Conference on concussion fails to give HIA its imprimatur

The International Consensus Conference on Concussion in Sport will not recommend current Head Injury Assessment (HIA) as best practice for other sports despite World Rugby recently stating the Berlin gathering had labelled the protocol as “field leading”.

"The return to play issue is being constantly debated," said Dr Michael Turner, a member of Berlin consensus committee. "We obviously haven't got the final answer yet because if we had everyone would be using the same protocol. If you have different protocols in different sports we obviously haven't got a unified result."

On January 9th World Rugby stated – in their statement following the investigation into the George North incident on December 5th, when the Northampton winger was allowed return to the pitch after sustaining a concussive blow – that the "HIA is recognised as field-leading by the Berlin concussion consensus group and as a tool to test for suspected concussion".

The Irish Times has learned that at least two doctors at the Berlin conference questioned how a concussion can be diagnosed within the 10 minutes permitted under a HIA. World Rugby's response has been that the HIA does not seek to diagnose head trauma but it is a tool to screen for suspected concussion.

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At the national concussion symposium, held in Croke Park last October, the following exchange took place between Ger Gilroy (Newstalk FM), Dr Rod McLoughlin (IRFU chief medical officer) and Dr Barry O'Driscoll (who stood down from World Rugby's medical board after vehemently disagreed with HIA protocols).

Gilroy: “The point of 10 minutes [for a HIA] is to give the clinician the opportunity [to diagnose a concussion]?”

McLoughlin: “To decide if he has a suspicion.”

Gilroy: “Okay, why would you instigate the 10 minutes if he didn’t have a suspicion?”

McLoughlin: “If I can give an analogy. If you go to your doctor with a pain in your tummy it may cross his mind that you have appendicitis. I think you would consider it bad practice if he said it crossed my mind so I’ll just remove your appendix. You would want him to do an assessment.”

Gilroy: “I get the analogy but this is elite sport where there is high contact happening. I’m not telling you I have a sore tummy. There has been an incident where ‘I, as a doctor, think these two...’”

McLoughlin: “No, that’s not true. There has been an incident where there has been the potential of a concussion. Not that an incident where ‘I suspect,’ that has the potential...”

O’Driscoll: “We disagree on this and have done for a long time. This is just what I was referring to about conflicting, confusing and contradicting World Rugby. Following the instructions of the pitch side doctor, you are taking off a person you suspect of concussion to see if you got a suspicion. The very fact you are taking that player off...”

Video analysis

In recent Champions Cup matches, the HIA was completed successfully in under four minutes by Leinster’s

Johnny Sexton

and in six minutes by Munster’s

Conor Murray

.

Turner, who was chief medical advisor to British horse racing for 21 years, revealed that in order to combat delayed concussion jockeys who have sustained a suspected head injury must wait at least 10 minutes before undergoing their established concussion test.

"Rugby has just published a paper in the British Journal with the results of their review and they are advocating the use of video analysis and replay," Turner continued.

“I don’t dispute that that helps greatly – that you have a neurosurgeon up in the stand – but how many games of rugby played in the UK and Ireland are capable of having video surveillance and experts reviewing every tackle? A tiny number.

"Nobody disputes the more technology you have the better chance you have of diagnosing concussion but if you can't roll that out on the playing fields of Samoa or schoolboys rugby in Dublin you are advocating something that is so sophisticated it simply doesn't apply to the rest of the sport."

World Rugby’s HIA is not expected to be supported, or criticised, by the Berlin consensus committee when their report is released next month.

Research conducted by the International Concussion and Head Injury Research Foundation, of which Turner is the European medical director, hope to eventually discover a global test.

“Most of the research is looking for an immediate test, what I call the lollipop test, where a cotton wool bud on a stick is placed in the person’s mouth, to get the person’s saliva so you can measure biomarkers. If the lollipop comes out pink you have got concussion, if it comes out blue you haven’t got concussion.

“Everyone, particularly in the States, wants to produce some form of test that can be done pitch side which will obviate the HIA. If you could find one that is 90 per cent successful you would have a huge leap forward.”