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Why World Rugby’s Brain Health Initiative is making my head hurt

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28th November, 2021
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World Rugby’s recently launched global campaign called ‘The Brain Health Initiative’, is aimed at educating people within rugby on the importance of brain health.

A statement made at a World Rugby Medical Commission conference in London, said that the purpose of the initiative was to “make rugby safer, and to make it the most progressive sport on public welfare.”

Its centrepiece was the release of a video, highlighting the work of “leading experts” who identified 12 modifiable risks of dementia so as to optimise brain health, and inform players about what to do if they suspect they have a brain injury.

University of Edinburgh professor, Craig Ritchie, explained how, “dementia isn’t necessarily a consequence of one factor”, and how rugby players can maintain good health by actions such as “tackling stress, anxiety and depression to reduce certain risk factors.”

World Rugby Chairman Bill Beaumont chimed in, saying that, “good brain health is much wider than what happens on the field, and we have more control over it than what we think.”

“It’s about creating community, starting conversations and building an understanding of how we all can make lifestyle changes that can positively impact our long-term wellbeing.”

Perhaps the Pimms had been too liberally splashed across World Rugby’s board table that day, but Beaumont presents as the New York news reporter pointing to a fire in a sidewalk trash can, while the Twin Towers burn and collapse over his shoulder.

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Welsh player Adam Hughes is one of a group of players – now numbering in the vicinity of 175 – who are taking legal action against rugby’s governing body, as a result of brain injuries suffered as a result of playing the game. He spoke for many when he said that the video was “disappointing” and felt “just a bit patronising.”

Hughes qualified his comments by praising an initiative to allow ex-players access to specialised brain clinics, so as to monitor their health more regularly. But there is no getting past the fact that, by incorporating a range of lifestyle behaviours into the discussion, emphasis on concussion and its main causes and effects, has been substantially watered down.

“The video basically says, ‘look, there’s 12 reasons why any current or former player can be suffering from brain health, only one of which is getting your head knocked around playing rugby’,” said Hughes.

Even if the video is strictly medically correct, in the context of rugby’s concussion problem, it is misleading and dangerous. By identifying and grouping together all possible causes of early onset dementia, World Rugby has effectively picked out eleven pieces of small, low-hanging fruit, while the watermelon in the room – repetitive head injury – has merely been afforded equal standing.

Further, dementia is just one of many debilitating conditions potentially in play. By being so narrow in its focus, World Rugby’s announcement does not fully account for all of the medical considerations and concerns faced by concussed players.

A concussion advert during th Six Nations Rugby Championship

A concussion advert during the Guinness Six Nations Rugby Championship match between Scotland and Ireland at the BT Murrayfield Stadium in Edinburgh, Scotland. (Photo By Ramsey Cardy/Sportsfile via Getty Images)

As respected neuroscientist, Associate Professor Michael Buckland, from the University of Sydney, noted about the misplaced emphasis on Twitter; “not the sole cause of dementia, but repetitive head injury is the only known risk factor for CTE”.

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What is clear is that, while rugby players suffering the after effects of repeated concussions may have some lifestyle factors in common, and others not, what they indisputably all have in common, over the course of their playing careers, is being hit repeatedly in the head.

So, what are we to make of this development? Is it conspiracy or stuff-up? Convention usually points to the latter, but there is no escaping the feeling of an uncomfortable shimmy to the former.

To its credit, World Rugby can point to a body of work on concussion management, adopting an evidence-based approach to incorporating a number of adjustments to laws and refereeing guidelines, designed to make the game safer.

Under World Rugby’s guidance, national unions administer programs which ensure that concussion protocols are enforced at all levels of the sport, and which carry extra protections for junior players. For professionals, a guideline to limit the number of contact minutes in training to 15 per week was introduced in September.

By contrast, in adhering to 2017’s global Consensus Statement on Concussion in Sport, World Rugby still employs return to play protocols that allow, in some cases, concussed players to return to play within a week of suffering a concussion. This despite research from neuroscientists, including Melbourne-based Associate Professor Alan Pearce, indicating that the brain can take 28-30 days to recover from the impact of trauma.

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Not only is the Consensus Statement dated, it was discredited when a 2020 expose by Jeremy Allingham of the Canadian Broadcasting Corporation found that of the 36 expert panellists who compiled the statement, 32 happened to have connections to organisations and sports where concussion is a major issue.

There are numerous examples of global corporations failing to adequately address matters of health and safety. Tactics employed typically include inadequate response to failures and breakdowns, obfuscation, the creation of confusion in calling for more evidence, the commissioning of lengthy, irrelevant research or studies with pre-determined outcomes, abnormally high legal and public relations costs.

There is now widespread awareness of concerns around concussion in rugby, due to the advocacy of affected players like Alix Popham, Jamie Cudmore, and Steve Thompson; publicity around recent player retirements such as Carl Hayman, Dane Haylett-Petty and Dillon Hunt; the formation of new advocacy groups like ‘Progressive Rugby’; and the work of journalists such as Andy Bull (UK) and Dylan Cleaver (NZ).

Anybody who plays or who has played rugby, who has a child playing rugby, who watches rugby, will have first-hand experience of concussion. Accordingly, there is not a person in the game unaware of the extent of the problem and who doesn’t understand the link between repeated head injury and brain damage.

As technology continues to deliver more diagnostic certainty, links between head injuries suffered in the playing of rugby and the range of medical conditions suffered by players will be confirmed beyond doubt.

The existence of CTE can only be confirmed in the brain post-mortem, however Magnetoencephalography (MEG) scanning is now being used to determine probable CTE diagnoses in affected players.

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In such informed times, it seems inconceivable that World Rugby would choose to follow in the footsteps of discredited corporations like Philip Morris, Volkswagen and the NFL, to deflect, or to ignore its responsibilities.

But for that concern to be countered, they will need to be far more convincing and to the point than their Brain Health Initiative purports to be.

Ryan Matterson of the Eels after a head knock

(Photo by Cameron Spencer/Getty Images)

This is not the time to be hiding behind calls for wider research. More education. Better management. Focus should be squarely on two things; how to adequately look after past and future sufferers, and how to minimise instances of concussion, as urgently as is reasonably possible.

Whatever the eventual outcome of the legal action launched by players in the UK, through Ryland Lawyers, it is not unreasonable to expect a financial settlement to be either awarded or negotiated, on behalf of players party to the action.

Ongoing, to take matters out of the court system, a mechanism to establish and maintain a ‘concussion fund’ for affected players will need to be established. Indeed, this is one of the key objectives of the fast-growing lobby group ‘Progressive Rugby’, which met with World Rugby in June this year.

As to where the money comes from, it is surely not unreasonable for a sport that generates revenue in excess of A$500m in a World Cup year, and which is awash with private equity investors looking to cash in on its global potential, to be able to fund a sizeable player fund.

Long-time AFL player advocate Peter Jess has pointed to the vast sums of money generated from AFL by sports betting agencies, and recommended that the AFL (and other sports) look to a levy or similar, as a funding mechanism.

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It’s fair to assume that private equity investors and gambling companies are not drawn to rugby for the opportunity to have their profits shaved by contributions to a player fund. But as Jess explains, “why should businesses profit from a sport where players are endangering their health, without there being an obligation to appropriately recognise the risks that are overwhelmingly borne by the players?”

No matter the work done to date to lower tackle heights, it is evident that a viable solution – one which improves player safety outcomes without losing the essence of rugby – remains elusive.

In the recent autumn international season, numerous players were injured and/or unavailable for Test selection as a result of concussions suffered. On one hand, this can be construed as evidence that player management is robust and effective. Regardless, the fact that head injuries are so prevalent, is a huge and growing concern.

An illustration of the extent of the problem comes via a random sample of different ways head injuries were sustained.

Australia’s Taniela Tupou, the tackler, got himself into an awful position, against Scotland. Ditto Beauden Barrett against Ireland.

Welsh lock Adam Beard suffered a head clash as a result of Australia’s Rob Valetini entering the tackling zone far too upright. Teammate Ross Moriarty carried the ball leading with his head low, and was heavily concussed as a result of contact made by the shoulder of New Zealand’s Nepo Laulala in a double tackle.

South African superstar Eben Etzebeth, also slipping to the ground after initial contact, was hit in the head by England’s Tom Curry. Having suffered three concussions this year, Etzebeth, on medical advice, now faces a three-month stand down from the game.

Australia’s Andrew Kellaway misjudged a jumping attempt at catching a high ball, and hit his head on the Principality Stadium turf.

James Parsons of the Blues

James Parsons of the Blues walks off with concussion (Photo by Hannah Peters/Getty Images)

An array of accidents, half-accidents and non-accidents. Unsurprisingly, player management, adjudications and sanctions were all over the place.

Despite obvious forceful contact being made to his head, Etzebeth wasn’t required to submit to a head injury assessment (HIA), and was allowed to play on. His physio is never far from the action. How does rugby ensure slip-ups like this do not occur?

Curry was judged to be a victim of circumstance and not sanctioned, unlike Laulala, who received a yellow card. How does rugby deal with situations where ball runners stoop low into contact and lead with their head?

Tupou, Barrett and Valetini all went high into contact because the modern game demands and rewards offensive tackling. How will World Rugby encourage or compel rugby coaches to accept a depowering of the contest at the gain line? Is such a thing even realistically possible?

Valetini received a red card, was suspended for six weeks, reduced to three for ‘good behaviour’, reduced to two for Valetini ‘attending counselling’, with both to apply to two Brumbies trial matches that, in all probability, Valetini would not have played in anyway.

How does this outcome – effectively no suspension at all – provide confidence that World Rugby is providing effective deterrents to high tackling, and treating the issue with clarity and purpose?

These are just some of the high-profile cases, visible to television viewers all around the world, across three weekends. There were others. But what wasn’t visible to viewers were any sub-concussive hits; head knocks that don’t exhibit obvious symptoms, but which concern neurologists due to their deleterious cumulative effects.

Further, what isn’t known is the number of those hits suffered by those players in their junior and senior careers. A particular challenge is to reconcile action taken to reduce or minimise concussions with the probability that many of these players will already have suffered damage before they even became professional rugby players.

The autumn season also featured a series of Test matches between international women’s teams. How does World Rugby reconcile the growing popularity of women’s rugby with the evidence that females suffer disproportionately from the effects of brain injury?

And what of the player’s associations, at the moment hopelessly conflicted by financial ties to national administrations, and the desire of players to maximise their earnings while they are in the prime of their careers?

How comfortably does the obligation to advance their member’s financial interests sit alongside them sending their members into battle, to suffer head injuries in increasing numbers?

This is a devilishly difficult and complex problem to solve. It must be solved with haste. World Rugby’s Brain Health Initiative might sound warm and fuzzy, but it is no solution.

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