Concussion at the Bledisloe Cup, a big headache?

Head Injury Assessment Protocols in Test Match Rugby

Player welfare is the number one priority in World Rugby, which has driven the development of evidence-based protocols for the identification and management of concussion^1,2. Following my role as the Head Injury Assessment (HIA) doctor at Bledisloe 1 this year³, this blog aims to offer insights into the match-day HIA protocols and the team of medical professionals working behind the scenes to protect player welfare at an elite-level rugby game.

Head Injury Assessment Protocol:

The HIA protocol comprises of 3-stages for elite adult rugby teams for the management of head impact events. Stage 1 is a game-day assessment using the HIA Form 1, Stage 2 occurs within 3 hours post-match and Stage 3 occurs 36-48 hours post-match⁴.

Stage 1:

Stage 1 begins when there is a head impact event with the potential for concussion that is recognised by direct observation or on video review by a match official, team doctor (TD) or an independent match-day doctor. The potentially concussed player then undergoes HIA 1 assessment which has 4 components.

Component 1: Criteria 1 indications for immediate and permanent removal.

There are 11 Criteria 1 indications for immediate and permanent removal from the game. They are

• confirmed loss of consciousness,
• suspected loss of consciousness,
• convulsion,
• tonic posturing,
• balance disturbance/ ataxia,
• clearly dazed,
• not orientated to time, place and person,
• definite confusion,
• definite behavioural changes,
• oculomotor signs and
• on-field identification of signs and symptoms of concussion.

If a player exhibits one or more of the above signs, then they are immediately and permanently removed from the game and do not need to undergo the other 3 components of HIA 1, they will progress straight to Stage 2.   

Figure 1: A former test player who is clearly dazed following a head impact event. The associated video footage captured tonic posturing and balance disturbance/ataxia. In this event, the player displayed at least 3 examples of Criteria 1 indications for immediate and permanent removal from the game without the need for further Stage 1 testing.

If a player does not exhibit the above criteria but exhibits ‘Criteria 2’ indications, then they will undergo the other 3 components of HIA 1. The Criteria 2 indications are:

• head impact event where diagnosis is not immediately apparent,
• possible behaviour change,
• possible confusion,
• injury event witnessed with potential to result in a concussive injury and – possible transient or sub-threshold criteria 1 signs

Component 2: Off field screening tool.

If a player displays a Criteria 2 sign, then they are removed from the field of play and a temporary 10-minute substitution is allowed to be made. The player is taken to the medical room with a pre-appointed doctor to conduct the off-field screening tool. The tool that is used in elite rugby is the HIA Form 1, which is a reformatted version of the Sport Concussion Assessment Tool – 5^th Edition (SCAT 5)⁵. The HIA Form 1 checks for concussive symptoms, memory deficits and balance disturbance. At the elite level, the player will have previously performed this test when they are not concussed, which acts as a baseline for comparison. An abnormal HIA Form 1 occurs if the score is different to their baseline or a normative result and will precipitate the player’s removal from the game.

Figure 2: Tandem gait balance testing of one of the Wallaroos players as part of the off-field screening tool component of the HIA 1 assessment. The HIA 1 is available as a phone app and I am in radio contact with the match-day doctor who is simultaneously reviewing the video footage pitch-side with the HIA operator. (Permission kindly granted by the player to use this photo.)

Component 3: Pitch-side video review.

Dedicated pitch-side and medical room monitors are set-up with access to all available camera angles which is operated by a trained technician. The video can be reviewed in the first instance to supplement any sideline observations of a potential concussive event. If a Criteria 1 sign is identified, the player is immediately removed from play. If no Criteria 1 sign is seen, then a discussion between the match-day doctor (MDD) and the respective TD may result in agreement for the player to be removed for off-field screening assessment. If this occurs, then the video can be reviewed further during and following completion of the off-field screening assessment before the player is cleared to return to play.

Figure 3: HIA operator and HIA doctor reviewing pitch-side footage real-time for any events that may have the potential for concussion. We have radio communication to the MDD and the HIA-spotter

Component 4: Clinical evaluation by the attending doctor.

With the benefit of information from the procedures above, the player is evaluated by the independent doctor and can be removed from play if they have clinical suspicion that the player may be concussed.

The 4 components of the HIA 1 assessment must be completed and the player returned pitch-side to the 4^th match official within a 10 minute timeframe. If the player does not return within 10 minutes, then they are deemed to have failed the HIA assessment and are permanently substituted. Changes to the protocol in 2017 mean that even if the player has passed the assessment and returns to the match official early, they cannot return to play until the full 10 minutes has elapsed.

At Stage 1, a player is only definitively diagnosed with a concussion if they exhibit Criteria 1 symptoms. Even if a player is permanently removed from the match following Criteria 2 sign(s) and an abnormal HIA 1 assessment, they have a strong suspicion of concussion but diagnosis is not confirmed at this point.

Stage 2:

If a player has been removed from play to have an HIA 1, then they must enter Stage 2 and have an HIA 2 within 3 hours of the match finishing. The SCAT5 is the tool that is normally used for this assessment, supplemented by player baseline testing or normative values. At Stage 2, a diagnosis of early concussion can be established.

Stage 3:

The final stage of concussion identification and diagnosis has the player re-tested with a SCAT5 and a neuro-cognitive tool (e.g. CogSport, Impact) at 36-48 hours post-match. If they have had normal testing at Stage 1 and Stage 2, but an abnormal assessment at Stage 3, then they are diagnosed with a late concussion.

Match-Day Medical Team:

These protocols couldn’t be implemented without clearly defined roles and appropriately experienced medical personnel to fill them. World Rugby has processes in place for independent doctors to assist with the medical management of players on match-day in conjunction with the TDs and match officials.

The most important of the independent doctors is the ‘Match-day doctor’ (MDD) who sits pitch-side and co-ordinates the medical team on game day. Their primary duties include liaising with the TDs, communicating with the match officials and making the final decisions concerning HIA outcomes and whether a player is fit to return to play.

Secondary to the MDD is the HIA doctor who is also seated pitch-side and is the first reviewer of any suspicious events. Their role is to communicate with the MDD who decides whether a player needs to be removed or assessed. The HIA doctor is normally the agreed-upon doctor to conduct the off-field screening for both teams if required.

The HIA and MDD are also in radio communication with the HIA-spotter, who is another doctor experienced in concussion identification. They have a seat high in the stands for a birds-eye view of the game and a greater vantage point than what can sometimes be seen pitch-side. Following an event that may cause a concussion, the MDD, the TD, the HIA doctor and the HIA spotter seek a unanimous protocol-driven decision that promotes player welfare, but the final decision lies with the MDD.

Furthermore, not directly involved with concussion management but equally vital members of the match-day medical team are the independent immediate care doctors and specialists. In the event of a critical medical issue, there is a pitch-side emergency physician known as the ‘immediate care lead ’ who is assisted by another emergency doctor and nurse.  Also on standby as required are a group of specialists from orthopaedics, plastics, radiology and dentistry.

In summary, World Rugby has developed evidence-based protocols for the identification and management of concussion which aim to promote player welfare. I was fortunate to be part of this process as the Head Injury Assessment (HIA) doctor at a historic Bledisloe Cup double-header and hope my experience sheds some light on the match-day HIA protocols and the team of medical professionals that work at an elite-level match to make concussion less of a headache.

References

1. British Journal of Sports Medicine, World Rugby’s Concussion Journey: From Description to Intervention. Episode #394. In BMJ talk medicine, Dr Steffan Griffin, Ed. 2019
2. Tucker R, Raftery M, Fuller GW, Hester B, Kemp S, Cross MJ. A video analysis of head injuries satisfying the criteria for a head injury assessment in professional Rugby Union: a prospective cohort study. British Journal of Sports Medicine 2017, 51 (15), 1147.
3. Taylor N. Bledisloe Cup: Wallabies stun All Blacks in Perth. West Australian 2019
4. World Rugby. Player Welfare Putting Players First: Concussion Management. 2019
5. Sport concussion assessment tool – 5th edition. British Journal of Sports Medicine 2017, 51 (11), 851.