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World Rugby Concussion Guidance

Introduction

This World Rugby Concussion Guidance document has been developed to provide guidance and information to persons involved in the Game of Rugby (including the general public) regarding concussion and suspected concussion.

Individual member Unions are strongly encouraged to develop their own guidelines and policies, and must use this Concussion Guidance as minimum standards.

These guidelines apply to all male and female Rugby players including adults (over 18 years), adolescents (18 and under) and children (12 and under). Unions can adjust these age levels upwards at their discretion.

CONCUSSION FACTS

  • A concussion is a brain injury.
  • All concussions are serious.
  • Concussions can occur without loss of consciousness.
  • All athletes with any symptoms following a head injury:
  • must be removed from playing or training
  • must not return to playing or training until symptom free or until all concussion-related symptoms have cleared or have returned to pre-concussion level
  • must complete a Graduated Return To Play programme
  • should be assessed by a medical practitioner
  • Specifically, return to play or training on the day of a concussion or suspected concussion is forbidden.
  • Recognise and Remove to help prevent further injury or even death.
  • Concussion can be fatal - do not return to play if symptoms persist.
  • Most players with concussion recover with physical and mental rest.

World Rugby strongly recommends that all players seek the highest level of medical care available following concussion or suspected concussion (see definition of Advanced Care below).

Concussion information

What is concussion?

Concussion is a traumatic brain injury resulting in a disturbance of brain function. There are many symptoms of concussion, common ones being headache, dizziness, memory disturbance or balance problems.

Loss of consciousness, being knocked out, occurs in less than 10% of concussions. Loss of consciousness is not a requirement for diagnosing concussion but is a clear indication that a concussion has been sustained.

Typically standard brain scans are normal for someone with concussion and therefore a normal brain scan is not a reliable test of whether or not a player has concussion or suspected concussion.

What causes concussion?

Concussion can be caused by a direct blow to the head, but can also occur when blows to other parts of the body result in rapid movement of the head, e.g. whiplash type injuries.

Who is at risk?

Concussions can happen at any age. However, children and adolescent athletes:

Recurrent or multiple concussions

Players with a history of two or more concussions within the past year are at greater risk of further brain injury and slower recovery and should seek medical attention from practitioners experienced in concussion management before return to play.

In addition, a history of multiple concussions or players with unusual presentations or prolonged recovery should be assessed and managed by health care providers with experience in sports-related concussions.

Onset of symptoms

It should be noted that the symptoms of concussion can present at any time but typically become evident in the first 24-48 hours following a head injury.

How to recognise concussion or suspected concussion

Everyone involved in the game (including side-line medical staff, coaches, players, parents and guardians of children and adolescents) should be aware of the signs, symptoms and dangers of concussion. If any of the following signs or symptoms are present following an injury the player should at least be suspected of having concussion and be immediately removed from play or training.

Clear indicators of concussion / suspected concussion – what you see or hear immediately

Any one or more of the following clearly indicate a concussion:

Other signs of concussion / suspected concussion – what you see

Any one or more of the following may suggest a concussion:

Symptoms of concussion / suspected concussion - what you are told

Presence of any one or more of the following signs and symptoms may suggest a concussion:

What questions you ask adults and adolescents

Failure to answer any of these questions correctly is a strong indication of concussion or at least suspected concussion.

What questions you ask children (12 years and under)

Failure to answer any of these questions correctly is a strong indication of concussion or at least suspected concussion.

Recognise and remove and if in doubt, sit them out.

Managing concussion or suspected concussion

On field management of concussion or suspected concussion at training or during a match

Any player with concussion or suspected concussion should be immediately and permanently removed from training or play. Appropriate emergency management procedures must be followed especially if a neck injury is suspected. In this instance the player should only be removed by emergency healthcare professionals with appropriate spinal care training.

Once safely removed, the injured player must not return to any activity that day and should be medically assessed.

Side-line medical staff, coaches, players or parents and guardians who suspect that a player may have concussion must do their best to ensure that the player is removed from the field of play in a safe manner.

Immediate management of concussion or suspected concussion

If any of the following are reported or noticed then the player should be transported for urgent medical assessment at the nearest hospital:

In all cases of concussion or suspected concussion it is strongly recommended that the player is referred to a medical or healthcare professional for diagnosis and guidance regarding management and return to play, even if the symptoms resolve. It should only be in rare and exceptional circumstances that a player with concussion or suspected concussion is not medically assessed.

Players with concussion or suspected concussion:

Rest the body, rest the brain

Rest is the cornerstone of concussion treatment. This involves resting the body, ‘physical rest’, and resting the brain, ‘cognitive rest’. This means avoidance of:

ADULTS

Physical rest shall be for a minimum of one week for any adult player with concussion or suspected concussion. This physical rest comprises 24 hours of complete physical and cognitive rest followed by relative rest (activity that does not induce or aggravate symptoms) for the rest of the week. Cautious reintroduction of cognitive (“thinking”) activities are allowed following an obligatory 24 hours of complete (physical and cognitive) rest as long as symptoms related to the concussion are not aggravated.

After the one week physical rest period the player:

The only exceptions to the requisite minimum 1 week rest period and the completion of a Graduated Return to Play Programme are set out below (advanced level of concussion care).

CHILDREN AND ADOLESCENTS

Physical rest shall be for a minimum of two weeks for any child or adolescent (18 years and under) with concussion or suspected concussion. This physical rest comprises a minimum of 24 hours of complete physical and cognitive rest followed by relative rest (activity that does not induce or aggravate symptoms) for the rest of the two weeks. Cautious reintroduction of cognitive (“thinking”) activities are allowed following an obligatory 24 hours of complete (physical and cognitive) rest as long as symptoms related to the concussion are not aggravated.

After the two week physical rest period the player:

Children and adolescents must be managed more conservatively than adults. World Rugby requires any child or adolescent with concussion or suspected concussion to have physical rest for at least two weeks and if symptom free then complete a Graduated Return To Play programme following this minimum two week physical rest period.

Returning to play after concussion or suspected concussion

Any child, adolescent or adult player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery must be assessed and managed by health care professionals (multi-disciplinary) with experience in sports-related concussions and no further participation in Rugby must take place until the player is cleared by a medical practitioner with experience in concussion management. In rare and exceptional circumstances where there is no access to such health care professionals in the country where the player is playing rugby, they must contact their Union for further advice before returning to play.

ADULTS

Exceptions for adults:

CHILDREN AND ADOLESCENTS

Graduated Return To Play (GRTP) programme

The Graduated Return To Play (GRTP) programme incorporates a progressive exercise programme that introduces a player back to sport in a step-wise fashion. This should only be started once the player has completed the requisite physical rest period and is symptom free and off treatments and/or medication that may modify or mask concussion symptoms, for example drugs for headaches or sleeping tablets.

If a player already had symptoms prior to the head injury incident which resulted in the player’s concussion or suspected concussion, the player’s symptoms must have returned to the pre-concussion level prior to commencing a GRTP. However, in these circumstances, extra caution must be exercised and it is recommended that a player specifically seeks medical advice in respect of those pre-existing symptoms.

As a minimum, a GRTP programme must be consistent with World Rugby’s GRTP Protocol below. World Rugby’s GRTP Protocol reflects the Zurich Concussion Consensus Statement GRTP protocol which contains six distinct stages.

World Rugby requires that each stage of the GRTP be a minimum of 24 hours. GRTP stage length may be increased by member Unions at their discretion.

It is critical that all concussion or suspected concussion symptoms have cleared prior to commencing a GRTP programme. The player must only start a GRTP programme or proceed to the next stage if there are no symptoms of concussion during rest and at the level of exercise achieved in the previous GRTP stage.

World Rugby strongly recommends that a medical practitioner or approved healthcare professional confirm that the player can take part in full contact training before entering Stage 5.

GRTP Programme Table

Fase
Rehabilitatiefase
Beweging is toegestaan
Doel
1

Minimale rustperiode

Volledige rust van lichaam en geest zonder symptomen

Herstel

2

Rustige aërobische bewegingen

Rustig joggen voor 10-15 minuten, zwemmen of stationair fietsen bij lage tot gemiddelde intensiteit. Geen weerstandstraining. Klachtenvrij zijn gedurende 24 uur

Hartslag laten toenemen

3

Sportspecifieke bewegingen

Loopdrilloefeninge . Geen activiteiten met hoofdimpact.

Voeg bewegingen toe

4

Contactvrije drilloefeningen

Opbouw naar meer complexe drilloefeningen, bijvoorbeeld passing drills. Er mag gestart worden met opbouwende weerstandstraining

Oefening, coördinatie en mentale belasting

5

Full-contacttraining

Normale trainingsactiviteiten

Zelfvertrouwen herstellen en de functionele vaardigheden laten beoordelen door de trainers en coaches.

6

Terugkeer naar het speelveld (Return)

De speler is hersteld

Herstel (Recover)

It is strongly recommended that, in all cases of concussion or suspected concussion, the player is referred to a medical professional for diagnosis and guidance as well as return to play decisions, even if the symptoms resolve.

Advanced level of concussion care

World Rugby strongly recommends that all players seek the highest level of medical care available following concussion or suspected concussion. This highest level of concussion care is supplied in an advanced care setting and shall include at least all of the following:

An adult player with concussion or suspected concussion must have the minimum required one week rest referred to above unless that player accesses an advanced level of concussion care as verified by their Union and has received medical advice that the one week rest period is not required.

Advanced care is generally available within professional Rugby teams and allows for a more individualised management of concussion.

Even if advanced care is available:

There is currently no exception to the requisite minimum rest period which applies to a child or adolescent with concussion or suspected concussion.

NOTES

  1. The minimum standards are set out in this Concussion Guidance. A Union has discretion to introduce more stringent criteria.
  2. The definition of an adolescent for the purposes of this guidance is 18 years and under. The definition of a child for the purposes of this guidance is 12 years and under. Unions are at liberty to increase (but not decrease) this age threshold at their discretion.
  3. If rest periods and GRTP stage lengths are more stringent within a member Union, the player must adhere to their respective Union’s guidelines or policy.
  4. World Rugby strongly recommends that players seek the highest level of medical care available especially when a player’s condition deteriorates, concussions occur repeatedly or more easily in the same player, symptoms fail to resolve or the diagnosis is uncertain.
  5. Only in World Rugby approved elite adult matches is temporary replacement for a head injury assessment (HIA) applicable. The HIA and temporary replacement Law does NOT apply to community rugby at any level or age or to any matches or tournaments which have not been approved by World Rugby.
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