You have been criticised for Rugby having ‘controversial’ protocols. How do you respond to that claim?

Player welfare is of paramount importance and is always at the heart of all we do.   It is an extremely complex area and Barry’s opinion is just that, one opinion, while over 100 union medics, leading neurologists, the players and the world’s leading sports concussion experts, the Zurich Group, endorse what we do.

So, what exactly is World Rugby doing to tackle this critical area?

World Rugby puts player welfare at the very heart of its strategies and takes a proactive and diligent approach, working with Unions and independent experts to ensure that we deliver the best-possible level of care to our players at all levels.

Concussion is an emotive topic and misconceptions abound. The Rugby approach is in line with the recommendations of Zurich, incorporating a graduated return to play protocol and a pitch side suspected concussion assessment tool for the elite level of the Game.

Both have been invaluable and a huge step forward. The graduated return to play, coupled with our strong education programmes have addressed the abuse that we were seeing around the previous 3 week stand down period.

The PSCA has given players an extra level of protection with 25% more players being permanently removed from the field during the trial.  It is a real positive for the Game as it has given medics 5 minutes to assess players following a head knock and remove those with suspected concussion.  This simply did not exist before and players were being left on the field when they were potentially concussed.

Yes, but the PSCA was shown to be ineffective in the six nations and with the George Smith incident?

The 2012 six nations did not operate the PSCA.  Had it been in operation then it is unlikely that Brian O’Driscoll would have returned. The George Smith case demonstrated a need need to work together to support medics. The message is, if a player is unable to take his weight and clearly out, there is no need for the PSCA tool. Leave the field.”

What about long-term effects? American experts are saying that Rugby is a ticking time bomb.

Concussion is a complex area, both in sport and in life.  We always put player welfare first and take a diligent proactive approach. We advocate current best practice procedures, educate and continually evolve and review our strategies.

It is misleading to compare Rugby to American Football or Boxing as they are all inherently different, for example, attacks to the head are not permissible under Rugby laws and never have been.

The most important thing is that we always put the welfare of players first and continue to work with leading experts to greater understand this complex area and all the contributing factors, such as the frequency of injuries and the role of genetic and lifestyle factors.

But what is World Rugby doing?

Player welfare is of paramount importance and at the heart of all we do. The most important element is education and correct technique coaching.  Players and coaches at all levels must ‘recognise and remove’ and if there is any doubt, a player must leave the field permanently as per World Rugby regulations.  It is vital players understand and listen to their bodies.

In addition to education, we are undertaking extensive research in partnership with the Auckland University of Technology into Rugby and CTE to increase understanding and establish if there is a long-term link. We also evolve and adapt to recommendations made by the Zurich Group, recognised as the leading experts in this area.

Detailed notes

Can Rugby afford to ignore the research coming from American Football?

• Rugby certainly is not ignoring the research and opinions coming from American Football. There is no definitive that there is a direct link in Rugby, but we must ensure that the correct preventative processes are implemented to ensure that the player is always the paramount concern.
• In an article by McKee and co-authored by Cantu both from Boston University School of Medicine it is stated that “whether a single traumatic brain injury can trigger the onset of CTE remains a matter of speculation” confirming there is no proven link with a single concussive event. The frequency and amount of head trauma is implicated and there are suggestions that repetitive head trauma is the major issue which would explain why 85% of athletes confirmed CTE are boxers.
• Also from the same article McKee and Cantu highlight that “the easiest way to decrease the incidence of CTE is to decrease the number of concussions or mild traumatic brain injuries”. They go on to highlight that this is accomplished by:

1. Limiting exposure to trauma, for example, by penalizing intentional hits to the head (as is happening in NFL and Association football and NHL hockey
2. Adhering to strict “return to play” guidelines.

• World Rugby has taken a proactive approach in that regard and has worked in collaboration with other collision sports as co-authors of the Zurich consensus statement that underpins the guidelines that exist within the Game. Rugby’s approach is therefore in line with these suggested “prevention strategies”, suggestions from Cantu himself.

1. Penalizing intentional hits to the head has been central to Rugby Laws almost since the time the Game was born. It should be noted that it was only in 2010 that the NFL and NHL outlawed intentional hits to the head. Perhaps failure to protect athlete’s heads is a significant issue contributing to the confirmation of a handful of cases of CTE in NFL.
2. Adhering to strict return to play guidelines. World Rugby Concussion Guidelines reflect the return to play guidelines outlined in the Zurich Consensus Statement of which Cantu is a co-author. Rugby is proactively adhering to strict return to play guidelines and players are not allowed to take further part in playing or training if they sustain suspected concussive symptoms.
3. Preventative education is key and the World Rugby is working in collaboration with Member Unions and Players Associations to ensure that players, parents and coaches at all levels understand the risks associated with ignoring the signs of concussion.

It is Dr Cantu’s opinion that, given the increasing attrition in Rugby, CTE could become an issue in Rugby in future years?

• There is no evidence to suggest that concussive injuries are increasing in Rugby. It is certainly not in line with the RFU study which has been running since 2002. Concussion is an emotive topic and it is important that emotion does not drive the debate. So what is known and not known, debated and not debated?

1. Not debated – Management of concussion should be taken seriously
2. Not debated – no playing or training until full clinical and cognitive recovery has occurred.
3. Not debated – Graduated Return to Play following concussion is required
4. Not debated – The wearing of padded headgear will not prevent concussion. Such equipment is only approved on the basis that it will not harm other players. It protects against abrasions. There is no evidence to suggest that the thickness of padding will be beneficial, indeed there is evidence to the contrary.
5. Debated – link between concussion and long term cognitive and psychiatric deficits
6. Debated – link between concussion and sub-concussive events and CTE

One last point is that head trauma within NFL is considerably different to that seen in Rugby. Not only has intentional hits to the head been illegal for many years in Rugby rather than just 1 year in NFL but in Rugby we do not use a helmet. Dr Julian Bailes (former Steelers Team Physician) was quoted saying “football helmets have only made matters worse, encouraging players to use their heads as weapons”.

In addition helmets may be contributing to increased head trauma by increasing the mass of the head. If you imagine having a ball on the end of a flexible stick and when the stick is shaken you watch the movement of this ball. Now attach a bigger, heavier ball to the stick and watch how much more it moves when the stick is shaken. This is similar to adding a helmet to a head. If you increase the volume of the head (by wearing a helmet) it could potentially have a negative effect.