Concussion in Rugby- where do we stand as Physio’s?

 I am writing this from Auckland where I am for three and a half weeks with the Junior Wallabies at the annual IRB Junior World Championships (U20). Concussion has become a hot topic in contact sport of late. With unprecedented media coverage involving ex professional athletes who have suffered long term brain damage, to a $765 million USD settlement the NFL has made with former players, reflected in rule changes by the NRL and IRB, to unfortunate incidents involving junior players, concussion it is an emotive topic for all involved. The current mantra of "recognise and remove" is being rightly pushed by the IRB. Gone are the days where a player may have been deemed to have "a little concussion" but was allowed to continue to play. In the arena of contact sport legislative and cultural change is needed and needs to be driven from the top down. 

 
At the professional level we are seeing some great changes. 

 

 
I am writing this from Auckland where I am for three and a half weeks with the Junior Wallabies at the annual IRB Junior World Championships (U20). Concussion has become a hot topic in contact sport of late. With unprecedented media coverage involving ex professional athletes who have suffered long term brain damage, to a $765 million USD settlement the NFL has made with former players, reflected in rule changes by the NRL and IRB, to unfortunate incidents involving junior players, concussion it is an emotive topic for all involved. The current mantra of "recognise and remove" is being rightly pushed by the IRB. Gone are the days where a player may have been deemed to have "a little concussion" but was allowed to continue to play. In the arena of contact sport legislative and cultural change is needed and needs to be driven from the top down. 
 
At the professional level we are seeing some great changes. The IRB has introduced a 10 minute head bin where players deemed to have a concussion injury by either the team or matchday Doctor, or referee, are removed from the field of play for further assessment. Depending upon the initial incident and how the player responds to a  short battery of cognitive and functional tests a decision is made as to if the player has potentially suffered a concussive incident or not. If they are suspected of having suffered a concussive injury they are unable to return. Either way the player is followed up post match and repeatedly tested over the coming days until their test results have returned to their baseline level. Following this they then complete a Graded Return To Play (GRTP) protocol that involves increasing levels of cardio, skill and contact related rugby involvement and they must respond symptom free before progressing the next level and ultimately to returning to play.
 
At the top level the new assessment and decision making processes around an athlete deemed to have suffered a concussive injury are going to be well administered, reviewed and enforced. The issue we have is that most contact sport is not played in the professional environment and does not have adequate medical coverage. Using First Division Sydney Club rugby (historically the next step down from Super Rugby in Australia until the NRC kicks off later this year) as an example, the majority of Clubs do not have a Sports Doctor attending games which more often than not leaves the decision on concussion management up to the Physio staff covering the match. For a high level contact sport this is not good enough and unfortunately change is unlikely to happen until the ARU steps in and makes it compulsory for all home teams to provide a Doctor that is suitably qualified to assess concussion injuries using the appropriate assessment tools. Our current landscape provides a setting where it is only a matter of time before there is an unfortunate incident and a parent decides to take legal proceedings against the game or medical staff in attendance.
 
At the junior or lower Club level it is unrealistic to expect that we will ever be able to have a qualified medical practitioner present at all games. The governing bodies need to take ownership of the situation and solutions need to be found to protect both the players and the medical staff involved. During a match diagnosis is not essential but suspicion of concussion is. One possible solutions that I’d like to see adopted by the ARU and administered across all non-professional levels of Rugby Union in Australia is a system where the  referees have the ability to administer a "blue card" and any player suspected of suffering a head injury is removed from the field of play. Post match the referee reports this to the Union, who contacts the club and player involved and the player is not allowed to return to playing again until they provide written confirmation that they have undergone the Graded Return To Play (GRTP) protocol under the guidance of an accredited medical practitioner who has had additional training in the management of concussion injuries. Until then, as Physiotherapists working in Club Rugby we are walking a legal tightrope.