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Tackling sports concussion

Two innovative new research projects by academics in Trinity College Dublin (TCD), in collaboration with Leinster Rugby, are opening up unique avenues to improve the diagnosis and analysis of concussion in rugby.

The research has the potential to provide a whole new system to more accurately identify potential incidences of concussion and help predict when a player should be removed from play and when they should return.

Unlike a broken arm, a twisted ankle or any other external injury, concussion cannot immediately be spotted by an observer and the victim may not be aware that concussion has occurred. However, the aftermath of concussion has the potential to be just as damaging to a sportsperson’s career as any of the aforementioned afflictions. In fact, concussion can lead to serious long-term brain damage or death.

It is clear concussion is at the forefront of the minds of those involved in sport and medicine following a series of high-profile occurrences in the past 12 months, and increased pressure on the medical community to accurately diagnose and manage sports-related concussion. Concussion has also featured strongly in a number of medical conferences this year, while a number of sporting bodies have also recently launched new concussion management guidelines.

‘Concussion is such an important issue and I cannot stress enough how important it is to be aware of the risk of concussion in every contact sport’ 

While concussion has become a contentious topic in rugby, it is also a serious issue in all professional contact sports such as hurling and Gaelic football, soccer, American football, boxing, and horse-riding.

Both amateur and professional contact sports have become more physical and faster-paced in recent years, thus increasing concussion risk.

Awareness

Dr Michael G Molloy, Faculty of Sports and Exercise Medicine at the RCPI and RCSI, believes that the potential dangers of concussion cannot be highlighted enough. “Concussion is such an important issue and I cannot stress enough how important it is to be aware of the risk of concussion in every contact sport. Ideally, there needs to be a professional trained in dealing with this condition on hand in case an individual is concussed. This person, like we see in professional sport, will take the decision to remove the afflicted person from the field of play, regardless of their insistence that they can play on, and put them on an appropriate recovery plan.

“Concussion can have some short-term side effects such as headache, nausea and dizziness but if a person suffers a number of concussions over their lifetime, this can lead to longer-term effects such as impaired cognitive functions and even brain damage.”

For the reasons highlighted by Dr Molloy, it is pivotally important for medical personnel, team managers, parents, teachers or anybody present to recognise the moment in which a person who has taken a knock to the head should be withdrawn from any sporting activity. He told the Medical Independent (MI) that the prevention of the long-term side effects of concussion can be quite simple.

“The moment there is any suspicion of concussion, the player should be taken away from the field of play. The pitchside medical personnel can then examine the impact of the collision. Until it’s confirmed that full motor skill has returned, a victim of concussion should not be allowed return to play. Whether that conclusion is reached during the same game or weeks or months later is unimportant, as the wellbeing of the sufferer is paramount in managing concussion.”

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IRFU Concussion Poster

On the field

Former World Rugby medical advisor Dr Barry O’Driscoll, a long-time critic of the handling of concussion in professional rugby, cites the example of George North, a Wales international player who suffered a concussion against England earlier this year.

Having been assessed pitchside, it was decided that he be allowed return to play. The player had been a victim of concussion on a number of occasions before these incidents. Dr O’Driscoll, himself a former Irish rugby international, states that “there should be no more rugby for George North this year. Somebody who has four concussions in five months — two in one game — and is going back to such a brutal game as rugby should be having a long rest from rugby under the care of a neurologist”.

In contrast, another recent concussion case involving Cardiff Blues’ Rory Watts-Jones has been praised by sports medicine personnel. Mr Watts-Jones has recently been forced to retire from the game altogether due to a concussion he suffered in November 2014. In February this year, the Welsh club released a statement declaring that the 26-year-old “is to retire from rugby on medical grounds with immediate effect”.

In the case of North, Dr O’Driscoll maintains he should have been removed immediately from the field after receiving the first blow.

In the case of Watts-Jones, the Cardiff Blues’ medical team took approximately three months between the initial incident and the announcement of his retirement in order to properly assess if the player should have continued his rugby career. A young career was tragically cut short at its fledgling stage but had he been allowed to play on, his long-term health could have been at serious risk.

Guidelines

In December 2013, the Irish Rugby Football Union, in conjunction with Connacht, Leinster, Munster, and Ulster Rugby, released a set of guidelines on how to recognise and manage suspected concussions. Launched by Minister for Health Leo Varadkar, who at the time was Minister for Transport, Tourism and Sport, the guidelines use the acronym SIRR and are listed as follows:

 STOP – A player with suspected concussion must be removed immediately and must not return to the field.

INFORM – A player with suspected concussion must report it to a team medic, coach, teammate, friend or family member and be properly assessed and managed. They must not be left alone or drive a vehicle.

REST – A player with a concussion must undertake a mandatory rest period, as per IRFU guidelines outlined in the Guide to Concussion in Rugby Union (which can be found at www.irishrugby.ie).

RETURN – A player with a concussion must follow the IRFU Graduated Return to Play protocols and should be medically cleared prior to returning to full contact.

Essentially speaking, the guide calls on players to be honest with themselves and with medical staff in reporting symptoms. The risk of returning to play without having had a full and thorough medical assessment is highlighted.

Zero tolerance

Dr Rod McLoughlin, IRFU Head of Medical Services, feels that a zero-tolerance approach should be undertaken by medical personnel, coaches, teachers and parents when dealing with concussion. He believes that the attitude of ‘just running it off’ is outdated and should be discouraged.

“We are adopting a zero tolerance approach to concussion or suspected concussion in an attempt to dispel the myth of a ‘knock to the head’ or a ‘minor concussion’. If a player is suspected of being concussed they must be removed from training or the field of play, and not return until proper Graduated Return to Play guidelines have been observed.

“This guide is targeted at everyone playing, officiating or connected with a person who is playing rugby, and follows our recent concussion poster campaign aimed at players of all ages, to reinforce the core message of STOP, INFORM, REST, and RETURN.

“This guide, and our traffic light poster campaign, should be displayed in every rugby school and club in Ireland, to ensure more people recognise concussion and take action to reduce the risk of serious injury.”

The traffic light poster to which Dr McLoughlin refers is something that has adorned the walls of schools up and down the country since the guidelines were launched.

Fundamentally, any player wanting to return to play should only get the green light if there are no symptoms of concussion following a substantial period of rest.

Backing

The IRFU document also has the backing of the players and Mr Rob Kearney, Chairman of the Irish Rugby Union Players’ Association (IRUPA), has stated that the possibility of sustaining concussion has concerned professional players in recent times.

“A recent survey by IRUPA confirmed that concussion is a major concern for players. This concussion guide is a very positive step towards educating those involved in rugby at all levels,” Mr Kearney said.

“From a player perspective, I would welcome proactive initiatives like this guide and also the International Rugby Board (IRB) pitchside concussion assessment tool for the professional game.

“Concussion is a complex area and the research is evolving all the time. IRUPA will continue to track this research and work across the various national and international working groups to protect our members.

“As professional players, we must also acknowledge our own responsibility to ensure we are honest and show trust in our medical staff and coaches.”

The recent measures taken indicate a move in a positive direction in terms of educating people about concussion. They are also indicative of a welcome approach by rugby’s authorities to ensure the welfare its players.

Not every person playing rugby, or any sport, will have access to a team of medical personnel provided by a club, so how does one know if a person is concussed? The symptoms of concussion fit into four main categories:

Thinking and remembering – Is the patient thinking clearly? Do they feel slowed down? Are they able to concentrate? Are they able to remember new information?

Physical – Does the patient feel nauseous? Are they vomiting? Do they appear dizzy? Are they sensitive to light or noise? Are they experiencing problems with balance? Do they feel tired or lacking in energy?

Emotional and mood – Is the patient easily upset or angered? Do they appear sad? Are they nervous or anxious? Do they seem more emotional than usual?

Sleep – Is the patient sleeping more or less than usual? Are they having a hard time falling asleep?

While the answers to some of these questions may appear trivial, if patients show any of these signs, it is important that medical advice is immediately sought. This does not just apply to events on the sports field, as concussion can take place anywhere, at any time.

Prevention

World Rugby, the sport’s governing body, has already put measures in place to minimise the risk of concussion during the upcoming World Cup.

These include having pitchside video reviews of any incident with the potential to result in concussion. There will also be monitors present in each team medical room and all teams and players receiving concussion-related injuries will be asked to file reports on the incidents. As well as this, independent match-day doctors will be appointed for every match in a bid to crack down on concussed players playing on.

The experts spoken to by MI agree that active participation in sporting activities is something that should be encouraged in all children and adults but a player’s life and future are more important than the final score.

The research projects in TCD and the recent new, stricter guidelines issued by the GAA and IRFU aim to provide more thorough methods of recognising and preventing concussion, which have been welcomed by those in both the medical and sports industries as well as parents, teachers, and society as a whole.

Concussion: Diagnosis and rehabilitation advances

In June, the Sports Surgery Clinic (SSC) in Dublin hosted its 5th Annual Sports Medicine Conference, focusing on “Concussion: Diagnosis and Rehabilitation”, at which, a new way of managing the symptoms of concussion was presented.

The Post Concussion Rehabilitation Pathway, a new process which is being developed by Prof Paul McCrory, Chairman of the Sports Surgery Clinic Research Foundation, Consultant Neurologist, Internist and Sports and Exercise Physician from the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia, and led by Research Director Dr Andy Franklyn-Miller, was presented.

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Prof Paul McCrory

“The most commonly reported symptoms of concussion are headache, balance disturbance, confusion, dizziness, and nausea, and memory and concentration issues also feature. Although a standardised period of rest is the current guideline, this does not always reliably allow the full resolution of symptoms. The SSC rehabilitation pathway will address exercise, sleep, mood, balance, vision, and concentration in anyone from recreational to elite, to guide the recovery process,” Dr Franklyn-Miller commented.

According to Prof McCrory, a concussion policy advisor to numerous international bodies: “The focus in public debate about the issue of concussion to date has been on the recognition of players with concussion on the field and potential severity of concussion within sport, and successful campaigns from sporting bodies, including the GAA and IRFU in Ireland, have highlighted the need to ‘recognise and remove’. What we are saying today is that research into recording both the baseline and subsequent post-concussion injury rehabilitation data will improve our knowledge and inform the development of a care pathway that can be used internationally.”

Bringing together the expertise of diverse disciplines — concussion research projects in TCD

The two ongoing concussion research projects in TCD involve diverse disciplines, including physiotherapy and bioengineering, and innovative approaches such as the analysis of head kinematics, biomarkers and neurocognitive assessments.

One of the projects aims to marry research into what happens to pedestrians involved in car accidents, with studies into movement patterns in the human body during sports collisions.

Led by Associate Professor Dr Ciaran Simms, TCD School of Engineering, the research team is using multi-angle video footage of collisions to generate skeleton models of players involved in sport-related impacts to determine if movements undertaken by rugby players affect what kind of head injuries they obtain.

‘Concussion is one of the most complex injuries that any sports medicine team will need to manage. We ultimately require a reliable and comprehensive battery of tests that will help clinicians decide when to remove a player from the field and then when it is safe to return to sport’

Speaking to the Medical Independent (MI), Dr Simms said: “The research at TCD is being undertaken in conjunction with Leinster Rugby, who have allowed us ethical approval to take video footage of training ground incidents. Analysis is undertaken with a pitchside medical team. When analysing whether concussion has taken place, we measure the angle of the torso and the position of the head. I aim to relate this to the position of pedestrians when involved in car accidents, as I feel that there is a substantial link between the two.”

Dr Simms continued: “If you can understand a player’s movement patterns clearly in a specific collision incident, you have a very good starting point for developing counter-measures, for example, by taking a player off the pitch if the movement patterns suggest certain injuries or concussion is likely. In addition, different playing strategies could be developed to avoid getting into particular movement patterns that are more likely to cause concussion-type injuries. Future phases of our research would look to speed-up this kind of analysis to allow it to be used in real time. This would have the potential to provide feedback to a referee in a TMO sense to say that a particular collision was problematic, and that the player may need to come off the pitch for further assessment.”

Dr Simms acknowledged that the method may not be without flaws.

“It is difficult to establish how reliable the reconstructions are. We are collaborating with the University of Virginia in the United States to work towards these challenges and try and overcome them.”

Speaking on behalf of Leinster Rugby, physiotherapist Mr Brendan O’Connell said: “Concussion is obviously front-and-centre at the moment in rugby and in sport in general, and rightly so… the opportunity to develop another objective test to add to the existing range of tests already available was one that we were very keen to explore further, with the ultimate aim of making the management, assessment and return to play of players more objective.”

Mr O’Connell acknowledged that Leinster Rugby wants its players to perform to the best of their abilities on the pitch.

“We try to achieve this, while at the same time always having the best interests and welfare of those same players front of mind. I hope that this research can make a difference and that again, it is the players that benefit, both on and off the pitch.”

Another project being undertaken at TCD involves the development of a blood test, which could be used to quickly diagnose concussion in rugby players and other impact sports. The simple finger-prick test would allow medical teams to identify whether or not a player should be allowed to continue in the match. The project, which is being led by Assistant Professor in Physiotherapy at Trinity, Ms Fiona Wilson, and Associate Professor and Head of Physiology in Trinity, Dr Aine Kelly, involves examining specific blood biomarkers that may be present as a measure of brain injury in rugby players. Certain biomarkers have been shown to correlate with brain injury severity and can help identify cellular damage in a brain injury.

Speaking about the project and the initial findings, Ms Wilson said: “Concussion is one of the most complex injuries that any sports medicine team will need to manage. We ultimately require a reliable and comprehensive battery of tests that will help clinicians decide when to remove a player from the field and then when it is safe to return to sport.”

Ms Wilson stated that the new method is similar to the familiar means of managing diabetes.

“Our initial findings indicate that we have made significant progress in identifying a blood test that will add to the armoury of tests for sports medicine clinicians managing concussion. Furthermore, collaboration with a world-leading diabetes centre means that progress can be made towards development of a simple finger-prick blood test, which is already so familiar in diabetes management. This has great potential for simplifying the management of concussion.’’

Health Committee calls for consistent approach to dealing with concussion in sport

In October 2014, the Joint Oireachtas Committee on Health and Children held a number of hearings on the issue of concussion in sport, which featured leading medical and sporting experts.

The Committee highlighted the increased risks of concussion and brain injury, as a result of increasing physicality and speed of sports at professional and amateur levels.

A report was subsequently prepared on how to address the issue of concussion in sport in Ireland, which contained a number of recommendations. Any sportsperson experiencing or diagnosed with concussion should be immediately removed from play, regardless of pitchside assessments, according to the report, published last December. In addition, sporting organisations, schools, and medics need to do more work to roll-out standard guidelines on return-to-play rules, the Committee said.

The report recommended the establishment of a taskforce on sport and concussion to develop uniform guidelines and a consistent approach to how we handle brain injury in sport. The Committee suggested that the taskforce include medical experts, brain injury advocates, sporting bodies, youth organisations, and Government departments so that a coherent strategy can be rolled out.

The Committee urged the application of the Zurich 2012 Statement on Concussion across Irish sports at all ages. The report also suggested that State funding for sporting organisations be linked to the completion of sports concussion training courses for referees, medical professionals, and coaches.

The report also recommended that concussion in children needs to be managed differently than adults, with implications for school and amateur sports.

Commenting on the report, Committee Chairman, Deputy Jerry Buttimer said: “In recent years, high profile and very serious concussion incidents across a number of sports both at amateur and elite level have underlined the extent of the problem. As a country, if we don’t have a coherent strategy on sports concussion, we will put the lives of our sports stars at risk. This report seeks to chart a practical way forward to reduce these risks….

“Concussion can be fatal, especially if a player is left in a game and sustains a second impact, or second impact syndrome. Concussion can often have longer-term effects, with some evidence suggesting that repeat concussions can lead to early onset dementia.”

Deputy Buttimer said that the Committee was particularly concerned at recent developments in Irish sport, which are increasing the risk of sustaining a concussion. “The pace of games can be far more intense, while players are getting heavier and the number of tackles is increasing. Although some progress has been made in recent years, it was also very clear from the testimony that sports concussion is a growing risk, particularly for school children and amateur sports men and women.”

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