Advice on when to return to play after a concussion.

Folks, in the light of a few rugby-related concussions I've become aware of recently, including one to RDW_Scotland I figure it's worth having the IRB quidelines available as a ready reference, so I'm resurrecting MrsP's thread (below) and making it a "sticky". -KRD


http://irbplayerwelfare.com/concussion



This is a subject very close to my heart and a chat on another thread has just lead me to ask.

How many players/coaches/parents are aware of the most recent guidelines?

This is about protecting not just your rugby career but your quality of life and even, for youngsters, your life itself.

Summary Principles

Concussion must be taken extremely seriously to safeguard the long term welfare of Players.

Players suspected of having concussion must be removed from play and must not resume play in the match.

Players suspected of having concussion must be medically assessed.

Players suspected of having concussion or diagnosed with concussion must go through a graduated return to play protocol (GRTP).

Players must receive medical clearance before returning to play.

The new Guidelines are summarised below.

The IRB Recognise and Remove message incorporates 6 Rs[size=38]

Recognise -

Learn the signs and symptoms of a concussion so you understand when an athlete might have a suspected concussion.


Remove -

If an athlete has a concussion or even a suspected concussion he or she must be removed from play immediately.


Refer -

Once removed from play, the player should be referred immediately to a qualified healthcare professional who is trained in evaluating and treating concussions.


Rest -

Players must rest from exercise until symptom-free and then start a Graduated Return to Play. The IRB recommends a more conservative return to play for children and adolescents.


Recover -

Full recovery from the concussion is required before return to play is authorized. This includes being symptom-free. Rest and specific treatment options are critical for the health of the injured participant.


Return -

In order for safe return to play in Rugby, the athlete must be symptom-free and cleared in writing by a qualified healthcare professional who is trained in evaluating and treating concussions. The athlete completes the GRTP (Graduated Return to Play) protocol.[/size]


Who has read them or been made aware of their contents?


For anyone who has suffered a recent head injury, here is some excellent advice c/o Doctor Grey.


http://www.morrisrugby.org/images/pdf/2010parent-head-injury-instructions.pdf

And another video (about 10 mins) this time from the NFL giving some general advice about concussion.

http://www.nata.org/health-issues/concussion



For anyone who may be unaware of the extent or severity of the problem, this is an interesting Aussie TV program on the subject which aired just last week or so.

http://www.abc.net.au/4corners/stories/2012/05/10/3499950.htm

And this is why I am so animated about concussion!

http://www.theguardian.com/sport/2013/dec/13/death-of-a-schoolboy-ben-robinson-concussion-rugby-union

They actually look slightly watered down since I coached/reffed.

I have no evidence to support this (feel there should be a proper study done) but do feel that there are more incidents of concussion than there used to be - especially as the sport is much more physical. however it has taken a bit of a backseat to other issues in recent years. Concussion was the thing most monitored when I started playing with 3 weeks (rather than the 2 mentioned in teh document) as the minimum break. too many concussions and that was it, no more playing.

It is still 3 weeks before you return to play after a concussion unless the process is being supervised by a doctor.

The 2 weeks refers to return to execise.

Ah - proves I cannot read.

How long ago was the bang on the head then LT?

Should I add an option of:

I know about them but haven't read them properly?

Bravo, MrsP, thank you for this. Wonderful advice for all players - I shall bear it in mind when I'm banging my head of a brick wall

I think the advice on returning to "Banging your head off a brick wall" might be slightly different Asbo.

You should probably contact your sports national body to check. I believe their headquarters are in Glasgow!

Think theres less influence on coaching on how to tackle correctly/protect your head after going to ground.
I remember playing a match and no one else seemed to cover their head after going to ground, if they want to get a boot to head its up to them.

Mrs. P,
These guidelines are generally OK, and the graduated return to play is the right approach.

But, I don't like these guidelines for one huge reason. It gives mixed messages that it might be OK to not see a doctor after head trauma (the minimum 14 days before exertion if not seen by a doctor). This is completely wrong. If a person suffers significant impact to the head causing any of the well known symptoms, get to a doctor. There can be head trauma with knock-on effects not readily identifiable without proper evaluation. Only a proper eval can reveal the level of severity, if any at all. And properly diagnose if an post concussive symptoms exist.

There is a more recent body of study into what is now referred to as Second Impact Syndrome (SIS) where the brain has not fully recovered from a trauma when a second trauma occurs. In other words a player suffers a concussion and suffers a second one before the first has healed/stabilised. This is the most dangerous part of a concussion. The chances of permanent impairment and/or impairment later in life due to SIS is high. Most of the early research into SIS comes from the NFL.

When I was in medical school I banged my head and was knocked silly a couple of times. As a meathead at the time I did nothing except have a few beers afterwards and play the next week. Not generally considered intelligent. Also why sometimes I confuse the Rotator Cuff with the rectum (not really).

The guidelines are good to raise awareness about concussions. And, yes, I require my clubmates and the youth coaches to keep a copy since it is IRB issued. The IRB guidelines are too fussy and read as if they have been sanitised by bureaucrats and lawyers. But, their intent is 100% right.

Dr Grey,

I think we talked about SIS on the old 606, or was it here?

I know the guidelines must be well researched but I baulked a bit at the thought of anyone being back to full contact in 6 days. So much of the evaluation is dependant on full reporting of symptoms to the doctor.

I am concerned that the guidelines are not being dissemminated to players, coaches and parents.

Mrs. P,
You have a great memory, my congratulations.
Obviously you are not suffering from any post concussive symptoms, are you? And I think you are right, that was back on the old 606.

I think its terrific you are sharing the IRB guidelines. The safety aspects of rugby sometimes get shunted to the side. But for those of us who play and/or have kids who play, this is important. My main point is I don't want anyone thinking its OK to avoid a doctor in these instances. And I know you feel the same.

For anyone reading this, please take this seriously, and the IRB guidelines are quite good. Just please, make sure anyone who takes a head knock of any type, get checked by a doctor. If checked early, there is usually little to worry about. And thats followed by a nice, measured rehab.

doctor_grey wrote:Mrs. P,
You have a great memory, my congratulations.
Obviously you are not suffering from any post concussive symptoms, are you? And I think you are right, that was back on the old 606.

I think its terrific you are sharing the IRB guidelines. The safety aspects of rugby sometimes get shunted to the side. But for those of us who play and/or have kids who play, this is important. My main point is I don't want anyone thinking its OK to avoid a doctor in these instances. And I know you feel the same.

For anyone reading this, please take this seriously, and the IRB guidelines are quite good. Just please, make sure anyone who takes a head knock of any type, get checked by a doctor. If checked early, there is usually little to worry about. And thats followed by a nice, measured rehab.

nope, it's just regular senile dementia

Ignore Asbo,

He's from Scotland.


(Before I get into trouble from every Scottish poster, it's intended as an homage to Fawlty Towers)

Gotcha. But we should be kind to him, none the less.

No we mustn't Grey. We really mustn't. You'll only encourage him!

It's because he was raised on that terrible stuff they "make" up there. It's so bad they can't even spell it properly!

And, be warned, NEVER open a link posted by him!

You'll never be the same again I tells ya!

MrsP wrote:No we mustn't Grey. We really mustn't. You'll only encourage him!

My dear Mrs. P,
I remember in school reading about the land from whence Asbo comes. I recall it was a land tormented by constant winds and storms, populated with men with knobby knees who wear skirts and purses, and where people eat Hagrid (or is it called Henson, or Haggis, or whatever?).

Of course we shouldn't encourage Asbo over much. But we still need to treat him with tenderness and kindness. I admit it appears a fine balance. But I am bound by my medical oaths and my personal beliefs to help him. Madam, I beg you to understand. He is a Scotland/Exeter fan, and most likely the only one of his kind. From a purely scientific standpoint, both anthropological and sociological, fascinating (I wonder if we can dissect him at some point). Yet, strangely, I do find myself supporting the Rugby endeavours of his nation and club. He must be contagious.

But I will not open a link he posts. I may be a softy, but I am not crazy.

"... men with knobby knees who wear skirts and purses, and where people eat Hagrid ..."

I see you've met him too then!

MrsP wrote:And, be warned, NEVER open a link posted by him!

I thought we agreed not to discuss said incident - any anyhew, it never happened!

See.

I did warn you not to encourage him.

Aw c'mon, Mrs. P.
Look! He's happy. How nice. I feel good.

Well I suppose some good has come of it then Grey!

On a similar theme, once fractured my skull playing a Uni game, bit groggy no obvious concussion, played on for the rest of the game. Would have been good to have a proper Doc there, rather than the 2nd year medic who looked after us. No long term ill effects, apart from poor posts on message boards. I was very lucky!

Actually,

I know I really shouldn't joke about this but...if the IRB guidelines were to have the desired effect and significantly reduce the long term effects of repeated concussion, can you imagine the quality of discussions on fora such as this in 20 years time!

But, I really shouldn't joke.

It is a very serious issue and it is alarming if not surprising how few are aware of the advice.

An opposition team had one of their props take a blow to the head and i'm fairly sure he passed out. He then carried on playng and scored the winning try, surely that can't be allowed to happen?

If he took a knock to the head and lost consciousness then he certainly should not have played on.

This is one of the areas where the professional game has set a very bad example I feel. How often have we seen players KO'd and then get back to their feet and play on.

Madness!

I hope you aren't trying to have the try disallowed though.

Who really judges whether these players are fit to continue a match?

I have discussed concussions quite a few times with MrsP and with a number of other doctors here in northern New Jersey.
In consequence, we agreed to start posting links to relevent and hopefully easy to read articles and documents regarding concussion information. If anyone has access to good information, or even bad information in need of correction, please pop in in here. This is good for all players, coaches and parents of players.

All: Please read this first link I have attached. It is a short, very easy to read, two page document that highlights key aspects about concussions. Simply to baseline our knowledge.

Grey

http://www.morrisrugby.org/images/pdf/2010parent-head-injury-instructions.pdf

Good stuff Grey.

I have had concussion so many times and have been treated differently on so many occasions that i have absolutely no idea what is the proper way to handle it.

Being woken up on the hour every hour.
Being woken up every few hours
Having my head cooled with ice packs for hours on end
Having doctors prescribe me NSAIDS
Then having other doctors say, no NSAIDS.

It really gets confusing.

Anyone heard from RDW lately? I hope that he is feeling better.

He was feeling well I understand.

Till about 19:45 on Saturday.

Sudden turn for the worse.

Would be great to have another update from him about what his recovery was like and how much/often he was reviewed by the medics.

Quick note some of you remember me talking about David Duerson, a guy who suffered multiple concussions over his NFL carreer and suffered from a condition called CTE which led to him committing suicide. More detailhere in the penultimate paragraph.


Anyway, some of you may have heard Junior Seau a linebacker who retired two seasons ago, committed suicide on Wednesday. Some think he may also have suffered from CTE. But at the very least he couldn't deal with life after sport.

I suggest taking a few minutes to read today's BBC article about concussions. Nothing really new here, but it clearly shows the heightened level of research and concern about concussions. As a player, coach, father, and mate, I recommend everyone stay close to this as it unfolds.

http://www.bbc.co.uk/news/health-17959764

Here's a news feature that screened in Australia NZ recently. Ex-AB Steve Devine seems to be really suffering as a result of his concussions
http://www.abc.net.au/4corners/stories/2012/05/10/3499950.htm

just one to watch.

Last weekend in the Blues crusaders game Benson Stanley was heavily concussed,(bad tachnique going into a tackle) This is Benson 's Fifth concussion within the past 12 months.

Stanley is Clermont bound at the end of the Super xv season,There's a few subtley suggesting that Devine should have a chat to him.

Kiwireddevil,
Thanks for posting the link to that report. This is an excellent update for everyone. and I would recommend watching It does take 45 minutes, but is worth the time. One interesting aspect is how different sports treat concussions differently. But the point is clear, we have to treat concussions with great caution. For ouurselves, our teammates, kids, and for our sport in general.

I completely disagree with the premise that the NFL is somehow different. It is exactly the same - spear tackles (leading with the head/helmet) is a severe penalty. However, in the NFL, as in Rugby Union, League and AFL, things were more lax in the recent past as concussions were not treated as seriously as now.

The Benson Stanley case is going to bear watching. I wouldn't sign him. The risk of losing him to permanent injury and the notion of being somehow culpable in causing a lifelong disability, is too much.

Here is another link to a pretty fair overview about concussions. Some good explanations and how to manage. The video is about 10 minutes.

'If in doubt, sit it out'.

http://www.nata.org/health-issues/concussion

This may be of interest - IRB TRIAL

Thanks Penfro,

I can see a bit of sense in the trial and I particularily like the idea of trying independant doctors but this trial also directly contravenes the IRB's own recent guidelines.

There are some disadvantages to using independant doctors as the most subtle changes will be noticed by someone who knows the player well but it will remove the "serving two masters" effect that team doctors might face.

Hopefully we will get some information from the trial although I would think the sample size will be too small for any useful statistical analysis.

The IRB is a joke of a professional body it really is. Don't they have anybody overseeing their missives, or is the approach to have contradictory positions so they can chose the one that suits them best at a later date?

If people want to do serious research into concussions and their effects, then they need to look at what happens to guys who partake in "extreme" sports. Motocross,supercross, BMX and other sports like that are where concussions occur most frequently.

IRB need to step it up too, but I think that other sports are probably in need of closer scrutiny first.

Another one down

https://www.606v2.com/t31766-michael-lipman-s-career-over-after-concussion#1352902

Kiwi, I just saw you posted the link. I would like to highlight a short piece of the article, and a quote from Lipman.

"(The headache) is always there and you can feel the pressure in your head and when you start running and training it makes it a lot worse.

"You're just very confused really, and you're hazy and you're very clouded and not many things make sense.

"You just become very, very tired. You become exhausted straight away and you feel like going to sleep, when it should really be the opposite, because when you start working and training, the endorphins release and you get a pick-up. You shouldn't get totally down the way I've been."

Real damn shame it took him this long........

I played a school match once, in a ruck and had a class of heads. I stood up and could hear a ringing sound, I then promptly fell over and had to stumble crawl off the pitch. My coach took me off, but then let me back on after 15-20 minutes. Looking back I do question him allowling me to step back on the pitch.

Here is an article from the NZ Herald describing a test programme regarding concussions. To be trialled in the ITM Cup (old NPC) this upcoming season, it mandates a 5 minute down time where a player is evaluated. The player gets replaced in the same manner as a blood replacement.

Good idea in theory, but we need to see the reports after the season. Please giv ethis a read and let us know yur thoughts.........
http://www.nzherald.co.nz/health/news/article.cfm?c_id=204&objectid=10824486

Just in case anyone is in any doubt about how important this is.

http://www.bbc.co.uk/news/uk-northern-ireland-19512289

I had the heartbreaking experience of standing on the touch line a week later while my son's team lined up before their match and held a minutes silence for a lad they had never met and now, never would.

It was a situation I hope no one ever has to experience.

If in doubt, sit them out!

An honest but worrying interview by Paul Tito on the effects of concussion. I had no idea he'd been so affected.

Link here: http://m.nzherald.co.nz/rugby/news/article.cfm?c_id=80&objectid=10832845&ref=rss&utm_source=twitterfeed&utm_medium=twitter

Not sure if that'll work for everyone so I'll paste it on here too:

By Dana Johannsen & Dylan Cleaver

Paul Tito's career ended on March 3 this year, playing for his adopted Cardiff Blues in Treviso, Italy. "It was a poor one to finish on," he says from his home in Oakura, near New Plymouth.

On the contrary, most medical experts would say it was exactly the right one to finish on.

In the 62nd minute of the match, just another on the endless treadmill of fixtures the big European clubs embark on, Tito was replaced by Ma'ama Molitika. It's a banal statistic that tells nothing of the preceding drama.

Tito had gone in to make a front-on tackle, got his head in the wrong place and was left dazed. Worse, the ball had spilled loose and, despite Tito being in a foggy state, instincts honed over a lifetime of rugby kicked in.

"I dived for the ball. I wasn't feeling a hundy [100 per cent] already and that's when I collided with this big bugger. Not good."

As far as concussions go, it was big.

Tito returned to Cardiff, where he sat around at home for a month, not doing anything except creating a black cloud above his head.

In his spare time he had the opportunity to contemplate not just the events at Treviso, but another bad "knock" he had taken during a New Year's Day fixture against Welsh rivals Ospreys. There were a couple of other "knocks" too, which Tito had not reported.

To doctors, particularly neurologists, this would be a staggering oversight; to rugby players, according to Tito, it is part and parcel of the life of a professional.

"I think that's everyone's attitude," he says of failing to disclose injuries. "If you stop for every injury you have, you wouldn't play often. Ninety-five per cent of the boys I know will try to get around it."

Therein lies rugby's biggest dilemma: how do you effect a quantum shift in attitude, yet still cultivate players with the necessary tough-as-teakness to play at the highest level?

Tito's attitude may seem blase, shockingly so, but it permeates every level of the game.

Stephanie Bygrave didn't quite know how to react when she saw her husband Mike get laid out after a heavy collision in a club game. Fear and concern was writ large on her face. When Mike's Auckland University teammates and friends saw her state ... they laughed.

"They were saying, 'Oooh Steph, are you worried?' she remembers.

"They made me feel like I was over-reacting, like I had to play it cool and couldn't let on I was worried."

Mike, who had been concussed twice before, suffered transient global amnesia - characterised by short-term memory loss and repetitive behaviour.

As a confused and increasingly paranoid Mike asked the same question every 30 seconds during the drive to hospital, Stephanie failed to see the funny side of brain injuries.

New Zealand rugby folklore is littered with stories of bravado on the field - Colin Meads playing with a broken arm, Buck Shelford and his torn scrotum, and Dick "Red" Conway, who had a troublesome digit amputated so he could tour South Africa in 1960.

Our rugby culture demands a tolerance to pain. Getting back into the fray after a bone-crunching tackle is seen as a mark of a courageous player.

Dr Steve Marshall, an academic whose interest in concussion and rugby was piqued by Otago University's ground-breaking RIPP study in 1993, calls it the "badge-of-honour syndrome".

Marshall has been based since 1994 at the University of North Carolina, where he leads the Injury Research Prevention Centre.

"It is not wanting to let the team down. The game has evolved but the attitudes of some players haven't," Marshall says. "With muscoskeletal injuries there's a certain amount of bragging rights. The brain is different - we have to remove concussion from that part of the discussion. The brain is an organ of enormous complexity, but it's also an organ that has the ability to heal itself. But it needs time to heal.

"We need to convince players that they are doing their team a favour when they take themselves out of the game with a concussion. There are bigger things at stake here than points on the board. In saying that, the NZRU is making genuine ground."

Some of the ground has been gained by the ACC-driven RugbySmart programme. Operating since 2001, it gives information to all coaches and referees - from the under-14 grades through to the elite level - about best current practice on how to recognise, manage, assess and treat concussion.

Still, the messages remain at odds with deeply ingrained rugby culture.

It wasn't really Tito who called time on his career, but his wife, Hayley.

She got "really forceful" with their doctor after what Tito euphemistically describes as "an average month at home". He couldn't drive because his vision remained blurred. He couldn't even watch television for any length of time because it would spark severe headaches. With two young children buzzing around - Libby and Ollie, now 3 and 2 - Tito wasn't much use to anyone.

He couldn't exercise, the primary release of the athlete. Even now he limits himself to two jogs a week.

The doctor asked Hayley why he didn't know all that information about her husband before; she explained that was how rugby players worked.

"In the end the doctor sat me down and talked about the problems I could face after rugby," Tito says.

He looked at his kids, too, and, at 33 going on 34, rugby's significance started to fade. "I thought, 'What if I play one more game of rugby and something bad happens to me?' What if I wasn't able to chuck a ball around with my kids. It was sad I wasn't able to go out on my terms, but there are a lot of people worse off than me."

Among that number he counts Taranaki and Chiefs prop Shane Cleaver, whom he has spent time with recently. At just 25, at the start of a professional rugby career, Cleaver is wrestling with the same decision Tito had the luxury of making after 14 years of earnings.

"He's the sort of guy I feel sorry for," Tito says. "He has to make a decision and it might be the hard one."

Here's yet another article about trying to change player's and coach's attitude to head injuries.

http://www.nzherald.co.nz/rugby/news/article.cfm?c_id=80&objectid=10833633

Thanks to Kiwi for directing me to it.

Good to see some attitudes changing. It's relatively bad in rugby but in American Football it is far worse and it shows little sign of improving. Players and staff don't always disclose the full details and that is incredibly poor form

Really sad thing Thomond is that we had to bury a 14 year old lad to even start the discussion.

Let's make sure he's that last.