HIA Protocol

World Rugby supports that concussion must be taken seriously.

The HIA Protocol has been developed for matches which are supported by experienced healthcare professionals. The HIA protocol was introduced to improve the pitch side management of head injuries and concussion in the 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 individualised return to sport 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 four-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 is made up of the following four stages:

Stage 1 – in game assessment which includes the use using of the HIA1 Form.
Stage 2 – post-game, same day assessment the use of the HIA2 Form.
Stage 3 – 36-48 hour post-head impact event assessment which include use of the HIA3 Form.
Stage 4 – clearance to return to full play following completion of individualised rehabilitation which includes use of the HIA4 Form.

HIA Protocol Explanation

Temporary substitution for head injury was introduced permanently into law for elite adult rugby in April 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 HIA Protocol is not just an off-field assessment (HIA1), it is a combination of clinical signs, observable video signs, instrumented mouthguard alerts and clinical assessment which facilitate a comprehensive multi-modal and multi-point in time concussion assessment. The HIA Protocol is electronically supported by the Specialised Concussion rugby Management (SCRM) application. The SCRM app is used ny World Rugby for the HIA process in approved competitions and allows for the effective and standardised logging of HIA assessments (Baseline and post-head impact events), individualised rehabilitation stages and assessments, and an independent concussion consultant (ICC) consultation if needed. A user guide for the SCRM application is included in this module or can be downloaded HERE.

The ability to access the HIA Protocol is based on World Rugby approval and is only used in competitions or fixtures that meet specific minimum criteria set out by World Rugby. Competition organisers or Unions must apply to use the HIA via the World Rugby HIA application process. Competition organisers or Unions agree to uphold the player welfare standards outlined in the application document. This includes agreeing that all players will comply with the HIA protocol in full. Those players who do not comply fully with the protocol at any stage in the protocol (i.e. the HIA1 off-field assessment) will not be permitted to partake in that assessment.

The four-stage HIA Protocol consists of:

Stage 1 - HIA1 off-field Assessment:

In stage 1, players who sustain head impact events with the potential for a concussion are identified by Match Officials, Team Doctors, pitch side medical practitioners or Independent Match Day Doctor (MDD). The identification is via direct observation, video review or instrumented mouth guard (iMG) data.

The HIA1 off-field assessment has five components:

12 immediate and permanent removal criteria (known as Criteria 1 indications)
an objective assessment of head accelerations via iMG data
an off-field assessment tool
pitch-side video review
clinical evaluation by the attending doctor

The HIA1 assessment is therefore not solely an off-field assessment tool, but a series of a multi-modal assessments. Players displaying obvious on-field signs of concussion (Criteria 1) are immediately and permanently removed from play, and the completion of the off-field assessment tool is not required. Players who exhibit Criteria 1on-field signs are diagnosed as concussed. The player should be evaluated in the medical room by either the Team Doctor or MDD to identify if further investigation or management of their injury is necessary during the game. Criteria 2 cases are removed for an off-field assessment when players have the potential for concussion (Criteria 2 signs - clinical indicators) or when head accelerations measured by an iMG exceed an identified threshold. A player who has an identified Criteria 1 sign and an iMG alert is managed as a Criteria 1 sign. The use of iMGs in the premium level HIA protocol is necessary to access the HIA1 off-field assessment - the requirements are outlined HERE. In a small number of cases, players may have a medical exemption which precludes the use of an iMG, this must be formally referred to Lindsay Starling [email protected] at the latest, 48 hours prior to match day.

This World Rugby off-field assessment tool is a re-formatted version of the Sports Concussion Assessment Tool (SCAT) recommended by experts from the international concussion consensus conferences. This off-field assessment tool includes a check of symptoms, memory assessment and balance assessment, as well as an evaluation of video footage of the event. The SCAT tool has been regularly updated following concussion consensus meetings when new evidence is available. This is reviewed by the Independent Concussion Working Group, and combined with World Rugby Research to inform the HIA tool. The SCAT and HIA tools therefore change intermittently, but in this document will be referred to as 'SCAT' and 'HIA' respectively. Results of the HIA are compared to an individual's previously conducted 'baseline assessment', or to a normative result if an individualised baseline is not available. An abnormal off-field assessment 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 who is clinically suspected to have concussion must be removed from the game. To be clear, clinical opinion supporting a suspected concussion may over-rule a normal assessment.

The Team Doctor has the primary responsibility for conducting the off-field assessment but can delegate this role to the Independent Match Day Doctor and should be determined pre game. All return to play decisions must be discussed with the Independent Match Day Doctor who has ultimate oversight and decision-making with respect to return to play. The off-field assessment is conducted in the stadium's medical room or another agreed area if the 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 and the 12-minutes should begin when the player crosses the sideline to leave the field of play.

A player who has undergone an HIA1 off-field assessment and has been cleared to return to play must report to the 4th official within the 12 minute time-period but will not be allowed to return to play until the12-minute period has expired. If during the evaluation of a head injury there is a blood injury requiring suturing the time allocated for dealing with the blood injury and the off-field assessment is 17 minutes.

Where a team needs to carry out 2 simultaneous HIA off-field assessments, the Team Doctor should perform one assessment whilst the Independent Match Day Doctor undertakes the other assessment. The Team Doctor and Independent Match Day Doctor will discuss both cases at the summary stage before making a final decision.

In the unlikely event of three or more suspected head injury events occurring within the same time-period, if there is an appropriately qualified medical team member available with prior experience of undertaking HIA assessments (Immediate care lead or video match day doctor), and there is an appropriate area to perform the test (medical room) then they may perform the HIA1 off-field assessment but must again discuss the outcome with the Team Doctor and Independent Match Day Doctor at the summary stage prior to making any decision. If there is not a suitable member of the medical team available, the player must await either the team doctor of the independent Match Day Doctor to be available to undertake the assessment. In this scenario, extra time is made for the assessment so that the player has a maximum of 17 minutes for the assessment i.e. they may return at 12 minutes if their assessment is finished, but have an additional 5 minutes if required.

Video review has three roles in off-field HIA1 assessment:

Firstly, during play, the 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 the need for the HIA1 off-field assessment. If there are no Criteria 1 signs identified and agreed, the player undergoes the off-field assessment supported by the assessment tool.
Finally, the video of the incident is reviewed again after the off-field assessment prior to any decision being made regarding return to play.

IN 2024 the World Rugby Independent Concussion Working Group developed an updated Head Impact Monitoring Programme. These recommendations include mandatory use of iMG technology to measure head impact exposure (acute and chronic) in elite level rugby. The executive Board supported these recommendations, including the use of iMG as part of the HIA Protocol. Understanding head impact load requires an accurate capture of training l;oad as well as match load. Players are required to use their iMG in all training and play where a head impact might occur. Access to the HIUA1 off-field assessment will be restricted to those players who are compliant with iMG use. Players are eligible to access HIA1 on match day provided they meet the following three criteria on each match week:

Have worn the iMG during the preceding weeks training: Players are to wear their iMG in all training sessions where there is a chance of a head impact event. A means of defining this would be all training sessions where a rugby ball is involved. Usage will be monitored by the Competition Compliance Liaison on a weekly basis.
Be wearing their iMG at the start of the match: The pitch-side official will assess this through the iMG portal using their iPAd or tablet. This assessment is carried out digitally through the App, not through a physical examination.
Have worn their iMG for at least 50% of their match time preceding the incident: The MDD will be presented with this information on their iPad or tablet when they carry out the HIA1.

Players who are not compliant with iMG use will be managed as “Regonise and Remove”. If following a head impact event a concussion is suspected, the player will be removed from play and may not return. An HIA2, HIA3 and following individualised rehabilitation must be complete for the player.

Management of suspected concussion in 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 HIA1 off-field assessment. They must be removed from further participation in that game i.e. 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 still follow the HIA Process as described using the HIA2 and HIA3. Players who are confirmed to have a concussion should follow their Unions individualised rehabilitation protocols.

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 includes players who are criteria 1 cases and who do not complete the HIA1 off-field assessment tool). Ideally the HIA2 should be completed at the ground and by the person who completed the HIA1 or the Team Doctor. The HIA2 is performed using the SCAT tool supported by player baselines or normative rugby baseline values. The HIA2 assessment also provides an opportunity to discuss the events surrounding the player removal. If there is disagreement about an HIA1 assessment or Criteria 1 event it should be discussed and clarified at this stage.

The HIA2 assessment is also the most appropriate test for a suspected concussion occurring outside of a game, for example, during training for players 19 or over.

Sevens Rugby

In Sevens Rugby matches are played over a weekend (2-3 days). The HIA protocol for Sevens Rugby is therefore slightly different to other versions. A player who suffers a Criteria 1 event, they will not play again in the tournament and will have HIA2 and HIA3 as normal. A player who has a suspected concussion and an off-field assessment has their HIA2 within 3 hours of the game, but also has a second HIA2 the next morning. If both HIA2s are normal and the examining doctor is satisfied there are no clinical signs or symptoms of a concussion, the player may play on day 2 of the event. The player continues and has a HIA3 the next day (36-48 hours after the event).

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 later diagnosis of concussion (HIA3 clinical assessment). This HIA 3 consists of a clinical assessment supported by the SCAT and which maybe supported by an additional computerised neuro-cognitive tool of each team’s choice (e.g. CogState Sport, or 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.

Confirming a diagnosis of Concussion

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 if a clinical diagnosis of concussion is made supported by the HIA2 or HIA3 result which is worse than the player's baseline (or if baseline unavailable normative data) or the treating practitioner has clinical suspicion of a concussion, at any time during this process. 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 assessed as being normal with no clinical suspicion of concussion.

Summary

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

HIA1 off-field assessment containing

Criteria 1 - indications for immediate and permanent removal from a match
An off-field assessment including symptom checklist, memory assessment, balance assessment and cognitive tests performed by a doctor
An objective assessment by instrumented mouthguards of head accelerations that exceed a clinical threshold
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 by a doctor or relevant practitioner 48-72 hours after the incident
Assists with later presentations of concussion

HIA4

Completion of this form confirms recovery from the concussion event
This assists in identifying concussion history (duration of recovery)

Components of the HIA

HIA1

The HIA1 off-field Assessment is a fixed 12 minutes of absolute and not playing time - 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.

The HIA1 off-field assessment tool is a re-formatted Sports Concussion Assessment Tool (SCAT) and includes the following sections:
Section 1-12 indicators for immediate and permanent removal (Criteria 1 signs), 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 not applicable for HIA1 off-field assessment

Indicators for HIA1 off-field assessment (Criteria 2 signs)

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
Subthreshold Criteria 1 sign e.g., possible balance disturbance / ataxia
Other behaviour or motor response following a head impact event raising suspicion of a concussion
Instrumented mouthguard alert for head acceleration event (HAE)
event exceeding the clinical threshold for suspected concussion as defined by the World Rugby Independent Concussion Working Group

Components of the HIA1 off-field assessment

Immediate Memory - 6 x 5-word lists are included. In the SCRM application the 10 words are generated randomly from two of these lists. These are delivered by the application with one second between words. The player is asked to repeat the list three times and a score is created out of a possible best of 30. This is compared to baseline or normative data.
Maddock's questions - five orientation questions.
Digits backwards - strings of three, then four, then five and six numbers are called out the player at a rate of one per second and the player must repeat them backwards.
Balance tests - Tandem stance and single leg stance are both performed for 20 seconds with any errors compared to baseline or normative data.
Symptom checklist - players are asked to read aloud and identify any symptoms present from a list of nine.
Clinical signs - observation by the doctor informs answering of the three clinical signs questions.
Delayed Memory - the player is asked to repeat the list of 10 words from immediate recall. This must be performed at least five minutes after the immediate recall questions and is a score out of 10.

HIA2 and HIA3

Both assessments require:

Use of the 10-word Immediate Memory and Delayed Recall word list.
Completion of the single leg stance and tandem stance tests from the modified balance error scoring system (mBESS) balance assessments.
Minimum 5-minute time between Immediate Memory and Delayed Recall testing.

HIA4

This assessment is currently a simple confirmation that the player has been cleared to return to full play.
Failure to complete this assessment will mean the concussion 'case' remains open, prolonging recorded recovery and possibly creating a 'concussion history' in the player's file.
In the future, guided by research from the recent Rugby Readiness and Rehabilitation Enhanced and Personalised (RREP) study, the HIA4 test may extend to a clinical evaluation of recovery.

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.

Normative data:

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 – Score less than 4
Immediate memory (10-word list) - Score less than 16
Concentration score (digits backwards) – Score less than 3
Delayed recall score (10-word list) - score less than 4

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