Video Review

Review of video footage is an important part of the identification of suspected concussion events. As a basic standard a competition using the HIA protocol must facilitate access to video review to assist with the management of head impacts events occurring during the game, and for any HIA review process after the game.

For premium competitions minimum game video standard will be adhered to:

• Live and delayed (10 seconds) views
• Minimum 4 views (broadcast+ 3 others - ideally inclusive of a high wide view)
• Ability to mark incident
• Ability to stop/ rewind /slowdown/ replay vision
• Availability of sound or sports ears

When a head impact which requires a HIA1 off-field assessment occurs, the MDD and Team Doctor can discuss this and agree on removal of the player. The video footage of the event should be reviewed before and after the assessment before making a final decision on permanent removal of the player. The World Rugby 5-step video review process outlines the most effective way to review video of a head impact event.

In the event of a suspected concussion, when a player has an off-field assessment, the player should not return to play until the Team Doctor and MDD have fully reviewed the video footage of the event. To be dear, if a MDD undertakes the HIA1 and is cleared to return to play the Team Doctor MUST review the video before the player is allowed to return to play.

In the event of a video system review failure immediately prior to, or during a game, the HIA protocol may still be used. The MDD and Team Doctor should work in tandem to identify any visible significant head impact events. It is advised that in the absence of video review they operate a Lower threshold for removal of a player for an HIA off-field assessment. If a system failure is identified prior to the game all efforts must be made to repair the system or provide alternative means of sideline video review. If the game is to proceed without video review the MDD should ensure that there is some video footage of the game (Broadcast or performance) being captured for the game, this may be used in the case of untoward incident review.

Goal of Video Review

To determine the most appropriate action in the event of a head injury.

1. Criteria 1 – remove, view, discuss.
2. Criteria 2 – remove, assess, discuss.
3. Request TD to undertake an on-field assessment.
4. Discuss with TD to clarify the case.

Criteria 1 - Clinical Indicators

Twelve indications for permanent and immediate removal

1. Convulsion
2. Tonic posturing
3. Suspected LOC
4. Confirmed LOC
5. Clearly dazed
6. Ataxia
7. Oculomotor signs
8. Player not orientated in TPP
9. Definite confusion
10. Definite behaviour change
11. On-field identification of sign or symptom of concussion
12. Under-19 Recognise and Remove

Only the first six indicators in the above list can be identified using video signs

Criteria 1 - Video Signs

1. Convulsion
2. Tonic posturing
   • Rigid extended upper limb(s)
3. LOC – suspected /confirmed
   • Lying motionless for > 5 secs
   • Falling no protection
   • Failure to protect themselves on ground
   • Cervical hypotonia
   • Unusual postural reaction
4. Clearly dazed
   • Vacant or blank stare
5. Ataxia
   • Unsteady on rising
   • Unsteady on feet
   • Unusual postural reaction

Criteria 1 - Video Signs Comments

• Criteria 1 video signs are not always clear cut.
• Clinical suspicion of a Criteria 1 sign → look at multiple angles.
• Player and teammate reaction is often telling.
• Review using the 5-point in time process.
• Return to feet and return to play must be viewed.
• If there is a suspicion of Criteria 1 event – the player MUST be removed from play and a review of the video undertaken with the TD. As a minimum the off-field HIA1 assessment must be completed, and a second video review completed.

Criteria 2 - Clinical Indicators

Five indications for off-field assessment

• 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

Criteria 2 are clinical indicators of suspected concussion NOT video signs

Criteria 2 - Video Signs

1. Head impact where diagnosis not immediately apparent
2. Sub-threshold ataxia
   • Hands to balance on rising, crawling
   • Player collapses on impact
3. Sub-threshold LOC
   • Motionless 3-5 seconds
   • Referee / player concern
4. Sub-threshold blank stare
5. Multiple signs that don’t confirm a Criteria 1

 

Post probable head injury event

• On ground for more than 30 seconds
• Receives medical attention for > 1 minute
• Returns to ground after head impact
• Second medical review
• Slow to respond or slow to rise
• Avoids further game participation
• Poor performance on return to play

 

Criteria 2 - Video Signs Comments

• A Criteria 2 should be applied when there is a suspicion of a Criteria 1 event, but views are unclear, or an event does not reach the ‘threshold for a Criteria 1 video sign.
• An off-field HIA1 assessment is indicated if there is suspicion of an event, but you cannot be sure on available views.
• Where there are a number of individually “less serious” events or signs in a row.
• When you have not seen the event, or cannot see an incident on video but a player is behaving strangely or under-performing.
• When the player receives prolonged or repeated medical attention after a head injury event.

5-Step Approach to Video Review

World Rugby has developed a 5 step approach to video review which aims to improve consistency and accuracy of video interpretation.

The 5 steps are Look at the head impact, watch for the immediate response 0-2 seconds, note the delayed response 3-7 seconds, watch the return to stand and watch the return to play.

This 5 step approach supports a more accurate review of a head injury video

Video Review Process - 5 Steps

1. Look at the head impact event – identify a direct blow or whiplash, force of impact.
   • Direct head contact, the head will move away from the point of contact.
   • Whiplash the head will move towards the contact.
   • Beware of head contact with ground after an initial contact.
   • Beware contact from a second player AFTER the event.
2. Immediate response (0-2 second) – identify inappropriate postural response.
   • Player falling to the ground without head or neck control.
   • Player falling stiffly – displaying tonic posturing.
   • Player not protecting himself as he falls to ground.
   • Player not protecting himself on the ground from other players (boots etc.).
3. Delayed response (3-7 seconds plus) – identify inappropriate postural or functional response.
   • Evidence of convulsion or tonic posturing.
   • The time the player remains motionless > 5 seconds is significant.
   • Purposeful movements within the first 5 seconds.
4. Return to feet (if they have fallen) – identify inappropriate functional response.
   • Unsteady when attempting to stand
   • Player using hands to get up- or crawling
   • Player falling back to the ground
   • Player with a vacant look?
   • Player who is unsteady after getting to their feet – returning to kneel
   • Player resting in ”tripod” position to avoid unsteadiness
5. Return to play – identify inappropriate game actions/reactions.
   • Player clearly confused and not functioning properly- eg. missed tackle
   • Player not moving immediately to the correct position on the field of play
   • Player not trying to participate or avoid returning to the game

Video Review - Speed Tips

Always start with a normal speed view before viewing slower vision

• Head impact – determining the mechanism of injury or point of impact may require very slow speeds (<25%) or even frame by frame review.
• Immediate response - if the point of primary interest is the initial impact or assessment as they fall to the ground then viewing the video at 50% or 25% speed may assist.
• Delayed response - looking a potential loss of consciousness whilst on the ground - 100% speed is best.
• Return to feet and return to play - Reduced playback speeds may be misleading.