'We are going above and beyond these days to protect the players'

When the gifted young Wallaby Jordan Petaia fell to the ground in the third minute of the second Australia v England Test in Perth this summer, you may have noticed that one of the first individuals to attend to him was a petite blonde woman, who saw that the hulking 6ft 3in back departed the field safely, after a suspected concussion. For the eagle-eyed, it wouldn't be the doctor's first intervention for concussion in the white-hot intensity of what was a rip-roaring encounter. In the first Test, Alan Alaalatoa exited the field of play, again escorted by the same team doctor. Both individuals played no further part in the Series.

The lady in question was Dr Sharron Flahive, one of the most qualified medical experts in the game, with an expertise in concussion.

Speaking to Flahive in Sydney, the affable doctor, born in New Zealand, tells this writer about her Welsh ancestry, with a mother born in the Rhondda, and family tree hewn from the mines of South Wales. Rugby, it seems, is in her blood.

The improvement in concussion management has outpaced even Marika Koroibete in recent years and Flahive has been at the heart of advancements. Historically, she says the game has gone through a revolution in the treatment of brain injury. “I’ve been a qualified doctor since the start of professionalism and if you look at the process then, it was an automatic stand down for three weeks. Concussion was looked at with a broad brush and most experts thought that 95 per cent of players would be alright after that period, but what happened is that people in the game didn’t call it concussion. People would say, ‘Oh he’s had a bit of a head knock, a bit of a bang'. It was essentially a word driven underground, which came down to the lack of an overall lack of knowledge and understanding around the subject.”

As rugby moved into its teens as a professional sport, there was still nothing like the level of data to inform those in the game what getting a concussion could mean longer term. “It was very much a case of get up, shake yourself off and get back in the defensive line. I remember we tried to implement an on-field assessment, but when we recorded it timewise, it was less than 40 seconds. It went like this, ‘Player x, are you all right, I notice you had a knock?’ and the player would say, ‘Okay doc, I’ve been sparked’ and you’d say, ‘Okay, we’ll check on you in a few minutes.’

Now the definition of concussion is a transient neurological disturbance, meaning in a few minutes, for many, it would clear as the game progressed. This meant when you spoke to them a few minutes later and asked them how they were, they’d often say ‘I’m good to go’.”

A marked change in concussion management came at the 2011 Rugby World Cup in New Zealand, where the medical profession started doing more in-depth research. They saw that the assessment time of a doctor on the field of play was fleeting, on average 64 seconds. “At the Medical Commission Conference in November 2011, the introduction of a pitch-side assessment was agreed. Work was then done on introducing the PSCA in May 2012, which was the earliest version of what we now know as the HIA (head injury assessment). This was the first time you could actually get the player off the field, for at least five minutes.”

Flahive says with rugby’s intensely competitive nature, ways were found to keep players on the field. “Rugby union back then was dogged by the fact that coaches would try and get players off the field for other reasons because there is no free interchange, you know, once you’re off, you’re off. Coaches were okay with the blood bin but for head injury we expected some resistance, but we didn’t. We thought they would manipulate this replacement but they didn’t. This came through education, the HIA steadily rose and it’s now 12 minutes.”

Since the HIA was introduced, there have been subtle, yet important changes to the process. Initially a team would be able to conduct their own head injury assessment but now at elite level, the independent sideline matchday doctor has more authority and input to intervene, in a collaborative process. Both parties have the benefit of video to review signs of a head impact and what the consequences of that are.

Flahive says independent and team doctors have to go through a thorough match-day education process, where they have to learn the five stages of review: the head impact event, what happens immediately after the injury, what happens when the player is on the ground, how long they’re on the ground for and how they get up and their return to action. “During that period several things can happen”, Flahive explains. “When they have a head injury they can fail to protect themselves. Often players lie motionless on the ground and go floppy. While on the ground they can exhibit tonic posturing, when they get up and stumble. A clear example of this was Wales’ Tomos Williams against France in the Six Nations. What is important is that the independent doctor now has the authority to remove the player even if the team doctor says, ‘No, I think he’s fine’. They have the authority to say, ‘I want you to take the player off to assess them’. Huge strides have been made in making the game safer.”

Early recognition of concussion is absolutely key, which is why speed is of the essence when reacting to a suspected brain injury. “The beauty of the research done shows that the earlier you remove the player from the field for a suspected concussion the better their recovery. There are few notable studies which have shown players recovered 3 to 5 days earlier from early identification of concussion. With the advancements in video technology, we are now much better placed to spot these signs.”

What Flahive has also seen is much better education through the eyes of the players and coaches. “In the early days, the attitude would be, ‘Oh he’s alright, he’s a tough bugger.' Staying on the field was worn as a badge of honour. Despite highly emotive headlines in recent years, Flahive is adamant that authorities are doing as much as they can to mitigate brain injury. “We are going above and beyond these days to protect the players and maybe we’re paying the consequences for our actions 20 to 25 years ago, but not now. I am also the Chief Medical Officer of the NRL and because of my involvement with rugby union, in League we now have an independent doctor in an injury surveillance bunker, doing live video assessment and speaking to the ref and stopping the game. As sports, we are working collaboratively to improve player care.”

As part of improving that care among players, changing deep-seated attitudes and better education is key. “We did a survey of players around reporting symptoms and found that 20-year-old males are like fighter pilots. They think they are invincible. They are gladiatorial in their approach. It’s a natural human instinct to take risks when you’re young. As we know millions smoked in their twenties even though they were told they’d get lung cancer, yet they ignored it. However by their thirties, the health warnings started sinking in and by 40, they’d give up and think, ‘Oh my God, why did I do that?’ With concussion, once players get to their late twenties and early thirties, and some have a young family, they get a lot more responsible and flag anything they’re concerned about. I’ve found I really need to get players face-to-face to ask them if they have symptoms.”

Flahive admits that medical professionals fear missing out on in-game incidents due to the threat of retrospective legal action. “There was a case in the Ireland v New Zealand Maori game where Jeremy Loughman fell back and the Irish team doctor was off the field looking after someone else and it was missed. It was the same with Tomos Francis during the Six Nations.”

Closer to home, in the first State of Origin game, New South Wales’ Isaah Yeo appeared to stumble after a collision. This was not seen. Flahive, says her colleagues do everything possible to identify, but sometimes incidents are missed. Reassuringly a diagnosis of concussion was never made.

Flahive says no one can predict, with any certainty, what the after-effects of a collision will be, however serious incidents will look on TV, but often more innocuous incidents can have longer-lasting effects. “Jordan (Petaia) had a clear Cat 1 this summer. He was knocked out; it was head on head and he showed a lack of protective action. I was trying to control him as he was stumbling, yet 24 hours later he showed no side effects. If Jordy had come back on, there would have been a huge outcry because he’d clearly had a transient neurological disturbance. Compare that to Allan Alaalatoa. He didn’t have such an obvious knock, but he had a headache for five days. It’s hard to know which is worse than the other. We know which one looks worse, we know which one the public don’t like, but we can only deal with the facts that are ultimately presented by the players themselves post the event.”

Flahive stresses that progress has only been possible as medical science and technology has evolved. “A few generations ago, if you’d hurt your knee, they’d just say, rest up, it’s obviously sore. Now they can send you for an MRI, where they can tell you, ‘you’ve done your ACL, you have a bit of cartilage damage and you’ve torn your meniscus'. However, with brain injury, we can say you have a concussion, but we don’t have much more contextual data beyond that and at this stage an MRI doesn’t help us. We haven’t got a test which says you put something on his head and it says, ‘boom, green light, you’ve got concussion’.”

With further testing, there is some information that can be established in order to help with their return to play. “If the player ends up with balance issues, we can tell the player has vestibular damage. With eye issues, the ocular people help out. Some players have neck issues, so a physio can help, while some get quite emotional, so we treat them for psychological issues. It’s a big pot.”

As for future ramifications, Flahive’s hunch is that further research will show some players to be more vulnerable than others to long-term brain damage. “We try and make as early diagnoses as we can and get them off the field as soon as possible. We don’t get everything right. Not because we don’t want to, but because we don’t see or interpret correctly. Sometimes I do a match-day doctor role for club footy. In this situation you don’t always have the support you have at higher levels games and there is no doubt you can feel exposed and at risk of missing an incident. It’s not unusual to text friends who are watching on TV and ask them to be spotters for you. Some of the best doctors in the concussion space miss incidents and you just pray it’s not going to be you.”

Through education and increased resources, the medical support for international Tests is now class-leading. “During Tests, when I’m running the sideline, we have the matchday doctor, medical room doctor, an HIA doctor and someone watching and reviewing video, looking for incidents. At Australia games we even have an independent spotter in the crowd. It’s a big crew but rugby can’t service that level of resource down to the community level.”

The high-profile removal of players such as Maro Itoje in the second Test in the Australia v England Series, and subsequently missing the final deciding Test is proof that the 12-day stand down is being taken seriously by all of rugby’s stakeholders. “If a player sustains a criteria 1, the full loss of consciousness, like Maro, there’s an immediate 12-day stand down. He was sent home without fanfare. If the player has a significant concussion history; a concussion in the last three months, two in the last 12 months, or they’ve had a concussion where they’ve had symptoms for a long period of time, or a concussion where the blow has seemed glancing, it’s an automatic stand-down for 12 days. Those guidelines are becoming roundly accepted as being beneficial for the game.”

There are caveats to the 12-day stand down, as we saw with Johnny Sexton after failing his HIA in the first Test in New Zealand, as Flahive explains. “If they have a concussion where they fail the HIA 1 but they pass the HIA 2 - the test after the game, a day or two later - they can return within seven days in an accelerated return under the guidance of an independent concussion consultant.”

The conversation will continue, and in what is a hugely polarising issue, informed recommendations will be made. “I’ve had a lot of good conversations with neuro psychologists in America where from a financial point of view if you show any cognitive decline you get a pay-out. We think there maybe a lot of worried well. Obviously there will be cases where repetitive concussive events have a detrimental effect on the brain but how do you frame ageing? Your brain isn’t as sharp at 50, 60 and 70. The first time someone doesn’t find their keys they’re now thinking, 'well it must be rugby', but it’s not as simple as that.”

As research into making the game safer continues, Flahive says it is unrealistic to believe rugby can ever be entirely risk-free. “There is a risk getting into a car, riding a horse, or skiing but rugby gets the scrutiny as more games are televised than ever. World Rugby has gone to extraordinary lengths in trying to make the game safer to manage the welfare of players, and that drives research. It is vastly different landscape to what it used to be like, even a decade ago.”