Sports related concussions are in the spotlight more than ever with extensive media coverage and record settlements making headlines worldwide. As rugby’s showpiece quadrennial event fast approaches, we look at an overview of concussion in rugby and the ethical issues surrounding it.
To tackle this issue head on, we must first understand what concussion is. A panel of medical and neurological experts, the “Zurich Group”, at the 4th International Conference on Concussion in Sport in 2012 defined concussion as “a complex pathophysiological process affecting the brain, induced by biomechanical forces” [Reference McCrory et al PDF].
International rugby’s governing body, “World Rugby”, promotes a more useable definition for the layman: “a traumatic brain injury resulting in a disturbance of brain function… common symptoms being headache, dizziness, memory disturbance or balance problems” [Reference]. Importantly, this latter definition also effectively conveys the seriousness of the event with “a traumatic brain injury”.
A 2014 meta-analysis of concussion in rugby found an overall incidence of 4.73 concussions per 1,000 player match hours. This is a particularly high incidence and there are over 200,000 registered rugby players on both sides of the Tasman strapping on the boots each weekend, so we understand concussion is a common injury [PMID 25138311]. Additionally, updated 2014 guidelines for the management of sports-related concussion in Australian general practice summarised the associated complications of concussion into 5 points. [Reference]
- Impaired performance and increased risk of injury on return to play: Slowed reaction times and cognitive deficits may lead to increased risk of further injury.
- Acute, progressive diffuse cerebral oedema:
Also known as ‘second impact syndrome’ where the brain can fatally swell following repeated trauma when the initial insult was not noted.
- Prolonged symptoms:
There is level 2 evidence that 5-10% of concussed athletes take >10 days to recover and approximately 1% take >3 months.
- Depression and other mental health issues:
Evidence exists for a 2-3x increase in relative risk of clinical depression in retired footballers.
- Cumulative cognitive deficits i.e. Chronic traumatic encephalopathy (CTE): Recurrent head trauma has been associated with progressive deterioration in brain function.
The final complication, CTE, may be the most damaging in the long-term and illuminates how little we actually now about the chronic effects of concussion. For instance, we know very little about the type, amount or frequency of force required to induce a pathological process. However, we think repeated insults are a major risk factor and that early return to play has poorer outcomes.
Despite our knowledge gaps, CTE has recently worked its way into the lay press and NFL vernacular. This follows a tragic spate of retired player’s suicides linked to CTE and a $1 billion dollar settlement on the back of a 2011 lawsuit alleging “the NFL knew or should have known players who sustain repetitive head injuries are at risk of suffering… early-onset of Alzheimer’s Disease, dementia, depression, deficits in cognitive functioning, reduced processing speed, attention, and reasoning, loss of memory, sleeplessness, moods swings, personality changes, and the debilitating and latent disease known as Chronic traumatic encephalopathy.” [Reference] The settlement is to support retired NFL players who may experience detrimental health effects later in life likely linked to prior head injury.
Therefore, we have a broad definition and a modest understanding of concussion’s deleterious effects, but how de we first diagnose it?
In short: with difficulty.
The signs and symptoms of concussion can vary, can evolve over days and are largely non-specific. There is no objective marker to test for and hence diagnosis is significantly based on clinical assessment. To facilitate assessment, the ‘Zurich Group’ recommended use of the Standardised Concussion Assessment Tool 3rd edition (SCAT3) [Reference PDF]. The SCAT 3 is a checklist including Glasgow Coma Scale, Maddocks questions, symptom evaluation and cognitive assessment, with neck, balance and co-ordination examinations. [Reference] It is to be used by a medical practitioner in the event of a suspected concussion, but it is still not a diagnostic tool. Ultimately, diagnosis remains the premise of the practitioner’s clinical judgement, regardless of the SCAT3’s findings.
In the quest to develop accurate concussion guidelines, rugby is also using the Head Injury Assessment Tools (HIA 1, 2, 3) [Reference] and the King-Devick test [PMID 25748294], which can be downloaded as an app on iPad or iPhone. Additionally, recent advances allow sideline medical professionals to immediately review video footage of Super Rugby and International matches for signs suggestive of concussion; such as loss of consciousness, impaired balance and abnormal posturing.
Hence, once we have done our best to diagnose what we believe is a concussion and the player is medically stable, what next?
World Rugby emphasises the seriousness of a concussive event and endorses the advice “rest the body, rest the brain”. This entails the player not returning to the field of play and then progressing through the 6 stages of the ‘Graduated Return To Play protocol (GRTP)’. This protocol takes approximately 1 week to complete if each stage is readily achieved and the player must receive medical clearance before returning to play. Although new guidelines will be in place for the RWC2015 which suggest minimum of one week rest prior to the start of the GRTP unless advanced level of concussion care is available.
Thus, we have an idea of what we are looking for, with the inclination that it has serious long-term effects and how best to approach it with our current knowledge. However, overshadowing these components are a number of ethical issues one must concurrently negotiate.
One of the core values underpinning medical ethics is the patient’s autonomy to choose or refuse treatment. In the case of a suspected concussion, the player relinquishes this autonomy to paternalistic decision-making. Without negotiation, a concussed player is removed from the field of play, sometimes overtly disapprovingly, for monitoring and management. In this instance, where we really aren’t sure what the full effects of concussion are, is it justified to take control of another person’s autonomy?
Informed consent is closely related to autonomy and is when one is presented with all the pertinent information such that they can deliberate and make a decision on a course of treatment11. In the heat of action, informed consent can fall by the wayside, particularly in the case of concussion where players may not have the faculties to deliberate and make clear decisions.
Another core ethical value is beneficence, where the practitioner must act in the best interest of the ‘patient’. Often coupled with beneficence is the notion of non-maleficence, where one should do no harm11. These are particularly complex issues given the lack of understanding surrounding exactly how harmful concussion is and how best to manage it. Compounding the issue in professional sport is the butterfly effect that a single performance can have on an athlete’s or team’s fortunes. In this situation another ethical issue known as double effect can occur, where a single action can have two consequences. For instance, is removing a star player from the game saving them from CTE in their retirement but also squandering the hopes of a championship?
This notion leads into perhaps the most pervasive and delicate ethical issue facing doctors in professional sport; ‘conflict of interest’. The doctor has an immediate obligation to the player, but is also obligated to the team, the management and the shareholders. Complicating things further is the inherent and pervasive presence of financial reward in professional sport. When multiple parties apply conflicting pressure, whose needs does the doctor oblige and how do they make that decision?
The keys are:
- increasing understanding through ongoing research,
- education, and
- the presence of a neutral practitioner
To deny someone’s autonomy, we should be confident that we are acting in his or her best interests. We become more confident of this when we know we are acting with beneficence and non-maleficence. At present, research indicates we likely are acting in this manner, but we need clarity from further research into recognition, management and complications. Learning from and collaborating with research in other contact sports, such as NFL and NRL, will facilitate progression and development.
When we can develop more accurate and accessible testing protocols, with a deeper appreciation of what the acute and chronic effects are, then we can optimise management and educate those involved. Education leads to ‘buy-in’ and this is required from top-tier management, to the medical practitioners, to the players. When we have buy-in, especially from the players, then we have trust and understanding that leads to informed consent. Consent in this instance need not be left entirely to the playing field; instead the foundations should be laid in the classroom.
The final issue of conflict of interest can be partly addressed by the presence of a ‘neutral’ game day doctor. The neutral doctor wields powers to remove any player from the field to be tested for concussion. By having neutrality, they are largely immune to conflicts of interest, while also absorbing some pressure placed on the team doctor. This process has already been implemented at the professional level of Super Rugby and Internationals.
In summary, concussion is a traumatic brain injury that is commonly encountered in the sport of rugby union. Despite being commonplace, much research is required surrounding concussion’s long-term effects and how best to diagnose and manage it. World Rugby has aligned themselves with the ‘Zurich Group’ for current best practise guidelines, such as the SCAT and the “Graduated Return to Play” protocol. Medical practitioners involved with concussed players need to be aware of ethical considerations such as autonomy, informed consent, beneficence, non-maleficence, and conflict of interest. With increased understanding via research and collaboration, educating all key stakeholders and with the presence of an impartial medical party, the rugby medical practitioner can approach these issues with confidence.
- Paul McCrory et al. Consensus Statement on Concussion in Sport-the 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clinical Journal of Sport Medicine. 2013;23(2):89-117. [PDF]
- World Rugby. Concussion Guidance for the General Public. 2015 [21/07/2015]. [Reference]
- Andrew J Gardner, Grant L Iverson, W Huw Williams, Stephanie Baker, Stanwell. P. A Systematic Review and Meta-Analysis of Concussion in Rugby Union. Sports Medicine. 2014;44:171-1731. [PMID 25138311]
- Michael Makdissi, Gavin Davis, Paul McCrory. Updated guidelines for the management of sports-related concussion in general practice. Australian Family Physician. 2014;43(3). [Reference]
- United States District Court. National Football Players’ Concussion Injury Litigation. 2011. [Reference]
- Consensus statement: SCAT3. British Journal of Sports Medicine. 2013;47(5):259. [Reference]
- International Rugby Board. Head Injury Assessment Tool. [Reference]
- D. King, C. Gissane, P.A. Hume, M. Flaws. The King-Devick test was useful in management of concussion in amateur rugby union and rugby league in New Zealand. Journal of the Neurological Sciences. 2015;351:58-64. [PMID 25748294]
- Australia Rugby. Concussion Management Fact Sheet. 2012. [Reference]
- Edward Doe. In: A systematic review of guidelines for graduated return to play following concussion or suspected concussion in rugby union., 2015 University of York.
- Michael Boylan. Medical Ethics 2nd edition. 2013
- D. Testoni, C.P. Hornik, P.B. Smith, D.K. Benjamin Jr, R.E. McKinney Jr. Sports Medicine and Ethics. american Journal of Bioethics. 2013;13(10):4-12.