Leagues Behind: Why Rugby Needs to Learn from Head Injuries in the NFL

The following piece was completed on December 31, 2013 and is republished here, with the express permission of Kevin Whelan, in order to raise concussion awareness and educate those interested in the history of head injuries in football and rugby. I have added an update to the end of the paper in order to mention several football incidents that have happened since the paper was completed. Undoubtedly, more incidents will continue to occur during this weekend’s Championship Round games and February’s Super Bowl, and these (in addition to the NFL’s ongoing lawsuit) are worth keeping an eye on as well.

Leagues Behind: Why Rugby Needs to Learn from Head Injuries in the NFL

Sports and injuries have gone hand in hand for as long as sports have been around, from ancient wrestling and jousting to the sports of the twenty-first century. A lot has changed since these ancient times, however, from the sports themselves to the equipment and technology used in the sports that have endured. With the advent of modern medicine and the accompanying medical research, a great deal has been learned and applied to sports in order to make them safer. In the past quarter-century, head injuries in American football have led to a plethora of research and discussion on concussions and chronic traumatic encephalopathy (CTE). During much of this time, the largest American football organization, the National Football League (NFL), denied the severity of head injuries in their sport and attempted to refute medical experts and their research rather than dealing with head injuries appropriately, resulting in a substantial group of retired players with cognitive issues and a massive lawsuit in which the NFL paid out $765 million (€560 million) to a group of over 4500 former players. While the NFL continues to deal with the fallout of its past failures and the concussion issue itself, the same issues have emerged in the sport of rugby, leading to a series of events running parallel to those of the NFL. However, knowing the history of the NFL’s dealings with concussions, the International Rugby Board (IRB) would do best to reverse their current course of action and learn from the NFL, in order to improve the future of rugby for the players as well as to allow for the survival of the sport itself.

The severity of head injuries in American football was first discovered by medical experts in 2002, with the autopsy of former Pittsburgh Steeler Mike Webster, an event some describe as “one of the most significant moments in the history of sports” (Drenon). Throughout his life, Webster was “known for being very slow to anger off the field,” but, toward the end of his life, showed signs of a “startling change” that turned him into “a moody, explosive man who tore through all the family’s money and would lock himself in the bathroom for hours at a time” (Roth, “Late Steelers Great…”). At the time of his death, he was reportedly “so disturbed” that he “fantasized about shooting NFL executives” (Jackson). Dr. Bennet Omalu, who performed the autopsy, saw in Webster’s brain the signs of what is known as chronic traumatic encephalopathy (CTE), in layman’s terms meaning “a long-developing brain injury” (Roth, “Scientists hunt for…”). This diagnosis “helped explain [Webster’s] rapid descent into madness, and…set the stage for a scientific battle over football players’ brains” (Jackson). Even at this point, CTE had been known, seen in boxers, particularly “in sluggers, who…don’t tend to get a lot of concussions per se,” instead experiencing repetitive “subconcussive blows” (Roth, “Scientists hunt for…”). Head injuries were not unknown to the NFL either, with the league forming the MTBI (mild traumatic brain injury) Committee as far back as 1994. Still, Webster’s CTE diagnosis was the first of its kind in the NFL and brought new light to the severity of the problem.

Since 2002, CTE has been found in athletes from other sports as well. These athletes include Ryan Freel, the first baseball player to test positive for CTE, who committed suicide in December 2012 (Barney), and Chris Benoit, the wrestler whose brain showed was described as showing “massive damage,” who killed his family and himself in June 2007 as the result of “a gradual decline into violence and dementia” (Matlin).  Still, American football is still the primary offender when it comes to concussions and CTE, with separate studies showing that high school and college football players receive 11.2  and 6.3 concussions per 10,000 games and practices, respectively, and with experts agreeing that the reported incidence rates are much lower than the actual rate of concussions (Belson). While these numbers don’t seem like much, they add up, given that by the end of college football players receive an average of “8,000 blows to the head, with more to come in the pros” (Roth, “The tragedy of CTE…”). PBS’s Frontline crew have started keeping track of head injuries in the NFL, finding, in reported injuries alone, 171 in the 2012 season and 146 concussions so far in the 2013 season (Breslow). As a result of these conditions, a NIOSH (National Institute for Occupational Safety and Health) cohort mortality study of 3,349 players who played 5 or more NFL seasons found that the “risk of death associated with neurodegenerative disorders” is three times higher for football players (Lehman).

Before diving further into the NFL’s dealings with concussions and CTE, it is worth discussing these medical conditions a bit further. By definition, a concussion is “a disturbance in brain function caused by direct or indirect force to the head,” making it a “functional rather than structural injury,” and which results from “shear stress to brain tissue caused by rotational or angular forces” (Scorza). There are three grades to concussions, according to the American Academy of Neurology: Grade 1 involves transient confusion, no loss of consciousness, and concussion symptoms that resolve in less than 15 minutes; Grade 2 involves transient confusion, no loss of consciousness, and concussion symptoms that last more than 15 minutes; and Grade 3 refers to a concussion with any loss of consciousness, either brief or prolonged (Lark). The symptoms of concussion “usually start at the time of the injury but the onset of these may be delayed for up to 24–48 hours” (“IRFU Guide to Concussion”), making the diagnosis difficult and reliant on assessment tools (Scorza, “IRFU Guide to Concussion”). Symptoms most commonly include headache and head pain, although they can vary from loss of consciousness to confusion or low energy and much can vary by person, making individualized approaches necessary (Scorza, “IRFU Guide to Concussion”). Currently, there is no specific treatment for concussions aside from managing symptoms and using assessment tools to monitor recovery (Scorza).

CTE is “a degenerative brain disease that results from repetitive brain trauma and may cause symptoms of dementia such as memory loss, aggression, and depression” (Jackson). Experts agree that there is a connection between “repeated head impacts—even if they weren’t concussions—and eventually developing CTE” (Roth, “The Tragedy of CTE…”; Hanna). As for the biology of CTE, it involves a protein called tau, which all humans have, but, in CTE, tau “becomes damaged and begins to fill up the brain” (Roth, “The Tragedy of CTE…”), forming “tangles and clumps” which “can then infect nearby cells, hastening its spread through the brain” (Roth, “Scientists hunt for…”).

However, not all with damaged tau proteins get CTE, leading to the belief that another protein, a cholesterol transporter called APOE4, is involved in the process (Roth, “Scientists hunt for…”). The APOE4 protein has one modified amino acid (out of 299) that causes “the head and tail of the protein to curl toward each other,” and the body recognizes this change, removing the tail piece, which then damages tau proteins and causes problems within the brain (Roth, “Scientists hunt for…). Until recently, it was difficult to tell if someone had CTE while they were alive, but Gary Small and his team at UCLA have developed a method of detecting tau deposits in the brain using radioactively tagged tracers and PET scans (similar to an MRI), using the location of tau deposits to distinguish CTE and Alzheimer’s (Roth, “The Tragedy of CTE…”). Numerous treatments are currently being developed, from light therapy to drugs to fish oil supplements, but none has been studied extensively thus far (Roth, “Scientists hunt for…”).

With Mike Webster’s CTE diagnosis, the NFL entered a period of “denial” on the topic of head injuries, perhaps due to the warning of the NFL’s first brain specialist, Joe Maroon, who claimed “if only 10 percent of mothers in America begin to conceive of football as a dangerous game, that is the end of football” (Jackson). The NFL’s attitude of denial began to show following the 2005 publication of Dr. Kevin Guskiewicz’s survey of over 2,550 former NFL athletes, which concluded that players who had three or more concussions in the NFL were five times as likely to be diagnosed with a mild cognitive impairment (MCI) later in life (Hanna). The NFL and its MTBI Committee responded to this study by having committee member Dr. Mark Lovell attack Guskiewicz’s study, saying “we want to want to apply scientific rigor to this issue to make sure that we’re really getting at the underlying cause of what’s happening…You cannot tell that from a survey” (Hanna).

Yet this attitude of denial continued even after Omalu, Dr. Robert Cantu, and other independent scientists showed, in a series of studies between 2005 and 2007, that multiple NFL concussions cause cognitive problems and that the deterioration of cognitive function and psychiatric symptoms displayed by (the aforementioned) Mike Webster, Terry Long, and Andre Waters prior to their deaths was “at least partially” due to CTE triggered by NFL concussions (Hanna). The NFL responded not only by claiming that there was a lack evidence linking concussions and cognitive decline, but also by attacking the scientists involved, having its committee members Ira Casson, Elliot Pellman, and David Viano write a letter to the editor of Neurosurgery asking for the retraction of Omalu’s paper, in an attempt by the NFL to “[use] its economic, political and media power to attack pioneering research and try to replace it with its own” (Fainaru-Wada). Omalu, though, “found delicious irony in the NFL’s letter, given that neither Casson, Pellman, nor Viano are neuropathologists” and asked “how can doctors who are not neuropathologists interpret neuropathological findings better than neuropathologists?” (Hanna).

As Omalu pointed out, there was not a single neuropathologist on the NFL’s committee, and its chair (Pellman) was a rheumatologist , bringing the group’s expertise into question (Hanna). In fact, the committee, which had been around the NFL since 1995, was “made up almost entirely of NFL insiders” and its leader, Pellman, “exaggerated his credentials,”  but was appointed as head of the committee anyway, at least partially because his view on concussions was “perfectly aligned with NFL doctrine at the time” (Fainaru-Wada). What’s more, the NFL committee “used” scientific journals “to publish an unprecedented series of papers, several of which were rejected by peer reviewers and editors and later disavowed, even by some of their own authors” (Fainaru-Wada).

In July 2007, faced with mounting Congressional and media pressure, the NFL held its first concussion summit, where it invited independent scientists to present their work at the conference. Although the summit seemed to signal a change in the NFL’s stance on head injuries, it instead served as a means for the NFL to reduce external pressures to act on the issue, as the NFL returned to a state of denial immediately afterwards, releasing a statement in August 2007 stating: “Current research with professional athletes has not shown that having more than one or two concussions leads to permanent problems if each injury is managed properly. It is important to understand that there is no magic number for how many concussions is too many. Research is currently underway to determine if there are any long-term effects of concussions in NFL athletes” (Hanna). Guskiewicz, among others, saw this statement as an attempt “to pull the wool over the eyes of…medical personnel who had attended the summit” (Fainaru-Wada).

Later, in 2008, Dr. Ann McKee showed that the brains of two other NFL players, John Grimsley and Tom McHale, showed “distinct signs of CTE” and concluded that “the easiest way to decrease the incidence of CTE is to decrease the number of concussions,” stating “there is overwhelming evidence that [CTE] is the result of repeated sublethal brain trauma” (Hanna). Yet, even after this study was published in 2009, the NFL committee member Dr. Ira Casson continued to say “there is not enough valid, reliable, or objective scientific evidence…to determine whether…repeat head impacts in professional football result in long-term brain damage” (Hanna).

In September 2009, a University of Michigan study commissioned by the NFL found that former NFL players (specifically, males in the 30-49 age group) had cognitive diseases at rates nineteen times higher than the national average, resulting in Congress announcing a mandatory hearing to discuss “legal issues relating to football head injuries” (Fainaru-Wada). At the hearing, the House Judiciary Committee heavily criticized the NFL and its concussion policy, and NFL Commissioner Roger Goodell, “on at least two occasions” during the hearing, avoided offering a definitive answer on “whether multiple NFL concussions contributed to the early onset of cognitive decline,” deferring to medical judgment (Hanna). Ira Casson, a neurologist and the new co-chair of the NFL’s committee, was unable to attend the hearing, however, so a clip was played of Casson “repeatedly and emphatically responding ‘no’ when asked on HBO’s Real Sports whether football caused dementia, Alzheimer’s or any other neurodegenerative disease” (Fainaru-Wada).  Looking back, however, the most memorable moment from the Congressional hearing was Representative Linda Sanchez’s comparison of the NFL’s “denial of a causal link between NFL concussions and cognitive decline” to “the tobacco industry’s denial of the link between cigarette consumption and ill health effects,” and her encouragement to the league to “get ahead on this issue, if only to cover [the NFL] legally” (Hanna).

After the Congressional hearing, the NFL forced Dr. Ira Casson and Dr. David Viano to resign from the NFL MTBI Committee, and replaced them with “well-credentialed neurologists” Dr. H. Hunt Batjer and Dr. Richard G. Ellenbogen, chiefs of neurological surgery at Northwestern Memorial Hospital and Harborview Medical Center, respectively (Hanna). Additionally, after years of denial, NFL spokesperson Greg Aiello admitted in December 2009 that “it’s quite obvious from the medical research that’s been done that concussions…lead to long-term problems” (Hanna). These steps are symbolic of the strides the NFL has made in the right direction the past several years. Procedurally, the NFL has instituted a new series of rules “to eliminate hits to the head and neck, protect defenseless players, and prevent athletes who have had concussions from playing or practicing until they are fully recovered” (Dale) as well rules (backed by fines) that crack down on targeting and helmet-to-helmet collisions (Bass). The NFL has also collaborated with and donated $1 million in support of the Center for the Study of Traumatic Encephalopathy (CSTE), and put new rules into place mandating the availability of local doctors to examine players (Hanna).

Still, by the time the NFL accepted concussion research as fact, much damage had already been done, leaving a generation of players suffering with the effects of playing during the NFL’s denial era. Since Mike Webster’s autopsy in 2002, numerous other players have been diagnosed with CTE (most post-mortem), while others have been diagnosed with other neurodegenerative diseases such as Alzheimer’s or dementia.

Some played decades ago, such as Larry Morris, John Mackey, Willie Wood, Jim Ringo and Gene Hickerson, all of whom were named to the All-1960s team and now have dementia (Crossman). Morris, the recipient of at least four concussions during his NFL career (not including his college days nor concussions that went undiagnosed) and 1963 NFL Championship Game MVP, cannot remember the game that made him most famous, nor can he “sign his name…complete basic hygiene tasks…[or] dress himself,” all a part of “the price he is paying for having suffered multiple concussions playing football,” according to his neuropsychiatrist (Crossman).

Hall of Fame player Tony Dorsett, who played with the Dallas Cowboys in the 70s and 80s, told the New York Daily News last year that he “can’t remember the names of people,” needs to ask his wife how to get somewhere “almost every other day,” and gets “short-tempered” and then breaks down, asking himself “Man, what’s happening to me?” (Red). Fred McNeill, who played for the Minnesota Vikings for twelve seasons in the 70s and 80s, suffers from “advancing dementia” as well, resulting in the loss of his law license (he tried to practice law after retirement, until the dementia took hold) and his driver’s license, and he now needs “live-in caretakers and the help of his family to manage everything from doctors’ appointments to his finances” (Roth, “The tragedy of CTE…”).

Even Brett Farve, the infamous Green Bay Packers quarterback who played from 1991 to 2010, admitted that he is suffering from memory loss too, at the young age of 44 (Myers).  When asked how many concussions he suffered in the NFL, he said, ironically, that he “doesn’t remember,” although he did say that there were “a lot” of times that he “played with a concussion that with the new standards would have resulted in him sitting out” (Myers).

The number of recent players, like Farve, who are suffering from the effects of concussions at a relatively young age is unprecedented. Adding fuel to the fire, there have also been a significant number of deaths in this group, many by suicide. Chris Henry, who had played with the Cincinnati Bengals since 2005, died in December of 2009 (as an active player) after getting into a domestic dispute with his wife, and his autopsy showed that he was suffering from CTE (Roth, “The Tragedy of CTE…”). Jovan Belcher, who had played with the Kansas City Chiefs since 2009, killed his girlfriend and himself in December 2012 (also as an active player), leaving behind an infant daughter, as the result of probable CTE (Lupkin). There are players like Dave Duerson and Junior Seau, who committed suicide by shooting themselves in the chest, “presumably to preserve their brains to be studied for a disease [CTE] they were convinced they had…they were right” (Jackson). Other confirmed CTE sufferers include former Pittsburgh Steeler Terry Long, who killed himself in 2006 by drinking antifreeze, and former Philadelphia Eagle Andre Waters, who shot himself in the head in 2006 (Lupkin). The list goes on and on, so much so that there is some (admittedly unsubstantiated) speculation that OJ Simpson’s erratic behavior over the years could be the result of CTE as well (Matlin) and several players, such as Jacob Bell, have retired from the game in their prime to avoid further brain damage (Lupkin).

As a result of the combination of the league’s policy of denial for so many years and the increasingly poor conditions of the NFL’s former players, in 2013 the NFL faced a class-action lawsuit the likes of which are “unprecedented in sports,” resulting in the NFL paying $765 million (€560 million) to make a settlement with a group of more than 4,500 former players who “accused the NFL of concealing the long-term dangers of concussions and rushing injured players back onto the field, while glorifying and profiting from the bone-crushing hits” (Dale). August’s tentative settlement still needs a District Judge’s approval (Draper), but, according to the Associated Press, the settlement “applies to all 18,000 past NFL players and spouses of those who are deceased” and the “vast majority” of the settlement money will “compensate athletes with certain neurological ailments, plus plaintiffs’ attorney fees,” although the settlement also “sets aside $75 million for medical exams and $10 million for medical research” (Dale).

However, notably, “the settlement does not include an admission from the NFL that it hid information from players about head injuries” and “current players are not covered” (Dale). For these reasons and others, the settlement has already come under fire from some high profile players, such as Hall of Famer Tony Dorsett, who said, regarding the settlement:

When I look at my current situation, my quality of life is deteriorating daily. One of the things I was hoping for was health insurance for the rest of our lives. It’s going to get to the point where medical expenses are going to get extremely high. That’s my issue. The owners make billions of dollars, man. And the $765 million (settlement figure)—that’s like throwing a pebble in the sea…Football caused this. Football has caused my quality of life to deteriorate…What was the calculation—about $250,000 per person? What the hell is $250,000? If I get to live another 20, 30 years, $250,000 don’t cover my damn medical expenses if it gets any worse…And there’s a lot of guys that are probably in worse shape than I am. (Red)

In addition, several players have already started filing lawsuits against their individual teams, such as nine former players for the Kansas City Chiefs, who have accused the team of “[increasing] their risks by giving them ‘ammonia inhalants, caffeine cocktails and/or Toradol to abbreviate the need for concussed employees to miss working time due to a brain injury’” and say that “the team ignored decades of scientific research indicating repeated head trauma causes permanent brain damage” (Draper). More former players may file similar lawsuits with other NFL franchises in the future, creating the possibility of further headaches for the league.

Although the NFL is still a hugely popular, $9 billion industry, its response to head injuries has affected the league’s image, and there is evidence of decline. For example, there are 10 teams in the NFL who average less than 95% attendance at home games, double the number from 2006 (Bondy). In addition, HBO Real Sports/Marist Poll showed that 13% of parents “will not allow their kids to play tackle football” and about 33% are “‘less likely’ to permit such participation than…before news of all the head injuries came to light” (Bondy). In the most staggering statistic, ESPN’s Outside the Lines found a decrease in participation within Pop Warner youth football of 10% from 2010 to 2012 (Bondy). In order to remain a viable sport, the NFL must seriously and comprehensively address the issue of head injuries in football.

Despite the league’s efforts in the past few years, looking forward, the NFL still has a lot of work left to do. The new rules help lessen the chances of concussion, but there are still many concussions that do occur and many situations that leave players in danger. Two incidents immediately come to mind, the first of which is the career ending concussion of Buffalo Bills quarterback Kevin Kolb in August 2013 on an unremarkable, glancing hit during a routine tackle (Ley). The second is the concussion of Detroit Lions tight end Dorin Dickerson, which occurred while blocking during a kickoff (a kickoff that ended in a fair catch, nonetheless) and went unnoticed by others for several plays after the injury occurred (Wagner). Both concussions are serious issues for the NFL, as neither was (or could be) prevented by the new rules, yet one resulted in a career-ending concussion and the other resulted in an unnoticed concussion that left the injured player in the game, susceptible to further injury. The NFL must find ways to address these kinds of issues, using the vast resources at their disposal.

In addition, there are some serious concerns over some of the new rules that the NFL has instituted. As some pointed out when the new rules were instituted, the NFL’s “concentrated focus on eliminating head trauma…have increased players’ risk of knee and leg injuries” by creating rules that promote tackling players by hitting them low (Bass). Bass suggests that the NFL’s new targeting rules are only a “stopgap” and that they should “consider serious changes to the game in order to protect player safety” such as “making fields narrower, cutting it down to 10 players per side, and eliminating special teams” (Bass). An incident this year involving New England Patriots tight end Rob Gronkowski serves to back this argument. In a game against the Cleveland Browns, Gronkowski “suffered a concussion along with his knee injury as a result of the hit he absorbed…[when his] head banged against the turf at Gillette Stadium after Ward’s shot to the knee toppled Gronkowski to the ground” (Florio). Another injury occurred in the preseason, when Dolphins tight end Dustin Keller’s knee was injured after a tackle by Houston safety D.J. Swearinger. Although the play was “clean,” Keller suffered a torn MCL, ACL, PCL, and dislocated kneecap, and because “Keller was on a one-year contract with the team…his career may be over” (Bass). Thus, although the new rules prevent helmet-to-helmet hits and targeting, they may simply be replaced by other injuries. Bass is clearly of this opinion, stating:

Targeting rules are merely Band-Aids placed over gaping wounds. Instead of steering headfirst into the totality of an unsafe sport, officials are focusing on only one part of the problem. Their overcorrection is going to result in shorter careers…and a shift from violent headshots to gruesome leg injuries. Let’s just hope it doesn’t take as long to figure out as it did with concussion awareness. (Bass)

The league has a duty to its players to try to solve these injury problems instead of putting “entertainment of the general public…over the safety of NFL players” (Lark), perhaps by tweaking more rules or perhaps by making the more serious changes Bass suggests. There also needs to be an attitude change within the NFL, as there is still “considerable old-school resistance” to changes to the game, such as the occasional “sneering analyst comments” about head injuries (Bondy). In the end, the NFL has a duty to educate its players, coaches, referees, and fans on recognizing and treating concussions (Lark), fund further research on head injuries and sporting equipment (Belson), and promote safe play, whether this means rule changes or larger changes to the game.

The beginnings of the NFL story may sound similar to rugby fans, as the sport has begun facing similar problems in recent years. Although the two sports differ in play style and equipment, both are contact sports involving “brutal” collisions and head injuries (Roan). In recent years, some have tried to say that the research done on NFL football is not applicable to rugby, and that rugby “will avoid the concussion-related problems seen in American football,” because those are “helmeted sports,” but medical experts say “the collisions are different but it doesn’t take very much impact to shake the brain and cause a concussion” (Bech). In fact, concussion is “the most common injury in the professional game, with 5.1 instances for every 1,000 hours of rugby played” (Roan). Additionally, rugby players are “largely unshielded from collision forces, and the cranium is subjected to violent acceleration-deceleration and rotational forces,” and although some players use mouth guards and soft-shell head protection “their effectiveness in preventing concussion in rugby is open to question” (Marshall). Although there may not have been as many problems in the past, players today are about 7.2kg heavier than even two decades ago, such that “the force of their collisions can be the equivalent of what the body experiences in a car crash” (Roan). Furthering problems, rugby is often played “in situations in which medical personnel are frequently not present” and “medical personnel who are available are often not well trained in recognizing and managing concussions” (Marshall).

One study on collegiate athletes shows the injury rate per 1,000 player exposures due to concussions is 2.0 in rugby and 4.5 in American football (Keating), while other, more recent studies put rugby’s number higher, at 3.8, a number not statistically different from that in football (Marshall). According to Marshall, “Methodological limitations and administrative rules that required suspension for injured players may have suppressed reporting in previous epidemiologic studies” and the number is likely even higher than 3.8, as “many rugby concussions go unreported.” Other researchers back this assertion, showing in anonymous surveys that only 46.6% of players reported concussions to the appropriate medics, with players’ reasons for not reporting including “not thinking the injury was serious enough” and “not wanting to be removed from the game” (Fraas). As in American football, concussions are a serious issue in rugby.

However, like with football, it took a high-profile case to jumpstart the head injury discussion in rugby. Instead of a Hall of Fame retiree Mike Webster though, rugby’s wakeup call came in the form of Ben Robinson, a 14-year-old boy from Carrickfergus Grammar school in Northern Ireland. In January 2011, during Carrickfergus Grammar’s rugby match against Dalriada, Ben sustained a concussion at the start of the second half, but his coach “checked Ben for concussion” three times, and “allowed Ben to play on despite showing signs of head trauma,” until, with one minute remaining in the game, he collapsed and died (Douglas).

Since 2006, at least six people have died from head injuries while playing rugby (Bull). Ben’s death was the result of what is known as Second Impact Syndrome (Douglas). As Dr. Willie Stewart, one of Britain’s leading neuropathologists, puts it “adolescent brains can swell uncontrollably after a single bang on the head… the first one causes the blood vessels to become a bit leaky…the second one causes them to become much worse, and that leads to brain swelling…[the second hit] does not have to be concussive….a glancing blow, a jar, is enough to exacerbate the swelling” (Bull).

Ben’s death, however, “could, and should, have been prevented” (Bull). As his father stated to the press:

Ben took too many blows to the head in too short a space of time…For something like this to happen…there have to be so many failings…and on that day, unfortunately for Ben, there were so many failings…there should have been a chain of health-and-safety procedures in place, one that included players, coaches, referees and parents. If just one link in that chain had worked as it should have, Ben’s concussion would have been spotted. He would have been removed from the pitch, and he may have survived. (Bull)

The coaches and referees, for one, should have used the Standardized Concussion Assessment Tool (Scat) to look for any of the nine “red flag” symptoms of concussion, and immediately removed Ben from the game (“IRFU Guide to Concussion”). Yet, the majority of “club and school players, coaches, and referees have never heard of it,” because, in order to get a Scat card from the IRB, “you have to find it on their website and download your own copy” (Bull). The referee in charge of the match between Carrickfergus Grammar and Dalriada admitted at the first hearing, which took place almost a year after Ben’s death, “that he had never heard of the Scat…Neither had the Carrickfergus coach” (Bull).  Still, one “team mate said [Ben] had not been aware of the score” in the moments leading up to his death, and the signs should have been enough for the coaches and referees to remove Ben from the game (Brady).

When the pathologist’s tests came back a few months later, it had shown that  “Ben had three brain injuries, and it was probable that they had all been inflicted in that one match,” and “compared Ben’s injured to those you’d see in somebody who had been involved in a car crash” (Bull). Later, during the official inquest into Ben’s death, his family found that the school had hired a lawyer and turned the process “adversarial” (Bull), and they were forced to prove that Ben should have been taken off the pitch earlier, using video painful to Ben’s family, but which the coroner described as “‘extremely useful’ and…‘better than a witness statement’ because they could not be disputed” (Brady). What’s more, representatives from the Ulster branch of the Irish Rugby Football Union (IRFU) showed up to the inquest, as they had trained the referee, and received approval on its request to postpone the inquest a year. Finally, over a year after Ben’s death, the coroner ruled Second Impact Syndrome as the cause of Ben’s death, “the first diagnosed case in Northern Ireland and, probably, in the UK” (Bull). Still, the official report stated that “neither the team coach or the referee were made aware of his neurological complaints,” and the IRFU issued a statement expressing its “deepest condolences,” but also stating that “injuries of this nature are highly unusual in rugby” and insisting that they follow “all international best practices, as set out by the IRB” (Bull).

The Robinson family and many others want more to be done, though, given that these “best practices” had already failed once, and that, despite the case being “of great public interest,” “unless you went looking for information about concussion, you wouldn’t find it” (Bull). In other words, there seems to be a “complete lack of awareness” about concussion, how to spot it, how to treat it, and how seriously to take it, and the IRB was doing nothing to help (Bull). Ben’s father wants laws to be put into place to promote education, as he expressed to the Daily Mail, saying “it is about getting the message out…We had a policy in America, a template for all of this, that can be put in place tomorrow…I would love to fight for Ben’s Law” (Brady).

Adding to the family’s pain, the IRFU sent a coach to talk at Ben’s school in the time just after Ben’s death, but he spent his time discussing strength, conditioning, and scouting, while failing to mention concussions (Bull). Ben Robinson’s death marked the beginning of rugby’s “denial about the risks being taken by those who play it,” with the sport “struggling to square the blood, guts and glory attitude of its amateur days with the brutal power of the professional game” (Bull).

Doubling down on this attitude of denial, in the wake of the Ben Robinson case and other concussions, rugby’s governing body introduced the “Pitch-Side Concussion Assessment” (PSCA) in 2012, allowing players “to return to the field five minutes after a head injury as long as they have been cleared by medics” (Douglas). This “five-minute rule” reduces the time a player must stay off the field following a concussion from one week, a period that other recent rule changes had already reduced from three weeks (Roan). In order to return to the field, players must simply “answer a number of questions…and pass a balance test” (Douglas). The new rule is currently being tested, but is expected to “be introduced across all elite rugby in the near future” (English). Although the IRB claims that the new rule has reduced the percentage of players who stay on the field and are later diagnosed with a concussion from 56% to 13% (Douglas; Roan), there are many scientists and medical experts who dispute the rule (Roan; Cole; English). In fact, the IRFU’s own “Guide to Concussion” even states “signs and symptoms of concussion…may be delayed for up to 24–48 hours” (“IRFU Guide to Concussion”).

Barry O’Driscoll, a former player and IRB medical board member, says “all the top scientists” agree that players should not return to the game after a suspected concussion (Roan), but, with the new rule change, a “player who 18 months ago was given a minimum of seven days recovery time is now given five minutes” (English). O’Driscoll also says that “nobody in the world does a five-minute assessment apart from rugby” (Cole) and, most damningly, that “players are being sent back on with brain damage, there’s absolutely no doubt about it” (Douglas). O’Driscoll is so passionate about this issue that he resigned from the IRB medical board last year because of the new rule, saying he “couldn’t have his name attached to that decision” (English).

Two incidents from this past year serve to back O’Driscoll’s claims, one from July involving Australian George Smith and the other from March’s Six Nations involving his own nephew, Ireland’s Brian O’Driscoll (Douglas). Smith was brought back on the pitch after a collision with Lions’ hooker Richard Hooker “despite obviously being groggy,” causing “significant disquiet among ex-players, commentators, and fans” (Cole). At the time of the incident, Smith “wobbled off the pitch, held up on both sides by doctors” but still “passed the PSCA and returned to play” (Douglas).

In O’Driscoll’s case “twice standing [in the way of] charging France prop Vincent Debaty” resulted in O’Driscoll needing to be helped from the pitch (McCarry). According to reports, “Brian O’Driscoll lost his bearings, was clearly unsteady on his feet and had to be helped from the field…You did not need experience in pathology to know that the great man was out of it for a moment in time. Yet a few minutes later he was back on the pitch” (English). In this match, the five-minute rule was not being tested, and, according to the current IRB code “any player suspected of concussion must be taken off and not allowed back on to the field,” leaving many to wonder how he ended up back on the field (English). In addition to this incident, O’Driscoll was diagnosed with another concussion in November of this year (Watterson), and has had at least one other concussion back in 2009 (returning to the field in that match as well), causing his father to fear “for his son’s long-term mental health” (Peters).

Unlike the current IRB medical board members, Barry O’Driscoll has dealt with rugby’s lack of research by looking at what other sports have done, telling The Scotsman:

If a boxer cannot defend himself after ten seconds he has to have a brain scan before he comes back. And we’re not talking ten seconds for a rugby player, we’re talking maybe a minute that these guys are not sure what’s going on. They don’t have to have a brain scan, they have to have five minutes where they have to stand up straight without falling over four times, they have a basic memory test – ‘What’s the score? Who are you playing against? Which half did it happen in? And do you have any symptoms?’ These questions should serve as a landmark for when you examine them six hours later to see if they’re getting worse or if they’re bleeding into their brain. That’s why you ask them, not to see if they can go back on. They are already concussed at that point. You don’t need to ask questions to find that out. If six hours later their responses are worse than they were earlier you say ‘Wait a minute, this shouldn’t be the case, is this guy going to bleed?’ That’s why you ask the questions and so it has always been. But we’re going in the other direction now. We’re going from being stood down for three weeks to one week to five minutes with players who are showing exactly the same symptoms…The IRB said to me when I wrote to them about the lessons of American football, they said it’s a different game, that you can’t compare, they wear helmets, they have (or used to have) head on head collisions, but concussion is concussion is concussion. To say that we cannot take any of the facts that they’ve discovered in America because it’s a different game is head in the sand. I have no reason to doubt that we are going to get cases of CTE in rugby. They got them in the NFL so there is no reason to think we won’t get some in rugby. We don’t know because the research hasn’t been done, but it is our responsibility to learn from what is happening in America and act on that. We have to presume that it can happen in rugby or else we might have a very big debt to pay years from now. (English)

Even with the evidence currently available, experts say that rugby is not taking head trauma “seriously enough” and that there is “denial about it” (English). Chris Nowinski, who studies CTE with Dr. Ann McKee at Boston University, says that “Early census data suggests rugby is not that far off American football…There have been a lot of incidences [of concussion] and some of them have been extreme” (Kitson). Nowinski describes rugby’s physicality as “extraordinary,” and calls the five-minute rule “ludicrous,” saying that it “doesn’t make sense…it’s simply a matter of time before CTE is found in a rugby player” (English). Dr. Robert Cantu and his team, having done previous studies with the NFL, also believe they have “strong evidence to suggest rugby players are being affected by [CTE],” calling the IRB’s statement  that there is “no scientific link” between concussion and CTE “head-in-the-sand time,” and saying, matter-of-factly, “there will be cases of CTE in rugby” (Lyall).

About two years ago, Cantu told the IRB that “rugby was not taking head trauma seriously enough,” and yet, less than a year later, not only did the IRB institute the five-minute rule, but they also chose to test it first at the Under-20 championship, despite the fact that medical experts agree that concussions in teenagers cause even more problems than in adults (Fink; English). Simon Kemp, the head of the Rugby Football Union, insists “there is no ‘ticking time bomb’ in terms of longer-term health issues” (Kitson). Yet Dr. Michael Grey, a reader in motor neuroscience, calls this “rubbish,” saying “we have very good evidence of the link between concussion and dementia…there is very good evidence now that multiple concussions can lead to premature ageing and neuro-degenerative diseases such as Parkinson’s” (Bech).

Diving deeper into denial, the IRB’s chief medical officer Martin Raftery issued a statement last year claiming that “evidence supporting the theory that collision sports have a negative effect on cognitive function has been questioned by many scientists” (English). Raftery also “took issue with those who said five minutes was not long enough to properly assess if a player was concussed, labelling it a ‘poor argument,’” saying “five is better than zero,” a poor argument itself given that the rule changes the assessment period from seven days (Irwin).

These statements of denial are uncannily similar to those the NFL made in the mid-2000s, leading many experts to believe that rugby’s situation will end similarly, with a generation of players impacted and the sport facing massive lawsuits. One of those experts is Nowinski, who says that “the way rugby is behaving now is the way American football was five or six years ago” (English). Willie Stewart, a consultant neuropathologist at Glasgow’s Southern General Hospital, agrees, saying “America has moved on but in the UK and internationally there is talk about concussion but there is also denial about it…There is nothing different about an American brain compared to a British or Irish brain” (English).

Nowinski calls rugby’s concussion problem “almost less of a medical discussion and more of a legal discussion,” saying “people have learned there are financial consequences to recognising that brain trauma has lasting health consequences…there is a cost to brain trauma…someone has to care for people with dementia” (Kitson). Dr. Grey agrees, telling the Irish Examiner:

There’s the damage not only to the individual — and that has to be at the forefront of the mind — but we must also consider the sport itself…I believe we’re not too far off from coaches and sporting organisations being held accountable for the damage and we’re seeing that with the big lawsuit in the NFL…Absolutely a sport like rugby union could face something similar in the future, I wouldn’t be surprised at all if something like that happens…If we do nothing when we know there’s a problem, then I could see that type of lawsuit occurring…We know this is a problem and it’s very clear that the information is not getting out correctly to coaches and particularly to kids when we have an obligation to inform them of the dangers. (Bech)

Much like the NFL, rugby is starting to see some of the effects of concussions on its league. Although the effects on rugby are not as visible as those on the NFL so far, changes are still noticeable, and increasing media coverage and public awareness in recent months will surely have even more of an impact . Most notably thus far, however, the Rugby Players’ Association (RPA) disclosed the fact that “11 professional players have been forced to retire in the first two months of the season” this year (Kitson). To put that into perspective, players union chief executive Damian Hopley has said that “year on year…the overall number of retirements is up by 88%” (Kitson).

One of these recently retired players is Nic Berry, who played scrum-half for the English Premiership’s Wasps two years ago and suffered nine concussions that season, forcing him to retire at the age of 28 after his neurologist advised him never to play again (Roan). On his playing time, he recalls that “you would finish games and you wouldn’t remember the score, or how you played…I knew it wasn’t normal, but all my tests were saying I hadn’t suffered any permanent damage yet, so I took confidence from that…I look back now and it’s plain to see, a bloke who can’t stand up straight probably shouldn’t be playing” (Roan).

It is clear that if rugby wants to protect its players, and in the process avoid lawsuits, concussions need to be accepted and further changes made. One relatively easy adjustment would be cutting down on the number of full-contact practices allowed, from the current two per week over the eight-month season, as the NFL did when it restricted the number to fourteen over its eighteen-week season (Kitson). Barry O’Driscoll, the former IRB medical advisor, also wants concussion awareness training mandated, even at the grassroots level, saying “I would like to see a mandatory training as part of coaching courses [and] as part of schools lessons with young rugby players…What they need to do is get across a) the signs and symptoms and b) what to do” (Powell). Others call for rugby to “continue to utilize and fund research focusing on youth and college rugby,” to work on getting more “reliable reporting from medical personnel,” and improve equipment (Keating). Perhaps rugby, too, needs to consider changing the rules of its game as well as other “serious changes…in order to protect player safety” (Bass). Beyond the sport, “there are still a lot of unanswered questions about concussions” as well, including  the exact “mechanism” and “how to detect a concussion on imaging techniques” (Fink).

In fact, the Irish Rugby Football Union needs to solve these issues just to survive. The IRFU already faces a €26 million (£22m) deficit as the result of decreased sales on five- and ten-year debenture tickets in a down economy, as treasurer Tom Grace told the IRFU at their annual general meeting this summer “we are just going to have to borrow to fund that cash deficit over the next six years…There is absolutely no doubt that times are hard” (“Irish board faces…”). Thus, lawsuits resulting in any further loss of revenue would be crippling to the sport. In fact, the IRFU had already determined the impacts of a loss of 20% of its income, or €10/12 million, when faced with the recent Free-to-Air proposal (regarding television-broadcasting rights). They found that this loss of €10/12 million would result in:

Irish Rugby’s best players [moving] abroad…[the] need for a reduction in the number of professional Irish rugby teams…[the inability] of the Irish National side and the provincial teams to compete at the highest level [of] competitions…severe reductions in the annual budget for clubs and schools across the Island of Ireland…the rapid decline of Irish rugby into a second tier country…the end of the game’s mass appeal…[and a] serious threat to the €375 million rugby economy contribution to the tourism, travel, retail and jobs sectors around Ireland as a direct result of International and Provincial teams’ matches. (“Save Irish Rugby…”)

The sport of rugby, therefore, cannot even begin to afford facing a lawsuit on the scale of the one that the NFL currently faces, of $765 million (€560 million). If not even for the players’ well-being, rugby still needs to address concussions and implement significant changes for the sport to stay afloat financially.

Rugby and American football are two of the most brutal contact sports practiced in the world today, and, for years, this brutality has been part of their allure. Today, however, the evidence has shown that the seemingly superhuman performances on the field take a toll on their human participants, in both the short- and long-term. The NFL turned a blind eye to the problem for years, and, while they have recently begun to take the issue seriously, the grave effects of its years in denial are beginning to bear out, including retirees with cognitive issues and decreased participation in youth sports. Rugby, on the other hand, still lives in denial, and must reverse its course in the immediate future if it has any chance to avoid the same fate. From the equipment used to education of participants to medical technology, the NFL and the IRB must do their best to improve players’ safety. Perhaps they need to make even more drastic changes to their sports, such as the number of players per side, field dimensions, or other fundamental alterations (Bass). The answers are not always easy, but these leagues have a duty to their players, coaches, referees, and fans to promote safety. In the end, the way in which the IRB and NFL continue to address these issues will not only determine the future of each league’s players, but also of the sports themselves.


Since the completion of this paper, several related stories within the NFL that have come out…

On December 31, 2013, the mother of Jovan Belcher sued the Kansas City Chiefs, mentioning CTE repeatedly in the lawsuit, and alleged that Belcher “unknowingly sacrificed his brain” while the Chiefs “failed to protect Belcher and his safety and knew, or should’ve known, that Belcher showed signs of cognitive and neuro-psychiatric impairment.”

On January 3, 2014, the Cincinnati Bengals, Indianapolis Colts, and Green Bay Packers, with the help of local businesses and an NFL-permitted extension, narrowly avoided local television blackouts for their Wild Card round games (January 4 and 5), in what would have been the first NFL Playoff blackouts since Jan. 10, 2002.

On January 4, 2014, in the course of the Kansas City Chiefs and Indianapolis Colts AFC Wild Card game, Kansas City lost three players due to concussions (star running back Jamaal Charles, wide receiver Donnie Avery, and cornerback Brandon Flowers), factoring into the team’s late-game collapse, as the Chiefs lost to the Colts 45-44 in a game the Chiefs led by 28 points in the second half. In addition, two other players violated the NFL’s concussion protocols during the Wild Card weekend, and the NFL caught criticism for not fining these players.

On January 11, 2014, during the New Orleans Saints and Seattle Seahawks NFC Divisional Round game, Seattle wide receiver Percy Harvin left the game twice (left the game, passed a concussion test, and returned only to receive another hit that knocked him out for the remainder of the game). The following day, in the San Diego Chargers loss to the Denver Broncos in their AFC Divisional Round game, Chargers linebacker (and well-known player) Manti Te’o left the game with a concussion as well.

This past Tuesday, January 14, a federal judge rejected the NFL’s $765 million preliminary settlement with former players suing the league over the long-term effects of head injuries, fearing, among other things, that the amount was not enough to cover all players needing aid. Some players may even drop their agreement entirely and take their chances in court. This story will be interesting to monitor as it continues to unfold, and can only increase the fear within sports, such as rugby, with lesser financial resources than the NFL.

Another interesting aspect of the situation will be to see how media outlets cover concussions, as many of the leading television networks (ESPN/ABC, CBS, FOX, and NBC) have significant conflicts of interest as broadcast partners with the NFL (so they will want their own ratings to remain high and may face pressure from the NFL). For example, after news broke about the rejection of the NFL’s $765 million preliminary settlement around 12:45 PM on January 14, the 1 PM edition of Sportscenter opened with “breaking news” that the Detroit Lions had hired Jim Caldwell to be their new head coach (which had come out hours earlier), then segued into a discussion on new Titans head coach Ken Whisenhunt and discussions on the coming weekend’s conference championship games. The show, which featured a centerpiece on San Francisco 49ers head coach Jim Harbaugh, did not touch on the settlement rejection until 1:16 PM, and the story was not placed into the “breaking news” sidebar box or under the “breaking news” ticker category. One network to watch as this story continues to unfold will be PBS, whose Frontline program has provided excellent coverage thus far (and has no connection to the NFL).

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