Concussions and Protecting Our Players

Kane Douglas

All of you who watched the Waratahs v. Brumbies Round 14 clash witnessed this shortly after kickoff:



All of you who watched the Waratahs v. Rebels Round 15 match saw the same man named in the starting lineup less than six days later. Through this piece I would like to explore how it is possible for this to happen and why this is not alright. Are we protecting our footballers or our win/loss records?


The IRB Concussion Guidelines

Before we get started it's probably important to go over the concussion guidelines set forth by the IRB. From the IRB website here is a table of possible concussion symptoms:

It doesn't take a doctor to see that Kane very, very clearly exhibited all three of the primary symptoms listed above. The man was so much 'in a fog' that it looked like he was trying to navigate early morning London traffic while drunk and blindfolded. It's also clear that by his attempt to return to play that Kane almost definitely did not remember what happened only a few moments prior. While there are over a dozen concussion charts used depending on which part of the world you find yourself in any level of amnesia almost universally bumps a concussion from Grade I to Grade II. This also means that Douglas would be looking at an absolute minimum of two weeks of time off. Another angle of the incident reveals that this may have even been a Grade III concussion, which implies that the player was unconscious for less than one minute:



While I don't believe Kane was out for more than a few moments at most this would automatically rule him out of play for several weeks at an absolute minimum by the standard of nearly any medical professional on Earth.
The IRB's Graduated Return to Play (GTRP) protocols also reveal another aspect to Douglas playing again so soon:

By the IRB's own chart Kane was put back into play in the absolute minimum time window of 6 days. This would imply that Douglas' concussion was a mild one. I am no medical professional but I beg to differ. I have had mild concussions myself and I have seen others on the receiving end of a mild concussion. I have also had a severe concussion and have seem them happen to others as well. What happened to Kane Douglas was, in my eyes, absolutely not a mild concussion.

How Did This Happen?

So how did this happen, exactly? How does a man who has clearly forgotten where he was and had to be helped off the field return to play less than a week later and barely within the established guidelines of the IRB? There seem to be two major factors playing a role here.

A conflict of interest brought on by team medical staff doing the concussion tests is one potential issue. The other is the fact that players will misrepresent or deny symptoms. It is also no secret that some players will intentionally 'flunk' their preseason concussion testing. These preseason tests are used to establish a baseline for each player from which they will be judged when a concussion occurs. By bombing this baseline test these players are able to 'pass' even with a concussion.

First of all there is no excuse for the fact that independent medical professionals are not brought in to deal with instances such as this independently. As it stands the team doctors have a say in the concussion assessment process, this creates a conflict of interest. I am aware that this would cost money but if we are not spending money on player welfare then what is worth spending money on? There is a direct conflict of interest in the fact that medical staff which are paid by the club are involved in assessing the severity of concussions afflicting players of the franchise. This decision and assessment should be entirely in the hands of an independent professional paid by either SANZAR or the IRB.

Secondly the notion that players will intentionally give false reports about their symptoms or even cheat on their baseline concussion tests should not be a surprise to most of the readers here. Many of us who have played the game know what it is like and how hard it can be to leave the field and know you won't be returning for some time. None of this makes this okay. The notion of players misrepresenting symptoms is supported by this article on neuropsychological test and concussions: "the authors recommend relying on symptom checklists but fail to mention that, in some cases, athletes minimize or intentionally deny symptoms when they are, in fact, symptomatic".

The NFL has been attempting to deal with the issue of players cheating their baseline tests for years now. NFL legend Peyton Manning had this to say about his own preseason baseline tests: “Before the season, you have to look at 20 pictures and turn the paper over and then try to draw those 20 pictures. And they do it with words, too. Twenty words, you flip it over, and try to write those 20 words. Then, after a concussion, you take the same test and if you do worse than you did on the first test, you can’t play. So I just try to do badly on the first test”.

On the brighter side of things this article about the intentional sandbagging of these tests indicates that while it is not impossible to do this, it is somewhat difficult: "Seventy-five undergraduate athletes were re-administered the ImPACT neurocognitive battery, which they had previously taken to establish baseline functioning, but were instructed to perform more poorly than their baseline without reaching threshold on the test validity indicators. Eight participants were able to successfully fake significantly lower scores without detection by validity indicators".

The use of independent medical professionals for preseason baseline testing as well would also work towards eliminating any kind of conflict on interest. What worries me the most about these athletes which choose to cheat the tests is that they are eliminating any hope of legal recourse should they become the victim of a debilitating injury related to their history of concussions. These injuries can have devastating long-term impact and very recently have jeopardized or tragically ended the careers of rugby-playing athletes across the world.


Berrick Barnes and Rowan Stringer: A Case in Point

I'm sure that most of our readers here are familiar with Barnes' history of concussions and the footballer's migraine which nearly ended his career. You may be less familiar with the tragic story of a young girl from Canada named Rowan Stringer.

Rowan was a young woman from Ottawa, Canada who loved rugby and was the captain of her Grade 12 side. Ms. Stringer passed away tragically only a few weeks ago after a mid-air tackle went wrong and ended with Rowan absorbing much of the blow through her head and neck. She lost consciousness and never regained it. A week before the fatal incident Ms. Stringer had reported copping a head knock to her parents as well as the fact that she was taking medication to deal with the ensuing headaches. Two days before the accident she took another blow to the head but did not tell her parents, only her friends.
My heart goes out to the Stringer family.

Barnes is another case of a young person being severely adversely affected by a history of head trauma. In 2012 Barnes nearly ended his rugby career because of the development of what is known as footballer's migraine. Some may argue that footballer's migraine is not directly linked to concussion history. This paper says otherwise. A quote from Barnes in an interview with The Rugby Club details the effects of this condition: "I didn't suffer a migraine or a headache, I just lost all memory.especially for an hour after the game, I couldn't remember what I’d done, where I’d been, who I was playing for or what was going on".

As stakeholders in the game of rugby we must push for the issues surrounding concussions to be handled more seriously. The recent steps made by the IRB have been encouraging but are not enough. The implementation of independent medical professionals as well as stricter oversight on the return of players would be positive steps in the right direction. I am not saying we need to bubble wrap every player who hits his head during a game but more care must be taken in ensuring the welfare of these athletes. If there is anything the IRB should be spending money on it is the welfare of the players.

The fact that I could make a highlight reel out of Tatafu Polata-Nau knocking himself out and then getting back up to continue play does not sit well with me. It should not sit well with you either.

Submitted yesterday!

In the case of Kane and Berrick do you know that independent assessment wasn't sort?

In the case of Berrick (since it was an ongoing thing) there's a chance they may have sought medical attention outside of the camp, I'm not sure though. Kane was assessed by team doctors on the sideline I believe. There is supposed to be an independent medical professional present but the team doctors are also involved in making the assessment. From a purely legal standpoint the same doctors paid by the club to be there also assessing the condition of the players after concussion-related incidents is a conflict of interest.

As far as I know the team physios are the ones which conduct the preseason baseline tests. I have a bit of an issue with that, especially if players are likely to try and sandbag their results.

That was poorly worded on my part though, going to amend that now.

For anyone interested in what the wider medical/scientific community is thinking about concusion in sport and how it should be managed have a read of the following paper

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012


The British Journal of Sports Medicine also put out a series of podcasts targeted at the general population about concussion that I have linked to below and are also available on itunes.

Dr Paul McCrory on what athletes need to know about concussion

Dr Paul McCrory explains what parents need to know about concussion

Dr Paul McCrory’s 3-minute snapshot of what’s new in managing concussion

Much more research is needed into the long term effects of concussion and Repeated Trauma Encephalopathy.

I have had well over a dozen concussions with 6 or 7 resulting in loss of consciousness the worst having me unresponsive for over 15 minutes.

I often wonder what long term effects these incidents have had. I also wonder if there is a genetic pre-disposition or resistance to the development of some syndrome such as RTE. The problem for many of us is that many who have suffered such traumas have also led lifestyles which can in themselves cause damage to cloud the symptoms and results of any pre-mortem examination.

Perhaps the IRB could fund a world wide study of players who have suffered such traumas. Any Physiology PHD's out there willing to give it a shot?

Holy shit, 15 minutes? Were you hit by a car?

My biggest concern with all of this stems from the lack of comprehensive knowledge of the long term effects of these injuries. We've seen some of the devastating cases now coming out of boxing and gridiron but our knowledge is still very much in its infancy.

This is why things like rushing Kane back concern me so much. All we know is that this could potentially lead to devastating long term suffering. These guys are not gladiators and no victory is worth denying an athlete a reasonable quality of life after sport.

I think that publishing that without finding out the return-to-play protocol Kane Douglas went through would be sensationalist, inflammatory and downright reckless from a legal standpoint for the site.

First of all, the testing procedure you've outlined as a potential problem in Kane Douglas' case has, to my knowledge, not been used at the professional level in Australia since 2005. For the past FOUR years the CLUB side for which I was a trainer, were using the IMPact system. If that was happening at club-level, it was definitely the minimum standard at professional levels.


Now onto the diagnosis and management

All Super Rugby games require at least 4 different specialist medical practitioners (Reds have emergency specialist, orthopaedist, dentist, maxillofacial surgeon, neurologist.. and more) be in attendance in support of the team doctor, I am confident that his assessment was performed by a medical practitioner (team doctor); he would've then within an hour (if not immediately) been referred to a specialist.

The scan would've happened within an hour of the game finishing (during which time he would not have been left alone), and the results would've been made immediately to the consulting neurologist of the home game [shared with the Waratah's consulting neurologist (if away game)]. This scan would check for any swelling, small bleeds, hot spots, bruising etc. and I have no doubt that it is a much more comprehensive assessment tool than anything I can offer from my couch.

Table 2 of the IRB protocol documents goes through the concussion modifiers which may influence the investigation and management of concussion (including the GRTP). They include factors such as threshold, age, co- and pre-morbidities, and the symptoms. Very few of these are able to be seen from 5min of game footage.


My point? Given team doctors don't make decisions without consulting scans and expert neurologists (even sometimes via emailed scans from SA to Australia where the regular neurologist - with 8 years or more specialist training - is awoken to examine the scans - I know for a 100% fact this happens), surely we can't do a better job from our seats?

BUT now to the actual graduated return to play (GRTP) protocol.

The IRB guidelines state that the management of a GRTP should be undertaken on a case-by-case basis, dependent on the time in which symptoms are resolved. Replaying a guy stumbling around on the field repeatedly is all very well and good, but I doubt ANY of the forum posters are privy to how long it took for his symptoms to resolve. This decision is one for the neurologist and doctor.

The IRB GRTP guidelines state that a player must be symptom-free for 24hrs before they can restart Level 1 exercise. They can then move through the stages if no sumptoms of concussion are shown either during exercise or at rest in that 24hr period. At level 5 the player can return to full-contact training, and then Level 6 is a return to play. This process is managed by a medical practitioner.


What we do know:
- Douglas was injured only seconds into the match for the Waratahs, then he was removed from the field IMMEDIATELY! The injury clock started at around 7:45pm
- He exhibited the signs (not the symptoms - there is a difference) immediately

What we don't know:
- How long his symptoms took to resolve
- What scans were done, what they looked like and how to read them, especially considering they were looked at by people with many many years of study and experience
- What his return to training protocol was
- How he progressed through his graduated return to training
- What other extenuating factors he had - was it his first head injury ever? This year? Within the last 5 years?
- Berrick Barnes' official diagnosis from a neurologist - patient confidentiality is a bitch

We may look at sport as being a purely commercial enterprise, and we may assume that teams don't have players' best interests at heart in the pursuit of the mighty dollar. But I know that the players and their medical and training staff are very very close; they are like family and they genuinely care for and look after each other like they'd look after their own families.sometimes better. they're a team - that's why the support staff are in the team photos!

Quite simply, we're looking at that footage and making judgment like that's the whole story, but in reality we've seen 2min of a process which was 6 days long.

It's easy to look at that footage and get scared - and we should - but we need to also be very very cautious before questioning the medical ethics and personal integrity of doctors, neurologists and sporting teams on such a public forum. Regardless of what we think of the Tahs or the Reds or the Rebels, their on-field and support staff are people - good people - who care for each other.

Cat_A

• whats the difference between signs and symptoms - technically speaking;
• is there a doctor present at all times during GRTP?
• are the coaches schooled on the protocol - i.e. are they on the lookout for signs/symptoms (as the case may be)(I personally trust the coaches to do the long term right thing - maybe I am naive)

bloody good post.

A sign is an objective finding seen my an examiner - for example us watching him falling over on tv, a doctor checking his short-term memory recall. A symptom is subjective and perceived by the player: how bad is the headache etc.

The doctor travels with the team, and is available at all times on tour. When at home, under these conditions, NO ONE trains without the doctor's ok. There are daily meetings EVERY single morning to discuss this stuff.

The coaches don't do a thing without the doctor's say-so with head injuries. BUT there is also a dead-easy way to tell if someone has concussive symptoms at any level of the game: are they acting like they've been drinking when they haven't been?

I'm with you - I've never had any experience with a coach who will knowingly place the welfare of their players in jeopardy. This is even more so at Super level where they are spending 40+hrs per week with them for 10-11months of the year

Probably one other thing to mention:

One of the greatest benefiits of eliminating the compulsory time out after concussion was that players are now much more likely to tell medical staff that they have a head injury. If players think they will be automatically or customarily eliminated for the following game they will hide the symptoms. If, however, they know that by going through the GRTP and doing everything right, they have a chance of playing the following week, they will do so.

Without knowing Kane Douglas' exact situation but using my own experience, I think that if he trusted the medical staff he would not have hidden his symptoms. I'm a recently-retired trainer (since 1999), and probably 5 years ago we (my sister and I) noticed a cultural shift where players stopped hiding from us onfield if they'd had a head knock. The started either telling us that they themselves didn't feel right, or their teammate beside them would tell us that Stevo (or whoever) was acting a bit strange or slower than usual and could we have a look at them.

Throughout all levels of the club, from Colts 3 and 4th grade, through to Premier rugby, the coaches and players all know to tell us if they, or one of their teammates has had a head knock. They are not allowed to train until the doc has cleared them to do so. It's a lot of communication, but it's people's lives we're dealing with, so it's worth doing. This only works though if the players can trust that speaking up will not automatically rule them out of the following week's game.


Although I think issues such as those highlighted by USARugger are important to discuss, I also think it's crucial to do so calmly and without the drama and worried assumptions.

I think what said is all very valid etc and I have no doubt that Kane Douglas went though all the procedures described. At issue however is perhaps the perception that this example leave everyone in club land.

At local park level, or even the top club comps in Brisbane and Sydney I highly doubt that players will have a scan unless they report to hospital after losing consciousness or are still experiencing symptoms later in the week and actually tell someone about it. Even then the check will often be minimal. I was cleared to play by my local GP after missing just one game after a fairly major concussion who just asked about symptoms and checked for pressure behind my eyes. In fact this concussion had my in hospital for four hours which after a very brief examination consisted of me watching TV. No scans here.

Players and coaches will see the Kane Douglas of the world come back after one game and decide they can do it too. And the harsh reality is that at most clubs the player and coach will often ignore the trainer - usually a student Physio - who says otherwise.

The other really bad look at the elite level is players continuing to play after they are displaying the signs of being concussed. Often even enough for out much maligned Fox Sports commentators to notice. While the head bin has improved matters, the game day docs need to get bigger balls and actually get these players off the field, and if they aren't going to do it there needs to be a neutral doc who can tell the ref to do it. While it left the wallabies with 14 men when TPN was forced to leave the field by the ref on the spring tour last year was probably the best thing to happen for everyone.

Basically I can sum this who post up by saying - what happens at the elite influences clubland. Unfortunately clubland doesn't have the resources to do everything that the elites can. While the elite player may be cleared to play by the docs, for the sake of heads around the country - is it the best thing to do?

I think this is a problem that you can never solve.

You can't expect professionals with access to first rate medical staff and testing to then ignore the results and advantages it brings and go back to sitting out for a couple of weeks so you set a better example for players and teams without the medical staff or testing available.

So this is a different system to the one used in league

Concussions are obviously no laughing matter, but I find some of the supposition in the OP to be problematic. For instance, a quick Google search reveals that Berrick Barnes has his own independent neurologist and that he was not only consulted on recovery but present at games.

I'm not saying that everything is fine in the world of concussion and rugby, but we should be cautious about what we imply about the motives and actions of others.

Cat_A Thank you.

Nuke this thread

Hope you don't mean get rid of this thread USAR - it stands as a great example of the best GAGR can produce. I was absolutely with you in the concerns you expressed about Douglas, but I can't argue with the excellent contribution from Cat_A. It's opened my eyes.

It was half-baked and Cat/Richo are completely right about the fact that it shouldn't be up on our public forum.

I'd love to see Cats bit put into a thread though.