Dealing head-on with concussion

American football has been at the forefront of recent medical research into players who have suffered multiple concussions, impacts that have caused memory and cognitive issues starting with depression but leading to Alzheimers and dementia.

The governing bodies were slow to recognise these issues and faced calls following many high-profile suicides to act, partly because many of the concussions were caused without the loss of consciousness, making the cases easier to deny.

Having finally acknowledged the issue, the scale of the problem is now being recognised with more than 200 concussions being diagnosed annually within the NFL alone.

More startling was a study published in the medical journal JAMA that documented that from research conducted on 111 deceased NFL players a staggering 110 had suffered from CTE (Chronic Traumatic Encephalopathy, the term used to describe repeated brain traumas that produces similar symptoms to dementia).

One of the most extreme cases was found in Aaron Hernandez, the former New England Patriots tight end convicted of murder in 2015, who committed suicide in his cell.

These findings have led to changes in the rules, particularly in schools. This season has witnessed, for example, a reduction in the level of contact on a blindside block while also limiting a defensive player from striking the snapper’s hand or arm.

A recent study showed that American high school football players average 50 head impacts per week.

Given the similarities between the two sports it is not surprising that both forms of rugby are now having to deal head-on with the impact of concussion.

For the fifth consecutive season Premiership Rugby Union reported that concussion is the most common injury, constituting approximately 25 per cent of all match-day injuries.

While it can be argued that the introduction of Head Injury Assessments (HIAs) has led to an increase in the reporting of incidents it is the consensus view of all teams that improving awareness and promoting behavioural change is a priority.

Intriguingly, concussion occurs more to the tackler (47 per cent of all injuries) than the ball carrier (20 per cent) meaning that prevention is the key area for development.

This is why there has been a great debate this week about whether or not tackling should be banned in school rugby.

Fans of games involving an oval-shaped ball are not isolated.

Despite the relatively seemingly innocuous collisions with the ball when a player goes up for a header, footballers are subjected to a number of repetitive minor concussions.

There have been relatively few studies although the family members of Jeff Astle, a former England player who died in 2002 and whose brain was found to have suffered multiple concussions, have been campaigning hard.  The neuropathologist who examined Astle likened his brain to that of an old boxer.

Despite receiving assurances from the FA (who subsequently apologised for their inactivity over a 10-year period) Astle’s family persisted and it is only now that the FA has commissioned a study.

Given the relative infancy of the game it is perhaps surprising that the US is leading the way in research with one New York study determining differing levels of deterioration directly linked to the increased number of times a ball was headed over the course of a season.

Earlier this year the University College of London examined the brains of six former footballers who had died from dementia and found CTE in four of them.

The issue has been brought into stark focus by the retirement of a current professional footballer. 

Kevin Doyle, the former Republic of Ireland international, is only 34 yet has quit the game over fears about the long-term effects of continuing headaches resulting from several concussions he has suffered during his career.

Needless to say, this has led to calls for heading the ball to be banned in school sports in much the same way that they are now been asked to ban tackling in rugby. Schools may go this way for fear of being subjected to litigation.

Schools are bound by a UN convention to care for children and this duty is their Number One priority and cannot be compromised. However, using rugby as the example, to tackle or not to tackle, emanates around every individuals view of life - if risk of injury is part and parcel of life then tackling should be permitted. 

Alternatively, if you believe that it is better to eliminate all risk of injury (or to minimise as much as possible), then tackling should be banned.

The argument ‘for or against’ is blurred by the point of view that it is better that they exercise rather than sit on the couch. 

A sportsman will not give up sport due to a lack of contact or ability to head the ball. The issue relates to the dangers of certain aspects of each sport and so obesity is irrelevant in the context of this discussion (although remains a global ‘epidemic’).

However, one of the greatest problems is that children watch professional sports and will be inclined to copy what they see. 

Given the importance of these concussion concerns I personally believe that children should be permitted to tackle or head the ball but to learn to do so in a controlled environment, while learning about the consequences of poor technique.

Furthermore, given the time lag between the introduction of a new initiative at professional level and how this drips down the levels to beginners, I also believe that drastic action and education is required.

Personally, I do not believe that it serves the best long-term interests of children wishing to pursue a career in rugby to only introduce them to tackling at the age of 18. Touch rugby produces many skills although does not serve the whole game.

Ultimately, it is the responsibility of every governing body although each school has to make its own decision. 

I believe that this could be based upon the quality of the coaching staff that they employ. 

Given the inherent dangers now associated with poor technique perhaps schools could receive accreditation from national bodies based around their employment of coaches qualified to a certain level in each sport.

A school unable or unwilling to ensure safe practice should then direct children to local clubs that are far more likely to provide specialised advice. I appreciate that there will be no single solution and the total elimination of risk is virtually impossible.

Clubs and schools should ensure children play with adequate protection, as cricket has for many years. 

Another alternative would be to restrict contact sessions in training (although do not eliminate) to reduce the cumulative toll on players, in conjunction with seeking innovative ways to train how to tackle. Players could be introduced to tackling once they have played for a number of years.

Realistically, player health and safety extends beyond contact. It should also include repetitive injuries emanating from overuse (which would involve monitoring the levels of practice and children representing more than one team).

Mentally, with pressure to succeed ever increasing, more can be done to monitor depression, particularly in adolescents where schooling in those years can be challenging. Mental and emotional issues can affect seemingly healthy athletes.

Education levels also need to increase (consistently on a national if not global basis to achieve parity) concerning the use of pain-killers, particularly when used to encourage players to ignore minor injuries.

Of course, much of this could be achieved by organisations providing much greater access to health specialists. Corin Palmer, head of rugby operations at Premiership Rugby, said it best: “Player welfare is Premiership Rugby’s Number One priority.”