If in doubt, sit it out

Date published: August 13 2014

Jamie Lyall takes a second look at the hot topic in rugby right now.

Last week, I posted an article urging the IRB to look again at the trial regulation currently in place to deal with players suspected of suffering concussion, and adopt a more assertive – and less tolerant – stance on head injuries.

This trial regulation, commonly referred to as the “five minute rule” or Pitch Side Concussion Assessment (PCSA), has provoked widespread debate and controversy within the game since its introduction earlier this season.

For those unfamiliar with the PCSA, it states that a player suspected of concussion may return to the pitch if he can pass a series of tests and questions undertaken over a five minute period. Though currently still being implemented on a trial basis alone, it is widely expected that the PCSA ruling will be made permanent in the coming months.

This weekend, it emerged that Dr Willie Stewart, a neuropathologist at the Southern General Hospital in Glasgow, Scotland, has found what he believes to be the first recorded case of early onset dementia directly caused by playing rugby. Dr Stewart examined and compared brain tissue from a retired male amateur boxer (aged 67), and the male ex-rugby player (in his 50s), looking for the abnormal proteins that are often linked to head injuries and dementia. The results he gathered should be of great concern to the IRB and the sport itself.

In an interview with the BBC, Dr Stewart said: “What we are finding now is that it is not just in boxers. We are seeing it in other sports where athletes are exposed to head injury in high levels.

“Those sports include American football, ice hockey and also now I have to say I have seen a case, the same pathology, in someone whose exposure was rugby.”

It is important here to stress that the occurrence of early onset dementia and other forms of neurological disease in sports such as boxing or American football is not expected to be matched in any way by rugby union.

Taking into account the number of adults currently playing the sport – and the number of times an individual is likely to suffer concussion throughout their career – Dr Stewart estimates that around 1% of people who are playing rugby at international level may go on to develop long-term problems. 1% may be a reassuringly low number, but for the IRB, it should still represent 1% too much.

Put into perspective, the neuropathologist adds that “in any given Six Nations weekend, that's one or two players who may go on to develop a dementia they wouldn't otherwise have been exposed to. That is a realistic number.”

When personified in such a manner by today's treasured European stars, that 1% statistic becomes a great deal more lifelike.

It is also worth considering that an amateur boxer receives many more potentially concussion-inducing blows to the head in a much shorter space of time than does a rugby player. Therefore, it is interesting to note that in Dr Stewart's findings, the sample tissue from the brain of the ex-rugby player showed higher levels of the abnormal proteins than the corresponding sample taken from the retired boxer's brain tissue.

According to the BBC, both samples were shown to be broadly similar to a male (aged 27) who had suffered a “moderate to severe” head injury in an assault – a further demonstration of the sheer ferocity of the collisions observed at the game's highest level.

Perhaps most importantly, Dr Stewart reaffirms the need for caution in dealing with concussion and head injuries among professional players in order to protect individuals from potentially life-threatening complications in the future.

“What we are really starting to worry about now is the long term problems, the things that might happen 10 or 15 or 20 years down the line. Has that injury to the brain perhaps led to longer term damage?” he said.

“The general advice for a concussion is if in doubt, sit it out. So at all levels, if you think there has been a concussion the player should be removed and not expose himself to risk.

“There is a risk that a second head injury, coming within a short space of time and before the brain has properly recovered, can be much more severe and cause more problems and more symptoms.”

Dr Stewart also acknowledges that due to the nature of professional sport, and the win-at-all-costs attitude that can be adopted by those involved, players and coaches may attempt to sidestep any compulsory recovery period. Certainly in the past, coaches protested the IRB's former three-week mandatory sit-out phase, claiming that it was excessive in cases of minor concussion – other times; they simply claimed that no concussion had occurred.

“There is undoubted evidence that people will try to play on. That is something we would really like to discourage as much as possible.

“Just as we discourage people from playing on with a damaged knee, even more so we would really try not to have people carry on with a damaged brain.”

That, surely, should be the resounding take-home message not just to the IRB, but to the rugby world as a whole. In the face of compelling medical research, the PCSA may inadvertently provide a convenient loophole for players to return to the action as quickly as possible, and coaches seeking to avoid losing a star individual for a longer time period.

In doing so, however, it completely bypasses the need to safeguard players from suffering potentially debilitating complications later in life, and sends an extremely poor message to the wider world as to how seriously rugby takes the welfare of its participants.

With the continuing development and emergence of such medical studies, and stances taken by highly-respected doctors, players and former officials in strong opposition of the PCSA, it is becoming clearer than ever that for the IRB to fail to protect its players would represent nothing short of playing on with a damaged brain.

By Jamie Lyall