A man puts a band-aid Clermont's around the forehead of New Zealander fly-half Mike Delany who was injured during the French rugby union match between Clermont and Toulon on May 17, 2015 at the Marcel-Michelin stadium in Clermont-Ferrand, central France. AFP PHOTO / THIERRY ZOCCOLAN (Photo credit should read THIERRY ZOCCOLAN/AFP/Getty Images)

The spectacle of George North, the giant Welsh wing, remaining on the field despite being concussed not once but twice, after colliding with a stray English boot and then a teammate’s head, tarnished this year’s Six Nations opener.

A repeat in the World Cup could have devastating consequences, not just for the player involved, but the sport itself.

The issue of concussion already poses what could yet prove to be an existential threat to American football. Earlier this year the National Football League agreed a $1bn settlement with former and current players after estimating that about 6,000 of its 20,000 former participants will develop a neurodegenerative disease, such as Alzheimer’s or dementia, as a result of on-field collisions.

Evidence of chronic traumatic encephalopathy, or punch-drunk syndrome, was found in the brains of 76 out of 79 deceased former players. Two suicidal former NFL players deliberately shot themselves in the chest so that their brains could be dissected to provide further evidence of the link between American football and degenerative brain conditions.

Yet, by one measure at least, rugby union could have a bigger problem still. England’s Aviva Premiership saw 10.5 concussions per 1,000 player hours in 2013-14, up from 6.7 a year earlier, and double the level in American football.

Dr Allyson Pollock, professor of public health research and policy at Queen Mary University of London and author of Tackling Rugby, has gone as far as calling for scrums and tackles to be banned in order to protect players.

Despite this, most medical professionals believe the issue is manageable. “Would I let my son or daughter play rugby? Yes, absolutely,” says Dr Andrew Murray from the Royal College of Physicians and Surgeons of Glasgow, who advises the Scottish government on physical activity. “What you get from taking part in physical activity or sport has huge physical and mental benefits.”

Dr Martin Raftery, chief medical officer for World Rugby, the sport’s governing body, adds: “When you go into hospitals and look at head injuries, they are more likely to be from motorsports, roller sports, even watersports.

“We know that activity is good for physical health and also mental health. You can’t eliminate risk in life. Our job is to minimise it.”

The sport’s relative insouciance stems from a belief that, even if concussion cannot be avoided, the risk of long-term damage can be significantly reduced. A widely held view among medical professionals in the field is that a single concussive episode tends to resolve spontaneously in a few weeks.

However, a second concussion before the brain has recovered from the first can have far more serious repercussions, hence the North controversy. In 2011, “second impact syndrome” caused the death of Ben Robinson, a 14-year-old Northern Irish schoolboy.

“If [concussion] is recognised and managed appropriately then it’s very unlikely to lead to any short-term or long-term damage,” says Murray. “However . . . t he brain is that bit more fragile, it’s taking time to reboot itself. To take another hit at that point can cause significant damage.”

Raftery concurs, saying: “We know that we have to take concussion seriously, treat it as soon as possible, remove the player from the field of play and only allow them to return to the field once they have recovered.”

To this end, World Rugby is instituting a player welfare code at the World Cup that gives a match-day doctor authority to remove any player from the field. This forms just a part of the sea change in attitudes to concussion that has permeated the sport in recent years.

“Concussion used to be almost a badge of honour and a cause for humour, but people are recognising that we only have one brain,” says Murray, who has worked with the Scottish Rugby Union.

More research is being conducted, even if conclusions sometimes are unclear. A study released in July by Auckland University of Technology, commissioned by World Rugby, suggested ex-players who had suffered four or more concussions performed worse than retired non-contact sportsmen in tests of mental and physical co-ordination, motor speed and multi-tasking.

However, the rugby players performed better in some tests, while in others those who had suffered four or more concussions did better than those with a history of between one and three.

Joe Collins, head of medical at Saracens, the north London-based rugby Premiership club, is among those aiming to help fill in the gaps in knowledge. “There are so many unanswered questions. It’s extremely difficult to diagnose, which makes it extremely challenging compared with many other injuries we see,” he says. “There is no proven link between the size of an impact and concussion.”

Saracens created waves last season when its players began wearing impact sensors behind their ears in matches and training sessions. The sensors, which combine a gyroscope and an accelerometer, sense rotation, tilt, movement and speed.

Collins says the project is at an embryonic stage and there are no conclusions to draw as yet. Nevertheless, the club will step up the initiative this season by taking blood, urine and saliva samples from players and conducting psychometric tests and MRI scans.

“This will add to the knowledge base within the game and other collision sports. There is a paucity of information,” says Collins. He has worked with Tottenham Hotspur and Crystal Palace football clubs and in athletics, judo and squash but believes rugby is more advanced in sports medicine.

He adds: “We have taken quite a strong stand in terms of trying to protect the long-term wellbeing of the players. Rugby has one of the highest injury rates of any sport but our philosophy is every injury is preventable.”

It remains unclear whether incidents of concussion, or injuries in general, are actually on the increase. Raftery believes the dramatic rise in concussions reported in the Aviva Premiership is due to greater awareness and a lower diagnostic threshold, rather than an underlying increase.

Some think the advent of bigger, stronger, faster players since the introduction of professionalism in rugby union in 1995 has led to fiercer collisions and an increase in injuries. As Murray notes, force equals mass times acceleration.

However, Raftery points to the England Professional Rugby Injury Surveillance Project, the data for which are analysed by Bath University, which suggests both the size of players and the number of injuries have plateaued since 2002.

Rugby does appear to be succeeding in reducing neck injuries. Data from New Zealand show the number of serious neck injuries per 100,000 forwards fell from an average of 66 in 2002-06 to 52 in 2007-13. More recent data are still being finalised, but Raftery says they have more than halved since 2013.

This apparent success, which has been broadly replicated elsewhere in the world, is largely attributed to rule changes that have depowered the scrum. These have reduced the force of impact between the front rows. Stiffer penalties have also been enshrined for “tip” tackles, where tackled players are dropped on their back, head or neck.

“It’s clear that we can bring about a change in the rules of the game and have a dramatic impact [on injuries],” says Raftery. “The number of neck injuries has plummeted. That is what we have to do for head injuries.”

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