Concussion rates in rugby: Rates down, now pull on ONE rope, all together

10 Jan 2019 Posted by

Today’s short thought is not that short. It was inspired by a handful of emails and WhatsApp conversations I had with various colleagues and friends yesterday. I basically took what I had said in those and turned it into an article on Concussion risk decreasing in England’s professional rugby competition, and what that might mean. So here it is…

Last week the RFU and Premiership Rugby released their annual Injury Surveillance Report, called PRISP.  It tracks and documents injuries that happen in professional rugby in England and is the longest-running annual survey of its kind.  It is definitely the ‘market leader’, and any country or tournament wishing to do injury surveillance should contact those guys and get all the advice they can – it takes an army of researchers, co-ordinators, coaches, players and medical staff, and they produce these reports. 

One cool thing about it is that they show each year’s results as part of a collection of all the results, which means you can see trends and changes pretty clearly, and get a good understanding of injury risk in the professional sport in England.

This year, there are three major findings.  Two are expected – continuations of previous trends, and the third is a new finding, but cause for some cautious optimism, as well as a call to renewed action.

I won’t dwell on the first two here, other than one short mention – injury incidence (the rate of injuries) remains unchanged, but injury severity (days lost to injury) continued to rise.  The former is good, especially given that the game is changing in a direction where you might expect more injuries (more ball in play, higher activity rates, more tackles etc).  So a stable injury rate in the face of those changes is actually a positive finding. 

The latter (average injury taking longer to recover from) is bad, and asks many questions for more detailed research in order to understand and then address that problem.  There are a handful of likely contributing factors to this (not all of them bad – some are in fact also positive and praiseworthy.  Perhaps I can share those another time.

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Reduction in concussion rate – cautious optimism & call to action

What I want to talk about today is the third interesting finding – a reduction in concussion rate for the first time in many, many years (see the figure below, showing the number of concussions per 1000 hours of rugby)

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History of concussion – the ten year rise

By way of background to this figure, until 2011, there was no formalized process or mechanism to identify a concussed player and remove them for evaluation, or permanently.  It was up to doctors and match officials to make observations on their own, and so only the most obvious cases were detected.  Then after the 2011 World Cup, the first iterations of the Head Injury Assessment protocols were introduced, awareness grew, education was prioritized, and suddenly, more players with concussion were detected and removed.  That’s a significant part of why you see that more rapid progressive increase from 2011/12 on.

This is not likely to a “real increase” in the sense that players were suffering that many more concussions. The concussion rate was probably always up at least 14 or 15 concussions per 1000 hours, but they just weren’t being detected and logged prior to the HIA protocols, which lowered the threshold for diagnosis and co-incided with a real push towards awareness and appropriate treatment of the injured players.

The other part of that increase, potentially, may be the increasing physicality of the sport.  More frequent and larger collisions, more focus on stopping the ball, more higher contact tackles, more head injuries.  One thing about that – other injuries caused by these ‘direct’ collisions haven’t gone up in the last ten years, so I would lean much more towards awareness, not reality, driving the concussion rate higher.

Regardless of the relative weightings you assign to each, it meant that concussion became a priority for rugby, because it was soon the sport’s most common injury, with possible long-term implications, and everyone involved had no idea when or where the rate would stop rising.

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A downturn in 2017/18 – is it real, and how might those involved react?

2017/18 has finally provided the first ‘cessation’ in the rise in concussions, as you can see below.  The rate drops by 14.3%, from 20.9 per 1000 hours last year, to 17.9 per 1000 hours in 2017/18.

This is good news.  It’s not cause to break open the Moet, pop the corks, and declare a holiday, because everyone involved understands that you can have ups and downs in long-term data.  So it’s quite possible that the concussion risk graph starts to take on the pattern we have seen in overall injury rates, which is “bumpy” (see graph to the right).  Maybe next year, we’re back up to 20 concussions per 1000 hours, and feeling sheepish for ‘over celebrating’ what wasn’t a real reduction. 

So I appreciate that there will be a degree of circumspection around this, but I do think there needs to be a response other than downplaying it.  And that response should be two-fold. 

First, as mentioned, it provides reason for SOME optimism.  A lot of effort has gone into the education and awareness about head injury, and more recently, its prevention.  Literally hundreds of stakeholders have pushed messaging about awareness, identification, prevention.

And if we are going to be concerned about any small increase (as we have been for the last eight years), then it is appropriate that we should be encouraged by similar decreases.  Not in the same proportion, of course, because our reaction to the data drives our subsequent behavior, and if one got carried away with a
14.3% reduction, it would almost certainly predict a bounce back up in that rate the following year.  Qualified optimism is perhaps the compromise position. 

Second, this finding, a 14.3% reduction, should renew and reinvigorate our efforts at prevention, perhaps providing some inspiration to keep pushing, to keep trying the various things that have been tried in the last two years, because just maybe, that little downturn in the rate is a sign that they are helping.  Certainly, it can’t hurt to use that as positive momentum to do MORE. 

But in order to do this, you have to acknowledge the positive momentum, not downplay it to the point that you ignore its existence.  It’s like a boxer fighting a stubborn opponent whose resolute defences, prevent him from landing a blow for eight rounds. Then he does in Round 9, thanks to a change of tactics, a new approach.  That should would be a fool if he now retreats to his corner and asks “Did I really punch him?”, or says “I think I got lucky”.  He should instead intensify the same efforts, eyes open, but with new hope and energy.

And in that regard, this paragraph explaining the concussion result stands out as deflating and disappointing for what it doesn’t say:

See how in order, it says a) “Hang on, this drop in our number one prioritized injury might be nothing at all; b) “Even if it is something real, it is a really small change”; c) “It’s still a big issue”; d) “It’s probably just a measurement artifact anyway”.

I agree with c), but the rest is deflating and counter-productive towards continued prevention efforts, even if it is academically accurate. The problem is, nowhere in that entire sequence of educated explanations is there a hint or even the acknowledgement of the possibility that the huge prevention efforts of a lot of people all over the world may be bearing fruit. 

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Preventing concussion, controversy and anguish, for nothing?

If you’ve been part of the rugby community for any length of time, you’ll know that the big push in the last 24 months has been to get the tackler lower in contact.  That’s because a pretty detailed set of research studies (and disclaimer – I was heavily involved in them) looked to identify the risk factors for head injury, and it identified that:

  1. The tackle was the most likely match event to cause head injury
  2. The TACKLER was the player more likely to be injured, by quite a large amount – 2.6 fold more likely to suffer the head injury than the ball carrier
  3. The risk to the tackler AND the ball carrier was greatest for HIGH CONTACT TACKLES.  In other words, when the tackler was upright, and his head was at or near the level of the ball carrier’s head and shoulders, the risk was much higher (4.3 times higher, if you feel like putting a number to the risk).

And so, when World Rugby convened a group of expert coaches, players and officials to discuss this finding, their suggestion was clear:

“Make changes that drive the height of the tackler lower”

“Get the tackler’s head out of that danger zone near the ball carrier’s head by asking them to tackle lower”

“Shift the height of the tackle down, so that the tackler’s head is near the torso, hips and upper legs of the ball carrier”

“Go lower”

You get the idea.

And since then, pretty much 90% of the controversies you can think of in rugby have been the result of that mandate.  In 2017, World Rugby issued a high tackle directive which more severely punished players for high tackles.  The idea was to create a disincentive to tackling higher, by handing out harsher punishments or sanctions when a tackler went too high.  The hope was that players would respond to the “stick” by going lower.  Effectively, the idea was to put into the mind of players the requirement to “Go lower” by hitting them with yellow and red card when they didn’t go low enough.

And so we had, for instance, the Cipriani red card, and much gnashing of teeth. We had the Will Spencer tackle and Geordan Murphy comments controversy. The Jerome Kaino incident and hefty citing got people arguing again. Owen Farrell’s lack of arms capped the year off.

If you’ve watched rugby in the last two years, you know what I mean.  The media have been on it, in both directions.  “Game’s gone soft”, say the stupider ones.  “Important initiative”, say the more enlightened ones. 

It has been a long, intense and difficult process for World Rugby to try to get understanding and buy-in on this idea.  Even before the first yellow card was handed out, coaches, players, pundits and even some in the medical fraternity were criticizing the initiative, saying it would make things worse, even though there was data showing pretty clearly that the risk is lower when the tackler is lower.

In more recent times, I have been encouraged listening to commentators and analysts SUPPORT the issuing of yellow and red cards, because they’re finally recognizing “This is what the rugby authorities have recognized to be part of the solution to make our sport safer“. They say things like “That (yellow or red card) is important for the welfare of players”, and I think “Yes! The message is being communicated. Next, the culture will start to change”

And so here we are.  January 2019.  In a position where amidst many tantrums and controversies, the painful push has been for lower and thus safer tackles, and it’s starting to become part of the conversation.

January 2019, where in the PRL, for the first time in nearly a decade, concussion rates are down.  For context, the concussion rates are also down in the Pro14, the French Top 14, World Rugby’s Sevens tournaments, Super Rugby and the World Rugby Under 20 Championship. All in the last two years.

Yet you read this paragraph explaining the reduction and not a single mention is made about the efforts to prevent concussion through a lowering of the tackle height, and that these MIGHT be part of it, just as much as operational definitions, identification, and randomness might be. No acknowledgement of the referees’ potential role in this, even though the poor, much beleaguered and criticized referee is going to be asked to keep going, keep issuing cards!

This is disappointing, and disingenuous, not because of the past, but because of the future.  If we believe that one of the ways forward is to lower that tackle height, then the messaging must be strong, and it must be clear.  The same rugby community that wants to reduce the concussion risk is currently committed to lowering the tackle height.  That has not changed, as far as I know. 

It’s not the only string in the bow – for instance, I hope that this year, we can put some sharp minds to the task of figuring out how to reduce line speed in defence, which will in turn require the breakdown to be addressed, because currently, numbers on feet enables rush defence, which feeds increased injury risk.  So that’s a separate issue.  But in terms of the tackle, pretty much everyone is aligned that lowering the height is crucial.

There are, without doubt, some disagreements about HOW to achieve this? Is the harsher sanction for high tackles enough?  In other words, is the stick large enough, and is it used often and consistently enough to actually change behavior?  I have my doubts. 

Should we be lowering the legal height of the tackle from the shoulders to the armpits or mid-chest?  That trial is in fact currently being done, in England, in their second-tier competition.  It has logistical challenges, but perhaps that is the way to go? 

Or should we continue to explore a post-match, off-field sanction process for the high risk, upright tackles that cause head contact. This intervention trialed in the 2018 U/20 Championship showed some promise, with concussion rates reduced by 50% (admittedly in a small study).  Or will this prove too logistically challenging to implement globally?

These three options targeting a lower tackle height are in play, and they all ask legitimate and difficult questions.  They differ in the means, but not the purpose.  The purpose is “Go lower”.  It’s “Get the tackler’s head down and away from the highest dangers, and also protect the ball carrier”. And all three require the buy-in from match officials, especially the referee.

And so when you write an explanation for a 14% drop in concussion, and don’t even mention the push for lower height, and these prevention efforts at all, not once, then I think it undermines any future attempts to drive the concussion risk even lower. It fails to give any support or “gravity” to the law and referee as a means of player welfare improvement, and given that we’re at the infancy of doing this, I think this will create a set-back.

I want to be very clear that all the possible explanations for that 14% drop are plausible. It may well be “nothing”, and it is a “small” drop – I’d like to see the rate at 14 per 1000 hours in future. But that 14% downturn should drive a more aggressive push, not avoidance of what’s been tried, and of how many people have endured criticism for a two year long effort which has, at times, dragged the sport towards a different culture.

If the law changes are in part responsible, then we also can’t know which part, exactly, has the most effect.  Trying to assign relative value is like trying to tease apart the threads of a rope and then hoping the rope can still support the weight.  It won’t, so we shouldn’t even try to guess at what the height changes have done compared to the communication around those height changes.  The push is an all or nothing one.  But it’s nothing if the existence of those strategies and initiatives, which have caused so much negative press, is not even acknowledged in the scientific reporting.

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A realistic call to action: Alternative message

In terms of the public facing message around this finding, the approach, in my opinion, should be to say:

“We are very encouraged by the first reduction in concussion rate since the HIA was introduced almost a decade ago.  Concussion obviously remains the game’s priority – it is still the most common injury, and it happens roughly seven
times every ten matches, a rate that we believe is too high and can be reduced.  However, we are emboldened that the accumulation of our education efforts and various interventions to prevent concussions have begun to get the issue into our grasp.  We can’t say exactly which intervention has been most effective, and we don’t want to assign relative weightings to them – our approach for now is that the combination of all of them are
important, and we must keep going with all of them.

We can take heart from the early days of our prevention efforts, and we want to use that early evidence to intensify our efforts, to build on the early changes, to make sure that this positive change becomes a permanent trend.  That means we
want to work harder than ever to support our referees and the media to spread the message of “Go lower” so that we can change the tackle in a direction that data shows is safest.  We will work with all our stakeholders to achieve this in the most effective (and palatable) way possible”.

Isn’t that a message worth putting your weight behind?  But to leave it out entirely – well, next time there’s a disputed red or yellow card given out by a referee to a popular player at a crucial moment, and fans are upset about the punishment, you can’t ask the media or pundits to carry forth message “This is part of the solution”, built on a foundation of scientific evidence, because that foundation has been eroded by its total omission from the concussion and player welfare conversation.  You can’t even ask the referee to be the “lever” for player welfare and then write the paper as though their role in the process doesn’t exist. 

It feels like a lost opportunity to help promote future shared strategic goals.

Thanks for reading. As mentioned yesterday, I’m not on Twitter as much, but my email is ross.tucker@nullmweb.co.za, and the conversation is, as always, much more valuable than the first opinion!

Ross

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