Concussions and Protecting Our Players

[Strewthcobber]

But there has already been a 2 year trial using headgear with increased foam padding and the evidence was that it had no impact on concussion.

McIntosh performed a randomized controlled trial of rugby players in Australia with modified headgear in the 13- to 20-year-old age groups over a 2-year period. Comparison was made with the popular habit of not wearing headgear, standard available International Rugby Board headgear, and a new experimental headgear with added foam density. The intention-to-treat analysis showed no difference in the rates of head injury or concussion between controls and headgear arms. The final conclusion is that the board could not recommend modified headgear for reduction of concussions.

The issue McIntosh found was that the players simply stopped using the modified headgear - it was too hot/uncomfortable. It meant getting a statistically significant result was difficult as the n was too low

Also worth noting that even the modified headgear couldn't reduce enough energy under testing to attenuate the head impact forces experienced by players on the field.

However - from the study

Players wearing the modified headgear had the lowest rate of head injury
resulting in a missed game. The incidence rate ratio for concussion for
modified headgear wearers was 0.43 compared to no headgear (reference) and
IRB headgear 1.1. This suggests that the severity of the head injury or
concussion was reduced for modified headgear wearers compared to players
either wearing IRB approved headgear or no headgear.

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[Strewthcobber]

So, uh, just make the headgear thicker?

Players won't wear thicker headgear as it's too uncomfortable. It also results in more injuries/risks elsewhere - particularly neck injuries

(Yep, it's complicated!)

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[The Honey Badger]

I don't doubt the research for a minute. I am sure that the studies done have credible findings which may have been peer reviewed.

However, I do think the studies are floored in their design. (Mainly because players prone to concussion wear headgear)

For what it's worth, my conclusions on the studies show 2 clear findings;

1) The current adhoc and voluntary wearing of headgear (which is in my observation a small minority of players) does nothing to reduce concussion.

2) The current design of permitted headgear does nothing to reduce concussion.



Let me pose a Hypothesis.

If a trial were constructed where all 30 players on the field wore the modified headgear were conducted, we may see a statically significant reduction in rate of concussion and head injury.

The main premise for the hypothesis is the fact that head on head clash is no. 1 cause of concussion and the padding of every head will in effect double the padding. This would be expected to have a greater effect at diffusing force of impact and reduce concussion and injury in the process.


If all players on a field were required to wear headgear, then the idea that headgear leads to more dangerous and risky play would be nullified. Over time it would be normal and no perceived advantage.

As for heat generated by headgear, that should be able to be overcome through design and type of material used.

As for headgear having an unintended consequence in higher incidence of neck injuries. I have NFI.

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[The Honey Badger]

Just another aside,

Does anyone know what the incidence of concussion and head injury is in 7's rugby? Is it any different?



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[Quick Hands]

Just another aside,

Does anyone know what the incidence of concussion and head injury is in 7's rugby? Is it any different?



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I don't know, but I suspect that it's probably less than 15 aside.

I base this on the US study in 2001, which essentially says that to that point rugby worldwide substantially underreported concussions. It also notes the nature of the game.

I'll leave you with a couple of excerpts:

Concussion is of particular concern in rugby. Participants are largely unshielded from collision forces, and the cranium is subjected to violent acceleration-deceleration and rotational forces. Mouthguards and soft-shell head protection are used by some players, but their effectiveness in preventing concussion in rugby is open to question.2,3 To complicate matters, much of the world's rugby is played in situations in which medical personnel are frequently not present. Those medical personnel who are available are often not well trained in recognizing and managing concussions. An administrative barrier also affects concussion identification and management. Under the rules of the game, as promulgated by the International Rugby Board, any player who self-reports or is diagnosed as having a concussion is subject to an automatic 3-week suspension from all competitions and team practices. This mandatory 3-week “stand-down” period is supposed to apply even when a player sustains a very mild injury and returns to a normal level of functioning within minutes. As a result of these factors, we came to suspect that many rugby concussions go unreported.


The 10 studies reviewed herein were conducted in several different countries and covered both high school and adult playing populations. Nevertheless, the pattern is consistent, with all 10 studies producing estimates of concussion incidence well below those seen in Highland rugby. We present 2 explanations for this finding. First, the style of rugby played at Highland involves a greater risk of head impact or higher forces of the type needed to generate concussions, or both, resulting in a greater incidence of concussive injury. Second, previous researchers have underestimated the true incidence of concussion by varying degrees.
Specific characteristics of the Highland style of play are distinctive. More than half of the players have a background in North American football, which results in more emphasis on the “body-check” style of tackling. However, it seems implausible that differences in style of play could explain why rates of concussion in a Utah high school are 100 times greater than those reported in an Australian high school.7Methodologic differences must account for most of the variation in concussion incidence among the various studies. Assuming that the Highland data represent a valid estimate of the true incidence of concussion in the playing populations detailed in the Table, the previous epidemiologic studies5–13 have probably underestimated the true incidence of concussion in rugby, in some cases by a substantial margin.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155428/

 

[Strewthcobber]

Just another aside,

Does anyone know what the incidence of concussion and head injury is in 7's rugby? Is it any different?



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Epidemiology of concussion in men's elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup, Junior World Championship and Rugby Trophy, Pacific Nations Cup and English Premiership)
https://bjsm.bmj.com/content/49/7/478.short

Results The incidence of concussion in Rugby-7s was significantly higher than that in Rugby-15s (risk ratio=1.84; p<0.001). The severity of concussions were significantly higher in Rugby-7s than Rugby-15s (mean—Rugby-7s: 19.2, Rugby-15s: 10.1; median—Rugby 7s: 20, Rugby-15s: 7; p<0.001). The main causes of concussion were tackling (44.1%) in Rugby-7s and collisions (43.6%) in Rugby-15s. Significantly more (risk ratio=1.49; p=0.004) concussed players were removed immediately from the game in Rugby-7s (69.7%) compared to Rugby-15s (46.7%).

 

[Braveheart81]

This is what i always thought, but presumably a brain inside a hard helmet would still experience the exact same deceleration as a brain inside headgear, so why are NFL concussions less common? i would believe dodgy reporting or otherwise the impact must have some effect.

I wonder what the stats are like for higher force impacts, like motorcycle accidents where helmets are worn.

I would guess that in NFL tackles are generally lower because there isn't the need to stop a player from offloading. The sole requirement is to bring them to ground (and they don't even need to be held so diving at the legs is common). There are a lot of tackles that attempt to knock the ball loose but that is generally around waist height.

There are some helmet to helmet contacts and they tend to be brutal and are highly illegal where they are intentional. These generally result in the ball carrier coming off far worse and often occur when they are defenceless.

From what I have read, the NFL CTE problems seem to generally come from many lower impact acceleration/deceleration events over a career rather than a few concussions.

 

[Quick Hands]

I don't doubt the research for a minute. I am sure that the studies done have credible findings which may have been peer reviewed.

However, I do think the studies are floored in their design. (Mainly because players prone to concussion wear headgear)

For what it's worth, my conclusions on the studies show 2 clear findings;

1) The current adhoc and voluntary wearing of headgear (which is in my observation a small minority of players) does nothing to reduce concussion.

2) The current design of permitted headgear does nothing to reduce concussion.



Let me pose a Hypothesis.

If a trial were constructed where all 30 players on the field wore the modified headgear were conducted, we may see a statically significant reduction in rate of concussion and head injury.

The main premise for the hypothesis is the fact that head on head clash is no. 1 cause of concussion and the padding of every head will in effect double the padding. This would be expected to have a greater effect at diffusing force of impact and reduce concussion and injury in the process.


If all players on a field were required to wear headgear, then the idea that headgear leads to more dangerous and risky play would be nullified. Over time it would be normal and no perceived advantage.

As for heat generated by headgear, that should be able to be overcome through design and type of material used.

As for headgear having an unintended consequence in higher incidence of neck injuries. I have NFI.

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But the relevant studies didn't involve the "ad hoc wearing of headgear" There was a group wearing headgear and a control group not wearing headgear.

The evidence is clear though, that the more rigid and/or heavy the headgear the greater the risk of neck injury - presumably because the neck and spinal cord are quite thin and would be required to support greater weight than they were designed to.

What follows are my opinions, based on a lifetime of playing, coaching, refereeing and watching the game.

What I'd suggest is that it's the very nature of rugby (and rugby league for that matter) which is the issue.

Firstly, since the advent of professionalism all collisions now have greater force - even at elite amateur level. Players in 1st/2nd XV, 16A, 15A are mostly on S & C programmes have have much greater muscle mass than their peers of 30 years ago. Secondly, as the US study noted there are no forward passes or blockers in rugby and like American Football the teams line up opposite each other. This makes every phase of rugby confrontational, with collision impact at every tackle.

Interestly, go and watch a 13F or 15E game and most of these confrontational collisions don't exist. Tackling is largely grabbing and wrestling from the side (or non-existant), rucks are relatively passive, etc.

As you and others have noted - the majority of concussions occur at the tackle and involve a head clash. If the tackler is tackling low, then this can't occur. So despite the naysayers, I think that WR (World Rugby) is on the right track with restricting tackles to below the nipple line. Assuming that this law is enforced, then all injuries at the tackle which involve a head clash would disappear. I'd also stop lifting in general play (i.e. the Folau incident v Ireland)

 

[Quick Hands]

Epidemiology of concussion in men's elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup, Junior World Championship and Rugby Trophy, Pacific Nations Cup and English Premiership)
https://bjsm.bmj.com/content/49/7/478.short

Well there you go, I wasn't expecting that result. I presume because the speed of collisions are greater?

 

[Strewthcobber]

Well there you go, I wasn't expecting that result. I presume because the speed of collisions are greater?

I think there's a bit of evidence out there that concussion risks rise later in games and with more games in a torunament - There's no real equivalent in 15s of the fatigue that you feel in the 14th minute of your 6th game in two days.

Do they make more tackles/min? Probably more one-on-one tackles at least

 

[The Honey Badger]

Epidemiology of concussion in men's elite Rugby-7s (Sevens World Series) and Rugby-15s (Rugby World Cup, Junior World Championship and Rugby Trophy, Pacific Nations Cup and English Premiership)
https://bjsm.bmj.com/content/49/7/478.short

Strewthcobber, you are a world of information.

I would not have thought that.

I can only think the higher speed of the game leads to higher impact collisions.

Obviously a very complex subject and no easy fix.

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[The Honey Badger]

So despite the naysayers, I think that WR (World Rugby) is on the right nipple line. Assuming that this law is enforced, then all injuries at the tackle which involve a head clash would disappear.

Great Post QH,

There is only 2 ways to improve saftey in the game that I can think of.

1) through modification of the rules.

2) with the use of protective sportswear.

I would advocate much more can be done with both.


I am in favour of the Nipple line rule.

I even think jumpers should have a line at the Nipple showing the legal height. or else a V (old league style, like Waverly) where perhaps contact with the point of the shoulder would be permitted.

Just a thought and I am sure will have plenty of opposition on here.

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[Derpus]

From what I have read, the NFL CTE problems seem to generally come from many lower impact acceleration/deceleration events over a career rather than a few concussions.

I recall reading an article (probably Guardian - don't remember) which was reviewing a study that suggested professional soccer players suffered similar effects from constantly heading the ball. They suggested a large number of very low impact collisions will still have detrimental effects on the brain, often severe effects.

Whenever i consider this i always come back to the same problem; You simply cannot have contact sport without a significant risk of injury, either acute or chronic. Where do you draw the line between damage mitigation and detriment to the game?

If longevity of life is the aim of the game then no one should play contact sport, period.

Edit: Just read QH's post and i agree for the most part but disagree that the nipple line will substantially reduce concussions and brain related injury in the long run. Our discussions about concussion should focus more on education and informed consent than prevention.

Double edit: Will the nipple line rule have rules about how an infringement is governed if the tackled player was, for example, bent over when the tackle was attempted?

 

[Derpus]

As you and others have noted - the majority of concussions occur at the tackle and involve a head clash. If the tackler is tackling low, then this can't occur. So despite the naysayers, I think that WR (World Rugby) is on the right track with restricting tackles to below the nipple line. Assuming that this law is enforced, then all injuries at the tackle which involve a head clash would disappear. I'd also stop lifting in general play (i.e. the Folau incident v Ireland)

A head clash can't occur, but how often do we see the defender get his head on the wrong side of the legs and get knocked out that way?

 

[D-Box]

Some of the issues around epidemiology of concussion is it depends upon how you define an injury. A lot of research uses missed games as the criteria for an injury to be recorded. If you look at the AFL Injury survey (http://www.afl.com.au/staticfile/AFL Tenant/2017AFLInjuryReport.pdf) which uses this definition you see that concussions are at 1.46 per team per year, however actual concussions (from the same report using the same calculation) is at 7.

Things like this come to play in the study comparing concussion between 7s and 15s players. When you look at severity which is assessed as time to return 7s player are stated as taking longer to come back, however it also shows that if you were concussed in the first of a tournament pair you were more likely to return within 7 days than if concussed in the second weekend. You can draw from that that the speed at which you return is partially dictated by playing demands with 15s players more likely to return faster as they play every weekend.

The paper also shows, like others that greatest percentage of injuries occur to the tackler. (Collision being the second highest and I have no idea what that is as all other contact phases are listed). If you get injured as the tackler you are likely to have utilised poor tackling technique or everything is faster (https://bjsm.bmj.com/content/50/15/932 / https://bjsm.bmj.com/content/early/2017/10/11/bjsports-2017-097912.long). The second paper is also the one in which the nipple line tackle is based.

 

[Strewthcobber]

A head clash can't occur, but how often do we see the defender get his head on the wrong side of the legs and get knocked out that way?

Have a look at the links I posted a couple of weeks ago - there's extensive discussion on exactly this.

The trade-off between an increase in head to lower body impacts are vastly outweighed by the reduction in head to head and head to shoulder impacts

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[Derpus]

Have a look at the links I posted a couple of weeks ago - there's extensive discussion on exactly this.

The trade-off between an increase in head to lower body impacts are vastly outweighed by the reduction in head to head and head to shoulder impacts

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ay, but what do we do in 5-10 years when we decide that lower body impacts still result in an unacceptable number of concussions/brain injuries?

 

[Strewthcobber]

Strewthcobber, you are a world of information.

I would not have thought that.

I can only think the higher speed of the game leads to higher impact collisions.

Obviously a very complex subject and no easy fix.

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Open Google scholar -> search for what you want!

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[Strewthcobber]

ay, but what do we do in 5-10 years when we decide that lower body impacts still result in an unacceptable number of concussions/brain injuries?

Touch footy

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[The Honey Badger]

Players won't wear thicker headgear as it's too uncomfortable. It also results in more injuries/risks elsewhere - particularly neck injuries

(Yep, it's complicated!)

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Would like to a bit more about that.

Could it be that research comes from American football??

I could imagine a hard helmet transferring force to the neck but hard to see how soft headgear could do that.

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