Can we be doing more to reduce head injuries in Rugby?

 

It has recently been highlighted in the media that Steve Thompson, who won the Rugby World Cup with England in 2003, has been diagnosed with early onset dementia.

Thompson, 42, said he cannot remember winning the World Cup, would not want his own children to play the game “the way it is at the moment”, and that he regrets ever taking it up himself.

He, along with other players have received the same diagnosis – dementia with probable chronic traumatic encephalopathy (CTE), for which the only known cause is repeated blows to the head.

 

What is Chronic Traumatic Encephalopathy (CTE)?

Chronic traumatic encephalopathy (CTE) is a progressive brain condition that’s thought to be caused by repeated blows to the head and repeated episodes of concussion.

Any prolonged activity that involves repeated blows to the head or recurrent episodes of concussion is thought to increase the risk of getting CTE. But CTE and concussion are actually separate conditions.

Many people who get concussed do not go on to develop CTE, but evidence suggests a pattern of repeated minor head injuries increases the risk.

There’s currently no test to diagnose CTE. A diagnosis is based on a history of participating in contact sports, plus the symptoms and clinical features.

The most widely used tests for investigating neurodegenerative disorders are MRI scans and CT scans however Chronic traumatic encephalopathy does not always show up on routine brain scans and can sometimes be similar to other conditions and misdiagnosed. This means the only way of confirming CTE would be by carrying out a post-mortem after a person with the condition dies.

Research has found that the changes in the brain associated with CTE are different from those seen in Alzheimer’s disease, but both conditions are associated with shrinking of the brain (atrophy) and the presence of neurofibrillary tangles that contain a protein called tau.

Research is still ongoing to determine whether other brain imaging techniques will be able to help diagnose CTE in the future.

What does this mean for the future of rugby?

Concussion in rugby is the most common injury received.

Concussion was the most commonly reported Premiership Rugby match injury in 2015-16 (for the 5th consecutive season), constituting appropriately 25% of all match injuries, and the RFU medical officer said that the tackle is where the overwhelming majority of concussions occur.

When looking at professional players and the history of head injuries over the years we can see that there’s definitely an increase to in the amount of tackles per game with an average of 257 tackles per game at the 2019 Rugby World Cup – 163 more per game than 1987.

Our Sports and Exercise Doctor and England rugby’s former team doctor admits he “made mistakes” in missing concussions and says the sport must now make significant changes to protect players.

Dr Phil Batty, who looked after the England squad between 2012 and 2014, says he sent players back out to play who later turned out to be clearly concussed.

“I have missed concussions where I’ve taken people off for assessment and they’ve been assessed independently or by myself and they’ve been allowed back on the field of play.

“But with hindsight they were clearly concussed, and it became apparent that they were concussed.

“I’ve gone into various battles with experienced coaches in the past where I’ve taken players off and they’ve been really angry with me and even the players have been very angry with me but I am a human being, I’ve made mistakes, I’ve sent people back onto the field of play that at the time I did not know were concussed and I would’ve wished there was greater tools available for me at that time.

“I think hindsight is a really easy thing. I’m not aware of anything that I’ve done in the past where I’ve deliberately sent somebody back onto the field that I know has been concussed.”

According to the data collected through the RFU’s Community Injury Surveillance & Prevention Programme (CRISP) in age grade rugby (age 15 – 18) the most recent rate shown equates to 1 concussion per team every 10 games and 1 concussion per team every 25 games in adult male rugby. In professional rugby it is 1 every 2-3 team games.

The question is, are we doing enough to help prevent head injuries during training and match days?

Here’s what some of the elite players and rugby professionals had to say:

  • “When you play in France, you have a heart scan at the start of each season to get your permit,” said Thompson. “Why on earth are you not getting scans on your brain every year?
  • “If, during the week, instead of having several days of contact training with more and more impacts on top of each other, you do away with that, you’re going to phenomenally reduce the number of impacts over the season and that can’t be a bad thing.”
  • “The injury risk is far too high and we know players who are tired and who have got niggly injuries are at risk of further injury. So it may be that, by cutting back on contact time during the week, you actually reduce injuries in matches as well.”
  • “’If in doubt, sit them out’ – If you’re interested in the team’s performance, and there are people able to do a better job than you because they aren’t in an injured and vulnerable position, the decision is clear.”

The RFU, WRU and World Rugby released the following joint statement:

“Rugby is a contact sport and while there is an element of risk to playing any sport, rugby takes player welfare extremely seriously and it continues to be our number one priority. As a result of scientific knowledge improving, rugby has developed its approach to concussion surveillance, education, management and prevention across the whole game.”

“We have implemented coach, referee and player education and best practice protocols across the game and rugby’s approach to head injury assessments and concussion protocols has been recognised and led to many other team sports adopting our guidance.”

“We will continue to use medical evidence and research to keep evolving our approach.”

Eddie Jones, England’s head coach, said primary school age children should be banned from making tackles above the hip in rugby.

Jones said “ What I’d do for under 12s would be to make the tackling underneath the hips, so encourage players to learn good technique at the most formative ages of tackling low.”

He went on to say “I think in terms of senior rugby, and we’ve moved towards this to a greater extent, is zero tolerance of any contact with the head. I think that’s been refereed well, I think we’ve got to keep down that track and not loosen that stance in that area,”

 

So what can we, as a club, take away from this?

It is clear that minimising a players risk to the exposure of repeated concussion is extremely important.

Just like we try and prevent our player’s MSK injuries, we should be trying even harder to prevent head injuries.

Adapting the clubs training programs to reduce the amount of tackles during mid-week training will dramatically reduce the chances of unnecessary head injuries. Should all players play touch rugby mid-week and then enforce tackles below the waist during match days. Should we be bringing in fines for players that tackle above the waist?

Extensive concussion management training and information should be provided not only for the coaches and team medics, but for the players and parents / family members too. There are far more symptoms to concussion than you may think and the symptoms can last for several months after the injury happened.

 

Players within the team should be encouraged to feel confident to sit out of a game if they feel they’re not playing to their full ability due to injury.

As Steve Thompson said – If you want your team to win, don’t prevent this from happening by staying on the pitch when you can be substituted for a player that’s not injured. If a coach or medic advises you to sit out, listen to their advice and don’t refuse to leave the pitch. And remember – If in doubt, sit out!

Head protection during training and matches? The primary reasons for wearing headgear is to prevent lacerations and abrasions to the scalp and to minimise the risk of concussion. Although it is generally accepted that headgear will prevent surface wounds, it is far less clear whether it will protect against concussion. In fact, because of lack of evidence, the Canadian Rugby Union currently advises against its use to prevent concussion.

Should the Rugby Union and World Rugby make head wear mandatory for all levels of rugby until further evidence is provided? After all, boxers have to wear them, and they too are at a higher risk of repetitive concussion and CTE.

Edenbridge RFC will be working with coaches and players to promote further awareness about concussion and concussion management.

We want all coaches and management staff to be HEADCASE certified by completing the RFU head injury and concussion modules.

We will also be holding CPD courses for coaches on how to prevent and manage future head injuries.

We are looking to implement this to support the current protocols from January.