Rugby could be on a collision course

Concussion has been the most common injury in English Premiership games for the past two seasons. Photo / Getty Images

Rugby's ticking time-bomb is post-career health issues related to player head knocks.

There's not trouble at mill. There might be down the track, though. Big trouble - the sort that sounds hysterical and fanciful now but in 20 years might be unavoidable. Might be a bit too real.

Rugby has a potential ticking time-bomb - a generation of professional rugby players and more to come - who could be facing debilitating and severe post-career health issues related to multiple head knocks.

Concussion, if the pun can be excused, is the game's biggest headache. It's a problem because of the scale and potential longevity of the severity.

The latest injury surveillance project out of the English Premiership shows that for the second consecutive year, concussion was the most prevalent injury. There were 54 concussions on match days during the 2012-13 season and another five in training.

The severity is more contentious and harder to measure. Until recently, the weight of medical opinion and limited research in the field has supported the view that there is no accumulative effect in relation to concussion. There is consensus that playing with concussion is highly dangerous but divided views on whether picking up several head knocks in a career makes an athlete more prone to mental health and related conditions later in life.

In the past few years, the body of evidence has grown to challenge the established view. A successful class action has been mounted in the United States by former American footballers against the NFL.

More than 4500 former players have joined the suit - among them, some of the biggest stars of the game. Some of the plaintiffs have suffered early on-set of dementia, some have Lou Gehrig's disease, while more tragically there have been suicides of former players, linked to depression caused by repeated concussions.

Rugby hasn't seen or discovered a similar volume of troubled players, but there have been a few.

Former All Black halfback Steve Devine is one; he was forced to retire at 30 when he couldn't recover from a concussion, one of about between 30 and 40 he reckons he may have suffered.

His immediate retirement was dogged by severe headaches and lethargy. He struggled to cope with background noise and toughest of all was finding the energy to be the type of father he wanted to be for his young children.

"I have treatment now and if I look after myself, I am 100 per cent," he says. "I have endured an extensive amount of testing and my results are looking as good as they ever were and I'm now a full-time professional fire-fighter. I'm a very fit, competent individual but as to what my future holds ... no one knows.

"I have concerns. There are reports that say it [multiple concussions] will be all good and other reports saying they won't be good. I'm not sitting around crying about it but all I know is it is too late for me. I don't get caught up in it," says Devine.

Former All Black halfback Steve Devine was forced to retire at 30 when he couldn't recover from a concussion.

The battle to prevent it from destroying the game and people's lives is complex and, at the moment, across two distinct fronts.

Progress has been made and continues to be made on one front; in New Zealand, at the professional level, the management of players with concussion is exemplary. There is robust testing; there is, by and large, no overt or covert pressure applied by coaches to get players back on the field before they're ready and the seriousness of the condition is respected and duly acknowledged.

It's not perfect but, hand on heart, New Zealand can say its athletes are among the best managed after they suffer a concussion.

What is becoming increasingly apparent, however, is that when it comes to understanding and researching the possible longer-term health implications for those players who suffer repeated concussions, more needs to be done.

While the Rugby Football Union helps fund the annual surveillance report into Premiership injuries, there is no such centralised or co-ordinated collection of data in Super Rugby.

Most New Zealand medics linked to Super Rugby sides collect information on squad injuries - but that's mostly a recent practice so there is little cohesive, historic data around head knocks.

AUT has been commissioned by the IRB and New Zealand Rugby Union to study how well the brain connects with the body in retired contact sport athletes compared with those who didn't play contact sport. But the project has struggled to find enough subjects and may not be able to deliver meaningful results as a consequence.

NZRU medical director Dr Ian Murphy says the difficulty of conducting research is significant given the variables that may contribute to longer-term conditions.

"Is there any other factor that contributes to this [long-term effects of concussions]? We don't know: there might be issues such as binge drinking, or performance enhancing drugs or underlying mental health issues.

"What we would like is a long-term, nationwide study where we are able to control a whole set of variables. I think we need a partner for this and we are talking to ACC."

The need to understand more about the possible long-term effects is critical.

"Why is the brain different from the other organs? I don't think it is," says Blues medic Dr Steve Kara. "But we don't have the evidence where we can firmly stand there and say it [long-term damage] definitely happens. We think it happens but we need the research in rugby to be able to definitely say. But look, I think all of us are moving towards the point where we are pretty sure it does have an impact in the future and our management has to be with that in mind knowing that the evidence hasn't really caught up in rugby yet."

Last year, the first rugby specific evidence emerged. Glasgow-based neuropathologist Dr Willie Stewart revealed that he had found evidence of a former rugby player suffering from early on-set dementia.

"We have known that in boxing for instance repeatedly injuring your brain can read to a syndrome, punch drunk syndrome, and you can imagine what that is," Dr Stewart told the BBC. "The pathology of that is better classified as dementia pugilistica and we kind of assumed it was only boxing related and you had to be exposed to a lot of concussive injuries. But what we're seeing here and in America is that it's happening in other sports where athletes are exposed to head injury in high levels. Those sports include American football, ice hockey and now I've seen a case in a person whose exposure was rugby."

Devine is probably indicative of the prevailing view of players of his generation; he doesn't hold anyone responsible for his predicament. He is confident the medical advice he was given was the best available at the time. The doctors who treated him acted on what they knew. But despite concussion testing and mandatory education, rugby's governing bodies can't leave themselves open to accusations they haven't been proactive in determining the longer term impacts of head knocks.

The lack of research and split opinions leaves the players vulnerable and rugby, in time, could face a similar suit to the NFL.

All Black Conrad Smith, a qualified lawyer and victim of several nasty concussions, said last year in regard to a class action against rugby: "I could see it. I don't know whether it would ever get as long as far as it did over there. We have the whole ACC thing, so I don't know how that would effect it.

All Black Conrad Smith has suffered several nasty concussions himself.

"But it is obviously an area where a lot of work will be done. I don't think it will go away in a hurry and nor should it. There is a lot to be found about it for all contact sports - not just rugby. I don't think this will go away for a decade or so."

Dr Murphy says that looking for answers on the longer-term effects of concussion is probably more important in some respects than actually finding them.

It's his view, supported by many other experts, that a definitive answer on whether there are long-term effects of repeated concussions may never be proven.

"I think a definitive answer is a holy grail," he says. "The more I learn about the science of medicine as opposed to the art of medicine, the more I believe it is not so much about delivering black and white. It is about making the grey more white or more black. I am in no doubt that my role is to help us provide answers. We need to be cognisant of this issue and do everything we can to find meaningful science."

Former players interested in taking part in the AUT survey, contact Scott Brown on rugbyhealth@aut.ac.nz or (09) 921-9999 ext 5182. Former hockey, cricket and elite rugby players are particularly needed.