World Rugby, the game’s international federation, has established a three-stage protocol for identifying, diagnosing and managing concussions.
Concussions in rugby are an essential safety consideration, and the Head Injury Assessment (HIA) protocol is designed to protect players in elite adult rugby leagues. Here’s a closer look at the three stages.
Stage 1 – Off-Field Assessment
Players experiencing an event with head impact with the potential of a concussion may be identified by a match official, team doctor or independent match-day doctor. Players are assessed using four components, either in person or over video.
The first component is 12 criteria that provide immediate and permanent removal from the match. They include:
- Confirmed or suspected loss of consciousness
- Convulsions
- Tonic posturing
- Balance disturbances or ataxia
- Clearly dazed
- Lack of orientation to time, place or person
- Confusion
- Behavioural changes
- Oculomotor signs
Other off-field assessments as part of the protocols are a screening tool, a pitch-side video review and a clinical evaluation by an attending doctor.
Players with obvious on-pitch signs of a concussion in rugby are removed from play, and the off-field assessments are not required. In other cases, where a player may have a concussion but does not have obvious on-pitch symptoms, the player will undergo an off-field assessment that includes a clinical evaluation in a medical room, the multi-modal screening tool and a video review.
Based on the Sports Concussion Assessment Tool (SCAT5), recommended by an international group of experts, the off-field screening tool includes a memory assessment, check of symptoms, and balance evaluation. The off-field assessment is compared to a previously completed baseline assessment or normative result when available. If the screening tool results vary from the baseline or normative results and confirm a suspected concussion is removed from the match.
The team doctor is responsible for the off-field screening, though it can be delegated to the match-day doctor. The screening is conducted in the stadium’s medical room or an agreed-upon venue if that location is too far.
If a temporary substitution is necessary on the field, a 12-minute temporary replacement (absolute time, not playing time) is allowed. A player undergoing an assessment for concussion in rugby must report to the 4th official within the 12 minutes but is not allowed to return until the 12-minute period has expired.
Video reviews serve three critical roles in the off-field assessments. For one, independent match-day doctors can review video of on-pitch plays and identify suspicious head impacts that require permanent removal or sideline assessment. If a player is removed due to the video review, then a second video review is conducted with the match-day doctor and team doctor present.
The third use is a review of the off-field assessment, where the video is again viewed before a player returns to play.
Stage 2 – Identifying an Early Concussion
Any player under the HIA protocol has an early medical evaluation within three hours of the match being completed. This assessment is used to measure clinical progress and provide an early diagnosis. The Stage 2 assessment uses the SCAT5 tool with player baselines or normative rugby baseline measures.
Stage 3 – Identifying a Late Concussion
After two nights of rest (36-48 hours after a head impact event), additional medical testing is done to assess clinical progress and identify a concussion. Like Stage 2, this assessment uses the SCAT5 and a digital neuro-cognitive tool.
Some players may present with delayed symptoms or signs of a concussion in rugby but are not identified during the game. They can enter a Stage 2 or Stage 3 protocol and be diagnosed using those standards.
The HIA protocol is a powerful way to protect players and ensure safety.
