Will the law strike a knockout blow on concussion in rugby?

England players crunch into a tackle during the 2014 Six Nations. Gerry Penny/EPA

As the Six Nations rugby tournament approaches its half way stage, the usual media chatter on who might win the championship has been substituted by concern over a number of high-profile, concussion-related injuries.

Concussive injuries sustained by Wales’ George North in both halves of the opening game against England, the return of Ireland’s Jonathan Sexton against France after a 12-week lay-off due to successive head injuries and Mike Brown’s knock in England’s home game against Italy, have been the dominant images of Six Nations 2015.

Media comment has largely focused on whether existing medical protocols are not being fully enforced such that players are returning to the field of play within mere minutes of suffering an apparently concussive blow. More importantly, a number of [sports physicians]((http://www.theguardian.com/sport/2015/feb/09/george-north-concussion-rugby) have argued vehemently that even if pitch-side concussion protocols in international rugby are adhered to strictly, they are simply not of a standard that sufficiently protects the long-term welfare of rugby players.

Using their heads

The primary duty of care for rugby players’ welfare lies with the sport’s world governing body, World Rugby, and its various national representative bodies. These organisations are, rightly, sensitive to criticism on the matter of head injuries, the incidence of which rose 59% in English rugby in 2013-14 compared to the previous season and thus making concussion the most common match injury for rugby players for the third straight year.

Jonathan Sexton about to score vs France. wynnert, CC BY-SA

An example of that sensitivity can be seen in Ireland where, in light of what it called “disappointing and inaccurate commentary in the media by individuals with no medical expertise”, the Irish Rugby Football Union (IRFU) took the unprecedented step of issuing a press release on what it called the “medical management” of Jonathan Sexton. The IRFU noted that Sexton’s return to play had been sanctioned by independent neurologists in France and Ireland, his club doctors, as well as the Irish and French Rugby Federation’s medical teams.

Similarly, the RFU has highlighted that when Mike Brown was knocked out, following a collision with Italy’s Andrea Masi, he was attended to promptly by 13 England support staff and medics. In addition, the Welsh Rugby Union (WRU) was cleared of any wrongdoing in the medical handling of the George North incident.

Impact assessment

All of this risk prevention is welcome and necessary but all of it applies, almost exclusively, to elite level rugby. The vast majority of those who play rugby union at an amateur level are unlikely in their entire career to be assessed by as many medics as Sexton has had access to in the past number of weeks. Multi-angle, pitch-side video replays are available only in a handful of rugby stadiums globally. For many games at schoolboy and at amateur level, 13 supporters, never mind medical staff, would be welcome.

This is not to be facetious about the matter because, after all, a concussive injury is one of brain trauma, the acute and chronic impact of which can be devastating. A key aspect of the debate on concussion in rugby and other sports is, therefore, how it is being dealt with at the younger and amateur, but more player–populated, levels of the game.

A recent piece in the British Journal of Sports Medicine estimated a probability of 11.4% of a child or adolescent rugby union player in England sustaining a concussion over a season, equivalent to between one and two players in every school or club youth rugby team sustaining a concussion every season on average.

The analysis further noted that, compared to countries such as New Zealand, there is a lack of reliable data through routine monitoring and reporting in schools and amateur clubs and in hospital emergency departments in the UK in order to inform prevention.

A neurosurgeon, Michael Carter, wrote recently in the British Medical Journal, that too many child players were sustaining head and brain injuries on the rugby pitch and that children should be prevented from playing contact sports. However former England captain, Mike Tindall, dismissed this, remarking that if children were taught to tackle properly this should not be an issue.

But there are also legal implications to this concussion debate. The NFL in the US, the biggest sports league in the world with an annual turnover of $10 billion, is in the process of concluding a $1 billion collective settlement of about 250 lawsuits taken by about 5,000 former NFL players. The original lawsuits had accused the NFL, over a period of decades, of hiding what it knew about the acute and chronic impact of concussion and head injuries on NFL players. The NFL, although not admitting legal liability under the terms of settlement, has admitted that it expects about one-third of its near 20,000 retired players to suffer from diseases such as Alzheimer’s or moderate dementia.

Central to the NFL players’ legal claim was that the NFL knew about but hid the impact of concussion from players. In contrast, in rugby union the argument is not that World Rugby is failing to adequately warn players of the dangers posed by concussions – far from it – more the argument is whether existing concussion protocols are sufficiently caring and cautious of long-term player welfare.

Boxing clever

Bluntly, if such protocols are inadequate, a vulnerability to medical negligence may arise for rugby clubs, schools and governing authorities. British sport has been here before. Professional boxer Michael Watson successfully sued the British Boxing Board of Control (BBBC), receiving nearly £1m in damages for the inadequate medical care given to him ringside, after he suffered chronic brain trauma during a world title fight in 1991.

Former boxer Michael Watson speaks at a charity event. brainandspinefoundation, CC BY-ND

And boxing is an interesting sport on which to end this piece. The British Medical Association has long wanted it banned because in its view it and martial arts MMA are the only sports which reward direct, intentional violence to the head with scoring points.

That debate is for another day, but it is of interest that recently Frank Warren, the well-known boxing promoter, commented that, in Britain, any professional boxer who is stopped in a bout is suspended for at least 28 days, regardless of the circumstances. Should that boxer be knocked out or suffer excessive punishment to head or body, he receives a minimum suspension of 45 days, which would include sparring – and in either case no boxer would be allowed to fight on until receiving medical clearance from a BBBC doctor.

Warren compared this to rugby and football:

…where there are growing concerns about the alarming brevity of head-injured players returning to action, often only after a few minutes.

Warren has a point and it is one that the authorities in many other contact sports should heed. When it comes to head injury, in any sport and at any level; if in doubt, sit it out.

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