January 18, 1998, Heretaunga, New Zealand. 26 year old Leonardo Va’a collapses and convulses after attempting a tackle during a local rugby league match. He never wakes up, dying in hospital the next day.
Va’a died due to second impact syndrome, having sustained a concussion the previous day and telling club officials he had been cleared to play.
Watching that game and attending to Va’a as he convulsed on the field was Doug King, an emergency room nurse.
King was abused and blamed for the death of Va’a until it was revealed the player had been told to give the game away five years earlier after multiple concussions.
Wellington coroner Garry Evans, in 2001, recommended a register of injuries be implemented to give officials better oversight of player injuries.
However, the NZRL said it already had a well-known concussion policy including mandatory stand down periods, but everything came back to relying on truthful reporting from clubs and players.
Fast forward to 2012 and King, this time with a masters and two PhDs focussing on concussion to his name, watches a 17 year old convulsing after attempting a tackle.
This time the player survives but it’s possible he’s left with life long cognitive problems. That player was later found to have had four separate concussions that season.
This is part of the crisis local rugby league in both Australia and New Zealand is facing.
A lack of grassroots awareness coupled with a slowly moving governing body means children remain at a high risk for suffering head knocks and concussions while their brains are still developing.
It’s something that Dr King has continued to devote his life to helping to fix despite being abused and assaulted for trying to protect players.
“It’s been a horrid journey. I’ve been shunned, pushed, assaulted, abused and threatened because I wanted to keep players off the field when they were injured and everyone else thought it was a simple knock and put them back on,” he says.
In a systematic review published in the British Journal of Sports Medicine in 2015, it was found that individual child and adolescent rugby league players had a 7.7 percent to 22.7 percent risk of concussion across a season.
Meaning kids have close to a one in ten chance at the low end of suffering a concussion every season they play of junior rugby league.
Risk For Kids
Children are more at risk for concussion compared to adults for a number of reasons. Their brains are still developing, they have lower fitness levels, and they have a large head to body ratio.
Dr King says a combination of children’s bodies still developing alongside ill-informed parents contribute to the high risk of concussion in sport.
“The juniors, because of less strength, bigger head to body ratio, higher risk of them actually suffering concussions compared with non-contact sport players, and it’s more the awareness.
“In New Zealand, it’s not really a mandatory thing that we have qualified people on the sideline, so it’s the mums and dads that do it all, which is a concern because they haven’t got the information.”
He’s also witnessed training staff and coaches trying to convince children to stay on the field because they might be scouted by an NRL club.
“I’ve had people run out onto the field with a kid that’s laying on the ground who is still trying to come to, squirting water on them saying “quick, quick there might be someone from the NRL over here looking at you and we need to get you out there”. This is a nine year old boy.”
Much of the research being conducted currently is looking at the risk of head injuries and the consequences for adult professionals, but Dr King says it’s equally important to be looking at children because they don’t fully comprehend the injuries and their developing brain is more susceptible to trauma.
“There’s a thing called Pituitarism where the pituitary gland can get damaged and you get growth hormone problems with those sorts of issues. They’ve got sleep disturbances, they’ve got a higher risk of mental health issues later on, there’s a higher risk of suicide with them. There’s all these sorts of things that we’re now finding out.
“At least at the adult age, you can justify what’s going on and talk to these people. Whereas kids don’t fully understand the headaches are because they’ve had a bash to the brain, and they can’t go home and play their PlayStation and those sorts of things so it makes life just that little bit difficult.”
The largest difference between the professional levels and amateur levels is the special care elite athletes receive.
Club medical staff, players and coaches have been educated to understand the risk of concussion and head knocks, with sideline medical staff available to assess players on game days.
But for children, often the people making decisions about their health are their parents who may not fully understand the risk concussion presents to children and teens.
It’s something Dr King says he tries to address when he sees patients come through the doors of his emergency department on weekends.
“Just trying to raise the awareness more, and more, and more that there is an issue there, it’s only a game, they can rest off and come back a bit later on and see how things go. But it’s difficult because quite a lot of kids will play rugby union on Saturday then they’ll play rugby league on Sunday and you don’t talk about either game. So a kid could have been knocked out on Saturday and then they come and play on Sunday and we don’t know about it.”
“I do it from an ED perspective as well. Working on the weekends, I try to get hold of all the parents as they come in and keep educating these people.”
In New Zealand, a database does exist for tracking junior player injuries as was suggested in 2001 but Dr King says more is needed to ensure that kids are looked after properly.
“Yes we can register them, yes we require that they’re given a medical clearance, but what is it? Have you got any symptoms? No. Fine, you’re clear off you go. So unless you’re doing standardised treatments across the board, which isn’t happening, then you’ve got a big issue.”
The Professional Level
Dr King believes the NRL has a role to play here given the influence the elite level of the code can have on the way amateur competitions are run.
Attitudes are slowly changing in the professional ranks, with players taking more time out after concussions, however there are still instances where players seem to stay on the field after receiving a blow to the head or pass their head injury assessment when it seemed like they shouldn’t have.
Dr King says the NRL must lead the way in setting the standard for player protection so it filters into the lower grades.
Parents and kids often only see the outcome of a player’s treatment or assessment, without understanding how they have been cleared.
“The top level needs to change their attitude in my opinion. Yes, I’m going to put this player back on in six days, so why can’t Johnny go back on in six days? He’s been seen by a doctor, he’s been seen by a neurologist. We don’t see all that. These people don’t focus on it. All they see is who is running on the field and who is coming off.
“If you take a player off and he passes his HIA and goes back onto the field again, so if Johnny gets knocked out, and I take him off the field, why can’t he go back on? They’ve (the NRL) got to change what they’re doing at that level to represent what we should be doing at all levels.
“I think it’s got to go right across the spectrum and I think the professionals have to show the way. Yes, they’ve highlighted the issue of concussion. No, they’ve actually caused more problems because what we see on TV is what we think we can do.”
Dr King isn’t trying to “soften” the game of rugby league up, he is in fact trying to ensure the players are protected and that juniors continue to play the game.
After all, tomorrow’s Sam Walkers and Kalyn Pongas are playing under nines and under tens now, so ensuring their health and wellbeing at their current age should be a priority.
He suggests the NRL proceed with a simple, yet very visible awareness campaign such as that being used in Ireland across football, gaelic football, camogie and rugby union called “If In Doubt, Sit It Out”.
“Why not do what they’re doing in Ireland and get every team to put on their arm “If In Doubt,Sit Them Out”, or “Rest and Recover”, messages that are going to be bold and seen because people go out there and support their teams and buy the jerseys. If it’s everywhere, it’s in their face.
“But we don’t do it. We’ve got our main sponsors on each club and that’s all they really want to do.”
He adds that he is concerned about the future health of children playing the game given some of the cases of mental impairment being reported by retired rugby union players.
“We’re going to see the problems in 20 years time. The professionalism of rugby union is coming back to bite them now. 25 years down the line they’re starting to see these ex-international players and professional players saying they can’t remember games, they can’t remember internationals, they can’t remember world cups. What are we going to get from these kids as well?” he questions.
While changing the rules at an NRL level to make the game safer such as shortening the offside rule from 10 metres to five metres is unlikely to happen, Dr King suggests that such a move at younger age groups could lessen impacts and the chances of head injuries considerably.
He also believes that moving them towards lower contact versions of the game such as League Tag, OzTag and touch football in younger age groups could assist in fundamental skill development while protecting their brains.
“Under the age of 12, and it’s based on the research that they’ve done, the brains they’ve found and sliced and diced that have (played sport before) the age of 12 have had more CTE than those (who began playing sport) over 12.
“I believe that if we do leave these kids at OzTag or whatever you want to call it until those ages and give them more of the fundamentals, and getting them trained to tackle around the waist where the tags are, then I think we’re going to solve this problem of tackling high because it’s become an automatic response, and you’re going to decrease the risk of these sort of impacts going on.”
Dr King suggests the game move back to a five metre offside rule for children under the age of 17 to prevent them building up too much pace when hitting the ball up and to reduce the fatigue of defenders.
“These kids are bigger, faster, fitter, stronger, let’s go back to five metres. Let’s look at the difference in that. Not just in one year, but over 3-4 years. Are we going to decrease the number of impacts we’re getting? Are we going to decrease the severity of the impacts?
“Why not change the game slightly and manage the concussions better? It’s only a theory. Nothing has ever been trialled, but I think we would see a big difference.”
Another idea is to limit the number of full contact tackling drills at training. It’s something already in practice in the NFL and has been discussed by the NRL.
Dr King believes that limiting tackle sessions while focussing on technique and fundamentals will better prepare them for the higher intensity and levels of contact as they get older.
“Having games and conditioning games and everything else is fine, then you might go back and do a tackle drill, then do another conditioning game, then do another tackling drill. Well, only have one session of tackle, teach them how to do it right. As they get older you can start conditioning them more and more towards the tackle.
“This is all hypothetical, this is all theory stuff, but I think the only way we’re going to be able to do it is actually get out there and try.”
He adds that embedding these solutions now will help to retain talented juniors who may otherwise leave the sport if their parents deem it too much of a risk.
“What I think you’ll find is that more and more parents are going to become scared. As more comes out, they’re going to want to pull their kids out and make sure that they’re safe.”
Grassroots Concussion Testing
At the elite level, players have access to trained medical staff to assess the possibility of concussions or head injuries during games.
Local players aren’t as lucky, but Dr King says that is starting to change.
“I know some people here now religiously rely on the KD (King-Devick Test), just simply because it’s something that they can hold up in front of the parents and say “look, he’s failed, get him off”, which I think is really good.”
The only issue with trying to roll out a test across all junior teams is the cost incurred by clubs.
To monitor every junior league player in the Penrith district in 2021 using the King-Devick Test would have cost nearly $200,000.
But the King-Devick Test may not be the only option on the market in the next decade as science begins to simplify and find new ways to detect concussions.
“There’s the blood test one that’s coming out. There’s saliva testing that’s coming out, they still haven’t got it for the sideline. It’s come a long way in the 20 years since I started getting my teeth into research and concussion, but I think we’re still 10 years away from having something that’s safe on the sideline and say “yes or no”.”
Until those tests come out though, Dr King says we need to be more careful and protective of our junior players.
“So I think we’re just going to have to have a lower tolerance towards concussion, be more rigid on it and play the cautious game.”
The NRL did not respond to multiple requests for comment by publication date.
Assessing the impacts and risk of concussion and head knocks in the NRL.
In part two of the concussion series we’re looking at CTE, head knocks and how concussion is currently being treated in the sporting world.
Concussion remains a serious issue in rugby league and professional sport. So how is it being addressed by sports and researchers alike?