The IRB's Chief Medical Officer Talks With Bleacher Report
Player welfare in the rugby community continues to be a hot topic these days.
Our own Bleacher Report investigative series has outlined some of the major issues within the public debate and has dealt with some of the most important research—or lack there of—in regards to concussion management in rugby.
As our ongoing reporting has discussed, the recent confirmation of the rugby's first-ever CTE diagnosis, has shaken the community further and has led to an even more vigorous discussion around what is being done to protect players at the elite level.
The International Rugby Board's (IRB) new pitch-side concussion assessments (PSCA) protocols have drawn their fair share of criticism from players and experts alike.
Scotland international Rory Lamont has criticized recent episodes, such as George Smith's injury during the 2013 Lions tour.
The implementation of the PSCA's themselves led directly to the resignation of the former IRB Chief Medical Officer Dr. Barry O'Driscoll, who has accused his former organization in an ESPN article of "trivializing concussion," saying "there is no scientific, medical or rugby basis for the safety of this process."
So, to get to the bottom of what the IRB are, in fact, doing around the issue of player welfare and concussions, Bleacher Report conducted an extensive one-on-one interview with the man that replaced Dr. O'Driscoll as Chief Medical Officer (CMO)—Dr. Martin Raftery.
Here now, without further comment, is that extended interview.
An Extended Interview With IRB CMO Dr. Martin Raftery:
Bleacher Report: Thank you for joining us, Dr. Raftery.
Perhaps we could begin by having you respond to the comments that have been made by Scotland’s Rory Lamont, and others, regarding modern-day rugby player welfare. The criticism seems to be that people are acting with the best of intentions at the IRB level, but once the games begin at pitch-side, procedures are not really being followed.
Dr. Raftery: When it comes to any rugby at all at the non-elite level, the IRB’s position is recognize and remove. That is to say, that if anyone at all is suspected of having any kind of head injury or concussion, they should be removed from the field immediately. That’s black and white.
When it comes to what its happening at pitch-side at the elite level of the game, where we have experienced team physicians there, we’ve looked at it and decided this. Before our new protocols we were asking people at make an assessment on the run, and on the field.
Rugby does not have free interchange the way some other sports do. Doctors were being asked to make judgments about players during games and on the field of play. So we have developed the PSCA’s, to give doctors extra time to make a determination about the health of players. These protocols are used when a head injury has occurred, and the diagnosis of a concussion is not immediately apparent.
The Zurich Consensus Statement makes clear that concussions are among the most difficult injuries in sports medicine to diagnose, assess and manage. So we have a difficult injury to diagnose, with no perfect marker.
Bleacher Report: How would you respond to those that make the argument that IRB’s current procedures do not go far enough to protect players?
Dr. Raftery: The discussion we had was, can we move forward? Can we make this better for the doctors and players?
We are trying to do this in a sport where there is no free interchange. So we made the decision that we would give doctors more time to make their assessment off of the field of play.
So I think that people need to look at where we've come from and where we’ve moved to.
Is it far enough? We don’t know. What we agreed to do was to do research into this, to see how effective these changes were.
So we’ve gone from position A to position B, recognizing that we don’t know the right answer, and recognizing that we’re going to be doing research.
So to people who come out and criticize and say that we should go back to the way we were, I don’t understand that. That’s asking doctors to go back and make decisions under pressure.
We’ve moved in this direction not because of any one option, but because we know we need to get better, and it looks like we are.
Bleacher Report: Can you explain why you believe the new IRB concussion protocols have helped player safety get better?
Dr. Raftery: There was a study done by the Rugby Football Union (RFU) which is the English Rugby Union, from 2009–2011. That study found that 25 percent of players who were ultimately found to have a concussion, were being left on the field of play after being seen to by a team doctor.
So we said, ok. We have doctors trying to make decisions under pressure and on the field, and we know some of their decisions aren’t that good, because they were leaving 25 percent of players with concussions on the field.
We couldn’t stay in the same position. We had to move forward, we have to make change.
So as of now, we are still gathering information, but it looks like we are down to just about 11 percent of players, ultimately diagnosed with a concussion, remaining on the field of play.
Is that good? No its not, but we definitely moving forwards, not backwards. And we are moving forward in an environment where everyone agrees that there is no perfect marker for the immediate diagnosis of a concussion.
Bleacher Report: When the IRB constructed its new systems, did it give any thought to the idea that cooperation from coaches and players on the field may not be 100 percent? Players like Rory Lamont have spoken out about the pressures they sometimes feel to continue to play on.
Dr. Raftery: My background is that I was a team physician for many years before I held my current position here with the IRB. So I have been running on to pitches, I know what it is all about, and many of the things that you have said are true.
Our new protocols do try to cater to some of those issues.
Bleacher Report: What was your opinion on Rory Lamont’s comments?
Dr. Raftery: Contrary to what many might think, I actually applaud Rory for his stance. I think its hugely important to highlight some of the things that he was saying. Most of the things he said I agree with, and there were certain things I disagree with.
One thing that is important to point-out, is that one of Rory’s key arguments was that he felt players may me cheating on their concussion baseline testing. That has nothing to do with our new pitch-side assessment protocols.
I think that many team doctors, if they are keeping their eyes open, understand that players are doing that. They would answer questions more slowly so their concussion testing would be misleading.
What we should be asking is, why are players feeling they have to do that?
Back in 2003 we used to have something called the three-week rule, which would see players sit out for three weeks automatically upon a concussion diagnosis.
There was a consensus view out there, that the three-week rule was pushing the diagnosis underground.
I’m sure there are a minority of players who were cheating on their base-line testing. I think to ignore that idea would be to stick your head in the sand.
I think one of the biggest things in Rory’s statement that has gotten lost is that players need to take responsibility, and realize that they have to report their symptoms.
The IRB and every national union needs to work hard to educate players on the negative outcomes of hiding or ignoring a concussion.
There are already players out there that take this seriously, but there will be always be players who don’t, there will always be coaches who don’t. We have continue to work and work and work to get this message out there.
Bleacher Report: I’m glad you mentioned education, because I wanted to get your reaction to the hit on Canada’s Matt Evans that took place in a recent IRB tournament in Canada.
Evans was carried off on a stretcher from what looked to be a clear shoulder charge, and yet the Tongan Coach later stated he believed those were completely legal tackles. How do you feel about the success of education efforts when you hear comments like that?
Dr. Raftery: I know the incident. I saw it. I think you will always have people who, when they make statements, as the coach did, demonstrate that their knowledge isn’t up to speed.
As a game and as a body we have try to educate everybody at every level. Direct attacks to the head in rugby have been outlawed since the game was invented. They have been outlawed to protect the players.
Nobody condones incidents like that.
I think there have been incidents, like with Sam Warburton of Wales at the World Cup, where the player has stood up and taken responsibility for a dangerous tackle.
That to me shows that a player is educated and is looking out for his fellow players.
So I have a lot of respect for that player in that situation.
We don’t have a perfect system, but we need to work towards a perfect system.
Bleacher Report: The research team at the Auckland University of Technology (AUT) have been trying to conduct a study recently into the long-term brain health of elite rugby players. They seem to be having a great deal of trouble finding volunteers.
Why do you think that is?
Dr. Raftery: The IRB has sponsored that study and I was heavily involved in putting that together. We wanted to find out what was happening long-term to out players.
We selected New Zealand because everyone there follows rugby. We thought it would be easy to collect volunteers there.
Its unclear whether people are not participating because their worried about what they might find, or because they just don’t think there’s a problem.
We have made inroads recently but it remains difficult. To be honest, we just don’t know why we’re not getting volunteers.
We’re continuing to ask folks to come forward.
Bleacher Report: One of the big episodes that has caused some criticism about concussion management in rugby was the George Smith incident, during the recent 2013 Lions Tour.
When you see incidents like that, are you happy that rugby has the balance right?
Dr. Raftery: When we set about producing our new protocols we had three boxes to tick.
We wanted to improve the welfare of players, we wanted a system that wasn't open to pressure by coaches and we wanted a system that didn't undermine the fabric of the game.
Most rugby head injuries occur in the tackle. Well, it would be easy to say just get rid of the tackle, but then we aren't rugby doctors anymore. We need to work within the fabric of the game.
There is always an associated risk. Our responsibility is to minimize that risk.
We are now 12 months into our research, and we are just in the process of confirming changes to our protocols; changes that we hope will move our statistics from 11 percent down to 6 percent, and we'll continue to do that until we drive those numbers down further.
The other thing that I think people don't realize is that rugby is a world sport. In order to bring about change in a sport like rugby you have to get consensus from around the world, which is very difficult. Its like the United Nations.
There will always be an exception to every rule and what we have to do is make sure we are there to study those exceptions.
The George Smith affair has become a major issue, and we are incorporating the lessons learned from that incident to try and make sure that in the future, those kind of things won't happen.
We accept that there will always be accidents, but we want to make the game as safe as it can be.
Our goal is not see players get injured, are goal is to protect players.
Bleacher Report: Thank you so much for your time, Dr. Raftery.
Jeff Hull is a Featured Columnist for Bleacher Report.
This interview was obtained first-hand.
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