How the NRL fixed the concussion problem

In the face of widespread concerns over the NRL’s 2021 rule changes contributing to a plague of injuries, CEO Andrew Abdo met with club officials last week to placate their concerns.

As reported by the Daily Telegraph, Abdo presented injury statistics which, among other things, revealed that after four rounds of the 2021 season, just 12 concussion-related injuries had incurred, whereas the preceding three-year average was eight.

The inference was clear. Concern and panic over concussion is not supported by data.

Further, Abdo stated that this figure was achieved through “the code’s increased policing of head injury assessments (HIAs) and so too, the conservative approach to rest players after suffering a head knock”.

Both Abdo and Australian Rugby League Commission chairman Peter V’landys have recently asserted that player safety is paramount in rugby league. In announcing the introduction of an additional 18th man substitute, V’landys proclaimed “player wellbeing is a priority for the commission and this additional safety net ensures players continue to be protected”, before going onto say “our clubs are outstanding in the way they detect and monitor head injuries”.

The message to fans is unequivocal: the game is treating the issue of concussion with the utmost concern.

It’s a mantra that is duly picked up and repeated by media commentators and fans, happy to reinforce the narrative that, aside from a few of the inevitable accidents that occur in a contact sport, rugby league is doing better than ever to protect players from head injury.

It isn’t. Not only is it doing worse, there are concerns around how the NRL seems more focused on the optics of the issue – how it is seen to be addressing the problem – than it is on actually addressing the problem.

Here’s what has really happened in 2021. By the end of Round 4, a total of 23 players either failed HIAs or exhibited such gross signs of concussion during first-grade matches that an HIA wasn’t required.

(Photo by Cameron Spencer/Getty Images)

This number (23) does not include players who passed their HIA despite exhibiting obvious signs of concussion, including St George Illawarra’s Matt Dufty, victim of a high hit by Jesse Ramien.

Leading Sydney concussion expert Dr Adrian Cohen said that Dufty “was visibly unconscious following a forearm to the back of the head. He left the field for an HIA in the 19th minute of the game and returned in the 34th minute. The NRL’s Guidelines for the Management of Concussion in Rugby League lists ‘loss of consciousness’ as a visible clue in the recognition of concussion, with ‘no HIA needed and no return to play that game’.”

This number (23) does not include players concussed at training or in the pre-season, such as South Sydney’s Liam Knight, who last week revealed that despite suffering debilitating symptoms, he hid these from medical staff in order to be allowed to return to the field earlier.

Note that a recent study by Sydney specialist sports and exercise doctor Thomas Longworth found that 22 per cent of NRL first-grade players had not reported at least one concussion during the 2018 and 2019 seasons.

This number (23) does not include players who passed their HIAs due to ‘sandbagging’ their baseline pre-season test and rote learning key words that are repeatedly used in the assessment.

It is clear that the incidence of concussion in the NRL is being significantly underreported, and is higher than the 23 failed HIAs – which is also the number of failed HIAs that NRL Physio counted.

An organisation truly believing that player safety is paramount might reasonably be expected to acknowledge the data, consider the extent of the problem, and announce measures to combat it.

But not, it seems, the NRL. As of last week, the NRL no longer defines a concussion as a failed HIA. A player who fails the HIA must now be reassessed and be clinically diagnosed during a follow-up assessment by a doctor. By this new measurement, in one fell swoop, concussion incidences plummeted from 23 or more to 12.

The NRL has not disclosed whether all 23 players presented themselves to a new doctor for a subsequent assessment. Thus it isn’t known whether or not there are 11 players now considered un-concussed simply by virtue of them not having had a follow-up assessment.

The NRL has also not disclosed how long following the original incident those reassessments were made.

How feasible is it that 23 players could fail a match-day HIA, and yet only 12 of them found to be suffering from concussion? The Roar put that question to associate professor Alan Pearce, a Melbourne neuroscientist.

“The doctor’s assessment and diagnosis is purely a subjective medical judgment,” Pearce says.

“Despite leading concussion experts from around the world calling for the inclusion of some form of objective biomarker to be incorporated into assessment of concussion, this assessment essentially relies on two things: symptom reporting from the athlete, and symptom observation from the doctor.

“There are countless examples of players hiding symptoms from doctors and manipulating the assessment. Further, player symptoms can resolve within minutes. But we know through research that symptom resolution is not a reliable indicator of concussion, and that irrespective of symptom resolution, a player’s brain typically takes 28-30 days to fully recover from a concussion.

“Accordingly, such examinations and assessments are completely unreliable.”

The NRL now claims that only 12 players have been concussed in 2021. According to Pearce, what the NRL is really telling us is that “only 12 players exhibited symptoms of concussion in the days following their failed HIA”.

As for the other 11 who failed their HIA, plus Matt Dufty, plus Liam Knight, plus who knows how many others? How many of those players might be aware that symptom resolution is no indicator of actual concussion? And how many might be aware that the NRL changing the definition of concussion has no bearing whatsoever on their actual medical condition?

Is the wellbeing of those players really the priority the NRL claims it is?

Look again at the claims of Abdo and V’landys concerning the increased policing of HIAs, the conservative approach to resting players after they have suffered a concussion, and the new 18th man representing a safety net to ensure continued protection of players.

These all refer to actions after players have suffered a concussion. How can these possibly be held up as responsible actions or achievements in preventing or limiting concussions?

None of these factors have any influence whatsoever on tackling players placing their head in front of knees and hips instead of to the side, on players running too upright into contact and clashing heads, or players hitting each other in the head with swinging arms and cocked elbows.

Two weeks ago the NRL announced a crackdown on foul play with respect to head high contact. What has happened since then?

Newcastle’s Kurt Mann was visibly concussed after being forcefully struck in the head by a raised forearm by St George Illawarra’s Mikaele Ravalawa. Ravalawa escaped penalty, sin bin or suspension.

Canberra’s Charnze Nicholl-Klokstad failed an HIA after being struck in the head by a swinging arm from Penrith’s Viliame Kikau. Kikau escaped penalty, sin bin or suspension.

Charnze Nicoll-Klokstad (Photo by Jason McCawley/Getty Images)

The Gold Coast’s Philip Sami failed an HIA after being struck in the head by the shoulder of Newcastle’s Tyson Frizell. Frizell was placed on report but escaped suspension.

And what about Canberra reserve grade player Matt Frawley, who was hit in the head with a late swinging arm by former State of Origin player Andrew Fifita, currently playing reserve grade for Newtown while on Cronulla’s books?

Fifita was placed on report, but escaped suspension for what can only be described as a brutal shot, (ironically, Fifita was subsequently suspended for three weeks for a crusher tackle this past weekend).

That’s some crackdown.

Similarly, what is there to be said for V’landys’ claim that clubs are outstanding in the way they detect and monitor head injuries? Anyone who saw Canterbury’s Lachlan Lewis concussed against South Sydney and allowed to play on would surely question V’landys’ definition of “outstanding”.

And what is to be made of the NRL parting ways with its chief medical officer of six years, Dr Paul Bloomfield? In what is surely a key role, the NRL is replacing a full-time sports doctor with a part-time advisory panel, to be headed up by what is understood to be a non-physician, “medical operations manager”.

It is telling is that all of the discussion from club officials and media commentators in the wake of Nicholl-Klokstad and Sami’s concussions was not about their head injuries, but about the fairness or unfairness of the 18th man rule, and an anomaly that didn’t allow either concussed player to trigger that replacement because the offender hadn’t been sent to the sin-bin.

This is symptomatic of a fundamental misunderstanding and manipulation of the concussion issue within rugby league.

The focus is in all the wrong places. Words are not being matched with actions. Concussions in the NRL have not been halved overnight, just because, as Pearce highlights, “in changing their definition of concussion, the NRL has moved the goalposts to suit themselves”.

Ironically, the outcome is one that people on all sides of the debate can agree on: the issue of concussion in rugby league has been fixed.