December 2023

Rugby World Cup

The 2023 Rugby World Cup was a huge success, producing some of the greatest, most competitive rugby we have ever seen.  Our focus, from the medical and player welfare perspective, was to ensure that all the medical services and provisions were delivered at the highest standard possible. In our September newsletter, Dr Emmanuel Reboursiere described those provisions, and I want to thank him for delivering an outstanding quality of medical support to all the teams in France.

On the concussion front, we very intensively monitor and observe the performance of the Head injury assessment process, effectively “auditing” every HIA case from start to finish, as well as working with Hawkeye and the Match Day Doctors to monitor all significant head impacts.  As a result, when the tournament ends, we have a good understanding of not only the concussion numbers, but how they happened, and how players progress through the HIA process. 

The results from 2023 are summarized the figure below, with 2019’s figures shown for comparison.  We were encouraged to see that the concussion rate was down by 23%, from 12.2 per 1000 hours to 9.4 per 1000 hours.  It is, of course, a relatively small data set (48 matches), and so one has to be careful about over-interpreting its relevance, but over the last two men’s Rugby World Cups, the combined concussion incidence in 93 matches is 10.4 per 1000 hours, which does represent a small reduction compared to the rates in the global club game over the last decade. 

There is still much work to be done, however, to bring this rate down further, we in the post-RWC debrief discussions, we will actively engage with the International Rugby Players, World Rugby’s match officials, and consultant coaches to continue to research and drive behaviour in a direction of greater safety.

With the overall figures, there are some interesting findings.  The tackle remains the match activity causing most concussions, and in fact, it was almost exclusively responsible for our RWC cases.  20% of the concussions in 2023 were the result of what match officials identified as foul play, compared to only 8% in 2019.  Related to this, 43% of the red cards and 19% of the yellow cards given for foul play resulted in players leaving the field with head injuries.  Those figures are broadly in line with what we’ve seen in the elite club game since 2021, where tackles that are sanctioned with cards are considerably more likely to cause HIA1s and concussions than legal tackles, so we believe it is appropriate to continue to hold a strong position on head contact and foul play, though part of the debrief above is discussion about the Head Contact Process used for these decisions, so that we continue to improve its performance.

Instrumented mouthguard research

Away from the Rugby World Cup, our instrumented mouthguard (iMG) research continues to be published, this time in the form of the elite player pilot study.  This research followed on from our community rugby study in New Zealand, and had 92 elite male players and 72 elite female players wearing the iMG during their 2021/22 seasons.

The paper was published last month in Sports Medicine, and it described the rate of head acceleration events (HAEs), as well as the likelihood that a tackle and ruck would cause an HAE.  The figure below shows two of the key graphs from this paper

The two most interesting findings from the study are:

1. Men’s HAE rates are significantly higher than women’s. For example, men’s forwards experience an HAE exceeding 40g once per player per hour, compared to 0.3 per hour in women’s forwards
2. Tackles and ball carries are similarly likely to cause an HAE, whereas rucks are significantly less likely to result in HAEs. For instance, an HAE 40g or higher was seen in 3.6% of carries, 3.4% of tackles, and 1.7% of rucks in the men’s game

The reason these findings are so interesting is because we know from our clinical data and studies that the concussion incidence is similar between men and women, and that it is the tackle that causes most of our concussions.  And so we have intriguing findings that:

1. Women experience a similar number of concussions despite lower HAE numbers, suggestive of susceptibility to clinical outcomes at a lower HAE magnitude
2. Tacklers are much more likely to experience clinical outcomes (concussions) even though they experience the same number of HAEs per 100 tackles than ball carriers

Exploring and understanding these will not be easy, but may prove very valuable to our understanding of why certain impacts cause concussions and others do not, and that may in turn guide our prevention efforts.

Concussion Working Group recommendations

It’s been a busy year on the concussion front, aside from the iMG research described above.  A number of meetings have been held with World Rugby’s Concussion Working Group, which is a group comprised of independent concussion experts from around the world, and World Rugby’s medical and scientific staff.

That group has made a number of recommendations regarding player welfare, and these were agreed by the World Rugby Executive Board in November.  They come into effect on 1 January, and are:

1. It is recommended that Mouthguards are used by the whole game.
2. The inclusion of Instrumented mouthguards (IMG’s) in the HIA protocol as an indicator for an off-field assessment. This will apply to all competitions which access HIA with elite player welfare standards in place.
3. It is advised that there is a minimum community individualised rehabilitation period of 21 days post-concussion for all levels including adult.
4. In the HIA Protocol, allow 17 minutes for a HIA1 off-field assessment should medical staff be engaged in two other contemporaneous HIA1 off-field assessment.
5. Strengthen relationship with International Wheelchair Rugby Federation (now “World Wheelchair Rugby”).
6. Review Contact load guidelines.
7. Promote Tackle competency programmes, especially in at-risk groups, children and adult rugby adopters.
8. Recommend minimum rest periods & non-competition window in the elite game

Looking ahead – Brain Health Service to launch in 2024

That brings 2023 to a close, though the rugby is by no means winding down.  In fact, with the EPCR tournaments about to begin, and the URC, PRL and TOP14 midway through their seasons, the Festive Season always produces an abundance of rugby.  Our immediate horizon is the 2024 season and the roll-out of the iMG mandate in the elite game.  The recent WXV competition had excellent iMG use, and produced some fascinating data, which we’ll summarize in our next newsletter, but next year will see all tournaments coming onboard with that mandate, which we are really excited will advance our head protection initiative significantly.

We are also really excited about the launch of an initiative aimed at assessing and supporting the current psychological health and cognitive functioning of retired players, and we’ll tell you a bit more about that in the New Year.

Until then, I wish you all the best over the Festive Season, and thank you for reading.

Prof Éanna Falvey