soccer field

Head Injury Assessment protocol

May 01, 2019

Mark Lambert (Harlequins and RPA Chair) and Mike Lancaster (Harlequins Head of Medical) in conjunction with Norton Rose Fulbright LLP

Co-authored by Adam Worth 

Rugby is a confrontational and physical sport. Its nature requires both players and teams to put aside the very real prospect of finishing the game pretty sore and even a bit beaten up. For many, the joy of the game and collective achievement outweighs the potential risk of injury, meaning that players sometimes do not appreciate what is best for their own physical wellbeing.

A deeper understanding of the risks of concussion has seen the game take proactive steps to protect its players.  The decision to continue playing has now been taken out of the hands of players as a result of the Head Injury Assessment (HIA) protocol. The HIA protocol was introduced by World Rugby in 2012 and has evolved with a greater understanding of concussion. Coupled with education around the potential short and long-term repercussions of both single and repeated concussions, there has been a big cultural change regarding how concussion is viewed.  

What is concussion? “Concussion is a complex process caused by trauma that transmits force to the brain either directly or indirectly and results in temporary impairment of brain function. This can cause symptoms including persistent and severe headaches, dizziness, memory problems and insomnia”.

From a player perspective, if you are unquestionably concussed during a game or in training then you are removed from the field.  If a member of the medical team (on field or off field) thinks you may be concussed, you will leave the field. If it is decided that you are displaying physical signs of concussion once off-field then you are permanently removed. If not, you begin a test which challenges your balance, short and longer term memory, and ability to group and manage information in your head.

If your results are in line with a baseline test conducted at the start of preseason, you are allowed to return to the game. If you fail the baseline test, you are permanently removed and enter the “Graduated Return to Play” (GRTP) timeline. The purpose of the GRTP protocol is to ensure that players are fully recovered by the time they return to play. This is a minimum 6 day process which begins when the player is totally asymptomatic of the concussion. It is only completed when all stages of the process are concluded without relapse and clearance is given by a doctor experienced in the management of concussion.

Players will inevitably want to return to play as soon as possible following a concussion. Coaches and management must exercise caution to ensure that:

  • all symptoms have resolved before commencing the GRTP protocol;
  • the GRTP protocol is properly followed; and
  • the advice of medical practitioners and other healthcare professionals is strictly adhered to.

Sanctions can be imposed where the HIA protocol is not followed correctly so it is important for clubs to understand their obligations under both the HIA protocol and GRTP protocol. A breach of either protocol is judged on strict liability basis, meaning that mitigating circumstances will not be taken into account.

Whilst the process is robust, it is not yet perfect. What is most encouraging for me as a player is the continued investment and research into creating faster and more reliable methods to keep players safe. Speaking from personal experience, concussion is not fun, so it is reassuring to see the game is doing what it can to limit that risk in what is a very physical game. In my opinion, English rugby is leading the way on this issue.  The positive effects of the commitment to player welfare and the HIA process can be seen in English elite rugby with a 14.3 per cent decrease in concussion rates (Source: 2017/2018 RFU Professional Rugby Injury Surveillance Project). While this positive trend looks set to continue, player injury prevention remains a focus in 2019 for The Rugby Football Union, Premiership Rugby and the Rugby Players’ Association.