THE sight of Luke Marshall being removed from the field in Ulster’s game against Saracens with a suspected concussion was sickening — a young man at the beginning of his career and full of promise had suffered a third concussion in four weeks, across three consecutive games. What were the long-term implications for his health?
When former Pittsburgh Steeler Mike Webster died at the age of 50 in 2002, the autopsy revealed his brain had been damaged by a protein called tau, most commonly found in Alzheimers patients.
Webster hadn’t got Alzheimers however, he had chronic traumatic encephalopathy (CTE), a degenerative brain disease caused by repeated head trauma.
The presence of the tau protein cannot be confirmed without cutting someone’s head open, so its usefulness as a diagnostic tool is limited.
However, early symptoms of CTE are memory loss, confusion, impaired judgment, poor impulse control, aggression, depression, and progressive dementia.
Boston University Centre for the Study of Traumatic Encephalopathy posthumously identified CTE in 34 of 35 former NFL players.
So it’s clearly an issue in the NFL — should rugby be concerned? You would think so anyway — the IRB professes to be “extremely serious” about it, and states in no uncertain terms in its concussion guidelines that CONCUSSION MUST BE TAKEN EXTREMELY SERIOUSLY.
We aren’t medical professionals (or lawyers) so we won’t be opining on how seriously it is taken, but we will share some of the practices in both sports. We think the sports are comparable, both are tremendously physical and aggression is ingrained — albeit helmet to helmet hits are allowed in certain circumstances in NFL, but head-to-head are not in rugby.
On the other side, NFL players wear more protection. A South African survey conducted in 2008 found similar concussion rates across the two sports — we haven’t found a comparable survey since then, but it’s fair to say the sport has got more physical since then, as has, to be fair, the urgency of concussion issues at the IRB.
The NFL is better than rugby for statistics — PBS tracked reported concussive or head injuries by NFL teams, and noted 170 for the year, across 256 regular season and 11 playoff games. We could not find a similar list for rugby players.
The NFL numbers are based upon injuries reported by the teams, and it is suspected it is not an exhaustive list. For example, last season, Detroit Lions wide receiver Calvin Johnson left the field following an illegal helmet-to-helmet hit against the Minnesota Vikings — he underwent sideline concussion tests and returned six minutes later. Johnson was not listed on the Lions injury list, but was quoted as saying, “Yeah, he knocked me good. You could tell. It was obvious.”
A month later, Johnson and the Lions issued a joint statement in which the player retracted his claims about being concussed and claims he misspoke. Johnson is not on the PBS list.
Now, of course, we can’t blame teams completely for this — players have admitted that they will hide symptoms to continue playing, and it’s hard not to understand why — can you imagine Brian O’Driscoll leaving the field under any circumstances whatsoever? Remember the England game in the Grand Slam year, and that huge hit from Delon Armitage?
In the NFL, players are assessed using the SCAT-2 sporting head trauma protocol. This is a series of tests, physical and cognitive, by which players are assessed, and then are scored by sideline medical professionals, who then compare the score to a baseline — typically the same test done pre-season — then make a judgement about whether the player is fit to continue.
There are some questions surrounding this test:
• The subjectivity element — there is no defined “cut-off”.
• The baseline test — is there a possibility this could be manipulated?
• The relative contributions of different tests — the ocular test is passed with a 100% score if the player spontaneously opens their eyes, whereas with the balance test it is extremely hard to fake — but both contribute equally.
It should also be noted the SCAT-2 tests usually take 10-15 minutes — that’s a smaller portion of an NFL game due to ad breaks, change of possessions, time-outs and simply the nature of the game. In rugby 10-15 minutes is a long time. There have been suggestions to use alternative tests, such as the King-Devick test, which is used in MMA and boxing and has had positive results and takes 40 seconds for a non-concussed person, but the problem of doing it immediately will remain — effects are often not felt until after the event.
Moving on to rugby, if a player has a suspected concussion or head injury, the IRB protocols are as follows:
• Players suspected of having concussion must be removed from play and must not resume play in the match.
• Players suspected of having concussion must be medically assessed.
• Players suspected of having concussion or diagnosed with concussion must go through a graduated return to play protocol (GRTP).
• Players must receive medical clearance before returning to play.
If a player has any suspected symptoms of concussion — physical, behavioural or cognitive — they are tested using the Pocket SCAT-2 protocols on the field of play — this test need not be carried out by a medical practitioner. The pocket SCAT-2 is a series of five questions. If the player is unable to answer any of the five questions, they are then removed from the field of play and subjected to the full SCAT-2 tests, by a qualified medical practitioner.
The five questions are as follows:
• At what venue are we today?
• Which half is it now?
• Who scored last in this game?
• Which team did you play last week/game?
• Did your team win the last game?
This is the key difference with NFL — for all the weaknesses of a SCAT test, they are conducted by a medical professional in the event of a suspected brain injury. In rugby, the Pocket SCAT-2 questions are an interim step, not necessarily conducted by a medical practitioner, and limited in scope. These questions have the benefits of not being subjective and having no baseline, but it’s clearly less in-depth than the full SCAT-2 or other tests.
Perhaps this is appropriate, perhaps not — we would love to see the research behind the five pocket questions. But more importantly, we really hope we never see a Mike Webster in rugby, and that Luke Marshall returns a healthy player.