed. Decent accuracy on a complex medical issue.”

    1. Though the problem with those statitistics is that concussion is a complex and difficult to diagnose situation. There is no scan that can ‘confirm’ a concussion, unless it is a particularly bad concussion that causes a degree of swelling in the brain. The majority of mild concussions which can still accumulate to repeat concussive damage may not show up in scans or post match analysis of a player’s condition. I gather there are plans now for “new rules” that just change the wording from “if the player has a concussion” to “if the player has a suspected concussion” or something to that effect. This is flawed in itself because surely if the player does not have a suspected concussion he wouldn’t be taken for a PSCA.

      Worsth thing is I have seen players go down unconscious and return to the pitch after a PSCA. That is an elementary mistake. Unconsciousness is the elementary definition of concussion. It’s possible that they’re conscious before the medics arrive and they miss that from their diagnosis, but someone needs to be reassessing that.

      My further gripe in recent years is that rules have been pushed through to prevent second impact syndrome. Under this comes a period of analysis that prevents players training and playing until recovery. This, for a minor concussion is a minimum of 7 days, i.e. if you are concussed in a saturday game, you can’t train until Wednesday during which time you will be tested for signs of concussion daily. You then cannot play again until the following Saturday if you pass all of the tests. I see too many players concussed on Sunday playing on Saturday. One incident sticks in my brain from last year’s 6N when Dowson was knocked out cold in a Sunday game. That is not a minor concussion and would require at least a week to heal, under the guidlines at least 2. Dowson was then playing in a Saturday game for England. Whether or not he passed his concussion assessment, there is a law to say he should not be playing for at least one week which was broken and ignored, but I generally doubt that someone who has been knocked out has recovered in that time

      1. I hadn’t consider that aspect of the stats. It is very difficult to be sure with concussions as you pointed out. Is it appropriate to get to a point where any head knock, however minor, means you leave the field of play? I’m not sure, that may be too far.

        On your points about post-match, I actually don’t think a week is long enough. One week after a concussion, if you were to get another head knock, you are very likely to be concussed again. Three weeks, whilst seems like a long time, was the rule at one point I’m sure, and should be the length of time out if you are concussed.

  8. I don’t think we need to remove anyone who has had a head knock. However, there are a lot of indicators that medics will miss by the time a player is back to the pits. This is what Steven was referring to earlier on, better diagnosis of concussion when it happens through better education of players and referees and more balls for those people to use their power and stand up and say “I think he has a concussion, he shouldn’t carry on”.

    I don’t expect a diagnosis of every concussion that’s not realistic, and I don’t expect any player with a head knock to come off. However, anyone who seems groggy after a big hit who isn’t better on the pitch should go off and stay off. I’d also like to see referees get into the mix with making decisions on this as soon as possible.

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