World Rugby supports that concussion must be taken seriously.
The HIA Protocol has been developed for the elite level of the Game which is supported by experienced healthcare professionals. HIA was introduced to improve the pitch side management of head injuries and concussion in the elite Game and specifically to address the consistency with which players with a head injury, where the diagnosis was not immediately apparent, were managed.
The sole aim of the HIA Protocol is to improve player welfare.
World Rugby recognises the heightened risk of concussion in children and adolescents. Extra caution must be taken to prevent such players returning to play or continuing to play or train if any suspicion of concussion exists. The HIA Protocol is not to be used for this age group. In community Rugby and aged-grade Rugby the message is "Recognise and Remove".
"Recognise and Remove" means that any community Rugby and aged-grade Rugby player with a suspected concussion should be removed from playing or training and not allowed to return to play or train on the same day. Referral for further medical assessment by a medical or healthcare practitioner with experience in managing concussion is recommended prior to return to any exercise.
World Rugby Regulation 10 identifies that all players diagnosed with concussion during a game or training must:
- be removed from the field of play and not return to play or train on the same day; and
- complete the graduated return to play protocol described in the World Rugby Concussion Guidelines.
During this module, you will have the opportunity to view short video clips that will provide a visual explanation of a topic. For example, you can view a player with a "suspected loss of consciousness".
At the completion of the chapter, you will be shown the three HIA forms used in the HIA process and provided with an explanation regarding their completion. It is important that you understand the mechanics around each of these forms.
The Head Injury Assessment (HIA) Protocol is a three-stage process introduced by World Rugby for elite professional medical 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, off field 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.
The HIA Protocol allows doctors to temporarily remove a player following a head injury, where the diagnosis is unclear, to undertake an off-field assessment. The protocol is supported by Law 3.11 and Regulation 10 and has been developed to provide doctors with extra time to assess players who have a head injury where the diagnosis is not immediately apparent.
The three-stage HIA Protocol consists of:
Stage 1 - 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), physiotherapists or independent match-day doctors (MDD). The identification is either by direct observation or on video review.
The off-field HIA1 screen has four components and they are:
- 12 immediate and permanent removal criteria (known as Criteria 1 indications) AND
- an off-field screening tool AND
- pitch-side video review AND
- clinical evaluation by the attending doctor
The off-field HIA1 screen assessment is therefore not limited to the HIA1 screening tool. Instead, the HIA1 screening tool is one component of the comprehensive HIA1 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 assessment, and video review.
The HIA1 screening tool is a re-formatted Sports Concussion Assessment Tool (SCAT 5), the pitch-side assessment tool recommended by experts from the Berlin 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.
From September 1, 2017, 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 off-field HIA1 screen protocol:
- 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 HIA 3 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 HIA 2 and/or HIA 3 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 are normal.
Regulation 15.2.1(d) confirms that a Match Day Doctor has the power to overrule a Team Doctor and remove an injured player from further participation in a game. This power should not be used during the HIA Process until the video has been jointly reviewed by both the Team Doctor and the MDD.
World Rugby is committed to employing the most evidence-based and up to date concussion management strategies. World Rugby closely monitors the efficacy, reliability and validity of all of the HIA process. A review of 13 479 baseline SCATs from 7 565 elite adult rugby players has provided new normative data which can be used when baseline studies are not available. This review has also led to some changes to the off-field HIA1 screen, aimed to improve its diagnostic performance.
In June 2019 the following changes were made to the HIA tools:
- Post-exercise baseline testing is no longer required.
- On baseline capture “trait” Vs “State” symptom reporting in line with SCAT recommendations have been adopted.
- Rigorous interrogation and investigation of baseline symptoms is recommended.
- Up to date baseline normative data is now recommended where baseline is not available
- 10 word lists are used for immediate and delayed recall
- The tandem gait test has been replaced by the mBESS tandem stance and single stance balance tests.
HIA 2 & 3
The neurological screen from the SCAT5 document was included in both forms.
Following an extensive review the following baseline scores are deemed to be below “normative” for adult rugby players, and merit repeat and investigation
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:
Modified BESS errors:
- Double leg stance – 1 or more errors
- Tandem stance – 4 or more errors
- Single leg stance – 6 or more errors