Concussion Can Kill

Cross party call for a Parliamentary inquiry into concussion

in sport

A five step charter
1. A full parliamentary enquiry into concussion in sport
2. A coherent set of concussion protocols covering all sports
3. Independent peer reviewed research into concussion and British sport
4. Better coordination between sports, schools, colleges and doctors
5. A clear message that concussion can kill

Lord Addington (Liberal Democrat)
Chris Bryant MP (Labour, Rhondda)
John Glen MP (Conservative, Salisbury)
Baroness Grey-Thompson (Crossbencher)
Chris Heaton-Harris MP (Conservative, Daventry)
George Smith, Australian flanker, continued playing after passing PSCA test despite clearly suffering from concussion in a
game against the British & Irish Lions in 2013. (Source: Mail on Sunday)
Concussion in sport: An Introduction

Following recent high-profile concussion cases in sport as well as the tragic death of teenager Ben
Robinson in 2011, a parliamentary roundtable, bringing together National Governing Bodies (NGBs),
parliamentarians and concussion campaigners, was established to give this issue an important
hearing. The ongoing concussion lawsuit against the NFL in the United States regarding the link
between multiple concussions and Chronic Traumatic Encephalopathy (CTE) has shown that this
issue isnt going away and UK sport cannot afford something on the scale of the $765m concussion
lawsuit in the United States. The time for debate is over, we need action. All five authors of this
report are lovers of sport and are actively engaged in sport. We dont wish to undermine sport but
to protect it from these types of future lawsuits
i
and more importantly to protect the welfare of its
participants from long term brain damage. This report lists a set of recommendations that seeks to
achieve this.


Our five step charter:

1) A full parliamentary enquiry into concussion in sport

The panel recommends the establishment of a parliamentary inquiry, by either the Culture, Media
and Sport or the Health Select Committee (or by a sub-committee of both committees), into the
issue of concussion in sport. We are thankful to those NGBs and campaigners who contributed to
the roundtable on the 4
th
March and for their constructive contribution. However only a formal
Parliamentary inquiry will be able to bring all stakeholders to the table and ensure that all the
necessary evidence and expertise is obtained and marshalled. We urge the two Select Committees
to consider initiating such an inquiry.


2) A coherent set of concussion protocols covering all sports

Our concussion protocols can be laughable at times. Cogsport [the computerised test used to assess
an injured players fitness to resume rugby] is the last hurdle people need to go through, but you can
pass that concussed or not concussed. I dont think its an acceptable guideline.
Alex Corbisiero, England and Northampton Saints Rugby Union player, speaking at the London
Premiere of Head Games on 4

March 2014
ii


We are concerned that there is a significant variation in the way different sporting bodies assess,
publicise and treat concussion, sub-concussive events and chronic traumatic encephalopathy
iii
.
Some sports have specifically sought to establish bespoke protocols, but we believe that there is
significant room for improvement in both the setting out and delivery of concussion protocols. We
are particularly concerned by the Pitchside Suspected Concussion Assessment (PSCA) which is
currently being trialled in Rugby Union.
iv
We believe that this assessment which requires players
suspected of concussion to undertake a five minute assessment is insubstantial. In 2012, former
Irish international Dr Barry ODriscoll resigned from the International Rugby Board (IRB) as medical
advisor following the introduction of this measure
v
and has said that no medical authority is
capable of telling whether a player does not have concussion within a five-minute period of
assessment
vi


As former Scottish Rugby Union player Rory Lamont noted in the Parliamentary roundtable, when a
players career is on the line, they are unlikely to take the cautionary approach and doctors and
referees need to be empowered to take this decision out of players hands. If doctors, teammates or
coaches suspect the player is concussed, they must be removed from play. In the words of a recent
initiative by the Scottish government on this issue, If in doubt, sit them out
vii
.

As Mr Lamont has noted, players work incredibly hard to get themselves into a position to play elite
sport and are often unwilling to give up their place on the pitch. However this working group
believes that players who are suffering from concussion are not in the correct frame of mind to be
making a decision on their welfare. In the case of Hugo Lloris last November at Goodison Park, both
the team doctor and teammates encouraged the player to leave but the player stubbornly refused
to leave the field of play
viii
. We believe that decision should not have been his to make.

Concussion protocols are often confusing
ix
, filled with jargon and generally inaccessible to the
average parent or amateur coach searching for simple and clear instruction. Furthermore, there is a
lack of consistency in concussion protocols across all UK sports from the elite level to grassroots and
different sports and different national governing bodies often acting unilaterally. For example, the
Rugby Football Union has recently announced its minimum stand-down period for professional
players to be six days while the Football Association does not have any formal concussion protocols
in place. National governing bodies must act together with other bodies, sports and the NHS. We
believe that the inquiry which we are calling for should explore international best practice in
developing these concussion protocols particularly looking at the USA where elite sports team
have their own medical consultants.

As a player, you feel like you have very little say or control over how you can actually change the
game. In rugby, we play 30-plus games a year. We do contact all through the week in training and
then take minimal time off in the summer before we are back into contract training and the season
x

Alex Corbisiero, England and Northampton Saints Rugby Union player, speaking at Head Games
Premiere (4
th
March)

We also need to have a debate about limiting exposure to head injuries for those participating in
sport, particularly young people. In the United States moves have been made to reduce exposure to
head injuries, with less full impact training and youth initiatives such as pee-wee ice hockey. Could
the UK follow this example? Could the number of full contact rugby training sessions be reduced
between matches? Is it appropriate for young children to regularly train and compete in full contact
rugby? Is there a way that the number of headers could be minimised in youth football? These are
all questions which could and should be explored by a full Parliamentary inquiry.

Former footballer Jeff Astle, died in 2002, aged 59 from dementia related to repeatedly heading in
both training and in competitive fixtures. Whilst it is often argued such problems reflected the type
of footballs used many years ago, there is no evidence to support this assumption and so the link
potentially still remains. For this reason this working group believes a discussion on limiting exposure
needs to take place particularly with regards to young people. As previously stated, all contributors
to this piece want young people to engage in sporting activities but want to ensure this takes place
in a safe environment. We believe that by making sensible decisions about limiting the exposure to
head impacts and injuries in childhood we can ensure sport is played in a safe environment without
preventing young people from engaging sport, harming their educational attainment or limiting their
progression into the elite game if that is the path they choose.

In light of the Jeff Astle case, we would recommend protocols covering the issue of headers in
football. We believe that there should be a graduated introduction of headers in youth football to
protect children. It seems strange to this working group that children are actively encouraged to
head heavy footballs at such a young age and that a lot of good might be done by introducing clear
protocols related to headers.

The tragic death of Ben Robinson has also illustrated the need for strict protocols to avoid the rare
fatal complications of concussion, including second-impact syndrome (SIS). Whilst this is also an
issue of concern for adults, it is generally accepted that children and adolescents are most
susceptible to these poor outcomes. For reasons unknown, in a very small number of individuals, the
brain may swell rapidly and catastrophically after a head injury. In many such cases, this follows a
second concussion minutes, days or weeks before the first one had recovered, hence second-impact
syndrome. Therefore it is vital that players who have suffered a concussion or who are suspect of
having suffered a concussion are removed immediately from play and do not return to training or
competitive sport until after they have been cleared by a medical practitioner, however long this
takes. Guidelines which outline arbitrary rest periods will not suffice and must be dropped in favour
of actual individual medical assessment.


3) Independent peer reviewed research in concussion and British sport

Very few concussions are actually reported - Rory Lamont, speaking at Parliamentary roundtable,
4
th
March 2014.

Concussion reporting

A study by Dr Doug King, a New Zealand-based researcher, has shown that as many as three out of
four concussions in rugby below the elite level go unreported. This is deeply worrying. It is absolutely
vital that there is accurate reporting of concussion, so more can be done to protect players during
their careers and to inform research into the long term effects of concussion in sport. This working
group believes that concussion is currently underreported and that more needs to be done to
ensure that concussion is reported accurately. As Rory Lamont noted at the Parliamentary
roundtable on this subject, very few players are willing to come forward and admit they have
concussion
xi
and many more are unaware that they have actually suffered from a concussion. Public
awareness campaigns, better concussion protocols and joined up thinking could very well see such
reporting improve. However more can be done by national governing bodies to ensure there is more
accurate reporting of concussion including lowering the threshold to what is more accurately
considered to be a concussion injury and regularly surveying professional players. The tragic stories
of athletes diagnosed with a form of neurodegenerative disease known as Chronic Traumatic
Encephalopathy (CTE; formerly punch drunk syndrome), have also highlighted the need for action
for better reporting. Previously thought restricted to boxers, recent reports have highlighted this
same pathology in a range of sports where risks of head impacts and concussions are high, including
American Football, Ice Hockey, wrestling, rugby union and, with Jeff Astle, football. In many of these
cases, there was no record that these players had suffered from concussion and CTE was only
confirmed following post mortem examination. This leaves us with a number of questions. Could
more be done to encourage post mortems in ex-athletes with dementia to gather more
information? Could better reporting have reduced the number of concussion injuries these players
suffered in their career? Could this in turn have reduced their chances of suffering from CTE? Could
these players have been offered specific support in light of their increased risk from CTE?


Long term research sporting bodies must be proactive not reactive

National governing bodies have a responsibility to their players and players families to invest and
contribute fully to long term research into the effects of concussion in sport. Far too often NGBs
focus only on what is immediately in front of them and whilst it is important to address to the
immediate concerns of concussions in those still playing sport, more must be done to look into the
long term ramifications of repetitive concussions.

The death of Jeff Astle is just one example of NGBs promising action but not delivering. In 2002, Jeff
Astle died of dementia aged 59 as a result of an industrial disease from heading footballs. The FA at
the time of his death promised his family that they would undertake a 10-year joint study alongside
the Professional Footballers Association to investigate the link between heading footballs and risk of
brain damage, including dementia among ex-professional players. However twelve years on, no
study has been published
xii
. This issue cannot be swept under the carpet, all sporting authorities
must act.

It is important that meaningful research is carried out independently of NGBs and that resources and
data are shared by sporting authorities. This sort of research should be actively performed in
prospective long term studies that build on our current understanding of concussions. Retrospective
studies are not helpful as these are limited by both under-diagnosis of concussion in the UK and a
dearth of baseline data collection. There can be no cover ups and the risk and prevalence of
concussion must not be underplayed. National governing bodies and players unions could play a key
role in establishing more evidence of the long term impacts of concussion in sport.

This working group notes the ongoing research from Dr Willie Stewart (Neuropathologist, Southern
General Hospital, Glasgow), Chris Nowinski (Sport Legacy Institute) and Dr Teena Shetty
(Neurologist, Hospital for Special Surgery, New York) who have been pushing research on concussion
up the agenda in both UK and US sport.


4) Better coordination between sports, schools, colleges and doctors

As expressed by many at the Parliamentary roundtable on the 4
th
March, there is a need for more
engagement with the NHS and schools on sporting injuries such as concussion. With regards to
health, it is not uncommon for concussion to be misdiagnosed or missed altogether.

Sporting bodies and the NHS need to ensure there is communication at all levels of sport and
healthcare so that people know what constitutes best practice when it comes to dealing with
sporting head injuries. It is not enough for players and coaches at the elite level to know of the
dangers of concussion. Amateur, youth and schools sport do not have the luxury of having a
medically trained professional at every match and steps must be taken to bridge this gap. Players
and their families at this level need to be sure that if they are taken to hospital with suspected
concussion, that this is properly assessed and recognised
xiii
. Furthermore it is felt that amateur and
schools sport would benefit enormously from first aid (including recognising concussion) training
which could be run in conjunction with national governing bodies, the NHS and the Department for
Education.

As previously stated, in the case of Ben Robinson, if just one person in a position of authority had
reacted appropriately, he could still be alive today. Its absolutely vital that there is a joined up
approach between national governing bodies, the NHS and the Department for Education to ensure
such failings dont happen again.

It is vital that there is not conflicting or contradicting guidance emanating from different sporting
bodies and from the different governments of the United Kingdom. We note that the Scottish
Government and the Scottish sporting authorities are particularly advanced on the issue of
concussion in sport including the new guidance leaflet If in doubt, sit them out Concussion can be
fatal. This working group also notes the recently published IRB public guidance
xiv
which reflects
much of the content in the Scottish Government document. We believe these documents should
serve as key starting points to work from going forward. We need a uniform approach and for this
reason we recommend that representatives of devolved administrations should be included in the
Parliamentary inquiry into this subject.


5) A clear message that concussion can kill

There should have been a chain of health-and-safety procedures in place, one that included players,
coaches, referees and parents. If just one link in that chain had worked as it should have, Bens
concussion would have been spotted. He would have been removed from the pitch, and he may have
survived - Peter Robinson speaking about his son Ben, who died from Second Impact Syndrome.
(Quote: The Guardian)
xv


We believe there is a pressing need for a large-scale and continuous public awareness campaign and
for simple and consistent messaging across all UK sport at all levels. There are many misconceptions
about concussion and as former England rugby union captain Lewis Moody has noted from his own
playing career, too often it has been treated like a joke by professionals
xvi
. We need to change this
perception and quickly.

As Peter Robinson has noted, had just one person, a teammate, coach or referee reacted
appropriately to his son Bens concussion, he could have survived. The case of Ben Robinson
illustrates quite clearly that concussion can be fatal. Players, coaches, doctors and parents need to
know about the dangers of concussion and to take proactive steps to ensure such a tragedy never
happens again.

In addition to the rare tragic cases of death, it is also important to note the other health risks caused
by repetitive concussions including: headaches, dizziness, cognitive difficulties, executive function
problems, depression, anxiety as well as serious and sometimes irreversible long term damage to
the brain. It is vital that more people are aware of the dangers of concussion. The inquiry which we
are calling for should also investigate these other health risks.

A large scale public awareness campaign in addition to improved literature and protocols on
concussion could go a long way to achieving this. This working group praises the Mail on Sunday
concussion campaign as well as campaigners such as Peter Robinson, Lewis Moody, Rory Lamont, Dr
Willie Stewart and Chris Nowinski. We hope that national governing bodies and others will engage
with such initiatives and individuals to ensure that more people are aware of the dangers of
concussion.

It is important that sports broadcasters and the media in general engage with the public awareness
campaign and commit to improve attitudes towards concussion in sport. Sports broadcasters have
the ability to undermine such a campaign in a matter of minutes with ill-informed views. We can
only change perceptions of concussion if the media are fully engaged and fully briefed on the
dangers of concussion.


i
http://www.theguardian.com/sport/2013/nov/07/rugby-union-legal-claims-concussion
ii
http://www.dailymail.co.uk/sport/rugbyunion/article-2576417/Rugbys-concussion-tests-laughable-claims-
England-star-Alex-Corbisiero.html
iii
Source: Review of UK Sports agencies publically available, on-line guidelines on concussion management.
McGivern, K
1
, Hay, J
2
& Stewart, W
1,2
.
1
University of Glasgow, Glasgow, UK;
2
Southern General Hospital,
Glasgow, UK
iv
http://www.irpa-rugby.com/wp-content/uploads/2013/08/130812-PSCA-Procedures-and-Definitions.pdf
v
http://www.espn.co.uk/scrum/rugby/story/190715.html
vi
http://www.irishtimes.com/sport/six-nations-championship-and-celtic-rugby-adopt-irb-s-concussion-
protocols-1.1667459
vii
http://www.scotland.gov.uk/Resource/0044/00441743.pdf
viii
http://www.bbc.co.uk/sport/0/football/24797343
ix
http://www.bbc.co.uk/sport/0/rugby-union/24767245
x
http://www.dailymail.co.uk/sport/rugbyunion/article-2576417/Rugbys-concussion-tests-laughable-claims-
England-star-Alex-Corbisiero.html
xi
http://www.theguardian.com/sport/2014/mar/04/rugby-union-concussion-controls-lacking-moody-lamont
xii
http://www.bbc.co.uk/news/uk-england-birmingham-26637436
xiii
http://www.bbc.co.uk/news/uk-wales-24554550
xiv
http://www.irbplayerwelfare.com/pdfs/Concussion_Guidance_for_the_General_Public_EN.pdf

xv
http://www.theguardian.com/sport/2013/dec/13/death-of-a-schoolboy-ben-robinson-concussion-rugby-
union
xvi
http://www.dailymail.co.uk/sport/rugbyunion/article-2428431/Lewis-Moody-We-used-treat-concussion-
joke--I-worry-dementia.html