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Cross-party Parliamentary report into Concussion in sport. By Baroness Grey-Thompson, Chris Bryant MP, John Glen MP, Lord Addington & Chris Heaton-Harris MP
Cross-party Parliamentary report into Concussion in sport. By Baroness Grey-Thompson, Chris Bryant MP, John Glen MP, Lord Addington & Chris Heaton-Harris MP
Cross-party Parliamentary report into Concussion in sport. By Baroness Grey-Thompson, Chris Bryant MP, John Glen MP, Lord Addington & Chris Heaton-Harris MP
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
(Sports and Athletics Preperation, Performance, And Psychology) Robert Schinke, Robert Schinke - Introduction to Sport Psychology_ Training, Competition and Coping-Nova Science Publishers, Inc. (2013)