HIA Procedures

What are the indications (Criteria 1) for immediate and permanent removal from play following a head injury?

There are 12 Criteria 1 signs and symptoms 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 new nystagmus)
  • On-field identification of signs or symptoms of concussion

Identified pre-game:

  • Under-19 – Recognise and Remove

What are the indications (Criteria 2) for an HIA?

  • Head impact where diagnosis not immediately apparent
  • Possible behaviour change
  • Possible confusion
  • Event witnessed with potential to cause a concussion
  • Sub-threshold Criteria 1 sign e.g. possible balance disturbance, possible LOC

How is a player diagnosed with concussion?

Under World Rugby's Operational Definition a player has a confirmed concussion if:

  1. There is confirmed Criteria 1 sign or symptom as per the HIA1 form
  2. There is an abnormal HIA2 post game, same day assessment (an early concussion)
  3. There is an abnormal HIA3, 36-48 hour assessment (a late concussion)
  4. The treating doctor has a clinical suspicion that the player has a concussion.

Under this operational definition a concussion can be diagnosed immediately following a head injury but cannot be excluded until completion of both the HIA2 and HIA3, that is 36-48 hours after the injury.

Are the immediate and permanent removal signs and symptoms (Criteria 1) confirmed during an onfield assessment?

No. Criteria 1 signs may be identified from the side-line, on video or en-route to attend the injured player. The symptoms and oculomotor signs are identified whilst the team doctor is attending the player.

If identified on video, the player should be removed from play and the video reviewed simultaneously by the Team Doctor and Match Day Doctor (MDD) and agreement reached before enforcing permanent removal from further game participation.

What assessment is required to identify an ‘oculomotor’ signs?

An oculomotor sign is generally, immediately apparent and include such signs as new onset nystagmus, asymmetrical eye movements, pupil size and reactions. Whilst not a common sign of concussion, if present following a head injury, they are indicators for immediate and permanent removal from further game participation.

Who can request an HIA1 off-field screen?

The on-field medical staff (as defined by each Union), the referee or the MDD are allowed to request an off-field screen. A member of the opposition’s on-field medical staff is not allowed to request an off-field screen on an opposing player, nor are they allowed to make comments on incidents involving opposition players.

Who completes the off-field HIA1 screen?

The Team Doctor will complete an off-field HIA1 screen on a player when indicated unless the Team Doctor assigns this responsibility to the Match Day Doctor (MDD) prior to the commencement of the match. If the MDD completes the off-field screen the responsibility for the return to play decision rests with the MDD. If the MDD completes the off-field screen it is good practice to collaborate with the team doctor before reaching the final decision. The final decision of the of- field HIA1 screen rests with the MDD.

In Sevens, the off-field HIA1 screen will be completed by the Team Physician, Match Day Doctor or World Rugby Tournament Team Physician.

When does a player fail or have a positive off-field HIA1 screen?

A player fails or has a positive off-field HIA1 screen and must NOT return to play if:

  • the player answers “Yes” to one or more symptoms or
  • the player answers one or more memory questions incorrectly or
  • the player scores below baseline or below identified Rugby norms for SAC assessment or
  • the player fails the balance test (more errors than baseline, if no baseline test is available WR normative data shows Tandem stance 4 or> errors, Single leg stance 6 or > errors indicate abnormal test scores)
  • the player exhibits an abnormal sign as observed by the Team Doctor or
  • the doctor performing the off-field screen has any clinical suspicion of a concussion.

Any clinical suspicion of concussion by the doctor performing the HIA1 off-field screen for any reason should see the player removed permanently from the match, even if the HIA off-field screen is normal.

If a player reports a positive answer to any part of the off-field screen test that can be explained by an alternate reason rather than a head injury, the team doctor does retain the ability to over-rule the positive HIA1 in consultation with the Match Day Doctor. In this case an explanation must be recorded on the HIA1 form identifying the reason for this over-ruling decision.

What is the role of the MDD (independent doctor) and what role does the MDD play in the decision on fitness to return to play?

The MDD will observe the off-field screen with the Team Doctor delivering the off-field screen unless assigned this responsibility by the Team Doctor. If the MDD is assigned the responsibility for undertaking an off-field screen by the Team Doctor, the MDD will complete the off-field screen and be responsible for deciding return to play.

If the MDD completes an off-field screen because there are two players requiring an off-field screen at the same time, then the Team Doctor will retain the decision making responsibility regarding return to play.

If a player is cleared to return to play or returns to play but the MDD is concerned or notices signs or the player complains of symptoms suggestive of concussion, a discussion between the Team Doctor and MDD should be undertaken. If a dispute persists, the MDD has the right to request another off-field screen independent of the Team Doctor or to unilaterally remove the player from the field.

If the player has any indication for permanent removal from the field of play (as listed above) then there is no dispute, the player must be removed from field of play.

Each nominated competition or tournament is able to determine if “independence” of the MDD is mandatory, and if so, what is the definition of “independence” for their competition or tournament.

Where should the off-field HIA1 screen be completed?

The off-field screen will be completed in the medical room. If the off-field screen cannot be completed in the medical room because the medical room is too distant from the field of play for an off-field HIA1 screen to be performed within 12 minutes, the MDD, with the Team Doctors, will identify an agreed and appropriate area prior to the commencement of the match.

Can a player undergoing an off-field HIA1 screen be replaced or substituted?

A player undergoing an off-field HIA1 screen will be replaced for 12 minutes. The player will not be allowed to return to play until the 12 minutes has expired and if the player undergoing this off-field screen does NOT present themselves to the 4th official within the 12 minute, the temporary replacement becomes a permanent replacement. This 12 minute period refers to actual time not game time.

What happens if a player has a head impact event just prior to half-time and requires an off-field screen?

The off-field screen still must be completed within 12 minutes of leaving the field. The off-field screen cannot be delayed. The player must present to a match official prior to commencement of the second half or they will be considered a permanent replacement.

What happens if a player will not co-operate with an off-field screen?

A player failing to co-operate with an off-field screen will be assumed to have concussion and be removed permanently from the match.

If the player has a head injury requiring further off field assessment and a co-existing blood injury how long is available to complete the off-field screen and control the bleeding?

In this scenario, control of bleeding will be the priority however the off-field screen must be completed as soon as possible. If bleeding can be controlled, suturing should be completed after the off-field screen. The total time available is 17 minutes to complete both the off-field screen and control the bleeding.

If a player has a second off-field screen requested during a match, does this mean automatic removal from the match?

No, a second off-field screen is not an automatic indication for permanent removal from the match. However, if a definitive diagnosis was not identified following the first off-field screen or the second assessment arises due to a low force impact incident then caution should be applied and that player removed from further match participation.

Are there any restrictions applied to the temporary replacement?

No. A temporary replacement is not restricted in any game activities and can take a penalty kick for goal and a conversion attempt.

What happens if a player undergoing an off-field screen does not return to the match?

The injured player will be considered to have been replaced for an injury and the temporary replacement will become a permanent replacement.

If a player is simultaneously removed as a tactical replacement and an off-field HIA1 screen, can the player return to play?

All players who are removed for a off-field HIA1 screen MUST return to the 4th official at or before the 12-minute mark if cleared, even if they have been tactically replaced. To be clear in this situation if the player does not return to the4th official at or before the 10-minute mark they are considered permanently removed because of a failed off-field screen.

If a player is removed from play for an HIA and that team have exhausted all of its substitutions, is a temporary replacement allowed?

Yes, if all substitutes have been exhausted, a temporary replacement for head injury is allowed by a non-injured player who was previously tactically substituted.

If a player requires permanent removal following a head impact event, irrespective of the medical room classification, that is immediate & permanent removal or off-field screen, the player who is the temporary replacement will be permitted to remain on the field even if the injured player does not return after expiration of the 12-minute off-field period.

To be clear, a tactically substituted player can return to play to replace a head injured player, even if other replacements have not been used.

What is the role of the opposition medical team in the off-field screen process?

Medical and non-medical staff from opposing teams cannot request an off-field screen on players that are not within their team. Suggestions or comments regarding an off-field screen for another team's member should not be made.

What is the role of non-medical team staff in the off-field screen process?

Non-medical staff can alert their respective team medical staff that they have seen an incident that suggests an off-field HIA1 screen or permanent removal. Non-medical staff cannot call for an off-field screen, this must be done by medical staff. Non-medical staff cannot overrule or question a call for an off-field screen requested by the on-field medical staff, MDD or referee.

What happens if the player has a simultaneous injury?

Apart from a blood injury the assessment of a simultaneous injury and the off-field screen must be completed within the 12-minute period allowed for the off-field screen or the replacement will become permanent.

What are the follow up processes for the off-field HIA1 screen?

All players who have an off-field HIA1 screen completed during a match irrespective of the outcome must complete:

  • The second 2 stages of the HIA process:
  • Stage 1: A post-match, same-day assessment using the HIA2 form and examination; and
  • Stage 2: Follow up assessment using the HIA3 form and examination which incorporates a computer neuro-cognitive assessment is completed between 36-48 hours following the injury.

Can the HIA1 tool be used to diagnose a concussion?

The presence of a Criteria 1 sign or symptom confirms a diagnosis of a concussion and the player must be immediately and permanently removed from further game participation and complete a GRTP. An abnormal off field screen supports a suspected concussion and the player is removed from further game participation. The follow up HIA2 assessment may confirm an early diagnosis of concussion if abnormal and or an HIA3 assessment, if abnormal, confirms a late diagnosis of concussion.

How should I interpret the HIA2 Form result?

The HIA2 form is the SCAT6. This tool is used to support an early clinical diagnosis of concussion by the Team Doctor usually within the first 3 hours of the injury. Each mode - symptom check, cognitive assessment (SAC) and balance - should be compared with the respective baseline. If a baseline is not available, normative data ranges were created using a database of 13 479 baseline SCATs from 7 565 adult rugby players. It should be noted that any symptom declared in the symptom list which is not usually experienced by the player following a Rugby match or training is strongly in favour of concussion.

In the absence of baseline testing any one of the following should be considered strongly in favour of a diagnosis of concussion:

  • Immediate Memory – score less than 16
  • Concentration score (digits backwards) – score less than 3
  • Delayed recall – score less than 4
  • Balance – double leg stance 1 or more errors, tandem stance 4 or more errors, single leg stance 6 or more errors
  • Abnormal neurological screen
  • Any athlete with any symptom declared in the symptom list which is not usually experienced by the player following a Rugby match or training is strongly in favour of concussion.

Players with baseline assessments below the above scores should be scrutinized to confirm that the baseline testing has not been manipulated by the player. Since June 2019 all baseline testing should reflect "how the player normally feels", where a player endorses multiple symptoms at baseline, these should be investigated to ensure they reflect the players' health status, and subsequently to exclude medical, physical or psychological causes for the reported symptoms. Any abnormal submodes (balance, cognition or concentration) below specified normative data should also be repeated and, or investigated.

A normal HIA2 assessment and clinical assessment (post-match, same day) does not exclude a concussive episode. It is possible for players to develop delayed symptoms and signs related to concussion, day or days after a head impact incident. The HIA process requires a normal HIA3 assessment and clinical assessment at 36-48 hours to completely exclude a concussion.

How do I interpret the HIA3 form?

The HIA3 Form is the SCAT6 with the symptom checklist expanded to identify severity and length of symptoms. In addition the HIA3 Form includes the results of the computer neuro-cognitive test used by the team. Interpretation of the HIA3 is as per the HIA2 and that is a comparison of each mode to baseline or normative data results. An abnormality of any modes should be considered strongly in favour of a diagnosis of concussion.

If an off-field HIA1 screen is called by a team's on-field staff, can this be cancelled by other on-field staff?

Once the team's on-field medical staff member calls an off-field HIA1 screen and it is acknowledged by the referee, then it must be completed. To be clear, a requested off-field screen by a team’s on-field medical staff cannot be cancelled.

Which players are required to undertake a Graduated Return to Play (GRTP) programme?

Players diagnosed with concussion during the match, after the match whilst at the ground or at the 36-48 hour follow up MUST go through a Graduated Return to Play (GRTP) programme that must be started at least 24 hours after the injury.

How do I manage a player who presents after the match with concussive symptoms? What off-field screen form should be used?

If a player does not have an off-field assessment during the match but has signs or presents with symptoms suggestive of concussion after the match and at the stadium a HIA2 Form and assessment should be completed before leaving the stadium. This should then be followed up at 36-48 hours with the HIA3 Form and assessment.

If a player does not have an off-field screen during the match but presents with symptoms suggestive of concussion after leaving the stadium but within 48 hours of the match, this player should be assessed using the HIA3 Form and assessment.

I have a player who sustains a head and neck injury and the player has an emergency evacuation. What HIA Form should be completed on this player in conjunction with a clinical assessment?

In this instance, an off-field HIA1 screen is not necessary as the player has been permanently removed from play. A HIA2 and or HIA3 Form should be used to support the clinical diagnosis in this instance.

When can a player return to play after a diagnosed concussion?

As per World Rugby Regulation 10, any adult player with a diagnosed concussion:

  • must be immediately and permanently removed from training or the field of play; and
  • should be medically assessed by an appropriately qualified person (as applicable in the relevant jurisdiction); and
  • must not return to play in the same match; and
  • must rest for at least 24 hours and must not return to play or train until symptom free; and
  • must undertake a graduated return to play program, which must be consistent with World Rugby’s GRTP Protocol applicable to adults.

What is meant by 'rest'?

The definition of rest is dependent on the time following the injury

  • Rest after a diagnosed concussion and within 24 hours of the injury means normal activities of daily living which do not worsen symptoms, vigorous activity should be avoided. Relative cognitive rest, limiting screen time etc.- ensure symptoms continue to improve or remain absent.
  • Rest after the initial 24 hours should be relative rest which is defined as ""activity below the level at which physical activity or cognitive activity provokes symptoms”.

Is there any evidence from research that the pitch side interventions have had a positive impact?

Prior to the introduction of temporary replacement for head injuries and standardization of pitch side head injury assessment, evidence confirmed that 56% of players with a confirmed concussion were returning to play on the same day following their injury. Research has confirmed that since introducing the HIA Protocol this number has reduced to less than 10%.

The following documents supporting these HIA Procedures are available as PDF pages in the appendices. 

  • Appendix 1 - HIA Procedure Definitions
  • Appendix 2 - Procedures for Team and Match Day Medical Staff
  • Appendix 3 - Application for Access to Temporary Replacement
  • Appendix 4 -HIA Review Process Explanation and Flowchart
  • Appendix 5 - Minimum Education Content, Risk Stratification guide, Advanced Level of Concussion Care
  • Appendix 6 - GRTP Recommendations
  • Appendix 7 - Player Consent and Research Explanation