Neurologist says players must not keep downplaying symptoms.
One of New Zealand's leading neurologists believes a "massive cultural shift" is needed if rugby is to properly tackle the issue of concussion.
Dr Rosamund Hill says the dangers of repeated head injuries are serious and ignorance widespread.
"In the past I've treated players that should have been retired earlier," she says.
"I suspect it hasn't been taken seriously, possibly because people didn't realise that there were potential long-term consequences."
The New Zealand Rugby Union is working hard to educate coaches on the serious risks associated with concussion through their ACC RugbySmart programme, which is compulsory for coaches of all grades to complete each year, but the system relies on coaches instilling a culture in their team that highlights the true risks posed by head injuries.
While awareness of the risks is growing, Hill believes the root of the problem is players downplaying the symptoms of concussion because they want to return to play, a point conceded on Monday by Paul Tito, who was forced into retirement this year after a series of concussions.
Hill says: "You're mostly dealing with young men, who as we know with other things, their ability to use their frontal lobes to make good, balanced decisions with the long-term consequences in mind, isn't the greatest - you can see that with their driving and their drinking. It's the same issue."
Poor decision-making still haunts National MP Mike Sabin, who knew his rugby-mad son should hang up his boots for good after he was hospitalised for six days with a bleed on the brain, but Darryl was adamant he would keep playing (see story, p53).
Sabin tried logic, he tried pleading, he tried emotional blackmail. And finally, when Darryl still insisted on playing rugby, Sabin tried getting a court injunction to prevent his son from endangering his life, but before the courts could intervene, Darryl took to the field and suffered a catastrophic brain injury.
Wellington lawyer Peter Cullen believes that because Darryl was 18 at the time, it would have been difficult to get an injunction.
"There isn't a lot of case law on this point but I feel it is unlikely that a court would be willing to grant such a remedy if the child in question is over the age of 18 and possessed of full capacity," Cullen says.
So if the courts can't act, who can?
Sabin firmly believes rugby unions should have the power to sideline players that are deemed to be a danger to themselves.
Following Darryl's accident Sabin was vocal about the need for the NZRU to do more to protect players at the amateur level of the game.
"It's obvious that the NZRU are concerned about the cream at the top [the elite players] but less concerned about the players beneath that," he told the Northern Advocate.
Three years later his views have softened, but he still maintains there is a place for unions to red flag players who are medically unsafe to play.
If players can be suspended and in some cases banned for foul play, why, Sabin asks, can't unions stop players that are at risk of serious head injuries from taking the field?
"There should at least be some sort of rule that gives unions the power to stop people from playing until they've seen independent verification of their medical status," says Sabin.
Anderson says the NZRU have looked into Sabin's proposal, but found at this point in time the system is unworkable.
"We absolutely tried to come up with a way to make this work, but we just couldn't find a way to operationalise it," he says.
"That's not to say we won't re-look at it again, because as our existing database improves and more clubs start to use it for the registration process then it may become more doable."
Neither Sabin nor his son bear any grudges against rugby or its administrators: "Darryl is an extreme set of circumstances and he made a bad choice. Ultimately the blame lies with Darryl. He made a choice and it was a poor one. Now it's about what opportunities are there to make good of the situation?"
Darryl is keen to be involved in the NZRU's education programmes, and hopes that by sharing his experience others will avoid his situation.
The attitudes that are starting to permeate through the professional ranks also have a trickle-down effect.
It is not feasible for the IRB's new pitch side concussion assessment protocols (see panel), which are currently being trialled in the Rugby Championship and ITM Cup, to be introduced at community and school level due to the lack of medical supervision. But it is hoped it will at least reinforce the message that concussion should not be ignored.
While the relevance of the research coming out of the US is the source of much debate in the medical community, what the experts do agree on is the need for further investigation into the long-term effects of multiple concussions and how it applies to our codes here.
Dr Hill said the tragic and very public cases of the former NFL players in the US represent only a small percentage of the playing population, but what isn't known is what percentage of players suffer more mild neurological conditions.
"What people are now wondering is could there be a large group of people that are mildly affected?"
The research commissioned by the NZRU and IRB should provide important data on the real long-term health risks of playing the game. Currently in the recruitment stage, the findings of the study aren't due to be published until November 2013.
Until that time, Dr Steve Marshall, a New Zealand academic who heads up the Injury Research Prevention Centre at the University of North Carolina, asks for extreme caution and urges the game's rulemakers and coaches to look at ways the game can be changed to make it safer without losing its essence.
"There are still ample opportunities for changes in the way the game is played. There are coaching opportunities. Coaches are a huge potential force for good and a huge potential force for bad," he says of their ability to teach technique and instil culture.
For those that get concussion, the key, says Marshall, is simple: "Access to appropriate professionals - like neurologists - for clearance."
Nothing is foolproof. As Players' Association boss Rob Nichol says, there are inherent risks in playing rugby, just as there are for fishermen, truck drivers or forestry workers.
But as all those industries look towards safer work practices, so must rugby.
New pitchside concussion assessment protocols
* The recommendation to remove the player can be made by either the referee, the independent match-day doctor or the player's team doctor.
* Once that command is made, the referee will indicate that the player is leaving the field of play with a hand signal where he touches his head three times.
* Once the player has been removed from the field of play and temporarily replaced, the team and independent match doctors will proceed through an IRB pitch-side concussion assessment procedure incorporating standardised questions and observations.
* If the player fails any aspect of the assessment and has relevant symptoms he will not be able to return to the field of play and the substitution becomes permanent.
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