Image: Tina Tiller
Image: Tina Tiller

SportsDecember 1, 2021

Concussions don’t just happen on TV

Image: Tina Tiller
Image: Tina Tiller

Concussion headlines are focusing on professional rugby players, but what about the playing fields where there are no cameras? Former player Shea Turner explores concussion culture in rugby, including his own actions.

I am 23 years old, playing my 99th premier club rugby game for Glenfield. It is the quarter-final against Massey and the conditions are perfect. I am captain and bursting with excitement for the game. After our semi-final loss the previous season, in 2015, there is a feeling among the team that we can go all the way this year. We fall behind early in the game, Massey are physical and they are bullying us. 

I take a knock to the back of the head in the first half – not a heaving collision, just a simple stray shoulder in a ruck. It isn’t the worst knock ever but something definitely feels off, incredibly hard to focus on. Staying on is a must, there is an obligation as captain to shake it off and soldier on, or at least I think there is. Making it through the rest of the game is a blur, it is as if the rest of the world is moving really fast but mine isn’t. The game ends up as a heavy loss. We have one more game in the season, the play-off for third and fourth. It’s the only opportunity for me to reach that 100-game milestone. Keeping the fuzzy feeling in my head relatively hush is a must as doubt creeps in on whether passing a head assessment is even possible. Telling the physio and risk missing my 100th game isn’t an option. In my head, playing 100 games at 23 is some sort of an achievement, that it will prove something. I play the game; I reach the centurion milestone and I come out of the game with my head intact. But have I?

I spent a good 21 years of my 28-year lifetime playing rugby. Growing up like most Kiwi kids, dreaming each night of being an All Black was part of life. Getting through rugby relatively unscathed, with no broken bones or serious injuries, has been a blessing. But after sitting down with rugby concussion researchers Karl Zimmerman and Doug King and looking back over my playing days, I am a little worried to think how many concussions may have gone unnoticed. When I am forgetting where the keys are or where I have left my wallet, am I a ticking time bomb? Have the impacts taken their toll or have I just always been this forgetful?

Shane Delahunt of Connacht holds his head during a match between Connacht and Cardiff Blues, April 2019. (Photo: Piaras Ó Mídheach/Sportsfile via Getty Images)

Doug King is a clinical nurse specialist with three PhDs completed and a hard-as-nails look. He is a concussion expert and is recognised internationally for it. He is also accustomed to resistance to his work. 

King has been onto the field to collect players and has been physically assaulted. He has had his medical kit urinated through, his car damaged, and his family threatened. 

In one study conducted by King, he used hi-tech mouthguards in players from the Hutt Old Boys Marist Rugby Club’s premier team to measure impacts to the head, work that left him horrified and confirmed his fears. “When we downloaded the first lot of data I freaked,” he said. “I absolutely freaked at what I was seeing.”

What King was seeing was not just a handful of impact instances, but players accumulating dozens of impacts to the head per game.

“I thought ‘there is something wrong with this mouthguard’. So, I downloaded the next player’s data and it was the same. It just kept going week in and week out, it was just the same sort of stuff.”

 King soon realised that it wasn’t just the direct knocks to the head that they needed to be looking for.

“It’s like holy shit, these people are taking a massive amount of impacts and what was even more scary was that it was coming from the body. The tackles and rucks and scrums. They all accumulate.”

The study, published in 2015, found that players in the 2013 premier club season recorded an average of 77 impacts to the head per game or 1379 impacts over a season. In comparison, a contact sport facing similar issues with concussion, American football, had a mean of 16 to 29 impacts per game or 520 to 652 per season.

King’s findings needed to be looked at further. After seeing the results, he wanted to work with New Zealand Rugby to see how they could potentially work together to fix this issue, not being met with open arms he continued his work alone.

“I thought screw this, I need to get out there and expose this more and more.”

The mouthguards weren’t the only eye-opening result that King uncovered. 

A study by King published in 2013 followed a New Zealand premier rugby team in 2012 with a squad of 37 players which competed in 24 games. The study found 22 concussive incidents recorded over the season, which is close to one a game. But the scary part of the study was that while five were “witnessed” concussive events, the other 17 were unrecognised.

That is effectively an entire team sustaining a concussion over the season.     

ACC’s data of witnessed concussions in rugby union for 2019 showed there were a total of 2648 concussion-related claims with the average age being 20.1. Looking through the lens of the study, does this mean that we have a potential 8865 concussions going unnoticed per season?

Blood pours down the face of Tom Curry of England after he sustains a head injury during a match between England and France, February 2019. (Photo: Charlotte Wilson/Offside/Getty Images)

An unnoticed concussion opens a player up for a repeated concussion or a secondary impact. It is these secondary impacts that pose the greatest risk for players.

“Based on statistics I reckon we lose one a year to secondary impact,” King said, referring to players dying. “That’s one person a year in this country.” 

A UK study that Karl Zimmerman, a research technician in the Computational, Cognitive and Clinical Neuroimaging Lab at Imperial College London, was part of found that 23% of elite adult players had neuroimaging evidence of either axonal injury or diffuse vascular injury. In other words, evidence of mild traumatic brain injury.

However, Zimmerman has noticed resistance from clubs and players.

“As a researcher, it would be great to get buy-in from clubs and players. There are a lot of people who are interested in doing research on it but it’s about availability of players and support from clubs. It’s communication between scientists, governing bodies, players, all the people who are involved and trying to support one another,” said Zimmerman.

Concussion research is currently hindered because of the underlying culture of resistance, as well as few missing pieces. “We actually have a really poor understanding of what concussion actually is.” 

But in New Zealand, King has seen change.

 “In 15 years we’ve come so far forward in this research and when you think about when I first started doing this there were three published papers in one year on concussion now there are seven a day that get published related to concussion.”

Some of the research being published is based on concussion identification with biomarkers. Biomarkers are a biological molecule found in the blood or other body fluids that is a sign of a normal or abnormal process. Identifying concussions has always been tricky but tests using blood and saliva are looking promising. 

A UK study again featuring Zimmerman’s work that was published in 2020 found glial fibrillary acidic protein was elevated in the blood one hour after a suspected head injury. They found this in combination with neurofilament light chain displayed the potential as a reliable biomarker for brain injury evaluation. Head impacts directly affect the levels of these markers in the blood. In other words, a simple blood test after a game could potentially be used to diagnose a concussion.

King and Zimmerman are not only researchers, they are also fans of the game. Zimmerman believes the positives from kids and adults participating in the sport far outweigh the negatives. 

“All the research, in general, would show that rugby prolongs your life. It’s great for your cardiovascular health, great for your mental health” said Zimmerman, who in his own spare time is a player and coach of the equally heavy-hitting sport of ice hockey.

King said he played rugby growing up and he can usually be found going about his work out on the sidelines at club matches in Wellington most weekends. He understands why people play contact sports.

“It’s not about stopping the kids playing because that’s not what I’m for, I’m here to say we need to manage the injuries,” King said.

But kids are being pulled from the game with or without the work of researchers. 

School Sport New Zealand’s data the last time this country hosted the Rugby World Cup in 2011 showed that 31,203 secondary school kids played rugby. In 2015 that had dropped to 28,105 and by 2019 there were only 24,731. Sports participation in general in New Zealand schools peaked in 2015 at 279,229 but had dropped by over 15,000 to 262,891 in 2019.

Not just rugby union: Kyle Turner of the Rabbitohs is assisted from the field after a concussion, August 2015. (Photo: Cameron Spencer/Getty Images)

Rugby governing bodies have been introducing laws at grassroots levels to increase player welfare.

By 2017 the majority of provincial unions in New Zealand had introduced the blue card for referees to use if they suspect a player has had a concussion. When presented the player must be removed from the field, stood down and follow return-to-play protocols. New Zealand rugby even covers the cost of the medical clearance examination.

However, coaches and players quickly found a way around it. 

As a player, since the law was introduced, I can recall countless occasions on the field where a player would take a knock to the head, be slow to get up, and coaches would signal to physios and trainers to get the player off the field before the referee noticed them.

What resulted from the blue card was not an increase in concern for player welfare but coaches and players trying to cheat the system. 

Former Wellington Lion Isaac O’Connor, who was forced to end his playing days early because of concussion, is aware of the culture. O’Connor has seen coaches frustrated that their players are being diagnosed with head injuries instead of playing on. “Coaches have that mentality that it’s the team first but at what costs, you have guys going out there and absolutely destroying themselves,” he said. “And so what? So you can have the best team for two or three seasons?”

O’Connor said coaches needed to look at the bigger picture. He believes there may be some short-term pain of not having players available every week but in the long-term players know their welfare is taken into account, they’ll want to go out and play and they’ll be able to play for longer.

“What’s the point of forcing people to play through peer pressure, through pressure of coaches, if you are just propping up an old school mentality of the game that’s not going to last the distance,” he said.

If I could travel back to the 2016 Glenfield season, to that game, I would sit it out. But there was no way 23-year-old me, who was conditioned in a culture of pushing on, would ever be able to make that decision alone. Twenty-three-year-old me would likely have resisted researchers. I had the mentality they were out to change the game into something unrecognisable. Twenty-three-year-old me would have followed a coach’s advice to shake it off. I would have feared losing the hardman identity. Twenty-three-year-old me barely considered the future risk of concussion.

As players, coaches and administrators we owe it to our past selves and to those starting in the grassroots today to change this resistance culture. We owe it to the future of the game.

Keep going!