Handling concussion- A serious headache

May 17, 2014

A lot has been said recently regarding the effect of concussion on a player’s welfare and rightly so. The catalyst for the most recent discussion has been the evident concussion suffered by Florian Fritz in a recent French Top 14 game between Toullouse and Racing Metro.

The dangers of playing with concussion are well documented and has meant the end of a playing career for many players, former Rugby World Cup winning Springbok captain Francois Pienaar being one of them. Wallaby Berrick Barnes was forced to take a three month break from the game, with the diagnosis being “Footballers Migraine”. In 2014, All Black 8th man Keiran Read has had to sit out four Crusader’s games as he has been unable to shake the effects of a concussion earlier in the year. Suffering consecutive concussions is regarded as very dangerous with the immediate danger of brain damage and further serious issues later in life, including memory loss, poor concentration and body co-ordination problems.

Concussion has always been a worry for the IRB and players alike and whilst it is admitted that there is no scientifically accurate method to diagnose concussion in the time allowed during a game of rugby, the IRB have compiled a protocol to be followed in all elite rugby. This protocol is known as the Pitchside Suspected Concussion Assessment (PSCA) and details different levels of head trauma, the responsibilities of the match day Doctor, the Gradual Return to Play protocal and the guidelines as to when a player should be removed from the field immediately or to remove them from the field on a temporary basis in order to conduct the PSCA to determine if they are in a medical condition to continue playing. When testing a player though, the guidelines do not replace clinical judgement, so irrespective of the result of the test, a doctor could still allow a player to return to the field and herein lies the danger.

To quote directly from the PSCA document:

Permanent Removal from field of play – On Field Indications

A player must be removed from further participation in a Game if they have any of the following on field signs or symptoms:

1. Tonic posturing

2. Convulsion

3. Confirmed loss of consciousness

4. Suspected loss of consciousness

5. Balance disturbance / ataxia (If an athlete is unable to stand steadily unaided or walk normally and steadily without support in the context of a possible concussive mechanism of injury he/she should be considered to have balance disturbance / ataxia.)

6. Player not orientated in time, place or person

Anyone who saw the Florian Fritz incident will have no doubt that he had suffered a balance disturbance/ataxia as he walked 20 meters from the spot he took the knee to the head and then collapsed pitch side. He had to assisted off the field by the medical staff. In terms of the PSCA, the correct decision would be for Fritz to withdrawn from the game immediately and a PSCA test was not prescribed, yet he was cleared to return to the field. Fortunately for him, he did not reappear after half time.

Another case in point was George Smith’s injury against the British and Irish Lions in 2013. He was clearly knocked out on the field and he should have been withdrawn from the game at that point, yet he was back a few minutes later giving his all for his country.

The overriding concern here is that the clinical judgement referred to in deciding on a player’s suitability to return to play after undertaking the PSCA test seems to have extended into the realm of when a team is obliged to withdraw a player from the game. What is even more worrying is the possibility of undue influence from the coach’s box, the team’s own medical staff or more worryingly the player deciding for themselves that they are capable of continuing when they are possibly not in a position to make a rational decision – both in terms of their own knowledge of the effects of concussion and also an irresistible urge to return to battle.

Is the player’s welfare secondary to that of the result?

Words: Ryan Jordan

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