No worries, and thanks for writing it. I’m not majorly opposed it much of it, and I appreciate what you’re doing to get the conversation out there. It’s important for everyone to be open and even for WR to be held to account. And I can see your point about the messaging, and we must learn from such engagements. I was particularly impressed by the discussion here, which is what triggered my replies.

As for the Brain Initiative, it’s a really difficult one because as I said elsewhere in a comment, I don’t think it is fair to characterise it as a marketing play in the same vein that tobacco used, because the science (eg: Lancet) is quite clear about the multifactorial nature of dementia, and so anyone who is involved in prevention and/or treatment would recognise that a holistic approach towards it would involve management of all those factors.

It’s kind of like if you wreck your knee running, you see a sports physician, and yes, the running is clearly the trigger for that injury, but that doctor is also obliged to assess your shoes, your gait, your flexibility, muscle strength imbalances, leg length discrepancies, core strength, your running habits (always running on the one side of the road, for instance) and then to manage your injury risk by adjusting those factors in addition to managing the training load.

So I do think the initiative has been misconstrued as ‘sleight of hand’ when in fact it is a genuine attempt to ensure that we can provide input that means fewer players at the age of 50 or above present with these symptoms. The sport is genuinely invested in reaching the best solutions as fast as possible, which I realise probably sounds trite, but it’s true!

Thanks for your work, I hope I didn’t come across as too defensive, but the dialogue here is important and welcome!

Ross

Well, that study, where to begin? I was in the meeting where the coaches and the researchers (not us, it was the RFU) discussed the trial and it was a hostage negotiation. The coaches didn’t want to do it. They said it was interfering with their competition, that they didn’t see why they should have to do it, they said they couldn’t teach their players new techniques quickly enough etc? That’s why it went from an initial plan of doing it in the entire season to doing it in the Cup competition of that same level of tournament. So it ended up being wedged into an 8 week period in the middle of the normal season, in a cup competition where the teams generally select second string players to give them a run, in a competition that didn’t have good historical HIA monitoring processes. It was doomed from the beginning because there was no buy-in, no collaboration and we (WR) didn’t think it would work anyway.

SO then what ended up happening, and you can see this if you look at the actual study, is that they found over the course of 8 weeks, 7 in which there is no meaningful variation from their weekly 1 to 3 concussions. But in one week, they had 7. Is this an aberration? Yes. They also had zero in two weeks of the control. So it looks very much like they were statistically underpowered to deal with those kinds of variations, because we know from regular monitoring that we do sometimes see many concussions on a weekend, and other times none, but over long seasons, that kind of comes out in the wash. Not in a study where you have basically eight data points from each.

Further, the way they communicated to the coaches, they created this situation where the players changed the way they played, because the change was too extreme – this is the point I was making above – if you make changes that are too sweeping and too large, and you make a really big deal of it, then you end up creating modified behaviours due to resistance, and you end up cancelling out the change you’re looking for.

Indeed, going back a few months, when we first found what we did about the research, we held a meeting in Dublin where a number of international coaches and players attended, and I shared with them the data showing the risk was higher when upright, and contact was high. Their advice then was a) use existing law and sanction more harshly to drive players lower, b) education on technique, c) explore protective equipment, d) prioritise rehabilitation, and then e) explore lower tackle heights in YOUTH competitions where you can do so safely.

So the elite coaches knew then that the idea of going into a pro competition mid-way through the season was doomed. They advised against it. We didn’t think it was a good idea to thrust this literal change in height on adult elite players. However, we did think that it would be very useful in younger players and lower level players, and so we backed two other studies. One was a study in University players in SA, which has just been completed (it was meant to be done in2020, but covid happened), and it shows that injury risk comes down over time as players adjust to the new height. So in other words, for the first few weeks, there is no change in risk but by 3 months, it’s started to decline and ends up being lower. And then the French have a trial in all their competitions below D2 (so third division and lower) which has shown the same thing – no change at first, but the message gets through, the adjustment is made, and then the risk is lower.

The RFU are now trialling a similar concept in children, and it will, I am confident work, because it’s the appropriate group for long enough.

The idea that that study wouldn’t work was obvious to anyone who saw its implementation. But equally, the data are so clear, in both League and Union, and it’s also logical – prevent the heads from being in riskiest “airspace” and you’ll reduce the risk of harmful head contacts. And we know, from looking at close to 10000 tackles across three studies in two codes, what the riskiest situation is, and it’s not a bent BC and bent tackler, it’s when players are upright. This, by the way, is probably a biomechanical issue, because it likely limits rotation of the head or linear acceleration (think of boxers in the ‘safe’ position during fights).

There’s a research article in The Lancet, the latest iteration of an ongoing series that explores risk factors for neurodegenerative disease. If you’re a clinical, and Ritchie is, and you did NOT acknowledge all the factors that are described in that article, you’d be negligent and guilty of not doing your job properly. To accuse him, and by extension WR, of using a playbook like antivaxx and tobacco, is an insult to science. If the picture is becoming clearer, and the risk factors are known (and even quantified – look up Lancet, and see how it is informing best-practice in the dementia and neurodegenerative space), then clinicians are obliged to communicate that message, and apply the science to their practices. The fact that WR are then partnering with these already existing clinics should be applauded, not condemned. And yes, insert accusations of my own bias here, but I just cannot see how anyone who is actually involved in the world of treating these patients could do so without trying to contribute to mitigation and prevention by applying the FULL set of knowledge, not the selective bit you wish to.

The misinformation, ironically, is coming from you, because the science is quite clear.

This is incorrect. The HIA has been assessed for accuracy and its performance is comparable with most diagnostic tools used in clinical settings. There are numerous research studies on it. It’s not perfect, not at all (sensitivity and specificity are both in the range of 90%).

This is better than the EEG scans and other brain scans you all seem to believe hold the answers. If they did, I guarantee you the sport would be using them in the elite game, but they do not yet have the necessary specificity in particular, and there is significant dispute among experts as to how best to interpret these brain scans in the diagnostic process.

Woodpeckers have a hyoid bone that basically acts like a seat belt for the brain, preventing excessive accelerations when they peck. They also appear to vary the path of pecking so that they don’t get overuse injuries or repetitive damage in the same area of the brain. World Rugby (well, I did) considered this, actually, to see if the principle of the hyoid in particular might inform helmet design, but to date, there is no helmet that is known to prevent concussion.

May I ask then – put WR on track. What should they be doing, in your opinion? What would your wishlist for 2022 look like? You talk about “mitigation”. What do you mean, that isn’t already being done?

I feel this is an unfair characterisation of the initiative. Those brain health clinics already exist – they apply the research into dementia and neurodegenerative disease into informing the treatment of people with those conditions. World Rugby identified and then partnered with them to offer a service to players that is intended to support their after-career health and improve outcomes. I believe it is unfair and inaccurate to characterise this, as the original poster did, as a “cast some doubt marketing playbook”.

There is a study, published in Lancet, totally independent of sport (or any other single entity or domain) that very clearly outlines the contributors to dementia. That article, incidentally, even goes so far as to quantify the size of the contribution made by each to the overall societal number of the cases.

To take that, the leading current thinking on this subject, and then base an intervention strategy that aims to support players, is not marketing. It’s best practice. It is saying that if Person A, for whatever reason, develops dementia or any other symptoms, the clinical approach will be to consider 12 factors and optimise and change those than can to improve that person’s outcomes, just as it would be for Person B. That A did not play rugby and B did is not relevant to the clinical care received by the player after the fact.

What has happened here is that you have, either accidentally or deliberately, portrayed this as some kind of sleight of hand, a “look over there gesture”, but that’s not fair or accurate. Instead, this is an attempt by WR to support clinical care by recognising that brain health clinics that ALREADY apply the known science to treatment may be able to extend that into the care of rugby players.

these studies exist. They show a very complex pattern. Q2 is higher than Q1 and Q4 is higher than Q3, so it would appear that half time allows a reset or recovery that reduces risk. But, then again, the change in players allowed by subs may be the factor there too. Until it is known a) who is injured? b) who is their direct opponent when injured, and c) how many minutes both injured and opponent have played, this question is impossible to answer with certainty.

Our data, for what it’s worth, found no increase in head injury risk over time in a game, but we could not account for substitutes in this, and given that by the last 10 minutes about half the players on the field have played less than half the match, there is a big piece of the picture still missing.

I just saw this and wanted to reply specifically to the subs thing. A lot of people think it’s really simple, but it’s not. It’s actually a really tricky area and if your’e not careful, cutting subs will raise the injury risk. that’s because there are two models to explain injury. One is a size-speed model (let’s call it kinetic energy), and the other is fatigue. If the first model is dominant, then cutting subs would help, because players would be slower as a result of fatigue, and smaller as a result of a change in conditioning (in theory, I’m not convinced this is true). But if it is the latter, and fatigue is dominant, then cutting subs would make the situation worse.

So a lot of people are of the opinion that cutting subs is obvious – far from it, and it would take significant and complex research to try to predict which of the outcomes is most likely. I am saying this from the perspective of being involved in that research. here is a podcast that explains the issues in a bit more detail: https://play.acast.com/s/realscienceofsport/should-rugby-reduce-the-number-of-substitutes-to-lower-injur

I have thoughts about the ruck – these things are easily solved from afar, but let me tell you, put half a dozen of the top coaches of international and elite club teams together and you discover, as they say, “it’s a little more complicated than that”

Hi all

Interesting article. For the sake of disclosure, I am the research scientist who did the research on how head injuries happen in rugby, and which is the basis for the attempts to get the tackle height lower (and the speed into contact, but that’s a broader story). I am a consultant to WR so you may interpret the below as biased if you wish.

I think a few things re the tackle are worth mentioning. The whole point, from the start in 2017 was to use sanction to drive behaviour change. It has been a back-and-forth with the coaches, media, players and referees because we are in effect trying to change culture, and that is always difficult. The first month after the ‘zero tolerance’ directive was announced, 95% of media articles were condemning of the attempts, saying that the game would be ruined by a spate of red cards. Referees, perhaps unsurprisingly, since they are human after all, did not apply the strict sanction of red cards often enough, because when they did, they were heavily criticised for ruining the game. This criticism cam from coaches, players, fans, and the media. It still happens, of course. I’m encouraged by the level of discourse in this discussion, actually. You seem to “get it” in ways that I can’t say many WITHIN the rugby family have at times!

In any event, the inconsistency and infrequent application of sanction meant that we didn’t feel the message was strongly enough sent and received. We had, for instance, ONE high tackle penalty a match, 1 yellow every 5 matches and a red card for a high tackle every 23 matches (if memory serves me – it was my job to manage and track the sanction application after we made the changes). So in response, we introduced the HTSF to try to give referees a systematic tool to guide the process. That too was met with major resistance, especially at the World Cup.

At this point, it’s worth pointing out that in all these decisions and changes, you absolutely HAVE to bring the players and stakeholders with you. If you implement a theoretically viable solution but lose the buy in from within the game, you lose everyone before you begin the journey. That’s not to say that the tail wags the dog, but it is realistic and understandable to accept that if changes are rejected because they’re deemed ‘extreme’ then you achieve nothing, and so you end up trying to find the best levers to pull to achieve change without alienating people. And finding that point, almost like ‘titrating’ the size of the dose you give, is a major challenge.

So now we have the HCP, the latest iteration, which is heavily driven by coaches and players, and the sanction you get for the cards is part of that. I understand the frustration at the apparently leniency, but again, as I mentioned above, we are constantly searching for the ‘threshold’ that will achieve a change in behaviour without totally alienating the game.

I say this because I see comments above, like “World Rugby stuffing it up since forever” and I find those very unfair (and yeah, you may accuse of bias here). If we said “12 weeks for a high tackle, no chance of reductions”, we’d be absolutely hammered from the OTHER side for being too harsh and punishing players for actions without intent (and don’t get me started on intent – one poster above nailed it with the drunk driving analogy, intent doesn’t matter, the outcome does as a consequence of the initial behaviour – there are loads of upright tackles that are not illegal, because they happen not to cause head contact. Anyway, i digress).

My point is, setting the appropriate sanction is tricky. The players, understandably reject very very long sanctions. Too short, and it’s not a ‘large enough stick’ to drive the behaviour change that the sanction is supposed to achieve. I am sure you can appreciate the dilemma here.

As for the softening of the sanction which the original author was critical of as “attending counselling”, the point there is that given our basic premise that sanction carries the message to change behaviour, offering technical education to players after sanction would amplify the message, and force the coach to really think about what the original error was. how can that player’s technique be addressed, and thus, by extension, can we ‘percolate’ that message to the rest of the squad? I think it’s actually quite a good way to make sure that the red card, applied to one player, creates a message that then reaches more than one player by going THROUGH the coach. Maybe some will disagree, but we are trying to drive the technique changes that I think many of you recognise matter.

Last couple of points, because i din’t want to write an entire article here – the bent ball carrier isa problem, but maybe not as large as you might think. The risk when the BC is bent, to either himself or the opponent, is actually quite low. Remember, I did the studies on this, and I can provide you with the exact figures if you want (or google Tucker head injury mechanism rugby and you’ll find a series of papers in both Union and League), and the bottom line is that if players were bent into contact, they would BOTH be protected, and so if we had to choose either bent or upright, it’s clear that we’d rather players are bent. The best combination of course is if the BC is bent, the tackler should remain up and ‘soak’ the BC into their torso, and if the BC is upright, the tackler should be bent (not fully, mind – head of the tackler near the torso of the BC is lowest risk).

And finally, I found the quote by Sean Edwards a bit disingenuous. He was involved in one of the consultancy processes we ran (we consulted top coaches very widely in trying to craft the strategy) and so the data was shown to them, and they know what carries highest risk AND lowest risk. Highest = high contacts, with head to head and head to shoulder proximity and impact, while lowest is when there is no head proximity for the tackler, or the tackler’s head is near ball carrier’s torso and vice versa. This is known by all, there is no secret being kept from them.

Anyway, that’s all from me for now, I have thoughts on the brain clinic I can respond to, but perhaps another time, I just thought I’d contribute to what is a very well informed discussion which I have enjoyed reading, thanks!

Ross Tucker