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HIA Protocol

HIA Protocol

Introduction

The Head Injury Assessment (HIA) protocol is a three-stage process introduced by World Rugby for elite adult teams to assist with the identification, diagnosis and management of head impact events with the potential for a concussion. This HIA Protocol consists of the following three stages:

  • Stage 1 – game day assessment using the HIA1 Form.
  • Stage 2 – post-game, same day assessment using HIA2 Form.
  • Stage 3 – 36-48-hour post-injury assessment using HIA3 Form.

Within this document is the following:

  1. HIA Protocol Explanation
  2. HIA Procedures
  3. Appendices
    1. HIA Procedure Definitions
    2. Procedures for Team and Match Day Medical Staff
    3. Application for Access to Temporary Replacement
    4. HIA Review Process Explanation and Flowchart
    5. Minimum Education Content, Risk Stratification guide, Advanced level of concussion care
    6. GRTP Recommendations
    7. Player Consent and Research Explanation

HIA Protocol Explanation

Temporary substitution for head injury was introduced permanently into Law for elite adult rugby in August 2015. The HIA Protocol has been developed to support Law 3.11 and Regulation 10, both of which are relevant to this temporary replacement for head injury and the management of concussion.

The three-stage HIA Protocol consists of:

Stage 1 – Off-field HIA1 Assessment:

In stage 1, players who sustain head impact events with the potential for a concussion are identified by match officials, team doctors (TD), or independent match-day doctors (MDD). The identification is either by direct observation or on video review.

The off-field HIA1 assessment has four components and they are:

  1. 12 immediate and permanent removal criteria (known as Criteria 1 indications) AND
  2. an off-field screening tool AND
  3. pitch-side video review AND
  4. clinical evaluation by the attending doctor

The off-field HIA1 assessment is therefore not limited to the off-field screening tool. Instead, the off-field screening tool is one component of a comprehensive assessment.

Players displaying obvious on-pitch signs of concussion (Criteria 1) are immediately and permanently removed from play, and the completion of the off-field screening tool is not required. Any other cases, where players have the potential for concussion (Criteria 2), but without clear on-pitch symptoms or signs, undergo an off-field assessment consisting of a medical room clinical evaluation by an attending doctor supported by the multi-modal screening tool, and video review.

The off-field screening tool is a re-formatted Sports Concussion Assessment Tool (SCAT 5), the pitch-side assessment tool recommended by experts from the international concussion consensus meeting. This off- field screening tool includes a check of symptoms, memory assessment and balance evaluation. Only used in the professional game, the results of this off-field assessment are compared to a previously conducted ‘baseline assessment’, or to a normative result. An abnormal screening tool result is indicated if the score is different from that player’s baseline assessment or the normative score and confirms a suspected concussion. Any player with an abnormal off-field assessment or if there is a clinical opinion of suspected concussion must be removed from the game.

The team doctor has the primary responsibility for conducting the off-field screen but can delegate this role to the match-day doctor. The off-field screen is conducted in the stadium’s medical room or other agreed venue if medical room is too distant from the field. If a temporary substitution for head injury is required a 12-minute temporary replacement is allowed. This is a set 12 minutes and is absolute time not playing time.
A player undergoing an off-field assessment must report to the 4th official within the 12 minutes but will not be allowed to return to play until the 12-minute period has expired.

Video review has three roles in the off-field HIA1 assessment. Firstly, during play, independent match-day doctors can supplement side-line observation with video reviews of incidents to identify any suspicious head impact events requiring either permanent removal from play or removal from play for further side-line assessment. At this point, the decision of the MDD is simply that the player be removed. A second video review is then undertaken with the MDD and Team Doctor present. If HIA1 immediate removal criteria (Criteria 1) are identified, the player is permanently removed from play without further evaluation. If there are no Criteria 1 signs identified and agreed, the player undergoes the off-field assessment supported by the screening tool. The final use of video is a review after the off-field assessment, where video is again reviewed prior to a player being returned to play.

Stage 2 - HIA2 Assessment - identifies an early concussion:

In stage 2, every player entered into the HIA protocol undergoes an early medical evaluation (HIA2 clinical assessment) within three hours of completing the match, to assess clinical progress and identify an early diagnosis of concussion. This Stage 2 assessment is performed using the SCAT5 tool supported by player baselines or normative Rugby baseline values.

Stage 3 - HIA3 Assessment - identifies a late concussion:

In stage 3 further medical testing is performed after two night’s rest (36-48 hours post-head impact event) to further assess clinical progress and identify a late diagnosis of concussion (HIA3 clinical assessment). This HIA3 consists of a clinical assessment supported by the SCAT5 and the computer neuro-cognitive tool of each team’s choice e.g. CogSport, Impact.

Players presenting with delayed symptoms or signs suspicious for concussion, but who are not identified with a head impact event during the game, can enter the HIA protocol at a later stage (stage 2 or 3) and undergo HIA2 and/or HIA3 clinical assessments as appropriate.

A definitive diagnosis of concussion is made if a player demonstrates observable signs of concussion requiring immediate and permanent removal from play (Criteria 1 e.g. loss of consciousness) or a clinical diagnosis of concussion is made supported by the HIA2 or HIA3 clinical assessment.

The HIA protocol allows for a diagnosis of concussion to be made immediately (Criteria 1) following a head impact event but a diagnosis cannot be excluded following a head impact event until both a HIA2 and HIA3 assessments are completed and normal.

Summary

The Head Injury Assessment (HIA) is a three-point in time process and includes:

Off-field HIA1 assessment containing

  • Criteria 1 - indications for immediate and permanent removal from a match
  • An off-field assessment including symptom checklist, medical evaluation, balance assessment and cognitive tests performed by a doctor
  • Video review
  • Clinical evaluation by the treating doctor

HIA2

  • A repeat medical evaluation performed by the doctor within 3 hours of the incident
  • Assists in an early diagnosis of concussion

HIA3

  • A further medical evaluation performed 48-72 hours after the incident
  • Assists with the late diagnosis of concussion

Summary of HIA Protocol changes (2017 & 2019)

Following the release of the 2016 Berlin Concussion Consensus Statement and review of the 2015-16 HIA monitoring data, World Rugby’s HIA Working Group recommended the following changes that will apply to the HIA Protocol from November 1 2019.

HIA1

  • The HIA1 off-field screen will now be a fixed 12 minutes – this means a player cannot return to play before 12 minutes even if the assessment has been completed. If a player fails to present to the 4th official before the 12-minute period is completed that player will be deemed to have been permanently replaced.
  • Players must read aloud the symptom check list and confirm their presence.
  • The time between the Immediate Memory and Delayed Recall testing must be a minimum of 5 minutes
  • The Immediate Memory and Delayed Recall number of words now consist of a 10-word list.
  • The single leg stance and tandem stance (mBESS assessment) are the balance tests used by the HIA1 off-field screen.
  • The following Criteria 2 indication has been added in 2017 - Possible transient or sub-threshold criteria 1 signs e.g., possible balance disturbance, possible loss of consciousness, possibly dazed etc.'

HIA2 and HIA3

  • Both assessments require:
    • Reading aloud of the symptom checklist
    • Use of the 10-word Immediate Memory and Delayed Recall word list
    • Completion of both tandem gait and mBESS balance assessments
    • 5-minute time between Immediate Memory and Delayed Recall testing

Baseline SCAT - Symptom Collection Process

  1. The initial baseline SCAT symptoms should be collected in a quiet environment and may be completed as a group that is of a manageable size so that all instructions are given and received as intended. 
  2. The athlete(s) should be given the symptom form and asked to read the instruction paragraph. 
  3. An explanation of the difference between ‘trait’ and ‘state’ symptoms should be provided and highlighted by the supervisor. 
  4. The athlete(s) should be told that only ‘trait’ symptoms (those typically present) should be reported in this initial baseline SCAT symptom checklist. 
  5. Athletes should also be advised that the report of any symptom(s) will be followed-up by the attending medical or healthcare professional.
  6. After completing the baseline SCAT symptom checklist, any athlete reporting any symptom(s) should be identified and a follow-up appointment confirmed. This follow-up should be at least 24 hours after the initial symptom collection and following 24 hours of rest from exercise.
  7. This follow-up assessment should be completed in a quiet environment and in a one-on-one situation by the medical or healthcare professional responsible for that athlete’s care. 
  8. Before completing this follow-up symptom checklist, the difference between a ‘trait’ and ‘state’ symptom should again be explained, and the player advised that only ‘trait’ symptoms are to be reported.  
  9. The athlete should also be advised that it is important that they concentrate and be truthful. 
  10. At the completion of this follow-up baseline SCAT, the clinician should discuss and confirm with the athlete any identified trait symptoms. If following this discussion ‘trait’ symptoms are confirmed, they should then be logged as confirmed baseline SCAT symptom(s) for that player.
  11. All ‘trait’ symptoms confirmed by this process require further review and investigation. The clinical guidance outlined below is provided to support this investigation.

Baseline cognitive and balance tests

Cognitive and balance tests are pivotal to the SCAT, and each is assessed using numerous sub-tests.  The verbal cognitive assessment has four sub-tests: Immediate Memory, Orientation, Digits Backwards and Delayed Recall, whilst the mBESS balance assessment consists of a double leg stance, tandem stance and single leg stance. 

Our large baseline SCAT dataset has been used to quantify performance during baseline cognitive and balance tests. These data have been used to determine a population-derived approximate 95th percentile “cut-off” level for each sub-test. Our recommendation is that these reference limits be used to identify when a baseline sub-test should be re-assessed (Table 1 and Figure 1). This re-assessment has been introduced in the collection process to address ‘player-effort’ issues and to improve baseline SCAT validity and reliability. 

Baseline SCAT - Cognitive and Balance Test Collection Process

  1. The initial baseline SCAT cognitive tests should be collected in a quiet environment and in a one- on-one situation. Baseline balance testing does not require a quiet environment.  
  2. Prior to performing both cognitive and balance tests, the athlete should be advised that it is important that they maximise concentration and performance. They should be advised that their results will be measured against reference limits and if their performance is outside of these limits the tests will be repeated.
  3. Following the initial baseline cognitive and balance testing, any sub-test outside of the reference limits identified in Table 1 must be re-tested by the attending medical or healthcare professional. 
  4. Re-testing of cognitive and balance sub-tests is only required for that sub-test identified as being outside of reference limits. For example, if Immediate Memory is outside of reference limits, it is not necessary to repeat Delayed Recall. 
  5. The potential for a learning effect with re-testing is recognised. However, the impact of this learning effect is unknown. As the most likely impact from a learning effect is an improvement in baseline scores which will ultimately produce a more conservative baseline comparison for that player, we recommend that re-testing be undertaken at a time that suits both the player and clinician.  
  6. Re-testing should not be undertaken if the player is receiving treatment for a concussion or another injury which might affect the test result.
  7. Prior to re-testing of the sub-test, the player should be advised that it is important that they concentrate and perform to the best of their ability.
    The best result from the original and follow-up assessments for each sub-test should be adopted as the player’s baseline performance. A sub-test(s) result that falls outside the 95% “cut-off” reference limits at initial AND follow-up testing requires investigation using the clinical guidance identified below. 

Baseline testing 2019 onwards

Annual full baseline testing is now not required, as research has confirmed that the baseline SCAT does not change with serial testing. 'Post exertion' testing is also not required as exercise does not significantly impact the overall baseline performance. 

Yearly testing of symptom checklists is recommended.

 Table 1: Recommended reference limits for SAC and balance sub-modes of SCAT5 and HIA assessments

  • The following are outside of reference limits for cognitive sub-tests, and require re-testing and if still abnormal, investigation:

    • Orientation – 3 or fewer correct answers 
    • Immediate memory (10-word list) –15 or fewer correct answers
    • Concentration score (digits backwards and months in reverse) – 2 or fewer correct answers
    • Digits backwards – 1 or fewer correct answer
    • Delayed recall score (10-word list) - 3 or fewer correct answers

    The following are outside of reference limits for balance sub-tests, and require further investigation:
    Tandem gait (3 m line) – a time slower than 13 seconds
    Modified BESS errors:

    • Double leg stance – 1 or more errors
    • Tandem stance – 4 or more errors
    • Single leg stance – 6 or more errors

Management of U19 players in elite adult rugby

  • Players 18 years and under playing in elite adult Tournaments where the use of the HIA has been approved must be managed with Recognise and Remove.
  • Players who fit this category and who have Criteria 2 signs or symptoms cannot be removed for an off-field HIA1 assessment. They must be removed from further participation in that game - Recognise and Remove. Criteria 1 players must be immediately and permanently removed from the game and are considered to have a confirmed concussion.
  • Following Recognise and Remove all players should follow the HIA Process as described using the HIA2 and HIA3. Players who are confirmed with a concussion should follow their Unions GRTP protocols.

Management of off-field HIA1 assessment replacements when all replacements have been exhausted

  • If all substitutes have been used by a team and a player requires removal following a head impact event, irrespective of the medical room classification, that is immediate & permanent removal or off- field screen, a tactically replaced player can return to play.
  • Even if all replacements have been exhausted this temporary replacement will be permitted to stay on the field if the injured player does not return after expiry of the 12 minute off-field period.
  • A tactically substituted player can return to play to substitute an immediate and permanently removed player or a player undergoing an off-field HIA1 assessment, even if other replacements have not been used.

Return to play recommendations for the elite adult player

  • Each stage of the GRTP is for a minimum of 24 hours starting from the time of the injury.
  • Players with symptoms present at 24 hours post injury, progress to Stage 2a. To be clear, if symptoms do not resolve within the Initial Rest (Stage 1) period then progression to symptom limited activities of daily living (Stage 2a) is recommended.
  • Players who are symptom free following the Initial Rest (Stage 1) should progress to Stage 2b
  • If any concussion-related symptoms occur during the stepwise approach, the athlete should drop back to the previous asymptomatic level and attempt to progress again after being free of concussion-related symptoms for a further 24-hour period at the lower level.

EACH STAGE IS A MINIMUM OF 24 HOURS

Stage  Rehabilitation stage     Exercise allowed     Objective
1 Initial Rest (Physical and Cognitive) Normal activites of daily living which do not worsen symptoms, vigorous activity should be avoided. Relative cognitive rest, limiting screen time etc- ensure symptoms continue to improve or remain absent. Symptoms must be absent before commencing Stage 2. Recovery
2a Symptom-limited activities     This includes activities of daily living that do not provoke symptoms. Consider time off or adaptation of work or study. Return to normal activities (as symptoms permit)
2b

Light aerobic exercise

Light jogging for 10-15 minutes, swimming or stationary cycling at low to moderate intensity. No resistance training. Symptom free during full 24-hour period. Increase heart rate
3 Sport-specific exercise     Running drills. No head impact activities.     Add movement
4 Non-contact training drills     Progression to more complex training drills, e.g., passing drills. May start progressive resistance training.     Exercise, coordination, and cognitive load
5 Full contact practice     Following medical clearance, participate in normal training activities.     Restore confidence and assess functional skills by coaching staff
6 Return to sport     Normal game play.  

 

HIA Procedures

1.    What are the indications (Criteria 1) for immediate and permanent removal from play following a head injury?

There are 12 Criteria 1 signs and symptoms with six possibly observed on video and the remaining five identified during the on-field assessment.

Typically observed on video:

  • Confirmed loss of consciousness
  • Suspected loss of consciousness
  • Convulsion
  • Tonic posturing
  • Balance disturbance / ataxia
  • Clearly dazed

Identified during on-field assessment:

  • Player not orientated in time, place and person
  • Definite confusion
  • Definite behavioural changes
  • Oculomotor signs (e.g. spontaneous nystagmus)
  • On-field identification of signs or symptoms of concussion

Identified prior to the game

  • Under-19 – Recognise and Remove

2.    What are the indications (Criteria 2) for an HIA?

  • 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
  • Possible transient or sub-threshold criteria 1 signs e.g., possible balance disturbance, possible loss of consciousness, possibly dazed etc.'

3.    How is a player diagnosed with concussion?

Under World Rugby's Operational Definition, a player has a confirmed concussion if:

  1. There is confirmed Criteria 1 sign or symptom as per the HIA1 form
  2. There is an abnormal HIA2 post game, same day assessment (an early concussion)
  3. There is an abnormal HIA3, 36-48-hour assessment (a late concussion)
  4. The treating doctor has a clinical suspicion that the player has a concussion.

Under this operational definition a concussion can be diagnosed immediately following a head injury but cannot be excluded until completion of both the HIA2 and HIA3, that is 36-48 hours after the injury.

4.    Are the immediate and permanent removal signs and symptoms (Criteria 1) confirmed during an on-field assessment?

No. Criteria 1 signs may be identified from the side-line, on video or en-route to attend the injured player. The symptoms and oculomotor signs are identified whilst the team doctor is attending the player.

If identified on video, the player should be removed from play and the video reviewed simultaneously by the Team Doctor and Match Day Doctor (MDD) and agreement reached before enforcing permanent removal from further game participation.

5.    What assessment is required to identify an ‘oculomotor’ sign?

An oculomotor sign is generally, immediately apparent and includes such signs as nystagmus, asymmetrical eye movements, pupil size and reactions. Whilst not a common sign of concussion, if present following a head injury, they are indicators for immediate and permanent removal from further game participation.

6.    Who can request an HIA1 off-field screen?

The on-field medical staff (as defined by each Union), the referee or the MDD are allowed to request an off- field screen. A member of the opposition’s on-field medical staff is not allowed to request an off-field screen on an opposing player, nor are they allowed to make comments on incidents involving opposition players.

7.    Who completes the HIA1 off-field screen?

The Team Doctor will complete an HIA1 off-field screen on a player when indicated unless the Team Doctor assigns this responsibility to the Match Day Doctor (MDD) prior to the commencement of the match. The Team Doctor can, in cases of emergency, assign off-field screen responsibility to the MDD
during a match. If the MDD completes the off-field screen the responsibility for the return to play decision rests with the MDD.

In Sevens, the HIA will be completed by the Team Physician, Match Day Doctor or World Rugby Tournament Team Physician.

8.    When does a player fail or have a positive off-field HIA1 assessment?
A player has an abnormal off-field HIA1 assessment and must NOT return to play if:

  • the player answers “Yes” to one or more symptoms or
  • the player answers one or more memory questions incorrectly or
  • the player scores below baseline or below identified Rugby norms for SAC assessment or
  • the player fails the balance test (Tandem stance – 4 or more errors, Single leg stance – 6 or more errors) or
  • the player exhibits an abnormal sign as observed by the Team Doctor or
  • the doctor performing the off-field screen has any clinical suspicion of a concussion.

Any clinical suspicion of concussion by the doctor performing the off-field HIA1 assessment for any reason should see the player removed permanently from the match, even if the off-field HIA1 assessment is normal.

If a player reports a positive answer to any part of the off-field screen test that can be explained by an alternate reason rather than a head injury, the team doctor does retain the ability to over-rule the abnormal off-field HIA1 assessment in consultation with the Match Day Doctor. In this case an explanation must be recorded on the HIA1 form identifying the reason for this over-ruling decision.

9.    What is the role of the MDD (independent doctor) and what role does the MDD play in the decision on fitness to return to play? How is independence defined with respect to the MDD?

The MDD will observe the off-field screen with the Team Doctor delivering the off-field screen unless assigned this responsibility by the Team Doctor. If the MDD is assigned the responsibility for undertaking an off-field screen by the Team Doctor, the MDD will complete the off-field screen and be responsible for deciding return to play.

If the MDD completes an off-field screen because there are two players requiring an off-field screen at the same time, then the Team Doctor will retain the decision-making responsibility regarding return to play.

If a player is cleared to return to play or returns to play but the MDD is concerned or notices signs, or the player complains of symptoms suggestive of concussion, a discussion between the Team Doctor and MDD should be undertaken. Every effort should be made to arrive at a consensus around management of individual cases. If a dispute persists, the MDD has the right to request another off-field screen independent of the Team Doctor or to unilaterally remove the player from the field, this should not be done without extensive discussion with Team Doctor.

If the player has any indication for permanent removal from the field of play (as listed above) then there is no dispute, the player must be removed from field of play.

Each nominated competition or tournament is able to determine if 'independence’ of the MDD is mandatory and if so, what is the definition of 'independence’ for their competition or tournament.

10.    Where should the HIA off-field screen be completed?

The off-field screen will be completed in the medical room. If the off-field HIA1 assessment cannot be completed in the medical room because the medical room is too distant from the field of play for an off-field HIA1 assessment to be performed within 12 minutes, the MDD, with the Team Doctors, will identify an agreed and appropriate area prior to the commencement of the match.

11.    Can a player undergoing an HIA be replaced or substituted?

A player undergoing an off-field screen will be replaced for 12 minutes. The player will not be allowed to return to play until the 12 minutes has expired and if the player undergoing this off-field HIA1 assessment does NOT present themselves to the 4th official within the 12 minutes, the temporary replacement becomes a permanent replacement. This 12-minute period refers to actual time not game time.

12.    What happens if a player has a head impact event just prior to half-time and requires an off-field HIA1 assessment?

The off-field screen still must be completed within 12 minutes of leaving the field. The off-field screen cannot be delayed. The player must present to a match official prior to commencement of the second half or they will be considered a permanent replacement.

13.    What happens if a player will not co-operate with an off-field HIA1 assessment?

A player failing to co-operate with an off-field screen will be assumed to have concussion and be removed permanently from the match.

14.    If the player has a head injury requiring further off field assessment and a co-existing blood injury how long is available to complete the off-field screen and control the bleeding?

In this scenario, control of bleeding will be the priority however the off-field screen must be completed as soon as possible. If bleeding can be controlled, suturing should be completed after the off-field screen. The total time available is 17 minutes to complete both the off-field screen and control the bleeding

15.    If a player has a second off-field screen requested during a match, does this mean automatic removal from the match?

No, a second off-field screen is not an automatic indication for permanent removal from the match. However, if a definitive diagnosis was not identified following the first off-field screen or the second assessment arises due to a low force impact incident then caution should be applied, and that player removed from further match participation.

16.    Are there any restrictions applied to the temporary replacement?

No. A temporary replacement is not restricted in any game activities and can take a penalty kick for goal and a conversion attempt.

17.    What happens if a player undergoing an off-field HIA1 assessment does not return to the match?

The injured player will be considered to have been replaced for an injury and the temporary replacement will become a permanent replacement.

18.    If a player is simultaneously removed as a tactical replacement and an off-field HIA1 assessment, can the player return to play?

All players who are removed for an off-field HIA1 assessment MUST return to play at the 12-minute mark if cleared even if they have been tactically replaced. To be clear in this situation if the player does not return to the field of play, they are considered permanently removed because of a failed off-field screen.

19.    If a player is removed from play for an off-field HIA1 assessment and that team have exhausted all of its substitutions, is a temporary replacement allowed?

Yes, if all substitutes have been exhausted a temporary replacement for head injury is allowed.

If a player requires permanent removal following a head impact event, irrespective of the medical room classification, that is immediate & permanent removal or off-field HIA1 assessment, the player who is the temporary replacement will be permitted to remain on the field even if the injured player does not return after expiry of the 12 minute off-field period.

To be clear a tactically substituted player can return to play to replace a head injured player, even if other replacements have not been used.

20.    What is the role of the opposition medical team in the off-field HIA1 assessment process?

Medical and non-medical staff from opposing teams cannot request an off-field HIA1 assessment on players that are not within their team. Suggestions or comments regarding an off-field HIA1 assessment for another team's member should not be made.

21.    What is the role of non-medical team staff in the off-field HIA1 assessment process?

Non-medical staff can alert their respective team medical staff that they have seen an incident that suggests an off-field HIA1 assessment or permanent removal. Non-medical staff cannot call for an off-field HIA1 assessment, this must be done by medical staff. Non-medical staff cannot overrule or question a call for an off-field HIA1 assessment requested by the on-field medical staff, MDD or referee.

22.    What happens if the player has a simultaneous injury?

Apart from a blood injury the assessment of a simultaneous injury and the off-field HIA1 assessment must be completed within the 12-minute period allowed for the off-field HIA1 assessment or the replacement will become permanent.

23.    What are the follow up processes for the off-field HIA1 assessment?

All players who have an off-field HIA1 assessment completed during a match irrespective of the outcome must have:

  1. A post-match, same-day assessment using the HIA2; and
  2. Follow up assessment using the HIA3 which incorporates a computer neuro-cognitive assessment is completed between 36-48 hours following the injury.

24.    Can the off-field HIA1 assessment be used to diagnose a concussion?

The presence of a Criteria 1 sign or symptom confirms a diagnosis of a concussion and the player must be immediately and permanently removed from further game participation and complete a GRTP. An abnormal off-field HIA1 assessment supports a suspected concussion and the player is removed from further game participation. The follow up HIA2 may confirm an early diagnosis of concussion if abnormal and or an HIA3 if abnormal confirms a late diagnosis of concussion.

25.    How should I interpret the HIA Form 2 result?

The HIA2 form is the SCAT 5. This tool is used to support the clinical diagnosis of the Team Doctor at that point in time. Any negative deviation from baseline data or normative data should be considered supportive of early diagnosis of concussion.
In the absence of baseline testing any one of the following should be considered strongly in favour of a diagnosis of concussion:

  • Immediate Memory – score 15 or fewer correct answers
  • Concentration score (digits backwards and months in reverse) – 2 or fewer correct answers
  • Delayed recall score - 3 or fewer correct answers
  • Balance – Double leg stance – 1 or more errors, Tandem stance – 4 or more errors
  • Any athlete with any symptom declared in the symptom list which is not usually experienced by the player following a Rugby match or training is strongly in favour of concussion.

A normal HIA2 and clinical assessment (post-match, same day) does not exclude a concussive episode. It is possible for players to develop delayed symptoms and signs related to concussion, day or days after a head impact incident. The HIA process requires a normal HIA3 and clinical assessment at 36-48 hours to completely exclude a concussion.

26.    If an off-field HIA1 assessment is called by a team's on-field staff, can this be cancelled by other on-field staff?

Once the team's on-field medical staff member calls an off-field HIA1 assessment and it is acknowledged by the referee, then it must be completed. To be clear, a requested off-field HIA1 assessment by a team’s on-field medical staff cannot be cancelled.

27.    Which players are required to undertake a Graduated Return to Play (GRTP) programme? 

Players diagnosed with concussion during the match, after the match whilst at the ground or at the 36-48 hour follow up MUST go through a Graduated Return to Play (GRTP) programme that must be started at least 24 hours after the injury.

28.    How do I manage a player who presents after the match with concussive symptoms? What off- field screen form should be used?

If a player does not have an off-field assessment during the match but has signs or presents with symptoms suggestive of concussion after the match and at the stadium a HIA2 Form should be completed before leaving the stadium. This should then be followed up at 36-48 hours with the HIA3.

If a player does not have an off-field HIA1 assessment during the match but presents with symptoms suggestive of concussion after leaving the stadium but within 48 hours of the match, this player should be assessed using the HIA3 Form.

29.    What happens if a player has a suspected concussion at training?

If a player suffers a suspected concussion during training, ‘Recognise and Remove’ should be employed, the payer should be removed and not returned to training. Appropriate immediate medical attention should be employed.

After training, the player should be evaluated with a HIA2. The player should undergo a HIA3 36-48 hours post-training. And if at either stage a concussion is diagnosed a GRTP should be completed.

30.    What happens if a player presents with a suspected concussion after training?

If a player presents to medical staff after a training session, this is dealt with similarly to a delayed presentation post-game. If the presentation is within 2 hours of the training session, then a HIA2 assessment is performed with subsequent HIA3 at 36-48 hours. If the presentation is outside of 2 hours post-training a HIA3 assessment should be completed.

31.    I have a player who sustains a head and neck injury and the player has an emergency evacuation. What HIA Form should be completed on this player in conjunction with a clinical assessment?

In this instance, an off-field HIA1 assessment is not necessary as the player has been permanently removed from play. A HIA2 and or HIA3 Form should be used to support the clinical diagnosis in this instance.

32.    When can a player return to play after a diagnosed concussion?

As per World Rugby Regulation 10, any adult player with a diagnosed concussion:
•    must be immediately and permanently removed from training or the field of play; and
•    should be medically assessed by an appropriately qualified person (as applicable in the relevant jurisdiction); and
•    must not return to play in the same match; and
•    must rest for at least 24 hours and must not return to play or train until symptom free; and
•    must undertake a graduated return to play program, which must be consistent with World Rugby’s GRTP Protocol applicable to adults.

33.    What is meant by 'rest'?

The definition of rest is dependent on the time following the injury

  • Rest after a diagnosed concussion and within 24 hours of the injury means normal activities of daily living which do not worsen symptoms, vigorous activity should be avoided. Relative cognitive rest, limiting screen time etc.- ensure symptoms continue to improve or remain absent.
  • Rest after the initial 24 hours should be relative rest which is defined as "activity below the level at which physical activity or cognitive activity provokes symptoms”.

34.    Is there any evidence from research that the pitch side interventions have had a positive impact?

Prior to the introduction of temporary replacement for head injuries and standardization of pitch side head injury assessment, evidence confirmed that 56% of players with a confirmed concussion were returning to play on the same day following their injury. Research has confirmed that since introducing the HIA Protocol this number has reduced to less than 8%.

Additional Resources

Additional Resources can be found below.

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