Head knocks - who's watching out for players?

Sonny Bill Williams of the Chiefs breaks away during the round three Super Rugby match between the Chiefs and the Crusaders. Photo / Getty Images.

Two recent incidents in which high-profile All Blacks Sonny Bill Williams and Jerome Kaino have effectively played on after suffering bad head knocks have placed the off-field concussion test in the spotlight.

But the bigger problem, and one that can be rectified immediately, is the fact doctors and match officials are not spotting what is obvious to the crowd and television viewers - that players are showing symptoms consistent with concussion and in some cases might have been knocked unconscious.

Williams was unavailable to play for the Chiefs against the Sharks in Durban this morning after running out of time, according to concussion protocols, to prove he was symptom free after clashing heads with Stormers prop Vincent Koch last weekend.

Koch's head came into heavy contact with Williams' jaw halfway through the first half of the Chiefs' victory, with the midfielder dropping straight to the ground. He was motionless before sitting and then jogging off the field where he passed a test and played on, only to develop symptoms after the match.

In Kaino's case, the Blues skipper clashed heads with a Lions forward when cleaning out a ruck halfway through the first half of the defeat at North Harbour a fortnight ago. Kaino, who had blood streaming from his head, clearly couldn't maintain his balance on all fours, and then stumbled when attempting to walk, however he too passed a test and re-took the field only to fail one straight after the match.

He was unavailable for his team's defeat to the Hurricanes a week later.

Blues doctor Stephen Kara said he was unsighted when Kaino injured himself. "It was on the far side of the ruck from me," he said. "What I saw was him holding his head and looking at his hand and he had blood on his hand. I saw the video from our analyst the next day and I saw him get up and stumble. He said he felt dizzy and light-headed.

Afterwards, yes, you could say he had 'ataxia' or the inability to walk straight.

"In hindsight if I had seen that, it would have been a case of 'that's enough for me'. I have a low threshold for getting guys off. It's just a game of rugby."

If players are suspected of having concussion, they must undergo an off-field test - a Head Injury Assessment Tool - which involves a series of simple questions, plus a balance test and the requirement to repeat back to the doctor a series of random words and a string of numbers. There is no definitive test for concussion.

But there are several indicators which result in permanent removal without the need to use the test, including: "confirmed loss of consciousness, suspected loss of consciousness, balance disturbance and definite confusion".

Last weekend, Blues flanker Luke Braid was removed from the field after being knocked unconscious by Hurricanes lock James Broadhurst, for which Broadhurst was cited and suspended. In the same match, Blues lock Josh Bekhuis passed an off-field concussion test after colliding with Tony Woodcock and played on, only to fail one after the match.

The major area of improvement must be the identification of head injuries as they happen. Kara said he usually followed a game behind the play - to see who doesn't get up from a ruck, for example - rather than seeing contacts as they happen.

One person who presumably can help in this area is the television match official, yet on the whole they are strangely reluctant to get involved.

Kara said more assistance would be a good thing. "Because it relies on one of those three people [team doctor, match doctor or referee] to witness it. I've been in games where players have told me 'this guy can't remember the lineout calls'. I've not seen anything, it may have been an innocuous event. Obviously those guys come off and often fail [tests] straight away."

Kara said professional players were lucky to have the support they did get. "The biggest problem is at the community level; at a school game, for example, with no doctors on the sideline. That's our biggest risk area."

Sample of questions from Head Injury Assessment Tool
What venue are we at today?
Which half is it now?
Who scored last in this match?
What team did you play last week?
Did your team win the last game?

Balance test
Players must walk forward along a 3.8cm line for 3 metres with a heel-to-toe gait. A total of four trials are done and the best time is retained. Players should complete it in 14sec. Players fail test if they step off line, have separation between heel and toe, or if they touch or grab the examiner or an object.

On-field indications for permanent removal from field
Confirmed loss of consciousness
Suspected loss of consciousness
Balance disturbance
Clearly dazed
Definite confusion
Not oriented in time, place or person
Definite behavioural changes
Convulsion