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Concussion in Rugby
Smith 'snake dance' prompts change to concussion trial
Graham Jenkins
September 5, 2013
Wallabies flanker George Smith is helped from the field during his side's 3rd Test loss to the Lions earlier this year © Getty Images
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The highly-controversial decision to allow Australia's George Smith to return to action during his side's third Test defeat to the British & Irish Lions earlier this year despite having been clearly concussed has prompted one of a series of changes to the global trial of the Pitch Side Concussion Assessment (PSCA) protocol.

Concussion Guidelines

  • What is concussion? "It's often difficult to distil it down into layman's language, but in essence it's a temporary functional disturbance of the brain as the result of the brain sustaining an impact. Typically we don't see structural changes in your brain, like you do with more major traumatic brain injuries."
  • What might we see? "At the more significant end of a concussive injury you might see an unconscious player while at the milder end you might see a player unsteady on his feet, or slow to answer questions or not being able to remember the plays."
  • Typical Symptoms: Headache, Dizziness, Nausea, Unsteadiness/loss of balance, Confusion, Unaware of half, opposition, score of game, Feeling "dinged", stunned or "dazed", Seeing stars or flashing lights, Ringing in the ears, Double vision
  • Physical signs: Loss of consciousness/impaired conscious state, Concussive convulsion/impact seizure, Gait unsteadiness/loss of balance, Slow to answer questions or follow directions, Easily distracted, poor concentration, Displaying unusual or inappropriate emotions, Nausea/vomiting, Vacant stare/glassy eyed, Slurred speech, Personality changes, Inappropriate playing behavior, Significantly decreased playing ability, Poor coordination or balance

Dr Simon Kemp, head of sports medicine at the Rugby Football Union and a member of the International Rugby Board's PSCA working group, has revealed that a review of the first year of the trial - including the Smith incident - has led to a number of 'refinements' to the trial that was originally introduced in the hope of creating a more appropriate environment and process for doctors to assess players with suspected concussion and ensure those displaying symptoms of such an injury were not returned to the field of play.

Smith was involved in a horrific clash of heads with Lions hooker Richard Hibbard during the clash in Sydney and dazed and struggling for balance, he had to be helped from field. However, having passed a PSCA test within the recommended five-minute timeframe and convinced the Wallabies' medics of his fitness he was returned to play.

The decision was widely criticised with former IRB medical advisor Dr Barry O'Driscoll, who resigned his post last year in protest at the introduction of the trial, one of a number of experts and former players to slam the conduct of those involved. Those concerns were shared by Kemp and his fellow medics and a similar display of what Smith himself called 'snake dancing' will now lead to a 'definitive removal' from the game.

"We have analysed all the data and feedback and reviewed a number of incidents including the George Smith one and we have made a few changes," said Kemp, speaking at Twickenham on the eve of the new Premiership season where the trial will continue. "The first change is a subtle one," he added. "The trial name has been changed to Pitch Side Suspected Concussion Assessment - this puts the emphasis on the cases where you suspect they are concussed. We want to make it very clear that if you know they are concussed then they are off and they don't go through this process.

"In terms of players who we have said must be removed from the field of play immediately, in the 'confirmed concussion group' we have added suspected loss of consciousness to confirmed loss of consciousness, so if you suspect they have lost consciousness then we would like them off. If they are unsteady on their feet or have gait disturbances and cannot not walk unaided for five metres we would like them off - and also if they are clearly disorientated. The aim of this is to move the threshold for definitive removal to be more inclusive."

Kemp, who described concussion as "most complex and difficult sporting injury to consistently recognise and assess", stressed that the PSCA is only one element of the medics' armoury. "We want to be very clear to our medics that this tool is just part of your sideline neurological assessment and there are other things you do as well," he said. "The argument that if you pass the tool and can go back on is not valid. If the player has no positive response to the assessment tool but you still think they are clinically concussed they don't go back on. It must overrule a negative PSCA."

 
"If the player has no positive response to the assessment tool but you still think they are clinically concussed they don't go back on. It must overrule a negative PSCA."
 

However, he stopped short of criticising doctors involved in the Smith incident and others. "There is a temptation to jump towards independent doctors in this assessment but in terms of concussion the data to date shows that a team doctor who understands the player and the process discharges his responsibility better than anyone else."

Dr Willie Stewart, a brain injuries expert at Southern General Hospital in Glasgow, recently fuelled the debate by reporting the first case of chronic traumatic encephalopathy (CTE) - a disease associated with repeated concussions - with someone who played international rugby. American football players who have suffered similar injuries and claimed the National Football League hid the dangers of concussion recently reached a $765m (£490m) settlement - but Kemp is not convinced rugby faces a similar crisis in the future. "You can't relate rugby player head injury causally with the development of CTE in that way," he said. "If you have got the brain of someone that shows CTE, it is not legitimate retrospectively to go back through their history and try and confirm whether rugby is the sole factor responsible. You can get to the stage where you think there may be a link but in order to prove it you are going to have to follow players over time."

Ex-players such as former Scotland winger Rory Lamont have also alleged that others have cheated the CogSport tests used to monitor brain function and calculate a baseline result that is used in any future concussion assessment. But Kemp denies the system can be manipulated in such a way. "The software has built in checks," he said. "It tests reaction time, decision making and memory and measures your response in milliseconds. If you deliberately go slowly the software detects you are going slowly and fails you. Our experience, having run this in the Premiership since 2004, is that it is impossible to fool the CogSport software."

Kemp also welcomed the results from last season's Premiership where 33 PSCA tests were carried out in 135 games - "the data clearly shows we were removing more players." He added: "What they showed is that 89% of players who had a positive PSCA or who were deemed by their doctor to be concussed and were removed from play were subsequently diagnosed as concussed. We got it right 89% of the time in terms of sensitivity. Of the players we put back on the field in the Premiership, 92% of them were later confirmed as not being concussed." The results also highlight what appears to be a difference in the thresholds for requesting a test with both the Currie Cup and Super Rugby producing a higher total and ratio than the Premiership.

In conclusion, Kemp said: "We believe the PSCA trial last season delivered most of what we wanted it to deliver and we have made some refinements based on our experiences. What is clear from all the debate around concussion, the game at all levels needs to ensure that players at all levels with suspected concussion come off for assessment. I believe what will run in the Premiership next season will continue to take us forwards and I think relative to other sports we are clearly taking this issue very seriously and putting a lot of resource into it."

© ESPN Sports Media Ltd
Graham Jenkins is the Senior Editor of ESPNscrum and you can also follow him on Twitter.
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