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LAS VEGAS -- Two-thirds of veteran rugby players surveyed in the U.S. said they have suffered concussions on the field, most of them more than once, and many didn't get proper care afterward, according to a new study.

"Many of these go unreported, and even more are reported inappropriately. The majority of athletes did not follow a [recommended] return-to-play protocol," said the study's lead author, Johnathan Chance Miller, MD, an orthopedic surgeon at Washington University in St. Louis, in a presentation at the 2019 annual meeting of the .

Concussion is a huge issue in rugby elsewhere in the world, said Boston University neurosurgeon Robert C. Cantu, MD, a leading expert on concussion in athletics, in an interview with MedPage Today. However, he said, rugby "has not been played at the same level in the United States as it is in other countries, and it hasn't received quite the recognition with regard to the concerns about concussion."

Miller, then at Columbia University, and colleagues, sent an online survey to about 115,000 active members of USA Rugby, which governs the sport of "rugby union" in the U.S. (The other main type of rugby is rugby league. The two types have different rules and team sizes.)

"Rugby union is the fastest-growing team sport in the United States," Miller said. "It is a collision sport, and it's got an inherent risk of concussion."

About 13,000 people clicked on an email about the survey, and 2,900 took part in the survey, Miller said. Participants were ages 15 and older, and the average age was 33 for males and 25 for females.

About 75% of players with 6-10 years of rugby experience reported at least one concussion, with an average of 2.6 concussions for men and 1.7 for women. Only 51% of those reported the concussion during the game or practice, and just 58% reported it to a qualified medical professional. Almost 28% of those who reported concussions said they hadn't reported at least one.

"Physicians unsurprisingly are not the first point of contact," Miller said. Players "most frequently reported concussions to coaches, teammates, and athletic trainers. Physicians came in fourth."

Those who didn't report concussions gave reasons such as not thinking it was serious, not knowing they had suffered a concussion, and not wanting to be pulled out of the game, Miller said.

"One of the most surprising findings was that only 38.6% of players who reported a concussion were sidelined for 7 days or longer," even though that is the recommended protocol, he said.

Cantu, medical director of Emerson Hospital's Cantu Concussion Center, explained that head collisions in rugby are accidental, rather than purposeful as in other sports. In fact, players don't wear protective padding for the most part. However, he said, "by the very nature of tackling people, you can't avoid hitting heads with other body parts as well as heads."

He cautioned that the new study relies on self-reported data. However, Cantu said he wasn't surprised by the study findings: "Rugby is years behind football in terms of recognition of [the risk of] concussion, with physicians being present for every game," he said. "They can do a better job having medical personnel present who are trained in recognizing concussion and a return-to-play protocol in place. There also needs to be a big outreach to the players themselves."

Cantu added that rules may need to be changed to lower the risk of concussion, especially in rugby-seven games with seven-person teams. "The speed is greater, collisions are greater, and the risk of concussions is greater," he said.

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