Two Welsh players have added their names to the list of people calling for rule changes to further combat concussion.

Rule changes intended to reduce the amount of damage done to professional players’ brains during play are a step in the right direction, but much more needs to be done according to Alix Popham and Adam Hughes.

Former Welsh international, Scarlets and Newport forward Popham, and former Dragons centre Adam Hughes are two of more than 200 former professional players who have come together in a lawsuit against governing bodies World Rugby, Rugby Football Union and Welsh Rugby Union.

The lawsuit claims a lack of care has been given towards players suffering head injuries.

Both agree that World Rugby’s latest rule change – which will introduce harsher penalties for high tackles in the hope of lowering the number of concussions due to impact to the head and neck – is a positive change, but that it will take some time for the data to reflect this as players get used to the change.

However, they believe that this alone is not going to help protect the current players and more needs to be done.

What is the issue?

A concussion is temporary damage to the brain, which is regularly caused by impact to the head, however, it is also caused by blows to the body which shunt the head forward or backwards, creating a force on the brain.

Many rugby players - as well as those involved in other sports - suffer concussions each year, but many are also missed – whether due to the injury not being reported because of a lack of awareness or because there are very minimal symptoms that are not noticed.

Concussions can lead to further, more damaging, permanent brain injuries – as found by the players involved in the lawsuit. Popham has been diagnosed with early onset dementia, traumatic brain injury and possible chronic traumatic encephalopathy (CTE), in April 2020.

Adam Hughes retired in 2018 due to concussion and has talked of how he does not remember large parts of his playing career. He has not received the same diagnosis as Popham but has been told by medical professionals that he is on the same trajectory as him and some of the others in the lawsuit.

Both men say they believe their conditions are the result of repeated concussions sustained while playing and want to see changes to the game they love to make it safer and for the injury to be taken more seriously.

“I loved rugby and I still love rugby, but things must be done to make the game safer for players," said Popham.

"Otherwise, there will not be a game of rugby as parents will see the injuries and not take their children to play, which would lead to a lack of players.”

Previously, Hughes said he has received abuse from coaches and medics for making a player leave the field when he noticed they had suffered a knock to the head in his new role as a referee and believes this is part of what needs to be changed.

Why is this so serious?

Despite efforts to increase awareness of concussion in rugby players, many people believe that concussion is only caused when a player is knocked out.

In 90 per cent of cases, a concussion follows an injury with no sign of losing consciousness. A 2016 study of Welsh players from international to grassroots level showed that just 20 per cent recognised this.

A recent study by the University of South Wales looked into a number of professionals and analysed their brain mass throughout a season/

It found that 23 per cent of current players who were tested have some form of brain abnormality and 50 per cent have reductions in white matter volume in their brains.

A 2019 study by Cardiff Metropolitan University found that over a four-year period, playing more than 25 matches in a season meant that it was more likely a concussion would be sustained than not.

It also stated that players who had already suffered a concussive injury were 38 per cent more likely to suffer another conussion compared with a non-concussive injury and suggest that the return to play protocols should be investigated more.

The University of South Wales today published a study co-authored by Professor Damian Bailey that followed a Welsh professional team across a season and found that players were likely to have a reduction in blood flow to the brain after just one season of play.

Professor Bailey said: “I think there is sufficient evidence now for us to start tackling this head-on and to consider interventions to manage it perhaps better than we are currently are, and for more studies to be supported.

“There is more surveillance, but I think we could be a lot more aggressive in terms of reducing contact in training.

"We could be much more aggressive in terms of substitutes not coming on fresh for the ‘big hits’, and also to be a lot more comprehensive in the way we screen players.

“We followed players over a single season, and the focus is to try to understand how over the long term recurrent contact impacts the brain.

“When a professional rugby player playing 15-20 years of rugby at the top end retires, does his brain fare better or worse than an age-matched, non-contact, fitness-matched comparison?

“Being physically fit is the best medicine for the brain. Because players have got this high level of aerobic fitness, it does to some extent mask the impairments if they exist.

“I have worked with professional boxers, and the vast majority of injury to the brain is incurred during sparring and training.

"It’s not the big hit, the big knockout punch, it is that cumulative exposure, and that is what we think is going on with rugby.

“This cumulative building up of these contact events, this impairs the way brain regulates blood flow to itself.

"The brain is a super expensive organ to run – the most expensive in the body to run as far as fuel is concerned – and when we impair that, this is where the trouble starts.

“This is probably the unifying feature of dementia over the lifespan that we see this reduction of blood flow to the brain.

“You have got super-fit, super-conditioned players, but yet we are seeing the way the brain is regulating flow to itself is impaired.

“Based on taking blood samples from the players, we think that is because we haven’t got enough of the good molecule, which the brain needs, and we think that is because of the inflammation – the mechanical damage – that is occurring as a result of the recurrent contact.

“We are not out there to try and stop the game of rugby – we are out there to make it safer.

“If you watch the sport at the top end, these are big impacts going in. I wasn’t surprised in terms of what we found. My big concern is the guys who are in retirement that are suffering with a poor quality of life.”

What is being done and what should be done?

World Rugby has targeted high tackles, with harsher penalties introduced for tackles above the shoulder.

Hughes said: “I believe it is something that World Rugby and match officials have to persevere with.

“We may have to take a step back at certain times, to fully understand what is and isn’t working, but without trialling laws, we will never know the impact it might have.

"It will take players a few seasons to fully get to grips with the new laws, and we need to concentrate on coaching the young players so that they never get into the bad habits that you may see from older players today.”

Popham echoed this, saying it's a positive change, but added he also wants contact to be limited during training sessions to help to protect the players.

“Before the game went professional, players were training twice a week, which were mainly contact sessions, and then playing a game on the weekend," he said.

“Now it's professional, there’s five days of training, most of which is contact, and a game on the weekend. Not all of those training sessions need to be contact.

"Harlequins did a trial last season of limiting the contact sessions for players during training and they went on to win the league.

“So it doesn’t necessarily have a negative effect on the matchday performance, but it goes a long way to protecting the players.

“During the trial, the players were monitored on their contact using specialist gum shields. One of the players was approached by the doctor after a training session to ask if he was okay because he took a knock.

“He said he was fine but was shocked when the doctor told him the force of that particular knock, which was a lot higher than it felt.”

Popham believes that World Rugby should look at the NFL’s concussion scandal almost a decade ago and the resolutions implemented there – which includes the reduction of contact in training.

In the NFL - the major American football league in the USA - the link between playing the sport and brain injuries was denied by the governing body for a number of years.

A Nigerian pathologist Dr Bennet Omalu examined the brain of a former player following his death and published his findings in a medical journal in 2005, where he found that the player had CTE.

This led to a lawsuit from a number of former NFL players for brain injuries and a reform of the way concussion is looked at in the sport.

Players are now limited on the contact sessions they have in training, helmets are fitted with sensors to measure the force of any impact to the head which is then fed in real-time to doctors who are able to view the replays and pull players off the field if necessary.  

Popham said: “There are also spot checks – like the random drug tests – in the NFL and the clubs get heavily sanctioned if they find the players have done more contact training than is permitted.”

Both Popham and Hughes believe that World Rugby’s independent concussion panel would be beneficial – if implemented properly.

The panel is in place for professional teams who have players returning to play 10 days or less from concussive injury; who have had two or more concussions in 12 months; or more than five since starting to play.

Popham said: “The concussion panel was first implemented in the Lions tour, and they were told they had to do the assessments in person because that’s the only way you can get a true assessment.

“So, Dan Biggar, Liam Williams and Luke Cowan-Dickie all suffered concussions on the tour and were assessed by these independent panels through Zoom.

"If the Lions, which is one of the biggest events in rugby, don’t implement it correctly, how are you going to get other teams to implement it correctly?”

Hughes believes that the return to play protocols themselves are not fit for purpose so welcomes a change.

“Any improvement that is made is very welcome," he said.

“I think a return to play protocols need to be a lot more individualised just like any other injury, some players suffer from knee injuries a lot more than others and can take longer to recover.

“I also agree there needs to be a more independent approach to making these decisions for the players, as staff at clubs are under a lot of pressure, especially if the player in question is a marquee player.”

Currently, the return to play protocol is a set standard for all players, with a six-step recovery process that eases the player back into the game based on symptoms.

However, this does allow for a player to potentially return to play from a concussion less than a week after the injury.

“Back in 1977, they realised that there was a problem with concussion and set the time out as three weeks after looking at boxers," said Popham.

"But in 2011, it was changed to this six-step return to play. It’s like it's gone backwards.”

Currently, if a player is concussed, they must have 24 hours symptom-free before beginning the return to play, between each stage they must be symptom-free for 24 hours to be able to progress.

This means, if a player does not show symptoms and is involved in daily training sessions, they could be back on the field very quickly.

“It leads to a potential situation like with George North, who had multiple concussions in one season and ended up having to take an extended break to recover,” said Popham.

The pair also want a better concussion diagnostic tool for the initial diagnosis during training or a game.

The current head injury assessment (HIA) tool involves a series of questions and some simple tasks. It is done via a scoring system - a change from the baseline test conducted at the start of pre-season is how concussions are diagnosed.

But some have claimed players are able to memorise the questions, meaning they are effectively able to "cheat" the assessments.

Hughes said: “I understand we can only move forward as quickly as science allows us to, but while we are still awaiting the necessary tests and equipment, I believe we should err on the side of caution.

“Instead of allowing a player to carry on because he answered a few questions during the HIA, if he has been KO’d (knocked out) he should not be allowed to return full stop.

“Independent doctors should also make more use of the replays that match officials are able to see, to help in the diagnosis.”

Popham agrees. He said: “With the HIA test, it is not accurate because it is quite easy for players to memorise the answers if they’ve had to do the test often enough.

“It should not be the basic diagnostic tool, there should be more done to analyse the brain itself as a diagnostic. The WRU have had tools to be able to do this since around 2003, but they have not been implemented.”

Both also want there to be better education and awareness from the governing bodies.

Hughes said: “We get drugs in sport presentations given to players every pre-season, so why is there not the same on concussion at every club at all levels?

“Players then should be required to answer a few questions on the topic before they can play a game or take part in contact training.

"This would make sure players understand what it is to look out for, and the repercussions of not taking it seriously.”

Popham believes that education should be a priority as well as the reduction in contact training and that these will help to keep players safe.

World Rugby said it “welcomes all research that can inform and support our recently launched strategy to cement rugby as the most progressive sport on player welfare”.

A spokesperson said: “The welfare of the global rugby family is and always will be our number one priority.

“We will always be guided by medical and scientific consensus to inform our concussion education, prevention and management strategies, and to make the sport as safe and accessible as it can be for all.

“World Rugby recently committed to double our investment in player welfare and new concussion research and initiatives.

“We are currently undertaking a wide-ranging evaluation of contact training volume across the game and look forward to the results of the ongoing Otago Rugby Community Head Impact Detection study, which is the largest ever study of playing and training head impacts in men’s and women’s community rugby.

"Both will inform the further introduction of guidelines and preventative measures that best support the welfare of all players.”

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