Clinical priorities – Recognise and Remove

Game events with the potential to cause concussion in Rugby Union and other collision sports are common and may not all be witnessed by attending healthcare practitioners. A high index of suspicion for the potential for concussive injury is therefore required. Although the initial presentation of a concussed player may be clear-cut, with a temporary loss of consciousness, more subtle presentations in a fully alert player such as headache, nausea or mild cognitive impairment resulting in a difficulty in remembering planned plays, may be less easy to identify. The post-concussive period of brain vulnerability to further brain injury, makes it essential that the concussed player is removed from play. If a cervical spine injury or a more serious brain injury can be excluded on the field or in the initial medical room, evaluation with a full history and physical examination should be started. This should be followed up with a more detailed history of the injury and an examination that includes assessment of symptoms, cognition and balance, to evaluate for concussion.

It is important to recognise that there is no single diagnostic test to identify a player with concussion, and players frequently want to continue playing. The challenge for healthcare practitioners is to consistently identify players with suspected concussion, remove them from play and using a multifaceted evaluation, perform a clinical assessment of a range of domains to confirm or refute a diagnosis of concussion. The SCAT6 assessment tool should form part of this evaluation.