Posted by Ian Carrier, Partner
Is head injury being taken seriously in sport?
Head injuries have too often been considered a necessary risk in sports such as football and rugby. But with the alarming scenes of Jan Vertonghen’s head injury during Tottenham’s Champions league semi-final, and the damning report from the Rugby Football Union and it’s focus on head injury, is it time to ask what more can be done to improve prevention, reporting, and treatment?
With the release of the RFU’s (Rugby Football Union’s) latest annual report on injury in rugby, it has been revealed that for the third year in a row concussion was both the most common and highest burden match injury. It accounted for 18% of all injuries to the ball carrier, and 37% of all injuries to the tackler; whichever way you look at it, concussions are a major issue, and not just in heavy contact sports such as rugby.
The risks to players of head injury
According to Dr Ajay Premkumar, an orthopaedic surgeon from the Hospital for Special Surgery New York City, who is conducting research into the frequency and effects of head injury in the 2018 football World Cup, there are many dangers if sporting concussions are not caught in time. For example:
- playing on with a concussion increases the sportsman’s risk of more traumatic brain injury, increased symptom severity, and a longer period of recovery;
- players are at risk of ‘Second Impact Syndrome’: a brain that is concussed a second time, having not recovered from the first, can result in disability or death.
The RFU’s response to these risks in rugby is to recommend a specialist neurological opinion be sought for players if they have experienced two concussions in a 12-month period.
You would have thought that with such high stakes, the precautions around concussion would be intense. In theory they are, but the reality is often very different. Referees and medical professionals come under pressure to keep games moving and players demand to be allowed back on the pitch; each making pragmatic decisions about concussion on the field that bit more difficult.
This seems to have been the case when Jan Vertonghen, the Tottenham defender, received a head injury during their crucial semi-final against Ajax. This has raised calls from some for a temporary ‘concussion substitute’, or an impartial concussion doctor at each game. Both these strategies are designed to remove the pressure of a player quickly returning to the field, removing a competitive bias, and giving the team the opportunity to field a temporary concussion substitute, whilst a more thorough medical examination can take place.
The tragic reality of ignoring head injuries
Unfortunately, Rugby has seen a number of fatalities in recent years due to head injury. With four of these fatalities occurring in France, the Fédération Française de Rugby has begun to look for ways to make the game safer.
Ultimately, however, there is a demand for ever-stronger and heavier players, and, as Rennes coach Yann Moison pointed out in a recent BBC report:
“we are all responsible for creating … rugby that favours collisions over movement (and) the media love it when a player crashes into another and knocks him to the ground”.
There would need to be a change in the fundamental culture of the game in order to divert it from this course.
This is a problem across sport though. Indeed, comparing concussion treatment in the 2014 and 2018 football World Cups, Dr Premkumar found that, in spite of new rules instituted by the FIFA medical committee, concussion identification and management had not improved:
- the concussion protocol was not followed in at least 63.3% of head collisions that resulted in two or more signs of concussion, up from 56.7% in 2014;
- of the 90 players thought to have two or more of these signs:
- 33 were assessed by healthcare professionals for between 13 and 253 seconds;
- 39 were assessed by the referee for under a minute; and
- 18 were assessed by another player or not at all.
What can be done to improve reporting of head injury and treatment?
Despite these problems in football, in rugby there are notable signs of improvement in terms of both the number and treatment of concussions. According to PRISP, for the first time since the 2009-10 season the incidence of match concussions fell in 2017-18 compared to the previous season. This can be attributed in part to the fact that education of staff and players around concussion as well as the operational definition of its symptoms remained stable; in order to reduce the risk of more serious injury, it is important that everyone is aware of which signs are important to look for and how serious the player’s condition might be.
How technology is used to avoid brain injury
VAR (Video Assistant Referee):
In medical assessments… Rugby and football have started using VAR as part of their medical assessments. This technology allows a second team doctor to assist the team doctor on the field by watching match footage in real time to have a better view of incidents leading to concussion injury. This began to be used in rugby in 2016, and the results are immediately noticeable given the aforementioned decline in concussion numbers: with symptoms more easily recognisable and more people able to assess the incident, concussion numbers have actually decreased rather than increased. In football use of the technology is much more recent, and the results therefore remain to be seen.
In training sessions… VAR technology is also being used to assist in training sessions, thereby reducing the risk of head injury from the outset: by re-watching and analysing training footage, coaches are able to identify dangerous player habits and behaviours and try to eradicate them at source. This is helping to establish better sporting practices generally, and instituting a culture in which exposure to increased risk of head injury is no longer an accepted side-effect of playing team sports but a preventable concern.
Exciting new research has shown that by means of a clever hand-held device an injured player’s saliva can be tested and concussion can quickly be diagnosed pitch-side.
The science behind it: springing from a study by The University of Birmingham, research has shown that certain molecules in blood, saliva and urine can act as signs of brain injury.
Speedy and accurate assessment such as this could increase the chances of correct diagnosis and thereby reduce the risk of serious injury. It would also mean players are less likely to argue the decisions of treating physicians, reducing instances in which they return to the field prematurely.
It is important to remember that, even with constant evaluation of concussion protocols and deep concern for player welfare on behalf of the sports’ governing bodies, head injuries still remain among the most prevalent and serious injuries in many major team sports.
The RFU recognises that the drop in last year’s numbers could simply represent a blip in an otherwise upward trend. It also recognises that the decrease represents only one fewer concussion every eight games: much more needs to be done to try to prevent it from occurring as frequently as it does.
However, concussion and head injury are being taken more seriously than ever before in sport, and one can only assume this will eventually lead to more a significant decrease in the number of incidents. With the consequences being understood more clearly, it seems likely players will be less resistant to the idea of being brought off for a concussion if it has been definitively diagnosed.
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