We begin the first in a threepart, collaborative series on concussion.
Concussion can be career- ending, deadly even. But at least neither ignorance nor arrogance are hindering efforts to minimise the dangers it poses in the elite game. GREGOR PAUL reports.
On average, the typical rugby professional is 30 per cent heavier and more powerful than his predecessor of even five years ago. There are some men, quite a few in fact, who are about the same dimensions as the family fridge and yet imminently capable of scooting about as if they are on wheels.
Three such creatures – Ma’a Nonu, Julian Savea and Manu Tuilagi - were in action throughout June and it was mesmerising. They are pretty much carbon copies of each other: close to the old six foot mark and anything from 108kg to 112kg of agile, explosive, muscular mass.
Those who were hit by them, couldn’t pretend it didn’t hurt. This is modern rugby – oversized, over- developed men committing freakishly athletic and explosive acts that create the most terrifying impacts.
And it’s as worrying as it is compelling. There are going to be medical casualties in their droves down the track. Supermarkets are going to be full of limping giants, unable to stretch up to pull tins off the shelf as shoulders no longer function and knees can’t be straightened.
That’s inevitable and probably most regular watchers had already grasped as much. But what no one thought was inevitable: what didn’t seem remotely
possible even five years ago is that rugby has a hidden, ticking time bomb. Head injuries and concussion are the single biggest short and long term threat rugby faces.
The latest injury surveillance project out of the English Premiership shows that for the second consecutive year, concussion was the most prevalent injury. There were 54 concussions on match days during the 2012- 2013 season and another five in training.
New Zealand’s competitions show a similar trend and similarly high volumes of concussion. In 2005, there were 4.5 concussions recorded for every 1000 hours of rugby played.
In 2013, that number had jumped to 9.6 per 1000 hours. In eight years, the volume of recorded concussions has more than doubled in the elite game.
Those numbers can be supported on a non- scientific basis. The preponderance of concussions can be illustrated by focusing on the current All Black squad. Almost half of them have suffered a reported concussion in recent years and have been forced to endure compulsory stand- downs.
Some, such as Richie McCaw, Kieran Read and Conrad Smith have endured multiple concussions. Go beyond the All Blacks and without having to dig particularly deep, it’s relatively easy to recall several professional players who have suffered serious blows to the head.
Piri Weepu was knocked out cold in Dunedin last year. Ben Afeaki still hasn’t recovered from a clash with Brodie Retallick earlier this year and Benson Stanley took some horrific blows to the head playing for the Blues. It is a small miracle these days if no one is concussed
“It is absolutely crucial these days that players are upfront and honest when they take a knock and they report symptoms to their medical staff immediately.” Former Chiefs captain Craig Clarke who was recently forced to retire due to concussion
“I have noticed a change in attitude towards concussion, which is great. I think the importance of player safety is at the heart of that change, however we need to make sure this continues.”
Crusaders and New Zealand Sevens player Adam Whitelock
“As leading professional players in New Zealand we need to set the example on this issue. Not only for our peers, but the next generation coming through. If you take a knock, always get checked out.” Chiefs flanker and Bay of Plenty
legend Tanerau Latimer
in a big game. When the Crusaders played the Chiefs in Hamilton this year, there were four head knocks in the first half alone – one of which was the collision that took Read out for so long.
There won’t be many players on the professional scene who haven’t suffered a concussion at some stage in their career so it’s not really a quantum leap or without foundation to suppose that the dramatic up- sizing of the athletes and the game’s obsession with the collision has put the players’ heads in greater danger.
“It is a contact sport and I guess if you get your head in the wrong way or going for the ball in terms of collisions... it is going to happen,” says All Black midfielder Nonu.
“It is getting really physical in terms of the breakdown and trying to win the ball and trying to steal the ball. If we can get across safety in terms of knowing where to put your head...”
But there is a positive of sorts attached to this increase – much of it is being driven by greater awareness, better diagnosis and a culture of honesty that has encouraged players to be truthful about the extent of head knocks and their associated symptoms.
As alarming as it is to see so many players leave the field in any given game, it is also reassuring: not so long ago they would have either tried to hide the difficulties they were in or most likely have been told to carry on playing.
“My gut feel is that it is probably no different,” says All Black doctor Tony Page. “It [ concussion] has been happening all the time but we are much more aware of it. Although the players are bigger and faster I don’t think it is
suddenly epidemic. What’s changed is the culture and the idea that honesty is a good thing because it is your brain.”
Concussion presents the rugby fraternity with a number of challenges. For players and coaches there is the short- tomid- term management of their health.
Read, the best player in the world in 2013, has barely got going in 2014 due to successive head knocks.
He missed four games for the Crusaders while he tried to recover, was given the all clear at the end of May, played against the Force and then woke up on the Monday feeling dizzy again. The All Blacks immediately scratched him from the first test and then didn’t pick him in the second because he was light on conditioning – a consequence of not being able to run due to his symptoms.
“It’s pretty frightening,” he says. “It is something I wouldn’t wish on anyone. It’s a tough process trying to recover. When you do take a big knock to the head, it’s so important that you take note of how you are feeling.”
On the same day Read was withdrawn from the England test, former Chiefs captain Craig Clarke was forced to retire. He took a blow to the head playing for Connacht in January and five months later he still hadn’t played. The 30- yearold had lost count of the times he’d been concussed and on unambiguous medical advice, he pulled the pin.
Neither story, however, was as moving as that of former Kiwi and England centre Shontayne Hape, who revealed the background to his decision to retire. He confessed to being knocked out more than 20 times in his league career alone. He was then, frankly, lucky to survive his final seasons in France.
He was eventually referred to medical experts after he was unable to take light contact without losing consciousness. “The specialist showed me on the chart the average score for someone with a normal brain,” Hape told the New Zealand Herald. “My score was just above someone with learning difficulties. The specialist explained that my brain was so traumatised, had swollen so big that even just getting a tap to the body would knock me out.
“He referred me to another top specialist in Paris but he was very clear - I had to retire immediately.”
For medics and administrators, concussion is equally challenging. Test rugby is not an easy environment for doctors to make quick and accurate decisions about any injury – least of all concussion.
A head knock can be easily missed and even if it is seen, there is the dilemma of wanting to look after the player’s health but also the team’s interests.
In years gone by, the latter often had the heavier weighting. Not now says Page who is confident the All Blacks have a strong culture of honesty when it comes to head knocks. He’s also a supporter of the sideline concussion test – particularly the decision to extend it from five to 10 minutes.
“It has got much better with the change in the rules,” he says. “There is not a lot of grey any more. The grey has shifted so if you are concussed or have signs that make it likely, then that is the end of your day and I think that has made it easier for medical people. If in doubt we are going to go the safe way.
“There are about six things now that could mean your day [ playing] is over. That might mean that you get hit on the head and you lie there and when you get up you have got the staggers. When you look like a foal getting up then that is a primitive
brain reflex that means you are not all there and that is the end of your day.
“If you have a twitch or a convulsion that is the end of your day. If you are knocked out at all... that is the end of your day. You don’t then have a concussion test - that is the end of your day there and then.
“There are, though, often situations where we are not sure what has happened and these are the ones where we will do a concussion test. Often the teammates will tell you. They will shout, ‘ doc, doc he’s not connected. We called a move but he wasn’t there’. No one saw the bang to the head. The good thing is we have more time to do the tests.”
The introduction of the sideline concussion test – where a player can be taken off and temporarily replaced after a head knock – has been one of rugby’s most progressive initiatives of the last decade.
It has been in operation since 2012 and in May this year, it was agreed that the time allowed to test players with suspected concussion should be increased.
That decision was made to help further reduce the instances of players who are concussed or are suspected of being concussed from returning to the field. The trial has been hugely successful in that regard: before its introduction research found that 56 per cent of players were returned to action in an unfit state, while during the trial, that number has dropped to 13 per cent.
The IRB is determined to see that number come down and there can be little dispute that the game’s governing body has been proactive in driving improved awareness and better management of head knocks.
“Player welfare is the number- one priority for the IRB,” says chief executive Brett Gosper. “This is not something we say lightly but a strategy that informs and guides every aspect of what we do. Without healthy players who are confident they are playing a safe sport, rugby would not experience the success and global growth that it currently enjoys.”
Concussion is not a fad or a populist issue that will soon lose its media appeal and cease to be a problem. It is very much for real and while that provides significant cause for concern, there is reassurance to be found in the united front the game has presented in turning attitudes and practices.
There is no sweeping under the carpet. There is no battle being fought to force
administrators to take it all seriously. No one within the IRB is in denial about the extent or consequences of concussion.
But the last month or so has shown both how much progress has been made in improving attitudes and how much work still has to be done.
The All Blacks withdrew Read from the first test against England the instant he complained of concussion symptoms. There was no wait and see approach: as soon as he said he didn’t feel right, that was it – he was no longer a possibility to start at Eden Park.
A few days after that, the Australian Rugby Union appointed a concussion specialist - a doctor designated to deal with just that single issue for all home tests.
But an investigation is currently under way to ascertain why Toulouse centre Florian Fritz was sent back out to play in the Top 14 semifinal when he was concussed. He took a major blow to the face that left him bleeding, dazed and distressed. His game should have ended instantly but Toulouse coach Guy Noves had other ideas – he wanted his star man back on the field. So he made it happen.
Fritz was ordered back into the fray and an unapologetic Noves, when quizzed after the game, merely said: “I have been knocked out, played on and was fine; as you can see, I am still standing here.”
But the IRB is fighting and largely winning the war, even if the odd battle is lost. Gosper says: “Any time cultural change is required, the process is never quick. But it is possible. It used to be socially acceptable to drink and drive but that is not the case any longer. And it used to be acceptable within sport to return to play even though you’d had your ‘ bell rung’. This, too, is changing as the full short- term and long- term dangers associated with concussive head injuries come to light.
“Concussion is a brain injury. It is serious stuff. It is not to be taken lightly.”