HIA Procedures, Frequently Asked Questions
1. How is a player diagnosed with concussion Under World Rugby’s operational definition, a player has a confirmed concussion if:
- There is confirmed criteria 1 sign or symptom as per the HIA1 form
- There is an abnormal HIA2 post-game, same-day assessment (an early concussion)
- There is an abnormal HIA3, 36-48 hours assessment (a delayed-onset or delayed-presentation concussion)
- The treating doctor has a clinical suspicion that the player has a concussion.
Under the operational definition a concussion can be diagnosed immediately following a head injury but cannot be excluded until completion of both the HIA2 and HIA 3, that is 36-48 hours after the injury.
2. Are the immediate and permanent removal signs and symptoms (Criteria 1) confirmed during an on-filed 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 or pith side practitioner 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 MDD and agreement reached before enforcing permanent removal from further game participation.
3. What assessments is required to identify an ‘oculomotor’ sign?
An oculomotor sign is generally immediately apparent and includes such as 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 remvoval from further game participation.
4. Who can request an HIA1 off-field assessment?
The on-0field medical staff (as defined by each union), the referee or the MDD are allowed to request an off-field assessment. A member of the opposition’s on-filed medical staff is not allowed to request an off-filed assessment on an opposing player, nor are they allowed to make comments on incidents involving opposition players.
5. Who completes the HIA1 off-field assessment?
The Team Doctor will complete an HIA1 off-field assessment on a player when indicated unless the Team Doctor assigns this responsibility to the MDD prior to the commencement of the match. The Team Doctor can, in cases of emergency, assign off-field assessment responsibility to the MDD during a match.
In Sevens, the HIA will be completed by the Team Physician, Match Day Doctor or World Rugby Tournament Team Physician.
6. When does a player fail or have a positive HIA1 off-field assessment?
A player has an abnormal HIA1 off-field assessment and must NOT return to play if:
- the player answers "Yes" to one or more symptoms that exceed their trait 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 (Tandem stance - 4 or more errors, Single Leg stance - 6 or more errors) or
- the player exhibits an abnormal sign as observed by the Team Doctor or
- the doctor performing the off-field assessment has any clinical suspicion of a concussion.
Any clinical suspicion of concussion by the doctor performing theHIA1 off-field assessment for any reason should see the player removed permanently from the match, even if theHIA1 off-field assessment is normal.
If a player reports a positive answer to any part of the off-field assessment 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 abnormaLHIA1 off-field assessment 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.
7. What is the role of the MDD {Independent Match Day Doctor) and what role does the MDD play in the decision on fitness to return to play? How is independence defined with respect to the MDD?
The MDD will observe the HIA1 off-field assessment with the Team Doctor delivering the off-field assessment unless assigned this responsibility by the Team Doctor. If the MDD is assigned the responsibility for undertaking an off-field assessment by the Team Doctor, the MDD will complete the off-field assessment and be responsible for deciding return to play. The MDD however should discuss their findings with the Team Doctor prior to finalising the result in the SCRM application.
If the MDD completes an off-field assessment because there are two players requiring an off-field assessment at the same time, then the Team Doctor should discuss their findings with the MDD prior to finalising the result in the SCRM application.
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. Every effort should be made to arrive at a consensus around management of individual cases. If a dispute persists, the MDD has the right to request another off-field assessment independent of the Team Doctor or to unilaterally remove the player from the field, this should not be done without extensive discussion with Team Doctor.
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.
8. Where should the HIA1 off-field Assessment be completed?
The off-field assessment will be completed in the medical room. If theHIA1 off-field assessment cannot be completed in the medical room because the medical room is too distant from the field of play for anHIA1 off-field assessment 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.
9. Can a player undergoing an HIA1 off-field assessment be replaced or substituted?
A player undergoing an off-field assessment 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 thisHIA1 off-field assessment does NOT present themselves to the 4th official within the 12 minutes, the temporary replacement becomes a permanent replacement. This 12-minute period refers to actual time not game time.
10. What happens if a player has a head impact event just prior to half-time and requires an HIA1 off-field assessment?
The off-field assessment must still be completed within 12 minutes of leaving the field. The off-field assessment 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.
11. What happens if a player will not co-operate with anHIA1 off-field assessment?
A player failing to co-operate with an off-field assessment will be assumed to have concussion and be removed permanently from the match.
12. What happens if a Player does not wear an instrumented mouthguard (iMG)
A player who does not wear an iMG will not benefit from the protection of the iMG alert in the event of a significant head impact event. The player will therefore be managed more conservatively and managed under 'Recognise & Remove' process and may therefore not return to play in that game. The player will be eligible for HIA2 and HIA3 to confirm a potential diagnosis of concussion. The player may also be prescribed and avail of the individualised rehabilitation programme to return to play (as normal) if a concussion is diagnosed.
13. 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 Assessment and control the bleeding?
In this scenario, control of bleeding will be the priority however the HIA1 off-field Assessment must be completed as soon as possible. If bleeding can be controlled, suturing should be completed after the off-field Assessment. The total time available is 17 minutes to complete both the off-field Assessment and control the bleeding
14. If a player has a second HIA1 off-field assessment requested during a match, does this mean automatic removal from the match?
No, a second off-field assessment is not an automatic indication for permanent removal from the match. However, if a definitive diagnosis was not identified following the first off field assessment 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.
15. 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.
16. What happens if a player undergoing an HIA1 off-field assessment 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.
17. If a player is simultaneously removed as a tactical replacement and an HIA1 off field assessment, can the player return to play?
ALL players who are removed for an HIA1 off-field assessment MUST report to match officials to return to play at 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 the field of play, they are considered permanently removed because of a failed off-field Assessment.
18. If a player is removed from play for an HIA1 off-field assessment and that team has 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.
If a player requires permanent removal following a head impact event, irrespective of the medical room classification, that is immediate & permanent removal or HIA1 off-field assessment, the player who is the temporary replacement will be permitted to remain on the field even if the injured player does not return after expiry 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.
19. What is the role of the opposition medical team in the HIA1 off-field assessment process?
Medical and non-medical staff from opposing teams cannot request an HIA1 off-field assessment on players that are not within their team. Suggestions or comments regarding the need for an HIA1 off-field assessment for another team's member should not be made.
20. What is the role of non-medical team staff in the HIA1 off-field assessment process?
Non-medical staff can alert their respective team medical staff that they have seen an incident that suggests an HIA1 off-field assessment or permanent removal. Non-medical staff cannot call for an HIA1 off-field assessment, this must be done by medical staff. Non medical staff cannot overrule or question a call for an HIA1 off-field assessment requested by the on-field medical staff, MDD or referee.
21. What happens if the player has a simultaneous injury?
Apart from a blood injury the assessment of a simultaneous injury and the HIA1 off-field assessment must be completed within the 12-minute period allowed for the HIA1 off-field assessment or the replacement will become permanent.
22. What are the follow up processes for the HIA1 off-field assessment?
ALL players who have an HIA1 off-field assessment completed during a match irrespective of the outcome must have:
- A post-match, same-day assessment using the HIA2; and
- Follow up assessment using the HIA3 which incorporates a computer neuro cognitive assessment is completed between 36-48 hours following the injury.
23. Can the HIA1 off-field assessment 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 individualised rehabilitation. An abnormal HIA1 off-field assessment supports a suspected concussion and the player is removed from further game participation. The follow up HIA2 may confirm an early diagnosis of concussion if abnormal and or an HIA3 if abnormal confirms a Late diagnosis of concussion.
24. How should I interpret the HIA2 result?
The HIA2 is a composite SCAT assessment. This tool is used to support the clinical diagnosis of the Team Doctor at that point in time. Any negative deviation from baseline data or normative data should be considered supportive of an early diagnosis 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 15 or fewer correct answers
- Concentration score (digits backwards and months in reverse) - 2 or fewer correct answers
- Delayed recall score - 3 or fewer correct answers
- Balance - Double Leg stance -1 or more errors, Tandem stance - 4 or more errors
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.
A normal HIA2 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 and clinical assessment at 36-48 hours to completely exclude a concussion.
25. If an HIA1 off-field assessment 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 HIA1 off-field assessment and it is acknowledged by the referee, then it must be completed. To be clear, a requested HIA1 off field assessment by a team's on-field medical staff cannot be cancelled.
26. Which players are required to undertake Individualised Rehabilitation?
Players diagnosed with concussion during the match (Criteria 1, or during off-field assessment), after the match whilst at the ground (HIA2) or at the 36-48 hour follow up (HIA3) MUST complete Individualised Rehabilitation. This is stratified according to personal concussion history and symptom burden at diagnosis that maybe started after HIA3.
27. How do I manage a player who presents after the match with concussive symptoms? What off- field assessment 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 an HIA2 Form should be completed before Leaving the stadium. This should then be followed up at 36-48 hours with the HIA3.
If a player does not have an HIA1 off-field assessment 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.
28. What happens if a player has a suspected concussion at training?
If a player suffers a suspected concussion during training, 'Recognise and Remove' should be employed, the player should be removed and not returned to training that day. Appropriate immediate medical attention should be employed.
After training, the player should be evaluated with an HIA2. The player should undergo an HIA3 36-48 hours post-training. And if at either stage a concussion is diagnosed, individualised rehabilitation should be completed.
29. What happens if a player presents with a suspected concussion after training?
If a player presents to medical staff after a training session, this is dealt with similarly to a delayed presentation post-game. If the presentation is within 2 hours of the training session, then an HIA2 assessment is performed with subsequent HIA3 at 36-48 hours. If the presentation is outside of 2 hours post-training an HIA3 assessment should be completed.
30. What if 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 HIA1 off-field assessment is not necessary as the player has been permanently removed from play. An HIA2 and or HIA3 Form should be used to support the clinical diagnosis in this instance.
31. 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 significantly 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".
32. 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 later confirmed as having concussion were returning to play on the same day following their injury. Since introducing the HIA Protocol this number has reduced to less than 8%.
The following documents supporting these HIA Procedures are available as PDF pages in the appendices.
- Appendix 1 - HIA Procedures, Frequently Asked Questions
- Appendix 2 - HIA Definitions
- Appendix 3 - Procedures for Team and Match Day Medical Staff
- Appendix 4 - HIA Protocol Sevens Rugby
- Appendix 5 - Application for the use of HIA and use of temporary substitutions/replacements
- Appendix 6 - HIA Review Process Explanation and Flowchart
- Appendix 7 - Minimum education content and advanced level of concussion
- Appendix 8 - HIA Player Consent & Research Explanation - Premium Competitions