On the eve of the Rugby World Cup, Tom Hamilton assesses how far the game has come and how far it still has to go in its understanding of the most prevalent -- and damaging -- injury in rugby.
Lewis Moody played the whole of England's 2007 Rugby World Cup match against Tonga. He doesn't remember all of it.
His wife, Annie, does. She was pregnant, and sat in the stands as her husband was knocked out cold. Not once, but twice.
Watching the footage now, it feels like longer than 12 years ago that this happened. It feels like rugby from another age. An age before concussion awareness took hold of the sport and shook it from its stupor.
Moody was attended to by doctors twice. Each time, he told the medics he was fine to continue. No one batted an eyelid.
"Back then, I knew he'd want to carry on playing," recalls Annie. "You'd accept it. It was what he did."
It's true. Taking the knocks, shaking your head to clear the white noise and then returning to your team -- it's what happens when you play rugby. It still happens now, but the reaction from everyone -- players, referees, doctors, wives -- to a Moody-esque double whammy would be so, so different.
"To know what I know now, it terrifies me to think that second hit could've been it," says Annie. "I can't really think about it, to be honest... it's horrible."
We're chatting while sat in the picturesque Recreation Ground in Bath, England. It's where Lewis spilt blood in the twilight years of his career at club level. It's also where I once watched Justin Harrison, an Australian forward, get floored at least three times in one game. We cheered, some even laughed at his "spaghetti legs" as he trundled back into the defensive line, sometimes even going to the wrong side of the pitch first.
It was cartoonish comedy back then. We thought our heroes were like the animated characters Tom and Jerry -- Jerry flattening Tom with a bowling ball, caving his head in, the birds fluttering around Tom's head, but all it needed was a shake of the head and everything was back to normal. Back to the chase, back to the game.
They weren't like the rest of us, you see, these superhumans. We watched on in blissful ignorance.
Away from the limelight, after the knockouts and the coming round and the playing on, Lewis would feel dreadful that evening, stay away from the post-match beers if possible and then rely on Annie to wake him up every hour to ensure he hadn't fallen into unconsciousness. He'd grow increasingly frustrated at being woken up. More often than not the players would have the Sunday off and then be back in training Monday.
Concussion management back in 2007 was player-led. The medics would track their finger in front of a player's eyeballs, ask him to recite the alphabet, and then, more often than not, wave the player back to the side of the pitch.
The player knew best.
Perceptions would be changed, however, by a lawsuit involving the NFL in the United States. Former NFL players had complained of symptoms such as constant migraines, personality changes, depression, anxiety, vertigo, speech impediments and insomnia. The league was accused of not doing enough to warn players about the dangers of repeated concussions. In August 2013, the NFL reached a $765 million settlement with retired players who struggled with neurological-related illnesses after finishing their career.
Signs similar to "punch drunk syndrome" -- called chronic traumatic encephalopathy (CTE) -- started to be found in the brains of some dead NFL players. These symptoms were usually reserved for boxers, whose sport was built around head trauma.
Rugby was initially reluctant to entertain any notion of there being a connection between the nature of its own game -- aggressive, full contact, no helmets -- and CTE. It had begun looking into concussion management, using the 2008 Zurich concussion conference for guidance, but as the player testimonies grew and the NFL began being proactive in concussion management, World Rugby acted.
The sport's first concussion protocol was introduced in 2012. The pitch side concussion assessment (PSCA) saw medics given five minutes to decide whether a player needed to come off.
But then came one night in 2013 in Sydney where the concussion axis shifted again. I was there covering the British & Irish Lions tour of Australia for ESPN when, a few minutes into the third and final Test, the legendary Australia flanker George Smith was floored by a clash of heads and had to be helped off.
Somehow, Smith passed the PSCA and reappeared on the touchline, still looking groggy even to my own medically untrained eye. There was an uneasy feeling in the press box. What I was watching felt wrong, not funny or cartoonish. Smith managed 13 more minutes on the field before wobbling off.
That incident prompted further criticism of the PSCA and later that year, the British newspaper the Mail on Sunday launched a concussion campaign to raise awareness and hold the sport's stakeholders to account.
There was a growing mood around the topic, with confessionals from newly retired players. Rory Lamont, the former Scotland international and a soft-spoken player who left body and soul on the pitch, was one of them. I approached him about telling his story to ESPN. He wanted to write a column, looking back on a career where he had undergone facial reconstruction surgery and still walked with a limp after breaking his leg in the 2012 Six Nations.
But it was the damage he "couldn't see... The damage that may well be lurking in my brain and has the potential to cause serious neurological issues" that terrified him.
I remember the first time I read his notes for the column. It was a web of 6,000 words on his experiences of concussion -- a stream of consciousness that felt like a cathartic exercise for him. Reading it gave you anxiety, a feeling of guilt at having previously expected players to plough on through whatever was thrown their way. It seemed ridiculous, looking back, that a blood injury would be treated with far more 'respect' than a concussion.
Other players spoke out. Ex-England international Shontayne Hape in June 2014 talked of how players cheated the PSCA by fixing lower baseline scores in the season and how coaches pressured him to play through concussions. Concussions left him depressed, with constant migraines and memory loss. The eventual decision to retire came after a specialist told him a mere tap to his body would knock him out as his brain was traumatised and swollen.
Those times where we sat in the stands, cheering the players on and expecting them to get back up after being floored, now seemed negligent. They were not the invincible superhumans we once thought.
In this World Cup you will see players going through something called the Head Injury Assessment (HIA) -- a three-part test to ascertain whether a player needs to come off if he may have suffered a concussion. If there is any suspicion a player has been knocked out, then he is immediately removed from the game. it is worth noting that a player doesn't have to be knocked out to suffer a concussion.
During Rugby World Cup 2011, World Rugby says 53 percent of players who were assessed on the field and were cleared to play were later found to have sustained a concussion; in the 2015 staging, it was fewer than 1 percent. The latest RFU injury audit in England declaring it the most commonly reported injury for the seventh year running -- but the number of incidents reported in matches was down from 169 to 140.
There will be HIAs at the Rugby World Cup in Japan over the next several weeks, that much is certain. It remains a sport built on collisions. But it is also much more certain than it has been before that no player will be knocked out twice in the same game and play on, as Moody did in 2007. The preventative approach is omnipresent these days: a little over a week before the opening kickoff, New Zealand forward Luke Jacobson was ruled out of the tournament for delayed onset concussion, while Scotland's David Denton retired from the sport due to his ongoing concussion symptoms.
Concussion is far from an exact science and there is still so much we don't know about it; the game will continue to evolve its own understanding and adaptation.
With player welfare paramount, teams tried to enhance their own understanding of concussion. Saracens, the current club champions of both England and Europe, trialed an impact sensor that was placed behind the player's ears. But the readings were skewed due to the movement of the skin. They needed a fixed point to measure impact forces.
The Ospreys and Cardiff Blues trialed a new mouthguard last season, which will get a league-wide roll-out in the PRO14 -- a league involving club sides from Wales, Ireland, Scotland, Italy and South Africa -- this season. It measures impact forces, transmitted to a laptop so the team's medics can build a database of what each player goes through in training and in matches. If a player is concussed, they will know exactly what blows they sustained in the run-up.
How technology is helping understand concussions
ESPN investigates the technology within mouthgaurds used by the Welsh side Ospreys that measure impacts with the aim to get a better understanding of concussions.
But just like other professionals looking at concussion and impact forces -- there are similar studies going on at Stanford University with college football players -- the company and scientists involved emphasise that this is not a diagnostic for concussion, just something to help aid our understanding.
For all the work done, though, there are still fatalities.
Four players died in France after suffering injuries playing rugby in the last year. It was called an "unusual spike" by World Rugby boss Brett Gosper but rugby could not ignore the tragedy. The game's governing body in France, the Fédération Française de Rugby (FFR), wanted to act and put forward a list of changes to World Rugby, including lowering the tackling height in amateur French leagues, something that had already been trialed by World Rugby in last year's Under-20 competition.
They will trial it this season and the sport will keep a close eye on developments there, as well as in the landmark case in the French courts where Jamie Cudmore, the ex-Clermont lock, is involved in an ongoing lawsuit with his former club over the ill-effects he suffered after playing on with a concussion. Those four deaths prompted him to act, with his goal being that no one is left with the risks of second-impact syndrome in the same way he has been.
World Rugby is also taking a proactive approach to how players cope after retiring from the game, with 200 former players over age 50 participating in neurological testing and continual monitoring as they look into any potential links between the bangs they took during their careers and symptoms of neurologically-degenerative diseases.
Back in Bath, England, rugby remains central to the lives of Lewis and Annie Moody. Lewis does not regret anything about his time in the game. He says rugby offered him so much and he is a strong advocate of the values the sport instills in those who play it. Annie is already seeing similarities in their youngest child, Ethan, 8, and how he plays rugby like his father used to. He's already picked up his first concussion, after banging his head in the school playground.
Annie and Lewis now run a community interest company called Mad Dog Sport that, together with education, focuses on an individual's continued personal development, using rugby as the foundation. Player welfare is also a huge focus and they work with Return2Play to ensure all their players go through the right concussion protocols.The name of it is a nod to the nickname which became synonymous with Lewis during his career after the 2007 World Cup, where England finished runners up having won it in 2003. Moody played in both finals, but at what cost? Lewis is unsure whether the hits to his head will have any long-lasting damage. He gets forgetful sometimes, but then perhaps we all do as we get older.
Lewis can't change, and wouldn't change anything about his career, but knowing what they do about the potential long-term, life-changing effects the game's wear and tear may have on Lewis' body, would he and Annie want their kids to play rugby?
"I want my kids to do whatever they want to do -- if that's a rugby player, ballet, badminton, cricket or football or whatever then if they love it, that's great, that'll drive them to do well," Lewis says.
"I know how beneficial rugby can be. What can be better than going out and playing with your mates in a game you love?"