How does PSCA work?

PSCA? Yet another acronym. This one stands for Pitch Side Concussion Assessment, which is now a part of the game's laws aimed at making the game safer for players. Does it?

The PSCA is an IRB initiative and so it has a protocol of its own.

If the team's doctor or the referee suspects that player may have concussion, then they can ask for the player to under go a PSCA. The referee signals this by tapping his head three times to that the people in charge of the coming and going of players can get the timing right. The player's opponents may not request such a test.

The time allotted for such an assessment is five minutes.

During those five minutes the player is replaced  but his replacement is not allowed to kick at goal – for a penalty or a conversion. (clearly the lawmakers are concerned that a dishonest team may take advantage on the law to bring on a pinch kicker.) If the replacement becomes permanent the  replacement is allowed to kick at goal.

The player is then taken to the changing room area for an examination. The examination is usually done by his own team doctor or by the medical doctor allotted to oversee the match. The doctor overseeing the game may do it if the team doctor is engaged in attending to another injured player.

The aim of the assessment is not to give a dizzy player time to recover but to ascertain whether a player is concussed or not so that a decision can be made by the examiner whether to allow the player back on or keep him off. (This law was first tried out at the 2012  Junior World Championship in the Cape. Five players were assessed; three were allowed back on and two kept off for the rest of the match and for subsequent assessment.)

The decision of whether the player returns to play or not is taken by the team doctor though the match doctor has the power to overrule him.

The assessment consists of three parts

1. The first section is documents the player demographics and signs and symptoms of concussion

2. Part two are five questions (Maddocks Questions) that assess for confusion and loss of orientation

3. Part three is a balance test to assess proprioception (the ability to know where our limbs are in space without having to look).

Notes

1. Symptoms:

    Suspected Loss of Consciousness

    Ataxia (unsteady on feet)

    Disorientated or confused

    Player appears to have been "dazed, dinged or had their bell rung"

    Inappropriate behaviour

    Other symptoms or signs suggesting a suspected concussion

Note that players in whom concussion is deemed to be confirmed at the time of their initial on pitch assessment (confirmed loss of consciousness by a medical practitioner or medical practitioner witnessed concussive convulsions or tonic-clonic posturing) will be definitively removed from the field of play.

2. The Maddocks Questions

Dr David Maddocks, a neuropsychologist and concussion researcher who did research on gridiron footballers starting in 1989, developed the following concussion assessment questions:

At what venue are we today?

Which half is it now?

Who scored last in this match?

What team did you play last game?

Did your team win the last game?

If the player fails to answer one of these questions, he is not allowed to return to play,

3. The tandem balance test is used. This consists of walking forward with the heel touching the toe of the foot behind with each step.

The balance test lasts 20 seconds and is similar to the test given to somebody suspected of driving under the influence of alcohol. Failing four times disqualifies a player for return to the match.

Based on this testing a return to play decision is made, and this should be made based on the absence of signs and symptoms of concussion, normal memory and orientation, and normal balance.

The test is a snapshot , and thus not definitive. It cannot be used to diagnose concussion but it can be used to exclude a player from returning to play. Its main aim is to allow the doctor sufficient time off the field to ask the appropriate questions to assess any signs of concussion that may not be visible by observation alone.

A player who satisfactorily completes his PSCA and in whom suspected concussion is therefore not confirmed can return to the field of play within the five minutes

If a player has a suspected concussion and a co-existing blood injury, control of the bleeding will be the priority but the PSCA must be completed as soon as possible. If the bleeding can be controlled, suturing should be completed post PSCA. The total time available is 15 minutes to complete both the PSCA and control of bleeding.

A player failing to cooperate with a PSCA should be assumed to have concussion and be removed permanently from the game.

If a player has a second requested PSCA during a game the player should undergo a second PSCA as a separate and independent assessment.

Clearly the tests needed to be honestly and responsibly done, not yielding to a coach's pressure to get a valued player back onto the field of action. There was a once a rant from a famous coach who is coaching no longer: 'I don't want you to tell me he can't play. It is your job to get him uninjured and onto the field.'

The most criticised  incident of PSCA's deficiencies occurred during the B&I Lions' tour of Australia in 2013.  After just over four minutes in the third Test veteran Wallaby George Smith clashed heads with hooker Richard Hibbard and went off on rubbery legs to undergo a PSCA. He turned to the field of play, presumably after passing the test, and played on. By his own admission he did not play well.

The PSCA protocols were developed by an IRB working group consisting of experienced international team physicians, including Dr Simon Kemp and RFU Community Medical Director Dr Mike England, a player representative, a French neurosurgeon and an Australian physician with a PhD in concussion.

When developing the protocols, the group were asked to ensure the protocols would improve player safety, not undermine the fabric of the game and not be open to tactical manipulation by coaches.

IRB chief medical officer Dr Martin Rafferty, who was formerly the Wallabies' team doctor, has stressed that the PSCA was designed to be a step-by-step or 'multi-modal' tool to help assess cases in which concussion was not immediately apparent. he also made it clear that if a player was clearly displaying signs of concussion, he should not play on in that same match.

Rafferty said about the results since the introduction of PSCA: 'Before with the single modal assessment it was based only on memory and that picked up just 32 percent of concussed players.'

'In the past 56 percent of concussed players stayed on the pitch, now with PSCA it is down to 13 percent. Is that good? No? Is that perfect? No. Obviously we want to reduce that figure even more.'

Concussion is especially prevalent amongst younger players.

Not everybody has agreed with the IRB, most notably Dr Barry O'Driscoll who played for Ireland in the 1970s and is the uncle of the Brian O'Driscoll playing for Ireland now. He disagreed so much that he resigned from the IRB's medical committee after 15 years.  He felt that the new protocol 'trivialised' concussion.

He said: 'For someone with suspected concussion, all the top scientists say you take them off and watch them that night. If they incorporate the "five-minute rule" I think you're putting people with brain damage back on the field, and the arena they're going back into is brutal.

"The game has changed since I played. It's now a big commercial sport, and so what's important is to get the spectators in, get the television in. They love the big hits.

'The players have said "well, we know we're guinea pigs, but that's the deal." It's our job not to make them guinea pigs in an experiment like this.'

The Scotland player Rory Lamont is also doubtful, stating in 2013 that the current concussion protocols can easily be manipulated, that players would deliberately cheat the protocol.

'The problem with the PSCA is a concussed player can pass the assessment. I know from first hand experience it can be quite ineffective in deciding if a player is concussed. It is argued that allowing the five-minutes assessment is better than zero minutes but it is not as clear cut as one might hope. Concussion symptoms regularly take 10 minutes or longer to actually present. Consequently the five-minute PSCA may be giving concussed players a license to return to the field. '

There is general concern about the long-term effects of concussion in sport, especially contact sports such as boxing, gridiron football and rugby. Gridiron in the USA accounts for 56% of concussion injuries in all sports. According to data of England's RFU, concussion is the most common injury in the professional game, with 5.1 instances for every 1,000 hours of rugby played. Players are now on average more than 7,2kg heavier than they were 20 years ago, and the force of their collisions can be the equivalent of what the body experiences in a car crash. in 2013, former

Amongst the long-term effects have been brain damage, headaches, and depression that has even led to suicide.

It would seem that the laws of a collision sport like rugby are going to aim at greater care for players who have suffered concussion.