LIONS tour doctor Eanna Falvey admits player concussions can still get missed but believes the current Head Injury Assessment system is the best on offer to medical professionals in rugby.

Concussion remains a hot topic in rugby with Test wing Anthony Watson the most recent of the touring party to undergo the HIA protocols in order to prove his fitness for selection ahead of Saturday’s final Test against the All Blacks having received an illegal shoulder to the side of his head from Sonny Bill Williams in the first half of the second game.

Watson was allowed to return to the field after passing his initial assessment and the Bath and England star finished the match in Wellington but he has since completed all the necessary tests required to return to play.

Less fortunate have been the four players in the last five weeks that former Ireland team medic Falvey, on his first tour as the British & Irish Lions head of medicine, has had to tell their New Zealand campaign is over due to injury, among them Ireland centre Robbie Henshaw.

Henshaw tore his pectoral muscle in last Tuesday’s tour game against the Hurricanes, returning home for surgery last weekend following the second Test victory in Wellington.

“With regard to Robbie Henshaw, that was a pretty significant injury, he’s completely avulsed the muscle from the bone which requires it to be re-attached to the bone,” Falvey said in Queenstown.

“That’s usually about a 16-week recovery. He may do slightly better but that’s usually what we’re looking at with a situation like that.”

Henshaw’s regular Ireland centre partner Jared Payne may yet follow Henshaw, having stayed behind in the New Zealand capital to undergo further Tests on the regular migraines he has been suffering.

Those migraines, Falvey stressed, are not concussion-related, but several players have presented with symptoms on this tour and even in these times of heightened awareness of head injuries, the Cork doctor accepts that a few instances do get missed, despite the safeguards in place today that were not even available to medical staff when Falvey toured with the Lions to Australia in 2013.

“The whole HIA management is a collaborative event now,” Falvey said. “I’m not there on my own making a decision about that anymore. We’ve raised the stakes on how we do this considerably.

“For all our games, one of our medical team sits in the coaches’ box as a spotter. He has a computerised system where has got the broadcast feed and he can rewind that. So if there’s a bang, or somebody gets a bang, he can look at that for me.

“At the same time I also have access to a system on the sideline, an EVF system from the NZRU, where they have an operator working the system, and I have 12 views where we can look at any impact and decide whether or not it meets the criteria for an HIA or permanent removal.

“Added to that, you have an independent match-day doctors’ team, which is usually three doctors, who basically are on the sideline reviewing that and watching the game themselves.”

Falvey is long used to difficult chats with players who believe they should remain on the pitch despite showing signs of concussion and he is relieved the presence of independent practitioners can only help make his life easier.

“We made a conscious decision before the tour that the independent doctor would do all the HIAs, so basically we removed any even implication in any way that we might be favouring getting guys back on or not.

“The biggest thing as a medical person is that you want the team to win, the player wants to go back on — the player always wants to go back on — you know this guy, you’ve been working with this guy for weeks and weeks and weeks. He’s bitterly disappointed.

“I’ve had a couple of very tough conversations in this tour where players couldn’t go back on, and they were extraordinarily disappointed, particularly early in the tour, because they’re missing an opportunity to make their case for a test position. We have to look after them, we have go to protect players from themselves.

“So we’ve used the independent match-day doctor to do the HIA for us. It is a truly independent process, but even with that, things get missed. In the Joe Marler case (during the game against the Chiefs on June 20) for example, he clashed heads with Courtney Lawes, and we removed Courtney for an HIA which he passed.

“Joe at the time was okay, and the video review doctor and the match-day doctor were quite happy with him staying on. However, that evening and the next day, when we reviewed our own video, we could see that Joe had actually gotten up and fallen to the ground again, and that is a permanent removal criteria.

“There are 10 criteria on the HIA, which if you fulfil any one of those, you aren’t supposed to do an HIA. You are removed with a suspicion of concussion and you go through the graduated return to play.

“So then we moved Joe through a graduated return to play. Obviously that’s not ideal, but you’re in a situation there where, using the best tools that you’ve got available, something slips through the net, but we still found it the next day and made sure we looked after him properly, he wasn’t in any contact situation until it was indicated by the graduated return to play.

“It’s a difficult situation because people get bangs on the head all the time in many sports and you can get a bang on the head without getting a concussion, but we’re in a situation now where we have to make sure we do the right thing by somebody so when they do get a bang on the head like that the safe thing to do is remove them and use the tools that we have.”

There is still room for improvement, Falvey said: “Of course everything that we do we like to do as well as we possibly can. We’re continually improving it so for us, having the HIA process, which wasn’t there four years ago, we didn’t have it in Australia, it’s a big improvement. On-pitch video review, it’s a massive improvement. Having a spotter up there is a big improvement. Having an independent doctor doing the HIAs is a huge improvement.

“Is it the best thing? Absolutely not. Could we do better? Hopefully and we’ll keep trying to improve it. I work on the World Rugby Concussion Working Group for that reason.

“It’s an ongoing process, it’s not perfect, it’s taken quite a bashing over the time, but if you ask anybody who’s on the pitch looking after a player having the possibility of removing somebody, having pitchside review and having an independent doctor is a big step up from where we’ve been.

“I’d be really hopeful in four years’ time we ‘ll be even better. You’d hope.”

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