Brain surgeon: Owen Farrell headshots set precedent amateur rugby simply must not follow

Fukuoka bid farewell to the World Cup last Saturday, 14-man Ireland buffeting lowly Samoa at the Hakatanomori Stadium out by the city’s airport. However, the southern city didn’t immediately take down the bunting and all the other Rugby World Cup paraphernalia promoted its hosting of three pool matches at the finals.

With the games puts to bed, it left the way clear for delegates attending the World Rugby medical commission conference to flock in and share industry best practice and present evidence-based research findings in the quest to enhance player welfare for the future.

The head injury assessment programme used for concussion identification and player removal in elite rugby was on the agenda and the hope of one leading brain expert looking in from the outside was that there would at least be a mention somewhere along the line as to how England’s Owen Farrell wasn’t required to take a precautionary HIA when twice battered by red-card headshots at the finals.

USA’s John Quill and Argentina’s Tomas Lavanini were both sent off for shoulders illegally deposited to the head of the England skipper, but on neither occasion was he whisked away to undergo the 10-minute concussion assessment in use in Japan.

Asked if Farrell might have come off the pitch for a HIA in Kobe, England boss Eddie Jones said: “We have all the medical staff looking for that out there. That’s what they get paid to do.”

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Nine days later, the narrative continued with Farrell himself responding to queries about his well-being in the wake of the Lavanini collision in Tokyo. He missed a number of kicks off the tee that he would usually score from following the blow.

"I feel fine,” he insisted. “It’s obviously concussion that's the worry but I didn't get hit anywhere near the top of the head. Maybe your jaw gets a bit sore but I was fine and there was no need for a HIA."

The situation intrigued Dr Rahul Jandial, the USA-based neuroscientist and neurosurgeon who is the author of Life Lessons from a Brain Surgeon, the book that discusses and dissects his back catalogue of patients who have suffered from the most extreme cases of brain damage sustained through sports.

American football is usually Jandial's field of expertise but his interest has lately been piqued by rugby, particularly after writing a sideline concussion testing paper with Greg Whyte, the sports scientist who represented Britain at the Olympics in the modern pentathlon.

With Farrell now all set to lead England in their quarter-final versus Australia, Jandial hopes he will come through this latest challenge unscathed. But he would love to know more about how a player who shipped two horrible looking bashes to his head was simply able to dust himself down and get on with resuming play on the next whistle.

“Even experts, we can’t tell on some of the concussions,” he told RugbyPass during a visit to London from California. “It is a very diverse and varied sort of reaction to head injury. Every person is different. Every eight billion brains out there are different when they get hit and that is where you need something more technical.

“Every player should essentially have a brain game analysis before the season starts and if there is any suspicion when they get to the sideline, they do the same brain game as a way to have a digital examination with an iPad or something on the sideline.

“That way it takes the subjective component out. If there is any concern from the referees you go to the sideline, you do your brain game again and you see how you score. Because when you have a real concussion you can’t even see straight, let alone complete the programme.

“It will be obvious and most importantly give the coach and the player, ‘Hey listen, you have a 90 per cent on this a year ago or a few months ago and now you can’t even answer the questions’. It doesn’t matter that you feel okay to go back in.

“Concussion is like being drunk. You don’t have judgement, you can’t actually think for yourself and so that is where you need to have something technical, seemingly not subjective, so a referee can tell a coach, ‘They haven’t performed well on the sideline concussion testing, I can’t let this player back in’.

“There is definitely ambiguity (in concussion identification). Because it is not like blood pressure, it’s not like heart rate, it can’t be exactly measured and somebody can take a big knock and be fine and others will be passed out. The ambiguity is part of the challenge.

“What I would say is when we look at American sports, when we look at rugby, there will be concussions and we can try to limit them, we can change the tackling techniques as we have done in the States but ultimately what I want people to know and what my colleagues want people to know is like boxing, let’s not pretend that ramming your head against another opponent, ramming your head accidentally onto the pitch when you fall backwards, is not dangerous.

"We always knew with boxing it was dementia pugilistica, boxers get early brain injury. We knew it. When you go into boxing you know it can hurt your brain. But for a while in the States, like with cigarettes, they pretended that football was not dangerous.

"Even on the advertisements they would have two helmets banging each other with a little explosion. There were telegraphing, advertising, marketing the hard hits to the head and that is okay as long as now we can tell everyone, ‘Look, football and rugby has a dangerous component to it’.

“As long as people know they can get hurt from this then it is up to every individual to make their own decisions because they are informed. We don’t want to limit risk. We just want to be fair in explaining the risk to people so that they can make their own informed decisions. It is not about limiting activity.

“I love sport and want my kids to play. But my thing is ‘Listen, if you’re not feeling right after you have got hit in the head, look at a week or two (out)' because a second hit is a dangerous hit. A second hit on the same day is the deadly hit. We are built to take a hit if we fall off our crib or kids sitting at the kitchen table fall off, we can handle the occasional knock. It’s the second hit on the same day…”

This is what makes Jandial anxious. Just because Farrell was able to dust himself down after massive hits doesn’t mean kids inspired by him should do likewise.

“As you know American football required brain experts to be on the sideline when the concussion issues were happening several years ago and so my colleagues and I are part of those teams that decide in a neutral way which player is safe to return and to me that is very interesting because that is a luxury afforded only at the highest levels.

“My children play baseball, play football. I have three teenage sons, 13, 14 and almost 18 and on the American parks and neighbourhoods it’s basically the coach and the parents who decide is the kid okay to go back in, is the kid affected at all?

“There is this crisis where there is a conflict of interest and we need a neutral person who can say, 'Listen, the kid has had a concussion, they are wobbly, they are dizzy, they are not seeing straight, and that means they can’t play for a while'.

“It doesn’t mean they can’t play forever, they just can’t play for a while and that is why this topic is so important. The importance of having somebody who is not a parent - you can’t have a doctor, it would be too expensive. You need someone who can say, 'Look coach, you can’t put the kid back in'. That is why this topic is very important to me.”

WATCH: The RugbyPass documentary Knocked takes an unflinching look at the reality of concussion in rugby