World Rugby give their view on Cowan-Dickie's Lions concussion row

World Rugby have responded to criticism of the Lions' recent selection of Exeter and England hooker Luke Cowan-Dickie to play a tour match for them in South Africa just seven days after he suffered a Gallagher Premiership final concussion in London.

The front-rower was left sparked out on the Twickenham pitch after got his tackle technique wrong in a collision versus Harlequins. Cowan-Dickie flew out the next day with Lions and he was chosen on their bench for the following weekend's fixture versus Sigma Lions in Johannesburg.

This selection ignited online controversy. Ex-England scrum-half Kyran Bracken tweeted: “Luke is unconscious for over 20 seconds. Possibly 40-60 secs. How can he play the following week? I am absolutely disgusted that the powers that be allow this to happen. A stain on our great game.”

Concussion awareness group Progressive Rugby added: “How on earth is Luke Cowan-Dickie on the Lions team sheet just 5 days after this? Cowan-Dickie will have to undergo stringent return to play protocols and will not be able to progress to full training until he passes series of tests.”

This outpouring of negativity resulted in Warren Gatland having to twice defend the Lions' Cowan-Dickie selection decision, initially stating: "I take full advice from the medical team and whatever they say goes as far as I am concerned so he has been through all his protocols and we feel like we have been over and above with those protocols with him.

“We have had an independent consultant, a world-leading expert, have a look at it and he has given the all-clear as well. As far as I am concerned we have followed everything and the medical team have given him the all-clear. He is fit and good to go.”

This additional precaution taken by the Lions is part of a new World Rugby initiative whereby an independent concussion consultant (ICC) must now be consulted on whether a player should return to play following the successful completion of the six-stage graduated return to play process.

It's an additional layer of review that World Rugby used at the 2019 and 2015 World Cups and they have now set up a panel of independent consultants so that a concussed elite-level player looking to return to play ten or fewer days after a concussion has their case independently reviewed before receiving clearance to take the field.

"It's quite timely to speak about this given the incident around one of the players on the Lions that gained a lot of publicity," said Eanna Falvey, the World Rugby chief medical officer, at a media briefing where he explained the reasoning behind the introduction of the permanent use of independent concussion consultants.

"It's worthwhile looking at that purely from a scientific perspective, medical perspective. I can't talk about the individual case but I am well aware of the case, I have discussed it with the team and I very happy that the entire process was managed optimally from a medical point of view.

"What is worth noting is we, as an extra measure for the Lions tour, have helped the Lions implement concussion consultants for the tour and in that particular case a consultant who is a concussion specialist completely outside of rugby, actually from a different continent and from a different sport, was fully appraised of the entire case management and the assessment result and was very happy with the process around the player's recovery and that the player wasn't at adverse risk with regard to returning to activity.

"This is obviously an emotive area and there will be many opinions on this and we welcome those and having a situation where we are talking about this raise the awareness of the process, makes players more aware of it and probably will give pause for a number of players in the future coming back into activity, being more honest about their symptom reporting and being more careful in adhering to the process of outlined by their medical management. All of us will continue to work hard on this but the ICC process adds a layer of robustness to a process which we have been continuing to refine over the years."

Falvey added: "Luke was entirely symptom-free so you are going to be looking at this very carefully to ensure there aren't any delayed onset symptoms, that there isn't anything untoward and then at the end of that you have the independent review to ensure there is no stone unturned and that you have done the job as well as you can.

"We have to treat players individually, we have to treat them on the basis that we have and the evidence that we have because, in a professional game, players demand their care is individualised to their medical history and to their situation and that is what we deliver.

"The vast majority of these (concussion) situations are clear cut. The difficult cases are ones that sometimes cause controversy and sometimes cause an issue and it is one of the confounding and difficult factors around concussion that they are well defined central areas but there is a lot of grey on either side down to the point where there are groups who don't agree on the definition of concussion.

"Because there isn't definition we have developed what we call an operational definition for a concussion which we published back in 2012 which was the basis for the head injury assessment, the first sport to introduce an off-field assessment from that perspective."