Watching George North's body fall limply to the floor during Wales' Six Nations showdown against England in March is a deeply unpleasant experience.
Doctors rushed to his side and helped him get groggily to feet after a few frightening moments. The imposing winger's neck had flopped and his eyes rolled; His lack of consciousness meant his arms didn't extend to soften his landing. 30 minutes earlier the exact same thing had happened.
North, who was stood down from action having suffered four concussions all in during a four-month period, was defiant afterwards.
“At the end of the day it is rugby, isn’t it?" he said. "It’s not table tennis or tiddlywinks, it is a contact sport and you are going to get some bangs and unfortunately they were on my chin.” Later on in the same interview, he admitted that a neurologist had told him that he'd also suffered a third concussive blow in the game.
The incident and reaction seemed a nod to rugby and sport's historic laissez-faire attitude towards head injuries and the bigger the hits have got, the larger the issue has become. One man who knows the true cost of concussion is Shontayne Hape.
I know it's over
The 34-year-old was born in New Zealand, who he represented during his time in rugby league. His move to England represented a change of location and a change of sport. He was converting to rugby union.
Hape would go on to represent England in the 2011 World Cup and in 2012 he sealed a move to London Irish, where he began to notice something wasn't right.
"Halfway into the season against Gloucester I copped a knee to the head and was knocked out," he wrote in a painfully honest blog for the New Zealand Herald last year. "I told the club's medical staff I'd copped a head knock, but didn't admit the full extent of it, that I'd blacked out.
"The next week against Harlequins I copped another knock. It was a pure accident. Our lock Nick Kennedy kneed me in the temple and it put me straight to sleep. Concussion on concussion. That was the big one for me, the worst I've ever felt."
Hape was stood down for eight weeks after failing rugby's post-concussion protocol and moved to play for Montpellier in France for the summer. Five games in and he was out cold once more. He played on. The same happened the next week.
"There was constant pressure from the coaches. Most coaches don't care about what happens later on in your life. It is about the here and now. Everyone wants success. They just think 'if we pay you this you are going to do this".
"Players are just pieces of meat."
Migraines and memory failure were bothering the centre off the pitch but he played on until concussion struck again in a game. He continues: "At a team meeting our coach Fabien Galthie, a former French halfback, grilled me for lying in the ruck and giving a penalty away. I didn't want to admit that I was lying there was because I had been knocked out. It was humiliating". After the meeting, he came clean.
Results of tests showed his memory and brain function were consistent with someone struggling with learning difficulties. "The specialist explained that my brain was so traumatised, had swollen so big that even just getting a tap to the body would knock me out."
Danger across the pond
Over in America and the NFL is facing up to its demons, albeit reluctantly. On April 22, 2015 a settlement was approved by a District Court judge after a lawsuit brought by 5,000 players, who had accused the league of hiding the dangers of concussion. The New York Times described it as "a major step toward ending one of the most contentious legal battles in league history". Claimants can be awarded up to $5 million each, with the NFL reportedly agreeing to pay out a total of $1 billion to those suffering the effects of a life on the field.
Amongst those fighting the league are the family of Junior Seau, who committed suicide and was later found to have a degenerative brain disease, and Kevin Turner, a retired running back who has amyotrophic lateral sclerosis, commonly known as Lou Gehrig’s disease. “What matters now is time, and many retired players do not have much left,” he said after the ruling was announced. "I hope this settlement is implemented without delay so that we can finally start helping those in need.”
Their plight was highlighted by the release of the findings from a study from Boston University earlier this month. It found that 87 of 91 brains from deceased NFL players tested positive for a brain disease that is believed to be linked with repeated head trauma and concussions. The disease in question is known as Chronic traumatic encephalopathy - CTE.
Studies into rugby reveal similarly harrowing findings. Research funded by World Rugby and carried out by the Auckland University of Technology found that 94% of elite level rugby players had experienced one or more concussions, and that there could be a direct link between concussion and brain damage.
"We've got to go through that scientific process, but what I'm saying is that, as a scientist, it's irresponsible for people to say there are no long-term brain health issues," said Professor Patria Hume. "Because all indications so far from the analysis we have done indicates that there possibly are for the rugby players and for people who have been concussed more than four times."
An official World Rugby statement insisted that 'it was difficult to draw robust conclusions' from the research, which was commissioned in response the first settlement from the NFL of around £400 million, two years before the updated 2015 ruling.
CTE is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head.
Trauma from events such as big tackles and kicks to the head can potentially trigger progressive degeneration of the brain tissue which in turn leads to symptoms ranging from bouts of confusion to progressive dementia. Speaking of his own experience, Hape said last year: "My tolerance for my three young kids was zero. I was always angry around them, couldn't even last a minute without getting cross and losing my cool. My relationship with my wife Liana suffered."
Further research digging deeper into the issue from the Auckland University of Technology earlier this year used new wearable technology to track every single hit taken and delivered by a single amateur rugby union team across the season - and the results are startling.
The study found that on average every player took 77 hits equivalent to a light punch to the head each game across a 19-match season. That's almost 21,000 'punches' to the head in the season all in. The latest annual injury report for English rugby revealed that the number of reported concussions in English rugby rose by 59% in 2013-14 compared to the previous season, too - developments in fitness and nutrition means players are hitting harder than ever, although rugby's governing body puts the rise down to an increased awareness in diagnosing concussion.
"The research shows there are repetitive sub-concussive impacts to the head in rugby union and when compared with American football, in some cases these are higher in frequency,” Doug King, one of four academics involved in the study, told the Guardian. Given that the findings are based on an amateur rugby it's safe to assume that the numbers involved in the professional game will be higher.
Dr. Courtney Kipps, club doctor for Harlequins Rugby Club in the Aviva Premiership, remains reluctant to draw a link between long-term brain issues and repeated concussions, however - a testament to the confusion caused by the issue in the medical world.
Asked if Hape is more at risk of having a reduced quality of life post-rugby career he told GiveMeSport: "No. The more concussions you have, the easier it is to suffer another concussion with a lighter knock - and for the subsequent symptoms to go on longer each time. The question about Hape and whether his life will be different to anyone who hasn't suffered 20 concussions - I don't know the answer.
"The research about the brain injuries is only done on those who have died and can be cut up, and then you have to go back through their medical history and see how many concussions they had - and the difficulty is counting how many they've had because it's hard to know."
Times they are a'changing
There has undoubtedly been a shift in attitude in rugby, as well as other sports when it comes to dealing with concussion. Hape spoke of deliberately dumbing down on pre-season 'baseline tests' so that when tested for concussion in-season, they had a better chances of passing the comparison test. Athletes face a difficult choice between prioritising their safety and well-being, and their ability to earn, provide for their families or even just save face in an alpha male environment.
Last year, English rugby announced major changes to their concussion injury protocol, launching an initiative which includes players and coaches requiring to take an online module in concussion and making alterations to the head injury assessment process. Doctors now have 10 minutes to decide whether a player can return to action, independent medical staff are present at all Premiership and England games, and an independent review is held of the on-field management of all cases during Premiership Rugby and England matches.
The big question that looms for rugby is whether they will be forced to deal with the past in a manner similar to the NFL. The recent changes to concussion protocol are as a direct response to the repercussions faced by the NFL. Research amongst retired rugby players is limited and the extent of knowledge regarding players after they've hung up their boots is also unclear. Hape reports that he has the 'attention span of a kid' and worries about dementia, while the film Head Games: The Global Concussion Crisis, which was released last year, features a host of retired rugby players describing symptoms of depression, personality changes and memory loss. The documentary also claims there's a higher incidence of concussion in rugby than in American football, which suggests a similar case could well be bought against the rugby powers that be.
Dr. Kipps is quick to stress the differences between the NFL and rugby - and insists it's too early to draw conclusions.
"On average there's a concussion in professional rugby every two and a half matches," he tells GiveMeSport. "If you look at diagnosing concussion, there are no scans, no tests or investigations we can do that will tell us conclusively that someone has concussion. They will arrive one day when the technology is sophisticated enough, but we're not there yet.
"No sport fully understands it [the extent of the concussion issue], nobody does. We have to manage it on a conservative basis using clinical diagnosis conducted by an expert who is experienced with concussions. But as it is, neither sport and the medical profession fully understands the problem. We're finding out more, but we're not there yet - rugby is at least a good example of a sport being proactive."
That remains the problem for rugby and other sports. The issue isn't fully understood and it's difficult to know what is lurking around the corner. The NFL initially rejected a link between the sport and issues arising head trauma such as depression, however in 2009 a study found that former NFL players were 19 times more likely to suffer from early onset Alzheimer's disease than the general public that helped turn the tide.
Asked if rugby will face a similar fate to the NFL, Dr. Kipps replied: "Who knows. I know now, working in rugby for five years, that we diagnose more concussions, far better than we've ever done before."
That message is certainly true throughout rugby. Before the current World Cup, the game's international governing body, World Rugby, were in the process of drawing up a legally binding document to ensure strict player welfare guidelines and initiating the introduction of protocols that could see players or team doctors sanctioned for not following the correct concussion procedure.
That trend has continued throughout the tournament with organisers employing a firm who have developed software that helps "administer tests, compare data, share reports and control account access while engaging with players to help with concussion management."
But for all the protocols, tests and precautions there's not a great deal that can be done to stop concussion altogether; and neurologist Professor Laura Balcer, of New York University, has some sobering advice for professional athletes: "If you suffer concussion on three occasions, you should think of retiring."