Brain Injuries In Rugby: A Special Report

Sarah Mockford

An in-depth look at the biggest issue in the sport 

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Brain Injuries In Rugby: A Special Report

From law changes to legal action, much-needed research to modern scientific advances, so many stories in rugby right now involve brain injuries (or concussion or head impacts, depending on your preferred terminology).

There have been harrowing tales of former professional players being diagnosed with early-onset dementia; the rise in red cards as lawmakers look to limit incidents of contact to the head in matches; the worry of parents as to whether it’s safe to play rugby; the technology that can measure forces involved on the field…

Incidents in the 2022 Six Nations have brought the Head Injury Assessment protocols under further scrutiny too.

In a series of articles, we look at what is being done to minimise risk of brain injuries and what could happen in the future.

Brain Injuries In Rugby: Where does rugby stand?

A survey last year found that nearly two-thirds of adults who play the game and/or have children who do are concerned about the sport’s long-term effects on brain health. That’s why it’s so important to understand what the game is doing to try to make rugby safer and find out more about brain injuries…

RESEARCH PROJECTS

There is still a lot we don’t know about the brain, which is why research is vital. The Drake Foundation is committed to improving understanding in this area. The not-for-profit organisation funds research into head injuries, with particular focus on those suffered in sport, and last year published the results of two studies at different ends of the rugby spectrum.

One looked at retired players who played before the professional era and another involved current elite players. The BRAIN Study found that there was no difference in cognitive function before the age of 75 between players in the pre-professional era with three or more concussions and those with fewer.

It found that there was no overall group association between the number of concussions and worse cognitive function, although in the over-75s age bracket 29% of those who had suffered three or more rugby-related concussions did have worse cognitive function.

“We don’t know the reason, so it answers some questions but raises others,” says Lauren Pulling, CEO of the Drake Foundation. “What we do know is the game has become a lot tougher in recent years. Players are bigger, when they’re colliding there is more power, and there is a higher instance of concussion. We’re concerned the effects on modern-era players could be worse than the amateur era.”

That assertion is supported by the second study, which looked at biomarkers in elite players. Between July 2017 and September 2019, a group of 44 players underwent two MRI scans a year apart, so the structure of blood vessels and white matter in the brain could be assessed. The results showed that 23% of players showed abnormalities to the ‘wires’ (axons) of brain cells or small tears in blood vessels.

While the study doesn’t provide “the full picture”, Pulling is interested to see how players track over time when assessed at the brain health clinics that are being set up. Premiership Rugby and the RFU have partnered to open the Advanced BRAIN Health Clinic at the Institute of Sport, Exercise and Health, where retired elite players aged from 30 to 55 can undergo MRI scans, cognitive function tests and biomarker assessments.

World Rugby has also confirmed that it will support free brain health clinics for former elite players to access expert advice and assessment as part of its Brain Health Initiative. The hope is that the model could eventually be rolled out to the general public.

It’s crucial to understand how grass-roots players are affected by brain injuries too, as well as for those involved in the sport at all levels to be educated and aware of concussion. A study by Durham University found that former professional players are more likely to show signs of depression, anxiety and irritability than amateurs, with those who had suffered five or more concussions almost twice as likely to report those signs.

Dr Karen Hind, from the Department of Sport and Exercise Sciences at Durham, said: “Our study shows that elite-level rugby players disclosed more adverse mental health issues following retirement from the sport, compared to those who had played amateur-level rugby or a non-contact sport. This was particularly the case for those players who had experienced three or more concussions.”

An Otago University study, in partnership with World Rugby and New Zealand Rugby, has used high-tech mouthguards to monitor head impacts in community and age-grade rugby, with researchers now going through the data to see what can be deduced.

Those same mouthguards, made by Prevent Biometrics, were also used by the Red Roses and Black Ferns last autumn, both in training and Tests, and the hope is that more data from female players may be gathered during the Rugby World Cup.

There is very little research around how women are affected by brain injuries and England captain Sarah Hunter is pleased that the information gap is starting to be addressed.

“Studies historically have all been based around men, so when we heard about the research and how important it is, what it could help lead to… All we did was play rugby, but it’s pretty cool to be involved in research like that,” she says.

“Obviously there is anecdotal evidence that concussion impacts women differently to men. The return-to-play strategy comes from the men’s game and from what I’ve seen it probably takes women a little longer, so any help from proper scientific research is crucial.

“The first time I got a concussion, after a week I wasn’t back, then I started to worry that something was wrong. The research says that after seven days most players are back, but that research has always been done on men. I think I’ve had three concussions and all have been prolonged; it’s probably taken three to four weeks to get back. That’s why it’s vital that research is done on the female brain.”

Following its inquiry into concussion in sport, the Digital, Culture, Media and Sport (DCMS) Select Committee is also calling for more data and research when it comes to head injuries. The Government last month published an action plan on concussion in sport following the DCMS report.

Campaigners were disappointed that there was no mention of chronic traumatic encephalopathy (CTE), which is a progressive degenerative brain disease, or early-onset dementia, nor any proposed action to support players and families affected – former England hooker Steve Thompson described it as “a kick in the face” – but it does include the setting up of a sports concussion forum to identify gaps in research and fill them.

The plan also includes supporting a research project by the University of Oxford, in partnership with sports safety charity Podium Analytics, to look at the incidences of concussions in general and in sport in the UK, as well as tracking the prevalence by individual sports, age and gender.

All this research should help create a more rounded picture of the effects of head injuries, but there is also a need to try to make the game safer now.

CONTACT CLAMPDOWN

In the past couple of years we’ve seen more red cards brandished on rugby fields than ever before – and that is a result of the clampdown on head contact. There were as many red cards in the 2021 Six Nations as there were in the previous decade of championships combined, with officials taking a zero tolerance approach to high tackles, dangerous cleanouts, leading with the forearm to the head and the like.

World Rugby is hoping its Head Contact Process will stamp out reckless acts of foul play and reduce head impacts, yet the number of dismissals would suggest we’re not seeing a radical overhaul in player behaviour with upright tackles, with little to no bending at the waist still taking place. The ‘red cards ruin game’ debate also tends to detract from the reasoning behind the stricter officiating in the first place.

In a contact sport like rugby, you will never eradicate head injuries and ‘rugby incidents’ will happen, but there are ways to mitigate the risk. Going forward, it remains to be seen whether there will be a change in approach from players/coaches when it comes to tackling, ruck entry and so on or whether yet more law amendments will be introduced.

Last year World Rugby also brought in guidance on training loads, with a maximum of 15 minutes of full contact training, 40 minutes of controlled contact training and 30 minutes of set-piece training a week recommended.

Leinster coach Stuart Lancaster, who was involved in putting together the best-practice advice, says: “Some players were clearly doing too much contact and it’s just trying to get everyone into some sort of mindset about contact loading, with player welfare at the centre of it.

“We’re talking about 15 minutes of full-on, live, like a game. We (Leinster) would never do more than 15 minutes. Ever. And we’d be one of the top teams in Europe. So if we can manage to deliver a performance on a Saturday without killing our players on a Tuesday… That doesn’t mean we don’t go shoulder on and it’s physical sometimes, as you have to physically prepare someone, but I don’t think you need to go full-on.”

There has been criticism that these are guidelines rather than enforceable rules, like those in the NFL that limit teams to 14 contact practices during the season. Still, if it can help facilitate a change in mindset around contact training at all levels of the game, filtering down from elite to amateur, that should be a positive step.

Of course, another way to reduce impacts is to reduce matches, but fewer games at the top level is not likely to be supported by the powers-that-be given the sport’s desire for financial sustainability.

LEGAL ACTION

In December 2020 it was confirmed that a group of former players were planning to take legal action against World Rugby, the RFU and WRU over “their failure to protect them from the risks caused by concussion”.

World Cup winner Thompson, former Wales back-row Alix Popham and ex-England flanker Michael Lipman were the first players to confirm they were part of the test group for the lawsuit, with all three revealing they had been diagnosed with early-onset dementia and probable CTE.

Thompson can’t remember winning the RWC 2003 final, Popham recounted how memory loss had led to him causing a fire at his home after leaving a grill on and Lipman has described himself as “a walking timebomb”.

Over the past year more former players – professional and amateur, male and female – have joined the claim, including former All Blacks prop Carl Hayman, with more than 150 now represented by Rylands Law, which is bringing the lawsuit. It is still in the ‘pre-action’ phase, with submissions and responses going back and forth, and with a settlement currently looking unlikely, the case could go to court.

Richard Boardman, the solicitor representing the players, has been keen to stress that the case isn’t purely about financial compensation. He says: “The vast majority of the former players we represent love the game. They just want to make it safer so current and future generations don’t end up like them.”

Popham and his wife Mel have co-founded Head for Change, a charity that supports players affected by neurodegenerative disease and their families. The second Rugby Ride Challenge fundraiser is taking place on 5-6 March.

Independent groups are also putting pressure on governing bodies.

RAISING AWARENESS

Progressive Rugby was formed last year and comprises players, coaches, referees, teachers, GPs, neurosurgeons, orthopaedic surgeons and sports doctors. The lobby group has been calling for reform in rugby to make it safer, with focus on five key areas: reducing injury risk, prophylactic player welfare, concussion management, post-retirement welfare and access for all.

Members Kyran Bracken and Professor John Fairclough gave evidence to the DCMS inquiry while the group has also presented to World Rugby. There have been positive moves over the past year, such as the contact training guidelines and the research forum being convened by the Government, but Progressive Rugby still has many concerns.

“Probably the most thorny issue is return to play,” says Bill Ribbans, a consultant orthopaedic surgeon and professor of sports medicine at the University of Northampton. He’s talking about the six-stage protocol at elite level, with each stage taking a minimum of 24 hours, so players can return to action within a week if they have no symptoms or adverse reactions.

“We feel it should be a minimum of two weeks,” he goes on. “It used to be three weeks but the rule then changed. We know World Rugby is concerned that if it goes out to three or four weeks, players could be hiding injuries, which is a concern. While we wait for definitive research, we’ve got to go to at least two weeks; you get players’ compliance and some degree of protection.”

Ribbans would also like to see an overarching consensus across all sports of how long someone should be stood down for, saying: “It doesn’t matter if it’s hockey, rugby, cricket or whatever, a head injury is a head injury and there should be mandatory protocols.”

Another area of concern for Ribbans is schools and grass-roots rugby. He’s been impressed by the blue card system that operates in some southern hemisphere countries, where referees can remove players they believe have sustained a concussion and then log who has been shown a blue card so schools and clubs are aware and follow the guidance.

“I feel very strongly that schools and junior rugby isn’t receiving the attention it deserves. I’d really like to see more done specifically to coordinate schools and junior sport to make sure everyone is singing from the same hymn sheet. It’s understanding that youngsters need more time to recover and we need to get that message across.

“One of the problems is kids play multiple sports. If you’re concussed playing rugby you need to rest full-stop, not be playing basketball the next week. We need a system where everybody is aware when a young player is concussed. There needs to be more education all the way round, like tackle technique, teaching players from the age of nine safe tackling.”

There is undoubtedly more awareness of concussion these days. Ribbans recalls being at a county game in 2019 where six players left the field with head injuries in the second half, the referee making sure they went off if he spotted the signs and players recognising that their team-mates needed to be replaced. A decade previously, he says, none of those players would have come off. Yet he also acknowledges that pro players may not be as positive about changes that could affect their livelihoods.

“Many current players have said that we’re trying to ruin the game,” says Ribbans. “At Progressive Rugby we come from disparate groups but are all absolute rugby nuts. We love the game and want to preserve the game for future generations; we don’t want parents and schools to stop playing and for rugby to end up in the law courts.

“We’re a group of individuals brought together from different backgrounds who are dedicated to preserving the game of rugby by optimising player welfare, particularly in the realm of brain injuries. We accept you can’t stop all brain injuries but what we want to do is identify areas of the game, playing or training, where risk is increased and how we can mitigate those risks.”

Advances in science are helping people to diagnose and understand brain injuries, while technology is also playing a role. There are the aforementioned mouthguards while eye-tracking technology is being trialled in terms of diagnosing and managing concussion.

MORE ON BRAIN INJURIES IN RUGBY

The Government is also working with Love of the Game, a campaign set up by former Lions lock Simon Shaw and Laurence Geller, to identify technologies that could help prevent, diagnose and treat head injuries in sport.

There are many strands to the issue of brain injuries in rugby. This is not a problem where there is a simple, quick-fix solution. What is important is that the sport continues to learn and understand to make the game safer.

As Pulling says: “In the last couple of years we’ve seen a huge change in the general attitude to this topic. When the Drake Foundation launched it was not hugely discussed, but now it’s in the national media and we’ve seen how that’s translating across all levels. We’re a foundation of sports players and we’re trying to empower everyone at all levels to engage in sport safely.”

This article originally appeared in the February 2022 edition of Rugby World. 

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