With the 2015 Rugby World Cup kicking off in England and Wales this week, the issue of concussion is likely to be high on the agenda.
Amid high-profile cases such as those of England full-back Mike Brown and Wales winger George North, debate has raged for some time about how best to assess suspected concussion victims in rugby union and other sports, as well as how quickly they should return to playing and what the long-term effects of the injury could be.
A team of experts from the National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC), based at Queen Elizabeth Hospital Birmingham, and from the University of Birmingham, is currently undertaking a research study with the aim of providing some definitive answers.
The centre’s work has already been acknowledged by several sporting bodies, including the Rugby Football Union – the recent cases of Brown and North have highlighted an improved awareness of the dangers of concussion among those running the sport.
North’s difficulties began with a blow to the head while on Wales duty last November. A matter of weeks later, he was knocked unconscious during a defeat to England at the Millennium Stadium.
The final straw came with a collision while playing for his club Northampton Saints in March, which resulted in North being stood down from action by neurologists.
Brown, meanwhile, suffered headaches after being knocked out on Six Nations duty in February and did not play for the rest of the season.
Return-to-play protocols have been put in place requiring affected players to pass a series of tests before they can return to action. If, at any point, they fail one of the tests, they go right back to the first step, rather than receiving another attempt.
As head of the NIHR SRMRC, I have held talks with rugby union chiefs about concussion and am an independent assessor for concussion injuries during the forthcoming tournament. While the centre welcomes the recent improvements, we are keen to see further advances in diagnosis research to help club doctors and players at all levels.
The evidence linking concussion – especially repeated incidents – to future neurological difficulties cannot be ignored. For some time now, we have known that concussions can have a cumulative effect on the brain.
Certain groups of patients, such as athletes, soldiers and children, are at greater risk of repetitive concussion, potentially leading to a catastrophic form of injury known as second impact syndrome, thought to be a result of the second incident occurring inside a window of metabolic vulnerability.
Compounding this problem is the fact that athletes are highly trained, young, fit, motivated individuals who under-report concussive symptoms. They are, therefore, at significant risk.
At the NIHR SRMRC, we are working to raise awareness of the potential long-term effects of concussion, when not treated properly, and improve diagnosis on the field of play.
We have recruited 40 athletes for a research project and are using blood, urine, saliva and breath samples to identify ‘bio-markers’ of concussion alongside traditional MRI scans. We will also compare the effects of single and multiple injuries.
Among the initiatives being discussed for improved diagnosis are a small scanner that could be housed in rooms close to the field of play, and even the possibility of a ‘breathalyser’ test that could pick up these bio-markers at pitch-side.
Our research is vital to gain a better understanding of the effects of concussion on sportspeople, to diagnose it more accurately, and to provide evidence-backed guidelines for a safe and structured return to play.
It is often a very difficult job to recognise concussion on the pitch, and each sport has different questions to ask.
Rugby is a wonderful sport with huge benefits for those who take part – we simply want to make it safer.
Professor Tony Belli, Professor of Trauma Neurosurgery, University of Birmingham, and Consultant Neurosurgeon, Queen Elizabeth Hospital Birmingham