Brain expert: Evidence for a concussion protocol allowing players to return by following weekend ‘never really there’
This article was written by Progressive Rugby
A brain heath expert who acts as an independent advisor to World Rugby, says evidence to support the reduction of the elite game’s three-week concussion protocol was “never really there.”
Professor Willie Stewart said the three-week stand down after a concussion, introduced in 1977, was based on advice from experienced medics.
But, that when the six-stage Graduated Return to Play (GRTP) protocol was introduced in May 2011 (which can facilitate the return of a player in just six days), there was no supporting evidence to do so other than doctors being told by players that they “felt better” and were ready to take the field again.
Prof Stewart’s comments are likely to fuel the fire of those involved in the game who believe that players are often treated as nothing more than commercial assets and that on-field success and financial gain are put above player welfare.
Professor Bill Ribbans, of Progressive Rugby, said: “We are yet to see any evidence which justifies the introduction of a Return to Play protocol that allows a player to return to the field in time for the following weekend. We believe the current system is not foolproof and means players and medics can find themselves under significant pressure if the next match is deemed to be a pivotal fixture.”
World Rugby have stated that pre-2011 players could, and often did, return within the three-week period if signed off by a specialist, and that the GRTP was introduced to combat issues with players deliberately under-reporting symptoms.
Additionally, the governing body states that, on average, current players are stood down longer than their pre-2011 counterparts due to the individualised approach to concussion care and often point to the fact that less than a third of players return to the game within 10 days.
However, Prof Stewart, a consultant neuropathologist who advises World Rugby on brain health, said on the Scottish Rugby podcast, that the average length of time - even for elite players with the best medical care - was nearer two weeks minimum and that the original three-week time frame was sensible.
His comments appear to undermine World Rugby’s position that the approach to concussion management of elite players must be based on evidence and not emotion, and supports Progressive Rugby’s demand that the concussion protocol is extended to at least 12 days.
Prof Stewart, who was joined by Dr James Robson and Prof Craig Ritchie, director of Brain Health Scotland, told ex-international Chris Paterson:
“The introduction of technology and management is fascinating, because think back to when it was a three-week mandatory lay off following an injury.
“The amateur and youth level has pretty much stayed the same (in terms of extended return to play protocols) and will always stay the same because that cautious approach is really important.
“But the professional game shifted from that three-week layoff down to (potentially) a week, so you are kind of ready for the next match if you can be rehabbed rapidly enough.
“But the evidence that supported that was never really there, other than players felt better, and the doctors looking after them felt that if the players were feeling better - it should be ok.
“What has happened in the last 10-20 years is that we have far more sensitive tests for brain injuries – blood tests, brains scans, the virtual reality head sets to look at how vision is functioning etc.
“We have all these things that show us that actually, for many, many players - even the elite players looked after by the best doctors - it’s much longer than that week to recover. The average is nearer two weeks to see those sensitive signs getting better.
“Funnily enough that three-week layoff all those years ago was good common sense based on experience like James (Robson). The science is now backing that up and giving us more confidence (that it was correct).
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“When you go to elite players and say it’s the science - not just my opinion – but the science says you should hold off for a few more days, it works better than just ‘everybody to take three weeks off’.”
A World Rugby spokesperson said: “The overall approach to player rehabilitation from a head injury has evolved significantly over the last decade, always with the player’s welfare the top consideration.
“At the elite level of the game, prior to 2011, it was possible and common to return to play within a week if specialist clearance was given. That is no longer possible.
“The player-first six-stage graduated return to play process enables a player’s rehabilitation to be monitored throughout based on their individual risk profile, rather than an arbitrary timescale.
“This takes into account their medical history. More than two thirds of players do not return within 10 days, while any player with the possibility of playing within 10 days has to undertake an independent concussion consultation.
“We will never stand still when it comes to advancing player care based on evolving science, research and technology, and World Rugby is also trialling the use of the latest eye-tracking and instrumented mouthguard technology to inform and support the return to play process. Elite players have never been so well supported as they rehab after a head injury.”
World Rugby have launched a series of initiatives in 2021 including a community rugby head impact study, a panel of Independent Concussion Consultants (ICC) and the publication of new contact training load guidelines.
And last month it launched the Brain Health Initiative – a global campaign, endorsed by Prof Stewart, to educate and increase understanding of the importance of brain health within the rugby family which has come under fire from many including Dr Barry O’Driscoll who said the move seemed designed to “dilute the problem of concussion in rugby.”
Progressive Rugby’s Prof Ribbans, who himself worked on the Northampton Saints medical team for many years, added: “World Rugby has made significant strides in their bid to protect players, but a major sticking point remains the Graduated Return to Play protocol which we maintain is not fit for purpose.
“Professor Stewart’s comments simply back up what we have long suspected and we again ask that World Rugby provide evidence that the current process is sufficient, or install a more cautious approach which prevents an elite player who has suffered a concussion from returning to the field before at least 12 days have elapsed.”
Professor Willie Stewart