Overview

The long and short-term effects of head impacts in rugby league and union are becoming bigger talking points by the game. Brain injury is now beginning to be taken more seriously.

Red cards are on the rise as governing bodies try to reduce head-high tackles in response to the increasing number of former players diagnosed with Chronic Traumatic Encephalopathy (CTE). Carl Hayman, Alix Popham, Michael Lipman, Steve Thompson, Carl Hayman, Dan Scarbrough, Neil Clarke, Tim Cowley, Jason Hobson, Neil Spence, Adam Hughes, Bobbie Goulding have all been diagnosed with CTE.

For a man in his 30s or early 40s, the odds of getting this diagnosis is around one in 10,000. And yet 75 former union players contracted in England or Wales during the first 15 years of the professional era have now been diagnosed with CTE. This represents roughly an odds of one in 20. With the women’s players beginning to echo the early years of men’s professionalism in bulking up and becoming fitter, faster and stronger – what does the future hold around brain injury in rugby?

This has all meant that contact load training, head injury assessment, concussion education, management and prevention are now key talking points across rugby. Has brain trauma in rugby suddenly become a problem or is it that we haven’t been noticing it? It’s a combination of both.

In rugby brain trauma has become overly focused around bigger impacts, concussion and contact load, rather than the appreciation that multiple smaller sub-concussive impacts over a period contribute to neurogenerative disease.

There is a need to reduce rotational forces to the brain, opposed to measure and manage after an impact is received. Rotational forces occur from angled hits to the head, be it head-to-head, head-to-ball, head-to-ground impacts, all of these cause the brain to rotate inside the skull and brain cells to shear in a twist-like movement.

Also confused in this debate around brain trauma in rugby is that former players have CTE with dementia like symptoms, and not dementia as is understood in the context of aging. Dementia is an umbrella term, not a specific condition, and refers to a number of cognitive symptoms. Conflating CTE and dementia by the media, governing bodies and wider means that CTE as a condition is not being understood, nor the risk factors appreciated.

The most significant mitigation to reduce brain injury in rugby is reducing the transmission of rotational forces to the brain from concussion and sub-concussive impacts. Halos® is uniquely and intentionally designed to lessen the risk of rotational brain injury due to the reduction in the transmission of rotational forces to the brain.

Scrum caps are regulated by World Rugby to limit their meaningful protection to the head. This is why scrum caps are only protection against superficial cuts/grazes and protecting the ears, they do nothing to reduce brain injury.

The risk of brain injury in rugby

In rugby union, as many as 22% of all recorded match injuries are concussions. For the last nine seasons, concussion has also been the most commonly reported injury. On average each match concussion resulted in 16 days missed, and 23% of concussions came in training (RFU).

Rugby league is even more dangerous, largely because tacklers are instructed to hit the ball-carrier around the shoulder region to prevent them offloading the ball. As a result of this, concussion occurs frequently at a rate of 18 per 1000 hours of game time in league. This is one of the highest concussion rates of any sport and that includes American football (15 per 1000 hours of play).

The governing bodies for both codes of rugby – the RFU and RFL – have introduced head injury protocols, but they focus on concussion. What they overlook is the number of repetitive, sub-concussive impacts which don’t produce overt signs or symptoms, but nonetheless cause damage to the brain.

Female rugby training session

How do head impacts injure our brain?

Concussion occurs when an impact to the head or body sends a strong force to the brain, resulting in significant, acute brain injury with symptoms including headache, mental fogginess, changes in memory, balance, coordination, behaviour, irritability, and slowed reaction time. Greater than 90% of concussions are not associated with a temporary loss of consciousness, and more than 80% of concussions are diagnosed the next day or several days later.

Repetitive, sub-concussive impacts cause injury to the tiny blood vessels in the brain. This in turn results in damage to the ‘blood brain’ barrier, a structure designed to protect the brain. When this structure is damaged by repetitive trauma, an abnormal ‘immune” mediated inflammatory response is triggered, with the production of neurochemicals. The neurochemicals and inflammatory response should be protective. However, the problem arises when the brain is subjected to repetitive blows before the protective neurochemicals and inflammatory changes from the initial head injury have had time to return to normal.

The subsequent, repetitive head injuries can then result in an abnormally exaggerated further production of neurochemicals and an exaggerated inflammatory response which is harmful to the brain, instead of protective. This response damages the brain tissue and eventually leads to the irreversible death of brain cells. Over time, this abnormal inflammatory pathway which is triggered, repeatedly by frequent head injury in contact sports eventually leads to changes in a brain protein called tau.

The tau protein which is found within cognitive brain cells normally stabilises brain cells to ensure they work efficiently and communicate effectively, with all the other cognitive brain cells, so an individual can think and behave normally. When the tau protein becomes damaged, it can no longer stabilise the brain cells and the brain cells lose their ability to function efficiently and effectively. As the tau protein spreads around the brain, it affects and kills more and more precious brain cells, needed for thinking and control of emotions and behaviour.

Limiting contact in training

The governing bodies for both codes of rugby – the RFU and RFL – have introduced head injury protocols, but they focus on concussion. World Rugby have introduced a new framework which sets out non-mandatory contact guidelines for training sessions.

Rugby logos

It aims to help inform coaches and players of the best practices for reducing the risk of injury and optimising match preparation throughout a season.

These guidelines have been developed because training environments are much easier to control than competitive matches. They advise reducing the cumulative contact loads and time spent tackling in training to the lowest possible levels, reducing injury risk while still allowing for adequate player conditioning and technical preparation.

Reducing contact loading and the levels of physicality away from match-days is one of the changes demanded by The Rugby Players Association (RPA). The group is made up of former players, and they are also in favour of incorporating data analysis into full-contact training.

In rugby league, contact loading is also a focal point. The league is preparing to launch a game-wide three-year research project to quantify head impact and acceleration exposures. Rather than impose arbitrary restrictions, the data gleaned will be used to reduce elements of contact training that are of particular risk and protect players from repeated blows to the head.

Female rugby player - Blaydon Rugby

The limits of measuring contact load

We know that repetitive head impacts, in the course of game play and training cause damage to the brain from concussion and sub-concussive impacts. The risk and severity of CTE is caused primarily by multiple smaller, sub-concussive impacts, and not by one hit concussions. Sub-concussive impacts are those which are of sufficient force to adversely effect the function of the brain cells, but do not cause symptoms of concussion. Players and those around them are not aware of these impacts. 20% of people with CTE diagnosed after life were recorded as never having sustained a single concussion.

There is no known safe threshold tolerance for rotational forces to the brain from concussion and sub-concussive impacts, or evidence if a certain number of impacts leads to later-life brain degeneration, or if there is a safe threshold of repetitive impacts in a game, season and career. Meaning, the focus should be on what level of brain trauma is too much, and why reducing rotational forces and protecting the brain from rotational forces is a smarter focus.

How are head injuries assessed during and after a match?

The Head Injury Assessments (HIA) Protocol has been developed for the elite level of the rugby union and has improved the pitch side management of head injuries and concussion. HIA does not diagnose a concussion, it is a tool to help identify a suspected concussion.

HIAs take place when the referee, another match official or a pitch side doctor see a player take an impact to the head which may have caused a concussion, even if there are no immediately obvious symptoms. It allows doctors to temporarily remove a player following a head injury, where the diagnosis is unclear, to undertake an off-field assessment.

HIA is a three-stage process that consists of the following:

  • Stage 1 – game day, off field assessment (When not showing clear on-pitch symptoms or signs, players must undergo an off-field assessment consisting of a clinical evaluation by an attending doctor who is aided by screening tools and video reviews. Players cannot return before ten minutes for assessment has elapsed. Players taken off for HIA can be replaced, and any replacement can take a kick).
  • Stage 2 – post-game, same day assessment (After the match every player entered into the HIA protocol must undergo another evaluation within three hours. This is done using a check of symptoms, memory assessment and balance evaluation – compared with previous player baselines).
  • Stage 3 – 36-48-hour post-injury assessment (the player will be assessed again, going through a symptoms check-list, studying a player’s balance and using a cognitive assessment tool).

Players displaying obvious on-pitch signs of concussion must be immediately and permanently removed from play, without further assessment.

HIAs in rugby league have free interchanges which allows for a HIA in place to allow clubs to deliver the medical attention required for possible concussive injuries, without having to use an interchange.

The pitfalls of HIA and amateur rugby

HIAs have little utility, because they are after-the-event intervention when brain trauma has already been incurred and the injury will continue to unfold.

There are no HIAs in amateur rugby union. If there is a suspicion that the player is confused or disorientated, they should be safely removed from the field for further assessment and should not return to play that day. If, at any point during a match or training, a player is concussed or has a suspected concussion, that player must be immediately and permanently removed from the field of play. This is known as “recognise and remove”. Whether this is enforced in amateur rugby specifically is another question.

Physios in the professional and amateur game are relied upon to check the physical wellbeing of players. Unfortunately, there is not always one present in amateur rugby, just like there is not always trained medical staff and ambulance crews on hand in case of emergency. The responsibility for safeguarding players then falls on each individual club, while rugby’s governing bodies are seen more so as the overseers of the professional game.

This oversight means that amateur players, both in league and union, are much more likely to remain on the field after sustaining head trauma. In the absence of medical practitioners, and a higher likelihood in having fewer substitutes to replace them, players continue to put themselves in danger, unaware of the potential consequences.

Side line testing and HIAs have flaws, false-negatives and little utility, and why reducing rotational forces and protecting the brain from rotational forces through Halos® is a smarter focus.

Graduated return-to-play (GRTP) – how long is needed for the brain to recover?

When a player sustains a concussion, they enter into what is known as the graduated return to play (GRTP) protocol. GRTP is a progressive program that brings an individual back to sport in a step-wise fashion. Under the GRTP protocol, the player can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.

GRTP is really an informed guess on how long it takes the brain to recover post injury. Damage to the brain cells from an impact can be both immediate (damage to the brain cell structure) and delayed (blood flow changes or neural inflammation). Research and opinion from medical literature reviews suggest that 30 days is the minimum period before returning to play post a concussion event.

Under current GRTP Guidelines

  • A player in elite rugby union can complete the six stages of the GRTP in a minimum of six days.
  • A player in amateur rugby union can complete the six stages of the GRTP in a minimum of 21 days for adults. and 23 days for children.
  • A player in rugby league can complete the six stages of the GRTP in minimum of 11 days.

Rugby has focused on evaluating brain recovery based on the level of play – this is a folly. There is no precise answer to how long it takes the brain to recover post injury.

Returning to play too soon can increase the risk of sustaining further injury and subsequent symptoms, requiring a prolonged period of recovery. Changes in white matter, brain connections and blood flow can persist a year or more after a concussion. Research provides a significant association between a history of concussion and lower extremity injury, especially lateral ankle sprain, knee injuries and muscle strains. All athletes of all levels in sport have a greater risk of lower body injury issues for more than a year following a sport-related concussion. In some cases, this risk is as high as 67%.

Technological solutions

Instrumented Mouthguards

Instrumented mouthguards are increasingly being introduced into rugby to help detect whether or not a player is at risk of a concussion or head trauma. Instrumented mouthguards are mouthguards as is used in rugby, but have in-built hardware to allow for the accurate measurement and reporting of head impacts in real-time. They calculate the force, location, direction and number of head impacts, while effectively filtering out false-positive non-head impact events. This data is fed to an online reporting portal to report by player the linear and rotational force, location, direction and number of head impact(s) received.

This data is intended to provide a greater understanding of when a player is in danger, by measuring the force of every collision they experience during a match. Rather than impose arbitrary restrictions, the data gleaned from the mouthguard will be used to reduce specific elements of contact training and protect players from repeated blows to the head. However, so far there is no known safe threshold tolerance for rotational forces to the brain, or evidence if a certain number of impacts leads to later-life brain degeneration, or if there is a safe threshold of repetitive impacts in a game, season and career.

More than 700 male and female amateur rugby union players, from adults to under-13 level, have taken part in the largest instrumented mouthguard study in New Zealand. The Rugby Football League has approved the game-wide introduction of instrumented mouthguard across the professional game, Women’s Super League, academy rugby and the community game.

Instrumented mouthguards are a measurement tool of head impact exposure, they do nothing to protect against brain trauma.

Eye-tracking technology

Eye-tracking technology is also being introduced to help with the detection and management of concussion. Studies have suggested that oculomotor function – eye movement – alters at the time of a concussion or shortly afterwards. This technology is being piloted in matches alongside HIA process and the return-to-play protocols. This technology does nothing to reduce brain trauma and protect against, it is a measurement and management option.

Measuring brain patterns

Measuring brain patterns through an electroencephalogram (EEG) is also being introduced to better spot and manage concussion. An EEG tracks and records brain wave patterns. Localised brain activity is recorded via a number of metal electrodes. The EEG brain test is typically used for tracking and observing brain state changes. This technology does nothing to reduce brain trauma and protect against, it is a measurement and management option.

All of these technologies focus on measuring and managing brain trauma after it has happened.

Rezon’s answer to brain trauma in rugby

The brain is at risk, not just to a single or high-force impact, but also to the multiple, relatively minor impacts which are invariably unnoticed and undetected in rugby. Every single impact to the head has the potential to be career ending and life-changing.

Whilst the effects of brain injury may be instantly visible, repetitive brain injury over many years may not be recognised until later, meaning it is never too early to protect the brain in sport. The way head injuries are dealt with in rugby is now an overwhelming priority, with World Rugby, the Rugby Football Union, Welsh Rugby Union, Rugby League all facing a lawsuit from retired players who have been diagnosed with CTE.

The most significant mitigation to reduce brain injury in rugby is reducing the transmission of rotational forces to the brain from concussion and sub-concussive impacts. Halos® is uniquely and intentionally designed to lessen the risk of rotational brain injury due to the reduction in the transmission of rotational forces to the brain.

Youth rugby match - wearing Rezon Halos