A Parental Diagnosis
“Frustrating” and “lamentable” not two words I expected to hear used to describe his son’s experiences with head injuries but as I spoke with Dr Richard Cudmore I continued to be surprised with how he spoke about rugby and head injuries not with the clinical matter-of-factness one would expect of a medical professional but with equal passion and enthusiasm for the game and player welfare. No matter what age your child is there is never a time when you will not watch them with the same concern for their safety, the same apprehension when they hit the ground and the same lump in your throat when they see them injured. It doesn’t matter if you are a doctor or not you are a parent first and foremost.
Dr Cudmore has the unenviable advantage of having watched his son’s return to the field of play in the 2015 Champions Cup semi-final against Saracens in Twickenham through the eyes of not only a concerned parent but a medical practitioner particularly au fait with head injuries. He watched with “surprise” as his son returned to the field of play still displaying the tell-tale signs of a disorientated and concussed player. Whilst Jamie would continue to play professionally following a difficult rehabilitation with little support from his club his playing career was undoubtedly shortened by the incident. Dr Cudmore would see his youngest son Luke’s rugby career also cut short by injury. Despite all of the reasons to justifiably have a gripe with rugby he is remarkably pragmatic and undeniably still a rugby fan, he himself being a former player it wouldn’t take a detective to figure out where his sons’ love of rugby was cultivated.
In Europe head injuries and concussion are growing topics of discussion, taking on greater significance with the additional worldwide coverage of games and with the increased knowledge emanating, by in large, from the states. In Northern America head injuries, concussion and CTE have “blown up”, to quote Dr Cudmore, in the last few years. NFL and NHL in particular have become sports where head injuries are now becoming as topical as the games themselves. The term “CTE” no longer requires explanation, if you have even the slightest interest in contact sports you know about concussion, you may not know enough to fully appreciate the risks or what is at stake but you still know concussion is a risk.
Dr Cudmore has noticed the significant increase in the number of reported concussion related injuries in recent years in his own practice and goes so far as to note in the last two years he has probably treated more patients for such injuries than he had in the previous twenty. He is not suggesting that concussion is a recent phenomenon of course, far from it, but the knock on effect (pardon the pun) of great knowledge is increased diagnosis. Concussions have always happens in contact sports and indeed outside the field of play in day to day life however as people learn more about the risks and symptoms they present more regularly and are diagnosed.
Undoubtedly with greater knowledge comes greater responsibility, as the risks become more apparent the onus is on those involved in all contact sports to take the appropriate action to safeguard player welfare. This is admittedly a moving feat, as the research emerges and evolves so too must the treatment, the tests, the precautions. Dr Cudmore is somewhat pragmatic about the situation and acknowledges that World Rugby are working within the accepted parameters, the SCAT5 being the acknowledged most up to date recognition tool for concussion, but that being said he agrees with my contention that rules are only as good as their enforcement. Using the available research to put in place the accepted best practices is the first step but ensuring their consistent and universal application is the equally important next part of the process.
When we discuss the diagnostic tools available to medics during the course of a game Dr Cudmore is quick to point out that diagnosis is a clinical judgment, a medic makes the judgment call based on the symptoms a player is displaying and there are the tell-tale “red flags”, such as vomiting, which would serve as further clear indications that a player should not return to the field. Dr Cudmore recalls his surprise at seeing Jamie returning to the field in Twickenham given how he had appeared when leaving the field but it would be after the game that he would find out in the intervening period off the field Jamie had been vomiting. There weren’t just red flags waving in the changing room as the decision was made to put Jamie back on the field, there were fireworks going off!
He reminds me that concussion is too often associated with a blow to the head with the attitude being that if there isn’t head contact a player couldn’t be concussed. The opposite is true however, a player can be concussed without any impact to the head and that is where it is key for players, coaches and medics to be live to the visual cues. In the professional game the hits get harder, the players get bigger but the risk doesn’t diminish, in fact it grows. The brain doesn’t learn to protect itself any better than it could 20 years ago but the tools for recognising the symptoms are better. The potential to educate players how to minimise risks through education not only on injury management but on risk prevention. Prevention is always better than the cure, even if it may cut down on a doctors’ workload.
The phrase “recognise and remove” is to the fore of the World Rugby’s concussion guidelines. Three simple words that, if adhered to, can make all the difference. You see a player displaying any of the signs of concussion and you remove him or her from the field, end of story. The reality is that players will not always instantly display the symptoms of concussion and this is where the HIA protocols come into effect but this is the only time they should be used, when there is a need to ask the question. Dr Cudmore assets that we should always “err on the side of caution” when it comes to concussion and where there is any doubt get the player off the field.
The overriding theme of our discussion isn’t one of attributing blame or looking to change the game but to improve how the game of rugby reacts to increased knowledge and research, to injuries as they happen and to players in their rehabilitation. Clubs need to take a compassionate approach to player recover. Head injuries will happen, they are inevitable in sports and eradicating the risk isn’t a possibility or Dr Cudmore reminds me of the most important consideration in concussion management, that there can’t be a “cookie-cutter approach”, no two brains are the same, no two players will recover identically or at the same rate of progress.
The take home message from him is clear, whatever the procedures and protocols we put in place they must follow evidence based research. He cites the lack of proper awareness of the risks and signs of concussion in the “trenches” of the game as of particular concern and it is only on reflection that the aptness of his turn of phrase fully strikes me, trenches conjures up images of a war being fought and for those of us who love the game of rugby the fight to ensure the highest standards are met to protect our players is well and truly underway with the cost of not pursuing that fight too high to risk.
- Iseult Cody, 2017