Sideline assessment of concussion and return to play – are we practising what we preach?

October 27, 2011 by 9 Comments

The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.

The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.

Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.

He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.

The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.

Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’

Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’

What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines – see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’

In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.

Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.

The Rugby Law blog was particularly vociferous on these events.

For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.

Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?

CJSM would like to hear your experiences and opinions.

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London Prepares series – 2012 test events in full swing

October 14, 2011 by

With less than 300 days to go until the start of the London 2012 Olympics on the 27th of July, and the Paralympics on the 29th of August, London is entering the final stages of its preparation. The City has been hosting the ‘London Prepares’ test event series in advance of the games and these commenced in May this year with the 2011 UK Athletics 20km race walking championships and an invitational marathon. Since then, there have been a number of other events including equestrian, modern pentathlon, sailing, triathlon, badminton and various cycling events.

The latest treat on the calendar was the 2011 London Archery Classic held at Lords Cricket ground from the 3rd to the 10th of October, and I was on hand to view events for myself as a Sports Medicine event doctor last weekend.

Lords Cricket ground is better known in the UK and worldwide as the home of Cricket, so it was a little strange to see such a different audience in the famous old pavilion, usually occupied by members of the Marylebone Cricket Club (MCC) in their distinctive red and yellow striped jackets and sun hats. Despite the unfamiliar appearance of the spectators, this famous old venue was a wonderful place in which to see the athletes compete in the archery event. Perhaps it was fitting that, in such a prestigious place, the archers rose the occasion by putting in some excellent and memorable performances, including two new world records. Korea’s Im Dong-Hyun managed to break his own  72-arrow world record in the ranking round, scoring 693 and exceeding  his previous record by two points, and followed this up by helping to set a world record in the men’s team competition.

From the medical side of things, everything seemed to go very smoothly with no major problems, the classic representing an ideal opportunity for the medical team to get to grips with things at the venue and to make the fine adjustments necessary to systems and resources prior to the games proper.

As far as test events go, there are many to go this side of Christmas with handball, boxing, table tennis and fencing amongst others to feature. In the new year, spectators can look forward to many more competitions including gymnastics, cycling and aquatics events before some paralympics test events commencing in April.

It is always exciting to be involved in test events prior to the main spectacle to come, and it was a pleasure to be able to watch these world class athletes perform and to talk with the other support and coaching staff. I was even fortunate enough to try my hand at the sport on a much shorter range, managing to hit the target with each of my 3 arrows. Having said that, I don’t think that Im Dong-Hyun and his colleagues have much to fear.

Archery was reintroduced to the Olympic games in the 1972 Munich games following a 52 year hiatus thought to be due to a lack of uniform rules.

Ertan and Tuzun found a prevalence of injury of 56.8% in a questionnaire study of 88 archers at the 2000 Turkish archery championships, although were not specific about their definition of a reported injury. Mann and Littke reported an injury rate of 38.1 injuries per 100 competitors from a retrospective questionnaire of 21 archers who qualified for the Canadian world championship team in 1987. Most injuries are reported to occur in the upper extremities. Ertan and Tuzun found the fingers to be the most frequently reported body part to be injured, followed by the shoulder of the drawing arm. This pattern was further supported by National Electronic Injury Surveillance System findings from the US product safety commission 2007 which included hunting-related archery injuries.

Acute injuries include blisters in the fingers and contusions to the bow forearm caused by string touches, also known as ‘bow slap.’ Most archers wear protection on their bow forearm to prevent this injury. Chronic overuse injuries include tendinopathies (see Rayan G, in Southern Medical Journal) and compression neuropathies in the arm (see Toth C et al, in Sports Medicine). For a comprehensive review of the epidemiology of injury in archery, see Hildenbrand JC (IV) and Rayan GM Chapter 2 in Caine DJ et al ‘Epidemiology of Injury in Olympic Sports’ , Wiley Publishing.

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