Until recently I was unaware that Coventry Rugby Club was involved in an University-led trial to investigate the effects of repetitive concussion on athletes across a range of sports of which rugby is one. I understand that Coventry is the only National One club presently involved, although Moseley was initially part of the programme a while back.
The aim of the trial, the correct name of which is RECOS (REpetitive COncussion in Sport), is to study ‘the window of brain vulnerability following single and repetitive concussion, with a view to guiding return-to-play policy’. For the purposes of this post, concussion is defined as a ‘brief period of loss of consciousness, memory loss or feeling dazed or confused following trauma to the head’.
With no training yesterday, Rowland Winter kindly offered me the chance to chat to Hannah Walker, (Head Physio at Cov) about Cov’s involvement in the RECOS trial and to sit in some of the concussion testing that was taking place that morning.
All the players were involved during the course of the whole day, in groups of 8-9, with testing lasting around 75 minutes for each group.
Hannah had worked with Professor Belli prior to her arrival at Cov some 15 months ago and the club was keen to get involved in the RECOS trial to provide players with an additional level of medical care well above anything offered elsewhere in National One and most likely on a par with most Championship sides and better than some.
The club is in its second year of the trial and is working closely with Professor Tony Belli, a neurosurgeon based at Birmingham University, with a particular interest in the concussive effects caused by traumatic brain injury (TBI).
Apparently, mild TBI resulting in concussion accounts for some 10-25% of all head injuries worldwide and whilst most patients suffering from a single concussion will make rapid improvement, repeated concussion (one of the occasional side effects of playing rugby, for instance) will prolong recovery rates, with those affected often suffering further cognitive and/or behavioural dysfunction.
Professor Belli and his team are working with athletes over a range of sports to monitor the effects of TBI in order to better understand the effects of repeated concussion on the human brain, whilst also providing protocols for clubs and individual athletes to follow in order to provide more effective post-trauma care.
Players are required to complete a series of ‘baseline tests’ which are undertaken at the club by a number of researchers from Birmingham Uni. These include information regarding all previous incidents of head trauma/concussion, a basic medical, a questionnaire to ascertain any mental issues that might also impact on outcomes, (ADHD, learning difficulties, depression etc) and a series of tests to determine basic brain function. These tests are carried out annually, or whenever a player has received a TBI, to determine if there has been any change in basic brain function.
In addition, players are asked to identify any protective equipment that they would use when playing sport – headgear, mouthguard, glasses and so on, as clearly this might also have some influence on determining the degree of potential trauma resulting from a head injury.
Information is also given to the players involved in the research project to educate them in how best to deal with any injury resulting from a TBI, as well as to test players’ own understanding of what is involved in such an injury,
Most supporters will be aware of the procedures for a suspected concussion at International or Premiership level.
The HIA (Head Injury Assessment) protocol requires a player to leave the pitch for at least 10 minutes if it is felt he has suffered any sort of concussion resulting from a TBI.
This is not a requirement at National One level and, in reality, it isn’t practical for clubs lower down the leagues to undertake HIAs as they require a neutral doctor and a private area in which to conduct the assessment. The assessment is very structured and, it would appear, somewhat flawed and certainly Hannah doesn’t believe it is necessarily the best way of determining potential brain trauma.
For instance, were a player to undertake an HIA, it is perfectly feasible that during the 10 minutes of the assessment any underlying physiological problems might not yet have manifested themselves into physical symptoms…sometimes the effects of a blow to the head aren’t immediate. It might well be that a player outwardly looks fine and is allowed back on the pitch only to suffer a second, and potentially far more serious, head injury.
Unless treated correctly, in some instances athletes are at risk of repetitive concussion – potentially leading to a catastrophic form of brain injury known as Second Impact Syndrome, thought to be due to the second incident occurring inside a window of metabolic vulnerability in the brain.
This is very unlikely to happen at Cov as any player believed to have suffered a head injury is immediately substituted and will not return to the pitch for the remainder of the game.
If a player is concussed during a Saturday game, Hannah will ensure the player is stabilised and either taken to hospital as a precaution or sent home.
And this is where you begin to see the level of support Hannah and her team bring to the club.
That same evening, the Saturday, she will email Professor Belli and outline the nature of the injury and the outcome of the various tests and mostly likely speak to him directly by phone on Sunday.
On Monday, the second day following the injury, she will accompany the player to Birmingham Uni where Professor Belli will meet with them and the player will undergo an MRI and a battery of tests using the Standardised Assessment Concussion Tool 5 (SCAT 5) to determine the extent of the injury. In all, this happened 6 or 7 times last season.
By being a part of the trial, Cov benefits greatly from the expertise offered by those involved in the RECOS project. Normally, a player is expected to have at least a mandatory 3 week layoff following a TBI (including a two week complete layoff and a one week phased return).
However, that is not necessarily the case at Cov as the club is allowed to follow the specialist advice of Professor Belli and his team and it might be that an injury that would otherwise have resulted in a three week absence is actually not as serious as first thought and tests might indicate that the player is able to play the following weekend.
With all the baseline data available from the initial assessments undertaken at the club, it is possible to see how much the TBI has impacted in the short-term on brain function and from there determine the appropriate treatment. Interestingly, Hannah says she insists on accompanying a player to the University as in the past the player has returned with a rather more positive account of Professor Belli’s findings than is actually the case.
If the concussion was very minor and after 24 hours there are no adverse side-effects such as headaches or blurring of vision, Cov players can have a 7 day turn around – far less than the usual 3 weeks – but this is only allowed if specialist medical care has been involved and is not something available to other National One clubs at present.
So, provided the player concerned has received a very minor TBI, the programme of recovery might be as follows:
- Day 1 (Sunday) – complete rest;
- Day 2 10 minutes of exercise (perhaps on the exercise bike);
- Day 3 Running (to include changes in direction);
- Day 4 Some ball skills work (to determine any effect on motor skills?);
- Day 5 Contact work;
- Day 6 Clear to play.
More serious injury obviously involves a longer and more structured programme of support.
Importantly, given the club now has it’s own Academy, players aged 19 or under need a 48 hour gap between each of the above stages, so that the minimum return to play for an 18 year old would be two weeks – this is because the brain of someone under the age of 20 is still developing so a longer recovery period is necessitated.
Attached are a couple of photos of two players involved in yesterday’s concussion testing, Kwaku Asiedu undertaking the written assessments and Pete White involved in some of the ‘physical testing’ to determine brain function.
When I got there, Pete was reciting the months of the year backwards and doing so with no difficulty whatsoever, I might add (although I tried to do so in my head a couple of times on the way home and was mortified when I stumbled a couple of times).
Pete was also asked to stand on one leg for 20 second and then repeat the same exercise with his eyes closed – apparently by removing sight from the activity, the brain is required to rely more on its central mechanisms and any potential damage following trauma to the brain might result in an inability to balance.
Whilst involvement in the RECOS trial is aimed principally at giving players additional medical care, care that is well in excess of anything they might expect elsewhere in our league, it also benefits the club.
Good players of the calibre we have recruited over the past two seasons will expect good medical provision and that is going to give us an advantage when it comes to recruitment. There are clubs in our league that have no real medical provision during the week at all and the onus is very much on the players to treat themselves, with all the potential problems that could create.
Hannah and her team are able to provide what is exceptional support at National One level, indeed many of the players who have joined Cov from the Championship have commented that the medical care and rehab is as good as most of the Tier Two clubs.
Forward-thinking = forward-moving.
The work being done at Cov to provide players with the best possible care off the pitch is one of the reasons why players suffered very few injuries last season (and remember the problems in the season prior to RW’s arrival when we could barely put a side together at one point and relied on a number of dual registered players and late additions to the squad to patch a team together…).
Head injuries are becoming more and more frequent in the game (George North is probably the most high profile example of a player suffering TBIs), a result of bigger players more inclined to put their bodies on the line with so much more at stake in the professional game.
Coventry’s willingness to work with academics to further research into TBIs, as well as provide its own players with the best post trauma care available, should be applauded and is something that might well lead to even safer TBI protocols in the future.
Finally, a big thank you to Hannah who took time out of a very busy schedule to chat to me, to the players for allowing me to watch them being tested and to Rowland Winter for inviting me in to observe the testing.