Premiership Rugby’s new method for diagnosing concussions

Premiership Rugby’s Head of Science and Medical Operations Dr Matt Cross has described a ground-breaking new method for diagnosing concussion using saliva as “an incredibly exciting discovery”.

The method, which could pave the way for the first non-invasive clinical test for concussion, was identified in a new University of Birmingham-led study in collaboration with Premiership Rugby, the Rugby Football Union and Marker Diagnostics.

With the help of the Premiership Clubs and elite rugby players, and the full support of the Rugby Players Association, DNA sequencing technology was used to establish if these ‘biomarkers’ could be used as a diagnostic test for sport-related concussion.

Testing these biomarkers in saliva samples from 1,028 professional men’s rugby players from Premiership Rugby and the Championship, the study found that specific salivary biomarkers could be used to indicate if a player has been concussed.

The research has also found these biomarkers provide further insights into the body’s response to injury as it evolves from immediately after trauma, to several hours and even days later.

Dr Cross said: “I think it’s an incredibly exciting discovery. It has the potential to further support clinical decision-making regarding the identification and diagnosis of concussion and highlights the possible utility of a test of this kind.

“Premiership Rugby is committed to continuing to support this research and further product development next season with elite club doctors and medical teams. We want to establish how our medics will use this test to complement the existing process.

“We also want to support the collection of more samples to refine and further validate the findings from this study in terms of the diagnostic biomarkers that successfully identify concussed players”

The results of SCRUM (Study of Concussion in Rugby Union through MicroRNAs) were published by the University of Birmingham today (March 23) in the British Journal of Sports Medicine.

In community sport, these biomarkers may provide a diagnostic test that is comparable in accuracy to the level of assessment available in a professional sport setting.

At an elite level of rugby, the concussion test may be used in addition to the existing World Rugby HIA protocol – and Dr Cross is excited by the possibilities.

“We want to have the best management in place for players and the findings from this study show the potential to be able to provide further support to the clinical decisions that our medical teams have to make on a regular basis,” he added.

“I think what’s also exciting is the potential for these findings to have broader implications in other levels of the game, other sports and also in other settings such as healthcare.”

The research team will now look to collect further samples from players in two elite men’s rugby competitions, in order to provide additional data to expand the test.

This additional data will help the test develop its use to guide the prognosis and safe return to play after concussion and to further establish how it will work alongside the HIA process.

Dr Cross paid tribute to the Premiership Rugby clubs and all the players and staff who have already contributed to the research.

“It’s really important to recognise the work of the players, the clubs and their medical staff that have participated in this and managed all of the data collection on the ground,” he said.

The team now aims to collect further samples from players in two elite men’s rugby competitions – one of which could be Gallagher Premiership Rugby – in order to provide additional data to expand the test and develop its use to guide the prognosis and safe return to play after concussion and to further establish how it will work alongside the HIA process.

The findings and planned next research steps will be presented at the World Rugby Laws and Welfare Symposium to be held later this month.

Senior author Antonio Belli, Professor of Trauma Neurosurgery at the University of Birmingham, Consultant Neurosurgeon at UHB, and Director of NIHR SRMRC, added: “Conducting a study in a professional contact sports setting has meant we have been able to collect invaluable data enabling us to make significant advances in our biological knowledge and understanding of concussion and its diagnosis.

“Crucially, the differences in the salivary concentration of these biomarkers are measurable within minutes of injury, which means we can make rapid diagnoses.

“The ability to rapidly diagnose concussion using biomarkers in addition to existing tools solves a major unmet need in the sporting world as well as in military and healthcare settings, particularly in injuries without significant visible symptoms.”

Author Dr Simon Kemp, RFU’s Medical Services Director, added: “This study is an important part of the portfolio of collaborative research initiatives the RFU undertakes into concussion.

“While still a way from having something that can be used in community rugby, it is extremely encouraging to now be able to start to develop a rapid and non-invasive test which could add real value particularly at a grassroots level of the game.

“We would like to thank all the players and clubs who participated in the study and to World Rugby for granting permission for us to extend the duration of the HIA from 10 to 13 minutes in order for the saliva samples to be captured. We wouldn’t have been able to do it without this support.

“We will now be working with World Rugby to secure further research options in two elite men’s competitions.”

Dr Éanna Falvey, World Rugby Chief Medical Officer, said: “Elite Rugby’s Head Injury Assessment process has proven an invaluable tool in the identification of concussion with an accuracy of over 90 per cent, but we are continually evaluating the latest developments in science and technology to identify potential enhancements.

“This study, its rigour and outcomes demonstrates the value in a targeted, scientific approach and reflects rugby’s progressive commitment to player welfare.”

Tinus Maree, CEO of Marker AG, said: “This ground-breaking validation of the biomarker panel shows that we can use the simple swab collection of saliva to accurately and specifically diagnose concussion.

“It is a biological measure of mild traumatic brain injury and will contribute to a new global standard of care for the injury and a meaningful reduction of the cost and health burden associated with concussion.

“We are grateful to our collaborators, especially to Dr Simon Kemp and the RFU, for their efforts and visionary support of this important work.”

Saliva samples were collected pre-season from 1,028 players. They were also collected from 156 of these players during standardised World Rugby head injury assessments (HIAs) at three time points – in-game, post-game, and 36-48 hours post-game.

The HIA protocol, used by rugby medical staff, includes a neurological examination, a series of cognitive tests and evaluation of gait and balance to determine if a player has been concussed.

‘Control’ samples were also collected from 102 uninjured players and 66 players who were removed from the game due to musculoskeletal injuries.

Using samples collected during the 2017-18 season, the team identified a panel of a combination of 14 salivary biomarkers – known as small non-coding RNAs or sncRNAs – that was highly accurate (96%) at identifying concussed players from all other groups.

This included players with suspicion of mild traumatic brain injury who had a concussion ruled out after a structured HIA; uninjured controls from the same game; and players who had suffered musculoskeletal injuries.

The panel was prospectively tested during the 2018-19 season, and the research showed it could successfully predict whether players would be positive or negative for concussion via the HIA protocol in 94% of cases.

  • The study was carried out in collaboration with the Universities of Bath and Cambridge, and London School of Hygiene and Tropical Medicine.

To access the research paper in full in the British Journal of Sports Medicine, click here

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