Concussions

Today I was involved in a debate over what should happen to Harlequins’ team doctor over the so-called ‘Bloodgate’ scandal where she, on the request of a player (possibly management), made a small cut to a player’s lip so he could make a ‘legal’ substitution.  I won’t get into this issue specifically, but took the stance that a small reprimand should be made, but I didn’t think she should be as harshly penalised as some were demanding.  Why I started this post, though, was because I added that there are plenty more severe examples of players, management, and medical staff who do not take the right actions for athlete welfare all for the sake of ‘the game.’  One of the most serious of these is concussions.

I don’t want to mis-represent the realities and severity of concussions, so have added some official documentation below that provides proper answers to the big questions.  I think I can say, however, that a concussion involves trauma to the brain which impairs function either temporarily or over a longer term, caused by either direct or indirect forces (i.e. a blow to the head itself or force elsewhere that causes the head move forward with great force – remember, the brain is essentially floating around in your head and the protective fluid can be displaced in the forces are great enough).  For some, the symptoms and implications might only last a short period and recovery can be speedy, for others they may linger or be the symptom of a more severe injury.  (Again, note the documentation I’ve added for further – and quite excellent – information, but always consult medical expertise in person if you’re involved in such a situation!)

My issue with concussion management in rugby surrounds two areas:  the duty of care of people in dealing with injury, and taking steps to prevent such injuries.

1.  Duty of Care – Everyone involved with a contact sport from player, to management / coaching, to medical staff, to parents / family should take great care to inform themselves about concussion prevention and management.  This is information which really should be passed from the top down, with national unions taking a firm stance on requiring staff to attend courses on rugby safety.  I had to take a SmartRugby course in Australia, which is an annual in-person requirement for all coaches.  One of the best ideas I’ve heard in areas where medical staff aren’t as plentiful, is a concussion management card which can be given to the player / family member / etc. so that proper care might be taken in the crucial monitoring period after a suspected or actual concussion.

Our club also had some strong policies to take extra care, such as having all players take a simple paper test that showed a person’s ability to match letters with corresponding coded symbols.  Upon suspicion of a concussion, the team doctor would re-administer the test to see if the player was able to match their previous results.  This was something that could be done very quickly, on-site to give an idea of how severe the situation might be.  It also adhered to the IRB Medical guideline stating that a player who has suffered a concussion should not return to play for three weeks, and with written declaration from a medical practitioner.  Earlier return is possible when symptom free and with medical permission for adults, but the three-week lay off is mandatory for age-grade players.

It really annoys me to see, even at the highest level, players receiving a severe blow that has them staggering – even out cold! – and making a re-appearance to the field.  No game, no matter the level, is more important than one’s short / long term health and these players need to be taken off immediately.  Even in a case where replacements are no longer allowed, I’d rather us be a player down.  In the aforementioned debate, I brought up an example of an Australian rugby league player who was out before he hit the ground after getting hit in the back of the head with a ball.  I remembered yelling at the tv later on in the match when he actually returned to play!  (Video and evidence of him being back on the field below … and in trying to find it, I found an article where the player talked about his catalogue of injuries and how they’ve impacted his life now that he’s approaching retirement in his early 30s.)

Knocked out in the 51st minute and taken off, but on the receiving end of a penalty-worthy hit in the 76th minute.

2. Concussion Prevention – The other aspect I think coaches need to pay greater attention to is educating players on how to avoid / prevent concussion inducing incidents.  I think the first should occur even before anyone steps on a practice field – protective equipment.  It’s been proven that the lightly padded helmets do little if anything to protect the wearer from concussions.  (Studies can be found here and here. )  While I think they are useful for preventing cuts and small bumps, and for people with long hair to keep it out of the way, I always fear that many wearers feel it makes them impervious to serious injury and as such play with greater intensity than is needed.  I used to play (American) football, and this was definitely the case – I hear the same for ice hockey – the extra padding made you feel that you could put in big and bigger hits.  Rugby padding should not be seen in the same degree, and quite frankly, neither should football / hockey padding as the evidence of concussions there is as prevalent if not more!

Once on the field, coaches should take all the time that is necessary to ensure that all players can be safe on the field – which might even mean more for some athletes, just to be sure.  A small part of me felt bad in the past that I’ve prevented certain players from taking the field until later in the season for safety reasons.  In one case, we even felt someone shouldn’t play the entire season, but were welcomed to continue monitored training with us so that the person could acquire the necessary skills over time.  I’d like to see a study on the frequency of injury compared to time spent training and quality of instruction.  The tackle area is probably the most obvious, and I have posted plenty of topics on how to do it safely (note the tags at the side).  One of my biggest pet peeves in this area are players tackling too high, risking a clash of heads or ‘whip lash’ from not having the head braced against anything – cheek to (ass) ‘cheek’ as we say ensures the head is stable in contact.  The other annoyance I have is seeing players put their head in front of the body of the ball carrier – whether straight on or from the side.  Both are perfect ways to get a concussion, so it’s up to us to ensure players have enough practice in the proper technique to ensure they do not get into these situations.

More detail on managing concussions:

Concussion – A presentation by the medical advisor to the Hong Kong Rugby Football Union

Concussion Sideline Management Intervention – a study from New Zealand which shows the results of proper first response management

Injury Management Guidelines – from the New Zealand Rugby Union, including both severe injuries and concussions, as well as return-to-play guidelines

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What else should we get out of rugby?

I had this conversation with some players that I coach who themselves have got into coaching.  One is a particularly intense front rower who is a force in contact situations, but always tries to maintain a positive attitude.  I commended her on such an attitude, despite her aggressive play on the field and she said that it serves the positive purpose for everyone involved.  One, as a bit to the rest of the team to remember this is just a game and that, ultimately, we’re here to have fun.  Two, to remind herself of that especially as she said in her younger days, she would let her emotions get the better of her, which led to silly penalties / physical altercations with opponents … and, Three, as a way of either reminding opponents the same reality as our team OR using it to unsettle that opponent who’s showing her intense aggression.  It’s a bit hard for many women (so she believes) to pull a dirty front row technique when someone’s telling you to “Smile!  It’s a lovely day to play a fun game of rugby.” with a big, beaming smile herself.  🙂

I think any such environment where you’re challenged with working with others to achieve a common goal provides plenty of opportunity to work on ‘people skills’.  Ideally, everyone on a rugby team would get along like the best of friends, but this is a big ask when you consider that a single team can have upwards of 40 registered players.  Every team should have expectations laid out for positive interaction and conflict resolution, decided upon by team members so that validity can be established and dealing with major issues can be resolved using previously agreed-upon methods and/or consequences.  Especially at a younger age, this is one of the most important values of any sport.  It’s much easier to deal with conflicts in such a structured and supportive environment as opposed to a more public and open one in which people might let their emotions get the better of them and resort to less than wise methods of ‘dealing’ with the issue.  Addressing conflicts in a sport which is not only very physical, but requires mutual support among team mates for both success and safety, is extremely important.  Teaching strategies for positive resolution and having mediated resolutions can provide players with better options to use in their ‘real’ lives and / or provide them with leadership opportunities to be able to assist in situations where they might safely and appropriately diffuse them.

One of the main things I stress, as do many of the players I coach, is growth.  Even if it’s just our summer club seconds side who are just out for the activity and camaraderie, it’s rare to find a player who doesn’t actually want to get better at their chosen level of competition.  Most players are happy with a really basic approach of ‘having an open mind and a willingness to learn new things.’  That’s a basic requirement that I ask of everyone.  Other players, esp. the first team, are more driven to achieve higher goals, so we can get into more specific goal setting with the SMART acronym.  They want to see those specific, measurable, achievable, relevant (or other ‘r’-words), time-referenced results that will add value to the time they take out of their days, weeks, season to participate in rugby.  These might not be rugby related, but might concern their own fitness or mental well being.

It’s in ways like these that we try and add value to just playing and hanging out with each other three times a week.

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