Knocked Out: Concussion & Prevention

My very first experience with a concussion was at an early age. In fact, it was in Primary school. What I remember was we were playing rugby. Then suddenly out of nowhere, I had blurry vision. Almost to the point I was blinded and could only make out the shadows of my friends and objects.

The bell rang to return from lunch. What happened over the next half an hour I will never forget.

After my vision returned the headaches started. A headache that didn’t want to stop. One that got progressively worse. It got more aggressive as time past. I hated my teacher that year so when I started to feel like shit, I didn’t feel like I could approach her.

I started to feel really sick. The pounding in my head continued. Eventually, I couldn’t take the pain anymore. I told my teacher I wasn’t feeling well. I was excused to the bathroom on this rare occasion.

As I rushed to the door, head held in my hand. Suddenly I had an uncontrollable feeling. I proceeded to spew up on the door mat. It was a spectacular power chunder of ham sandwiches.

What was happening? Concussion.

What is a Concussion?

A concussion is the sudden but short-lived loss of mental function that occurs after a blow or other injury to the head. It is the most common but least serious type of brain injury. The medical term for concussion is a minor traumatic brain injury. (NHS) In simple terms, it is getting smacked in the head in a variety of methods.

How do concussions happen on the Rugby field?

Head clashes Tony Woodcock and Richie McCaw. Face clashes (how I broke my cheek and got concussed in the process). The head hitting the hip in the tackle Daniel du Plessis. The knee hitting the head in a tackle. The head hitting the foot of another player Conor Murray. An elbow hitting the head from an arriving player Gio Aplon (this is how I broke my cheek for the third time).

It can simply be a big collision like Brian Lima or Ma’a Nonu.

It can happen due to poor tackle technique or running at high-speed Brendon Leonard vs Lockie Munro.

Getting the timing slightly wrong for example 2016 Mitre 10. The list continues with more reckless or serious foul play with head high tackles like this sickening tackle from Fritz Lee.

Swinging arms like Dylan Hartley or Brad Barrett. Kicks to the head, punching or other illegal offenses. If you want to scare your kids into playing another sport there is no shortage of video footage. Not even our toughest players are immune to a concussion. Sonny Bill Williams below.

Funny Rugby Concussion?

While a concussion is not a laughing matter we needed to show this video.

The Legacy of Concussion in Rugby

Back in the day (well not so long ago) a lot of the sickening head knocks we see in the game today would not have been reported. The players would have continued to play or return to the field after a short break. There has been a lot of controversy with the likes of George North returning to the field too early after concussion here and here. You can only imagine what happens at the amateur level. I am sure every player could tell you about a personal experience. A teammate who has been concussed or even played on through a concussion. Back in the day, it was almost funny when someone got knocked out. Largely because we didn’t know what the long-term effects might be. The change of attitude around concussion has helped us turn on corner on the subject and player welfare.

Lying about Concussion

As a player coming through the ranks I admit to lying to my physio or coach. Not only did I lie to the doc, I lied to myself. This was a number of years ago when I was young and stupid. I wouldn’t dream of doing it now. My advice to young players is to speak up and remove yourself from the field if it doesn’t get noticed. It was very foolish thinking the stakes were higher than my own health. At the time I felt if I didn’t play on, it would ruin my chances of impressing selectors. No good playing if you can not make good decisions on the field. What is the point if at the professional level the doctor tells you to retire.

Rugby brings concussion into the light

Concussion has become a highly talked about subject, not just in Rugby. I am very glad all our sporting governing bodies are making every effort to help keep our players safe. Some players who may have poorly managed their concussions are still suffering from the injury. For example, Steve Devines story below.

What are the symptoms of concussion?

  1. Loss of consciousness after the head injury
  2. periods of memory loss
  3. disturbances in vision, such as “seeing stars”, blurry vision or gray and white lines running across the eye limiting sight.
  4. Dilated pupils or changes in size of pupils
  5. a period of confusion, a blank expression, or a delay in answering questions immediately after the head injury
  6. Ringing in the ears
  7. Sensitivity to light or noise

If a brain scan is carried out, a concussion is only diagnosed if the scan is normal – for example, there is no bleeding or swelling of the brain. If there is bleeding or swelling on the brain we start calling it a hemorrhage or edema.

Sometimes the player responses and acts perfectly according to on/off field tests. This is when your doctor, physiotherapist or coach needs to know the player and carefully watch his behavior or emotional responses carefully.

What should we do if concussed in Rugby?

A player with a suspected concussion should assume he has a concussion. He should seek medical attention. Especially if he/she has suffered a loss of consciousness, repeated vomiting, severe neck pain, seizures, or weakness, tingling and burning pain in the limbs. It is better to be safe than sorry. You only get one brain.

Rugby Concussion Facts (check out the NZRPA concussion protocol)

  • A concussion is a brain injury.
  • All concussions are serious.
  • Concussions can occur without loss of consciousness.
  • All athletes with any symptoms following a head injury must be removed from playing or training and must not return to activity until all symptoms have cleared.
  • Specifically, return to play or training on the day of any suspected concussion is forbidden.
  • A concussion can be fatal.
  • Most concussions resolve with the recommended period of physical and mental rest.

Repeated Concussion in Rugby

While a one-off concussion may be considered a minor head injury there is evidence that repeated concussions could cause long-term problems. Memory loss, confusion or even trigger diseases like dementia. This type of dementia is known as chronic traumatic encephalopathy (CTE). 

There is a significant risk for rugby players who experience repeated episodes of severe concussion. Post-concussion syndrome (PCS) can also occur. There is inconclusive research on how this occurs and is poorly understood. It is where symptoms of concussion can last for weeks or months afterward. I have had many friends that have had reoccurring headaches long after a concussion.

Retirement from Rugby due to Concussion

It is not something to be laughed at. To consider retiring from Rugby or contact sport is a very smart move. I have known players who have retired based on medical advice and their own experience. It is a difficult decision as a lot of players have wanted to play Rugby all their life. To be told you can not play Rugby anymore can be devastating. It is not uncommon for players to struggle in life after rugby.

Why can’t we just overcome Concussion?

Most of the players today are aware of the risks. It is a hard concept for a player to remove himself from the field of play or consider retirement due to a concussion. As a player, we have always known the risks of injury in Rugby. We have often overcome serious injuries. For example, an ACL rupture, shoulder surgery or much worst debilitating injuries. When it comes to the head we struggle with the idea of it being career ending because we can not see the physical injury. We have often been asked by coaches or willing to play on in Rugby with other injuries. Due to the lack of understanding, we question why does it change with the head?

Retirement from Rugby must be considered when symptoms are still ongoing or you get a concussion from falling over playing touch rugby. If you have a young family there are also others to consider in your decision to retire. Should a player choose to play through repeated concussions later in life he may experience things like depression, anxiety, appetite loss, forgetfulness, inability to problem solve, inability to sleep or a lack of energy. Video about retirement from David Jackson or here.

Dan’s Recent Battle with Concussion

I have a number of friends who have had repeated concussion or retired due to concussions. Dan Waenga, a mate, agreed to tell his story about concussion in Rugby.

Enter Dan…

I played my last game in France on the 24 April 2015. After taking a knock during the game I started to feel very groggy, sick and I had blurred vision. I was removed from the field. I was ok sitting in the stand for a while.

After my concussion

As I stood up I wasn’t too good and fainted, needing medical attention. The months following I experienced really bad nausea. I particularly felt it when I was in the car. Headaches and migraines were so bad that I preferred to be in dark, quiet space. I was sleeping up to 18 hours a day.

I have experience depression and anxiety since my last concussion. At one point I couldn’t be around a group of people as this triggered anxiety really bad and I would freak out. I couldn’t stand being around my kids when they were crying. I started to block my family out the try to cope with symptoms. This as you can imagine put a lot of strain on my wife and kids.

Seeking advice from a specialist

I was regularly seeing a doctor to get some sort of improvement. I was prescribed three months of complete rest. There was very little improvement in this time. The telling thing for me was when I went to see a specialist in Paris. After completing a range of tests he said to me his recommendation was to stop playing Rugby forever. He couldn’t guarantee I would wake up if I took another knock. I have been KO’d more than 12 times. Thinking about my family it didn’t make sense to take the risk.

Making the decision to retire from Rugby

Making the decision to retire from the game I love was very difficult. Knowing it was the best thing to do for my family put me at ease. Fast forward 16months. I still couldn’t exercise or do anything too hard out which for me was very difficult. I gained about 15kg in weight.

Every time I tried to exercise would get a headache. Sometimes it was a spinning sensation or a heavy migraine.

Since returning to New Zealand

I have since found a specialist in New Zealand who is helping people who have problems with concussions. He has helped me a lot. Almost two years after my last game I am now back doing exercise. I am still unable to push myself to 100%. Small steps at a time.

Prevention of Concussion

There are a number of ways we can help prevent concussion or minimize the risk.

Headgear

Many players, parents, and coaches believe headgear can stop a concussion. There is inconclusive evidence to suggest that headgear alone can prevent a concussion. It is merely a means to prevent soft tissue injuries, cuts, and abrasions. Sometimes we see a player wearing headgear who is more likely to get a concussion. Due to his fearless attitude. Personally, I have tried wearing headgear and found I had better tackle technique when I don’t wear it. Maybe I am more conscious of where I am putting my head? We believe any protective gear around the head is good especially for kids.

Mouthguards (source BMJ)

There is some evidence to suggest that mouthguards can reduce the risk of concussion but research is still not conclusive. In any case, the mouthguard should be properly fitted for each individual. I know some of my friends are guilty of having a mouthguard in their sock rather than wearing it (not a good option). A mouthguard can help absorb shock, help stabilise the neck and head. It can even help limit the movement around the jaw. A good measure to help prevent concussion in Rugby.

Strengthen the Neck

It seems simple but can be very effective. Having a very strong neck can help reduce the movement or whipping of the head. It will not stop a concussion but another preventative measure is always good. Isometric holds can easily be added to your strength and conditioning program.

Correct tackle technique

Teaching players the correct tackle technique can reduce the risk of head injuries. Players who are the tackler and players who are getting tackled. 

Teaching the correct laws

An attempt to protect our players has seen the introduction of laws changes and contact around the head. While this is a good thing for our player welfare it must be managed correctly by referees so that those good hard tackles are not considered dangerous. We have seen a lot of the professional referees get it right and hope this can help those at the amateur level.

10-minute Concussion assessment

It is great to see the introduction of the 10-minute player screening. When a player is allowed to leave the field of play to get assessed by medical staff without it being considered a substitution. This, however, can be flawed. Sometimes symptoms can appear 10-30 minutes after a head knock. Should this time not be extended?

Educate our Players

Educating all players not just professional but amateur. Learn about the long-term side effects and the severity of a concussion. What does a concussion mean to a player? With more evidence and education around the severity the player can be honest with himself. He knows he should be leaving the field without question. Good video here on this subject.

Following a Graduate Return to Play Procedure

It is great to see many governing bodies applying a graduated return to play. We must educate our coaches and players about the severity of a concussion or repeated concussion. World Rugby Player Welfare has some very good information on concussion.

The World Rugby Recognize and Remove message incorporates 6 Rs

  1. Recognize – Learn the signs and symptoms of a concussion so you understand when an athlete might have a suspected concussion.
  2. Remove – If an athlete has a concussion or even a suspected concussion he or she must be removed from play immediately.
  3. Refer – Once removed from play, the player should be referred immediately to a qualified healthcare professional who is trained in evaluating and treating concussions.
  4. Rest – Players must rest from exercise until symptom-free and then start a Graduated Return to Play. World Rugby recommends a more conservative return to play for children and adolescents.
  5. Recover – Full recovery from the concussion is required before return to play is authorized. This includes being symptom-free. Rest and specific treatment options are critical for the health of the injured participant.
  6. Return – In order for a safe return to play in Rugby, the athlete must be symptom-free and cleared in writing by a qualified healthcare professional. A professional who is trained in evaluating and treating concussions. The athlete completes the GRTP (Graduated Return to Play) protocol.

Ongoing work on Concussion & New Technology

For further information about Concussion, watch this BBC mini-documentary: John Beattie video on concussion.

Photo Credit: leinsterrugby.ie

AUTHOR

Nick McCashin

Nick McCashin

Nick McCashin is a former Bay of Plenty representative who has played professionally in England, France and Spain. Nick is currently playing and coaching in Scotland where he is writing and developing content to help players excel on and off the field.

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