Protecting Players from Head Injuries IRB Player Welfare -­‐ Putting Players First Protecting Players from Head Injuries 1. Objective The objective of this paper is to gather all aspects of the International Rugby Board’s (IRB) approach to the prevention of head injuries so that they can be examined from a risk management perspective. 2. Background Rugby Union is a physical sport and there is always a risk of injury. The foreword to the Laws of the Game states; " Rugby Union is a sport which involves physical contact. Any sport involving physical
contact has inherent dangers. It is very important that players play the Game in accordance with
the Laws of the Game and be mindful of the safety of themselves and others". In this context the
IRB regularly reviews the Laws of the Game and has a well-established, proactive injury
surveillance and injury reduction strategy for all types of injury. There is however a growing awareness within the international sports medicine community that there is a need to provide an even higher level of monitoring and evaluation of head injuries and to provide even greater protection for players from the short and long-­‐term consequences of head injuries in all sports. Head injuries in rugby are generally minor in nature, consisting mostly of cuts, contusions and concussions; however, on rare occasions head injuries can be more serious. From a risk management perspective injury surveillance has shown that for most types of head injuries the likelihood of occurrence is moderate and the consequences are minor but there are some types of head injury where the likelihood is very low but the consequences are severe. The IRB has therefore put in place a number of regulatory processes (Laws of the Game), procedures and guidelines to minimise and/or prevent serious head injuries and to manage Players with potentially serious head injuries both on and off the field. In terms of the medical management and policy of head injuries, the following bodies and personnel within the IRB have responsibilities IRB EXCO (the Board of IRFB Service (Ireland) Limited) is responsible for medical policy and the confirmation of medical guidelines The IRB Chief Medical Officer (CMO) is responsible for generating the medical guidelines. The CMO operates within the IRB Technical Services Department. The CMO utilises the Annual Medical Commission Conference to consult with Unions and to identify specific medical issues that may need to be addressed in the Game. Working Groups are established that utilise a wide variety of subject matter experts from within and from outside Rugby. The Working Groups make recommendations and these lead to the generation of guidelines under the management of the CMO. The IRB also utilises a risk management consultant to advise on medical matters. There is an internal Medical Risk Group composed of the CMO, Head of Legal Affairs, Company Secretary, Head of Technical Services and the General Manager -­‐ Technical Services (Training, Medical and Anti Doping) to which the IRB Council member nominally responsible for medical matters is invited. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 1 of 47 Protecting Players from Head Injuries The Technical Services Department is responsible for promulgating the medical guidelines and any training and education that results from or is necessitated by the guidelines. 3. Methodology This paper is divided into two distinct sections; •
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Preventing / minimisation of an initial head injury Protection of Players with head injuries from further head injuries In each section the appropriate IRB activities will be examined and where possible referenced to specific IRB documentation contained in the Appendices to this document or available on the IRB website. The intention is to review the IRB approach to protecting Players from head injuries in a holistic and integrated way, while recognising that pure accidents can and do occur. 4. Section 1: Preventing Initial Head Injuries 4.1. The Laws of the Game The Laws of the Game are reviewed on a quadrennial basis by the IRB Council having been advised by the Rugby Committee which is in turn advised by a Laws Representation Group. Exceptions are made to the four-­‐year process in situations related to Player safety. Law 10.4 has been specifically designed to cover situations involving dangerous play and misconduct by players that may lead to serious injury. This Law is reviewed and amended regularly in light of emerging trends within the Game with a view to prohibiting on-­‐field acts which are considered to be Dangerous Play and to protect Players from acts of Dangerous Play. Law 10.4 has been reproduced in full as Appendix 1. The following acts of dangerous play may cause head injuries: •
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Punching and striking Kicking Dangerous tackling o High tackles o Stiff arm tackles o Playing a player without the ball o Tackling a player who is in the air Dangerously charging an opponent Charging into a ruck or maul Lifting a player from the ground and dropping or driving that player into the ground In 2009, the IRB Council recognised a situation whereby a tackling player in executing what was considered at the time to be a legal tackle, i.e. one in which initial contact by the arms of the tackling player was below the line of an opponent's shoulders, could on occasions make contact with the head of the opponent if the tackling player’s arm(s) slipped upwards after the initial contact. The Council therefore legislated that a tackle resulting in such an outcome should also be considered dangerous play irrespective of the intention of the Player. The Council's decision is reflected in Law 10.4 (e) (Appendix 1) A match official who observes any of the actions deemed to be dangerous play in Law 10.4 has three courses of action open to him/her having first awarded a penalty kick against the offending team, i.e.: 130723 SG IRB Player Welfare -­‐ Head Injuries Page 2 of 47 Protecting Players from Head Injuries •
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Penalise and admonish the offending player; Temporarily suspend the offending player from the match for 10 minutes in fifteen-­‐a-­‐side Rugby and 2 minutes in Rugby Sevens (Yellow Card); Send the offending player from the field of play for the remainder of the match (Red Card) In the third case (or where such an incident has been missed at the time by the match official but there is a retrospective off-­‐field citing for such an incident) the offending Player will have to attend a judicial hearing where there may be further sanctions applied to the offending player. Law 4 and Regulation 12 deal with players' clothing and in particular padded clothing including headgear. The IRB was mindful of how padded clothing had developed in another sport in North America which started from similar origins, where it was evident that players in that sport used their head gear as an offensive tackle weapon. Hardened headgear may prevent fractured skulls but does not prevent concussion. The IRB approach to padded headgear is that it must not have the potential to damage the wearer or another player coming into contact with that headgear. Manufacturers wishing to sell headgear for Rugby have to have their products tested in accordance with the standards contained within Regulation 12. The appropriate section of the Regulation pertaining to headgear is attached as Appendix 2. If headgear garments comply with Regulation 12, the manufacturer may apply for IRB approval labels to affix to the garment. Match Officials check players clothing before a match and only headgear bearing a label is permitted to be worn during a match. The IRB does not regard headgear as protective clothing in respect of head injuries – it is considered to guard only against cuts and abrasions. The philosophy is one where the headgear should do no damage to either the wearer or those who may come into contact with it. Thus far manufacturers have not been able to develop headgear which prevents concussion. Were they to do so, there could be a real concern that the head would be used offensively. Law 1 permits the use of padding for goal posts up to 300mm which is aimed at protecting players who may collide with goal posts. Regulation 22 relates to Artificial Turf and its principal objective relates to player safety. The standard contained within the Regulation ensures artificial turf used for Rugby equates to a good quality natural turf. Additionally there is one part of the standard which focuses on head impact with the surface. This is known as the Head Impact Criteria (HIC) and emanates from standards applied to playgrounds in certain jurisdictions. Artificial Turf installations are tested for HIC and if they fail the relevant installation may not be used for Rugby. 4.2 The Role of Match Officials 4.2.2 Merit Based Selection Match Officials at the elite level of the Game consist of a Referee, two Assistant Referees and a Television Match Official (TMO). The Match Officials apply the Laws of the Game. At the elite level, most matches are televised, often globally; the IRB therefore consider that Match Officials at this level of the Game act as role models for all other levels of the Game. Since 1997, the IRB has had a merit based system for the appointment of Match Officials to major fifteen-­‐a-­‐side international matches (most of which are televised). Those administrators responsible for elite Regional Club/Provincial Competitions, such as the Super Rugby in the Southern Hemisphere and the Heineken Cup in the Northern Hemisphere, have similar selection processes which contribute to the merit based approach. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 3 of 47 Protecting Players from Head Injuries With the global growth of seven-­‐a-­‐side Rugby, known as Rugby Sevens or simply Sevens, and the inclusion of Sevens as an Olympic participation sport, a similar approach to match official selection has been adopted in this version of Rugby. One of the important factors taken into account by the IRB Match Official Selection Committee during the selection process is the Match Officials' management of Dangerous Play. With effect from 2013, this issue has been an agenda item at every Selection Committee meeting for both fifteens and Sevens Match Officials. 4.2.3. Match Official Performance Management The performance of Match Officials is monitored by the two IRB High Performance Managers -­‐ Match Officials, one for fifteen-­‐a-­‐side Rugby and one for Sevens. They are supported by Performance Reviewers who have a process for review and one of the areas they will report on is if Match Officials fail to deal with Dangerous Play appropriately. There is a computerised reporting (AMS) system to which all merit based selected Match Officials and Performance Reviewers have access. This includes access to match clips which can include incidents of Dangerous Play missed or inappropriately dealt with. The IRB High Performance Match Official Managers are responsible for providing feedback to the Match Officials and the Match Officials' National Match Official Managers. The High Performance Match Official Managers are supported by the IRB Game Analysis Unit with statistics and the identification of issues through the use of video footage. 4.2.4 Guidance and Education of Elite Match Officials For fifteen-­‐a-­‐side Rugby the IRB High Performance Match Official Manager meets with IRB merit based selected Match Officials twice a year for briefings and the management of acts of Dangerous Play is normally a subject item that is both discussed and where guidance is given. Guidance is also provided by memorandum and two examples related to dangerous tackles and how they should be dealt with by the match officials and assessed by judicial personnel are included as Appendices 3 and 4.
4.2.5 The Extended Role of the Television Match Official With effect from January 2013 a global trial was introduced which extended the jurisdiction of the TMOs such that are required to review acts of Dangerous Play across the whole playing area. Previously, the TMO's jurisdiction was limited to acts of Dangerous Play in in-­‐goal areas related to the scoring of a Try or not. The Referee may ask for a review, and the Assistant Referees and the TMO may suggest to the Referee a review of potential Dangerous Play in an endeavour to: •
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Identify situations of Dangerous Play that may have otherwise been missed by the Match Referee; Deliver appropriate sanctions should there be any doubt as to the severity of the offence. The section of the IRB TMO trial protocol appropriate to Dangerous Play is attached as Appendix 5. 4.2.6 Education and Guidance for Non-­‐elite Match Officials Whilst it is vitally important that the elite Match Officials are role models, the majority of Rugby played is at the non-­‐elite level and match officials at all levels require training and education. The IRB has 118 Member Unions (at the date of this paper). In excess of 90% of those Member Unions 130723 SG IRB Player Welfare -­‐ Head Injuries Page 4 of 47 Protecting Players from Head Injuries are dependent on the IRB for all their training and education products. Those Member Unions who are self sufficient also contribute to the development of the IRB training and education Products. The IRB and Member Unions have a global workforce of 1300 volunteer IRB accredited Trainers and Educators, who educate and accredit Educators of Coaches and Match Officials. Each of the accredited Trainers and Educators has an appreciation of risk management principles related to Player safety and have to provide evidence of its practical application: failure to do so could lead to accreditation being removed. The IRB has three levels of referee education and at each level Player safety is emphasised as being of paramount importance. In addition Match Officials are encouraged to undertake the IRB RugbyReady (Safety) education programme and the IRB First Aid Programme. If IRB Trainers and Educators do not successfully complete the Rugby Ready and First Aid programmes they lose their accreditation when it is due for renewal. The RugbyReady and First Aid modules can be accessed at www.irbpassport.com 4.3 The Role of the Judiciary 4.3.1 The Judicial Framework The IRB has an independent judicial system with an independent Judicial Panel Chairman who is responsible for overseeing the judicial appointment process. The disciplinary process is enshrined in IRB Regulation 17 (Discipline and Foul Play) and Regulation 18 (Disciplinary and Judicial Matters). Regulations 17 and 18 can be viewed in its entirety at www.irb.com/LawsandRegulations/Regulations. These Regulations provide the framework, processes, procedures and sanctions table (complete with three tiers of entry point to sanctions to reflect low, mid-­‐range and high-­‐end offending) to protect the integrity of the Game. The sanctions table is mandatory across the entire Game and has been devised and agreed by a group of experts representing a cross section of relevant stakeholders under the umbrella of a Morality of the Game Conference (held initially in 2005 and reviewed in 2012). Two key criteria used in determining the sanction entry point for an offending Player are the location (Regulation 17.14.2(f)) and severity (Regulation 17.14.2(d)) of any injury caused to an opponent by an offending Player’s actions. 4.3.2 The Role of the Citing Commissioner At elite levels of the Game Citing Commissioners are appointed to act as off-­‐field referees. They essentially provide a further deterrent for players from engaging in Dangerous Play. The Citing Commissioner is located off the playing area (or indeed entirely at a remote location) and s/he has access to all the available television footage from varying camera angles. Citing Commissioners can cite a Player after the match for any act(s) of Foul Play which in the opinion of the Citing Commissioner warranted the Player concerned being Ordered Off (Red Card test). The exact role is detailed in Regulation 17. An extract of the relevant parts of Regulation 17 can be found in Appendix 6. The Citing Commissioner can cite a player even if the on field Match Officials have dealt with the matter at the time. 4.3.3 Matches where no Citing Commissioner appointed Where no Citing Commissioner is appointed to a match, teams may cite in accordance with Regulation 17.11.1. The citing can only proceed if the Judicial Officer / Disciplinary Committee establishes (i) that the incident was undetected by the match officials; (ii) that it meets the "Red Card test" (both 130723 SG IRB Player Welfare -­‐ Head Injuries Page 5 of 47 Protecting Players from Head Injuries Regulation 17.17.4(b)); and (iii) that the Union citing the Player has a representative at the hearing to present the basis for the Citing complaint and evidence in support (Regulation 17.18.9). If the Citing fails on any of these grounds it shall be dismissed. 4.3.4 The Role of the Judicial Officer and Judicial Committees Players who are ordered off by the Referee or cited by the Citing commissioner will appear before either a single Judicial Officer or a three person Disciplinary Committee. In the case of the single Judicial Officer that person must be legally trained and in the case of the Judicial Committee one of the members must be legally trained. This ensures that the regulated process and procedures are followed. The role of both is to establish, on the balance of probabilities, that the Referee's or Citing Commissioner's decision is correct and if so to apply appropriate sanctions. The Citing complaint must not be upheld unless the Judicial Officer is satisfied on the balance of probabilities that the Player concerned committed the act(s) of Foul Play that are the subject of the Citing complaint. If the Citing complaint is upheld (or admitted) the Judicial Officer shall determine the sanction, if any, to be imposed on the Player in accordance with Regulation 17.19 (again, see Section 7 of this Manual for further information). See Regulation 17.17.4(a). Following an Ordering Off the function of the Judicial Officer is to consider the case and determine his factual findings and what further sanction, if any, should be imposed on the Player. The Player may seek to show that the referee's decision was wrong. In these circumstances (subject to Regulation 17.17.2) the Judicial Officer may review the referee's decision and the surrounding circumstances. The Judicial Officer may not make a finding contrary to the referee's decision (i.e. to find that the incident did not warrant a Red Card) unless he is satisfied on the balance of probabilities that the referee's decision was wrong (Regulation 17.17.3). As with Match Officials there is a merit based selection process for Judicial personnel including Citing Commissioners. There are also regular workshops to assist consistency in process and sanctions. 4.3.5 The Sanctions that can be applied to Offending Players Should a Judicial Officer or Disciplinary Committee (Judiciary) consider that the Referee's or Citing Commissioner's decisions in relation to a sending off or Citing is correct they then have a range of sanctions available to them. The available sanctions are listed against each element of Law 10.4 (Foul Play) and the sanction table, which is mandatory, is included as Appendix 7. Regulation 17 also incorporates a core sanctioning process which must be followed by the Judiciary which gives guidance as to how the sanction process should be applied. The sanctions’ table is set out in a Scale based on the seriousness of the Player’s conduct. This scale has three levels: Lower End (LE), Mid Range (MR) and Top End (TE). The Disciplinary Committee or Judicial Officer in each case undertakes an assessment of the seriousness of the Player’s conduct that constitutes the offending and categorise that conduct in accordance with the entry points. The factors to be taken into account are included in Appendix 7 as are the aggravating and mitigating factors which the Judicial Officers and Disciplinary Committees have to take into account in applying the sanctions. The consistent application of the core sanctioning system should give rise to a consistency in the range of sanctions, but bearing in mind that the particulars of each case of Foul Play will be different depending on the level of intent/recklessness involved together with other on-­‐field factors, and the off-­‐field aggravating and mitigating circumstances that apply. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 6 of 47 Protecting Players from Head Injuries In terms of providing protection to players through deterrent sanctions the following amongst others (which are specified) are taken into consideration: •
the effect of the Player’s actions on the victim (for example, extent of injury, removal of victim Player from the game); and •
the vulnerability of the victim Player including part of victim’s body involved/affected, position of the victim Player, ability to defend himself. This assessment would apply to cases involving head injuries with disciplinary personnel being reminded of the seriousness of Foul Play and the potential for head and other injuries in memos to that effect from the Independent IRB Judicial Chairman/Head of Referees in 2009 and 2011 (as updated from time to time) which are attached as Appendices 3and 4. 4.4 Training and Education 4.4.1 The Workforce The IRB has a volunteer workforce known as Trainers, who are accredited to train Educators. The Educators are in turn accredited to educate and accredit Coaches, Match Officials, Strength and Conditioning coaches or medical care providers. The accreditation process is based upon assessments of competence of the Trainers and Educators. Accredited Trainers and Educators must be re accredited every three years based upon their activity levels, quality assurance of delivery standards and support from their home union and regional association. The Trainers and Educators have to demonstrate the implementation of safe practices and knowledge of risk management. There are 1300 Trainers and Educators worldwide. The coaches, match officials, medical care providers and strength and conditioners being trained must demonstrate safe practices and a knowledge of risk management relevant to their area of work. 4.4.2 Training and Education products The applicable training and education products available from the IRB are: •
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Rugby Ready: www.irbrugbyready.com Laws of The Game: www.irblaws.com Coaching: www.irbcoaching.com o Coaching -­‐ Levels 1, 2 and 3; Fifteen -­‐ a -­‐ side o Coaching -­‐ Levels 1, 2 and 3; Seven -­‐ a -­‐ side Match Officials o Match Officials -­‐ Levels 1,2 and 3 Fifteen -­‐ a -­‐ side o Match Officials – Levels 1 and 2 Seven -­‐ a -­‐ side Strength & Conditioning – Levels 1 and 2: www.irbsandc.com IRB Player Welfare: www.irbplayerwelfre.com o First Aid, o Concussion o Match day medical staff training 130723 SG IRB Player Welfare -­‐ Head Injuries Page 7 of 47 Protecting Players from Head Injuries RugbyReady RugbyReady is an on-­‐line and face-­‐to-­‐face programme which raises awareness of good practice and helps stakeholders manage the inherent risks of a contact sport by putting appropriate safeguards in place In some jurisdictions. Completion of Rugby Ready is a pre-­‐requisite to attending a formal coach or match official education course. The resource states: A Rugby Ready player will: 1. Be screened or profiled before they start playing 2. Play and train in a safe environment with well maintained equipment and an emergency plan 3. Have been taught and re-­‐taught safe techniques in all contact phases of the game 4. Be aware of the dangers of foul play 5. Have coaches and support staff who know how to deal with injuries and only return players to play when fully fit Specific references to the prevention of head injury are included in Appendix 7. Reference is also made to IRB Regulation 10 in terms of concussion: this is referenced in Section 5.1 below. Laws of the Game An online resource on the Laws of the Game can be viewed at www.irblaws.com . Coaches and match officials who are candidates for IRB coaching and match official accreditation must have successfully completed the on-­‐line Laws test. This includes the previously outlined Law 10. IRB Coaching An online resource for coaches available at www.irbcoaching.com: this resource includes best practice coaching guidelines and documentation that makes reference to the importance of a tackling player’s correct head position at side on tackles to prevent head injuries. Coaching Course Materials References are made in sections of the participant resource that specifically relate to preventing head injuries: •
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Picking up the ball Tackling Practice tips Falling in the tackle Contact skills Body position in contact Risk management Laws of the Game The level 2 coaching course requires the coaches to have pre-­‐qualified in RugbyReady and the Laws of the Game. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 8 of 47 Protecting Players from Head Injuries The first of the 14 principles for a coaching session is: " Safety is your first concern". Within the ethics section of the manual it states: "9. Follow informed, professional medical advice at all times When coaching maturing players, a player’s physical welfare is more important than the success of the team. It is not worth aggravating an injury to achieve short term success. This applies particularly to head and joint injuries, as damage to these vulnerable areas can have long term effects. You must know what is safe and effective, and have a knowledge of first aid. A sideline first aid kit should be provided by the club". At level 2, coaches are formally assessed in their ability to coach the contact elements of the game safely with a strong emphasis placed on the correct way to tackle. Officiating course materials This programme provides an emphasis on Safety as one of the key principles of refereeing. At Level 2, an emphasis is put on the need for Match Officials to ensure a safe environment. The course has a section on Foul and Dangerous play that emphasises the importance of dealing strictly with high tackles. As with coaching Level 2, a Match Official’s ability to referee safely and to deal with dangerous play is formally assessed 4.5 Strength & Conditioning programmes The Level 1 and 2 programmes have a strong emphasis on functional movement and anatomical adaptation. These adaptive exercises are designed to prepare players thoroughly for the demands of the game and include shoulder and neck strengthening exercises. At level 2, the coaches are formally assessed in their ability to screen and prescribe training for speed, strength and power. 4.6 Player Welfare resources These include specific modules on First Aid, Concussion, Match Day Medical Staff and Immediate Care. There are three levels of face-­‐to-­‐face courses: Level 1 -­‐ First Aid; Level 2 – Immediate Care in Sport and Level 3 – Advanced Immediate Care in Sport Support from the Game Analysis Unit The Game Analysis Unit codes and digitises all elite competitions in the world. They therefore have analysis information and vision of foul play and dangerous play. They also can track the on-­‐pitch management of head injuries by team physiotherapists and physicians and by Match Officials. This enables them to provide support to Match Officials via feedback, performance review and education. Video footage of any incident can also be supplied to the IRB Chief Medical Officer for retrospective review of current on-­‐pitch medical practices. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 9 of 47 Protecting Players from Head Injuries 5. Section 2: Protection of Players with Head Injuries from Further Head Injuries 5.1 Regulation 10 The IRB approach with regard to regulating matters of a medical nature is one of providing guidelines of best practice. These guidelines can then be implemented across the world in accordance with the best medical practices and facilities available in individual countries. The exception to this general approach is the specific requirements of Regulation 10 that relate to Concussion in order to prevent further concussive injuries. The Regulation was reviewed in 2013 and is included as Appendix 9. In summary, the Regulation states that all Players diagnosed with concussion during a Game or training must be removed from the field of play and must not return to play or train on the same day; they must complete the graduated return to play protocol described in the IRB Concussion Guidelines. In addition suspected concussion where an appropriately trained health care professional is not in attendance is managed as a diagnosed concussion with a removal from play and no return same day. The Regulation recognises that "the IRB Concussion Guidelines highlight the heightened risk of concussion and its complications in children and adolescent (less than 18 years of age) Players. Extra caution must be taken to prevent such Players returning to play or continuing playing or training if any suspicion of concussion exists". This recognises the dangers of receiving a second head injury particularly in children and adolescents. 5.2 IRB Support for the Zurich Consensus The Zurich Consensus Group is an international group that leads on concussion issues in sport. It is composed of medical experts in the field and sports medicine specialists from the following sports organisations, FIFA, NFL, IIHF and IRB. The IRB has been a contributor to and sponsor of the last two consensus group statement meetings. The science of concussion is at present still developing and to the layman it can appear at times to be imprecise; it is vital that the IRB continues to contribute and influence the developing clinical process of concussion management. There have been four editions of the Zurich Consensus (2001, 2004, 2008, 2013); the IRB Chief Medical Officer has been one of the lead authors in the last two consensus statements. 5.3 IRB Working Group on Concussion Following the first Annual IRB Medical Conference in 2009 a number of working groups were established one of which focused on concussion. The group examined the first Zurich Consensus statement and developed an IRB Guideline based upon the recommendations in that document. The Guideline was completed in 2011 and can be found at www.irbplayerwelfare.com. The guideline is divided into two distinct sections to recognise the difference between the elite game, where there is close medical supervision, and the amateur environment, where it is more difficult to supervise injury management. For the amateur game the Guideline is clear: if there is any doubt about a head injury remove the player from play, seek medical advice and have a graduated return to play (GRTP) when symptom free with medical clearance. If that is not possible the player must have a 30-­‐day stand down period from playing the game. For those games covered by health care professionals the graduated return to play can start as soon as the player is symptom free, which means the Player can return to play a minimum of six days following the injury incident. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 10 of 47 Protecting Players from Head Injuries 5.4 Pitch Side Suspected Concussion Assessment (PSCA) One of the difficulties experienced in the professional game was an appropriate time for health care professionals to assess whether a player had signs and symptoms of concussion. Prior to 2012, once a player left the field of play for a medical assessment (apart from a blood injury) and was replaced by another player that player was not allowed to return to the field of play. In this scenario players were reluctant to leave the field even if they knew they had symptoms of a head injury. In 2011, a Pitch-­‐side Concussion Assessment (PSCA) Working Group was established following a recommendation made and approved at the annual Medical Commission Conference. As a result the group developed a PSCA Tool that introduced a standardised pitch-­‐side assessment for suspicious head injuries. The PSCA was not intended to replace the clinical judgement of team physicians attending players with head injuries but rather to support their decision-­‐making process in reaching their clinical judgement. The PSCA Tool incorporates a symptom checklist, a cognitive assessment and an evaluation of balance. In 2012, the IRB EXCO and Council approved a PSCA trial that allowed a player to leave the field of play and be temporarily replaced for period of 5 minutes whilst a PSCA was undertaken. This trial continues through to the end of 2013 and forms part of a larger research project. The trial PSCA Procedures and Definitions are included as Appendix 10. The trial is supported by the Game Analysis Unit so that the process can be monitored. Unions participating in the trial are required to sign a standard set of Terms and Conditions (see Appendix 11). 5.4 Guidelines Under Review The PSCA Working Group is also reviewing the Guidelines, and in particular, the GRTP for children and adolescents. There will also be clear guidance for those with no medical training about "Recognising" potential concussions and "Removing" injured Players from play. The Guidelines will continue to develop on the basis of recommendations made by the international consensus group on concussion in sport . 5.5 The Role of Education Two on-­‐line resources have been developed related to the management of concussion as a result of the IRB Concussion Working Group which were developed in 2011. They can be viewed at www.irbplayerwelfare.com/Player Welfare Education/Concussion Education Modules . The two modules are titled: •
•
Concussion Management-­‐ Medical Practitioner and/or Health Care Professional IS present. Concussion Management-­‐ Medical Practitioner and/or Health Care Professional NOT present. The resource is interactive with video clips and an on-­‐line assessment test. 5.6 Long-­‐term Effects of Head Injuries The IRB has financed a research project which will examine the long term health outcomes of elite and community based Rugby Players compared with non-­‐contact sport athletes. It is hoped that this research will identify if long-­‐term issues related to head injuries exist within Rugby. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 11 of 47 Protecting Players from Head Injuries Summary The IRB has undertaken a significant amount of work related to head injury prevention and the management of head injuries to prevent further injuries. This takes the forms of Regulations, Laws and Guidance for those who apply the requirements of Regulations and Laws. The IRB has funded a number of ongoing research projects to assist in the development of policies and procedures related to head injuries. Additionally, Guidelines and education modules have been produced and promulgated throughout the Rugby community. The purpose of this paper was to summarise the research, education and training undertaken by the IRB in relation to the prevention of head injuries and to show that, from a risk management perspective, it was at the forefront of activities being carried out by international sports governing bodies. A summary matrix of prevention and management strategies for head injuries is included as Appendix 12. Commentary by Dr Colin Fuller, IRB Safety Management Consultant. There is a well-­‐established hierarchy of controls system that is used by all well-­‐managed organisations for managing organisational risks. In general terms, the hierarchy of controls principle provides six levels or types of control measure, which should be taken into consideration when definng a risk control strategy. The higher up the list a control measure appears, the larger the number of ‘at risk people’ who are protected. An assessment of the actions taken by the International Rugby Board (IRB) and which have been discussed in detail within this document would therefore serve to establish whether the IRB has also adopted the heirarchy of controls principle. Level 1 – Eliminate the hazard: eliminating significant head injuries, such as brain injuries and severe concussion, from rugby is an established and documented objective of the IRB. To this purpose, the IRB has modified the Laws of the Game to minimise the risk of injuries to the head. This has been achieved through, for example changing the Laws of the Game to ban hazardous player-­‐to-­‐player situations, such as spear tackles, short-­‐arm tackles and tackles above the line of the shoulder. Level 2 – Enclosing/modifying potential sources of risk: the aim here is to separate people from sources of risk. The advantage of this approach is that once the measures are in place they require little or no monitoring. The IRB has adopted this approach in several ways, for example: (i) introducing padding to goal posts, and (ii) establishing impact specifications for artificial turf pitches. Level 3 – Safe systems of operation: good safe systems consist of clearly written procedures that are understood by all and which are implemented and monitored by effective supervisors. This is an area of rugby that is very well managed by the IRB; they have the ‘Laws of the Game’ which define how rugby should be played and, within these Laws, player safety is a major factor. The Laws are implemented by well-­‐trained and assessd officials, who are assessed on their performance in an on-­‐
going review process. Additionally, the IRB provides an excellent range of worldwide training programmes for players, coaches and officials in the interpretation and implementation of the Laws of the Game. Level 4 – Modification of behaviour: whatever control measures are put in place, their use and application will always depend on the people who are intended to use them and the people who should ensure their implementation. If a controlling body develops a series of control measures but fails to support their implementation, they will quickly fall into disrepute. The IRB has a strong ethos 130723 SG IRB Player Welfare -­‐ Head Injuries Page 12 of 47 Protecting Players from Head Injuries for the safety of the game of rugby. The IRB operates within five ‘core values’, two of which are specifically related to player safety; namely – ‘integrity’ and ‘respect’. ‘Integrity’ advocates honesty and fair play among players; while ‘Respect’ advocates that players should respect both their own team mates and their opponents. The IRB also has very effective on-­‐pitch and post-­‐match punishment sytem for players who transgress any safety aspect of the Laws of the Game in order to emphasise the importance that the IRB places on player safety issues. Level 5 – Personal protective equipment: it is undesirable for personal protective equipment to provide the sole source of protection against injury, however, it can provide point-­‐of-­‐contact protection in some cases. The IRB has established specifications headgear and clearly defined which types of injury the equipment provides protection from and which types of injury the equipment provides little or no protection. Level 6 – Injury surveillance: monitoring and health surveillance should always be the last line of defence in any control strategy, as the existence of an injury effectively identifies conditions of failure in control. However, injury surveillance studies provide the prime source of information about whether the other control strategies are working and whether they are providing the level of protection planned. Injury surveillance studies also identify emerging and developing risks and in this respect they provide an essential aspect of the heirarchy of controls. The above brief discussion of the heirarchy of controls principle and the brief review of the IRB risk control approach demonstrates that the IRB is following best practice in terms of addressing the risk of head injuries in the game of rugby and the development of control measures to minimise the risk is appropriate and proportionate. 130723 SG IRB Player Welfare -­‐ Head Injuries Page 13 of 47 Protecting Players from Head Injuries Appendix 1 Law 10.4 Dangerous play and misconduct (a) Punching or striking. A player must not strike an opponent with the fist or arm, including
the elbow, shoulder, head or knee(s).
Sanction: Penalty kick
(b) Stamping or trampling. A player must not stamp or trample on an opponent.
Sanction: Penalty kick
(c) Kicking. A player must not kick an opponent.
Sanction: Penalty kick
(d) Tripping. A player must not trip an opponent with the leg or foot.
Sanction: Penalty kick
(e) Dangerous tackling. A player must not tackle an opponent early, late or dangerously.
Sanction: Penalty kick
A player must not tackle (or try to tackle) an opponent above the line of the shoulders even if the
tackle starts below the line of the shoulders. A tackle around the opponent’s neck or head is
dangerous play.
Sanction: Penalty kick
A ‘stiff-arm tackle’ is dangerous play. A player makes a stiff-arm tackle when using a stiff-arm to
strike an opponent.
Sanction: Penalty kick
Playing a player without the ball is dangerous play.
Sanction: Penalty kick
A player must not tackle an opponent whose feet are off the ground.
Sanction: Penalty kick
(f) Playing an opponent without the ball. Except in a scrum, ruck or maul, a player who is not
in possession of the ball must not hold, push or obstruct an opponent not carrying the ball.
Sanction: Penalty kick
(g) Dangerous charging. A player must not charge or knock down an opponent carrying the ball
without trying to grasp that player.
130723 SG IRB Player Welfare -­‐ Head Injuries Page 14 of 47 Protecting Players from Head Injuries Sanction: Penalty kick
(h) A player must not charge into a ruck or maul. Charging includes any contact made without use
of the arms, or without grasping a player.
(i) Tackling the jumper in the air. A player must not tackle nor tap, push or pull the foot or feet
of an opponent jumping for the ball in a lineout or in open play.
Sanction: Penalty kick
(j) Lifting a player from the ground and dropping or driving that player into the ground whilst that
player's feet are still off the ground such that the player's head and/or upper body come into
contact with the ground is dangerous play.
Sanction: Penalty kick
(k) Dangerous play in a scrum, ruck or maul. The front row of a scrum must not rush against
its opponents.
Sanction: Penalty kick
Front row players must not intentionally lift opponents off their feet or force them upwards out of
the scrum.
Sanction: Penalty kick
Players must not charge into a ruck or maul without binding onto a player in the ruck or maul.
Sanction: Penalty kick
Players must not intentionally collapse a scrum, ruck or maul.
Sanction: Penalty kick
(l) Retaliation. A player must not retaliate. Even if an opponent is infringing the Laws, a player
must not do anything that is dangerous to the opponent.
Sanction: Penalty kick
(m) Acts contrary to good sportsmanship. A player must not do anything that is against the
spirit of good sportsmanship in the playing enclosure.
Sanction: Penalty kick
(n) Misconduct while the ball is out of play. A player, must not, while the ball is out of play,
commit any misconduct, or obstruct or in any way interfere with an opponent.
Sanction: Penalty kick
130723 SG IRB Player Welfare -­‐ Head Injuries Page 15 of 47 Protecting Players from Head Injuries The sanction is the same as for sections 10.4 (a)-(m) except that the penalty kick is awarded at
the place where play would restart. If that place is on the touchline or within 15 metres of it, the
mark for the penalty kick is on the 15-metre line, in line with that place.
If play would restart at a 5-metre scrum, the mark for the penalty kick is at that place of the
scrum.
If play would restart with a drop-out, the non-offending team may choose to take the penalty kick
anywhere on the 22-metre line.
If a penalty kick is awarded but the offending team is guilty of further misconduct before the kick
is taken, the referee cautions or orders off the guilty player and advances the mark for the penalty
kick 10 metres. This covers both the original offence and the misconduct.
If a penalty kick is awarded to a team but a player of that team is guilty of further misconduct
before the kick is taken, the referee will caution or send-off the guilty player, declare the kick
disallowed, and award a penalty kick to the opposing team.
If an offence is committed outside the playing area while the ball is still in play, and if that offence
is not covered by any other part of this Law, the penalty kick is awarded on the 15-metre line, in
line with where the offence happened.
(o) Late-charging the kicker. A player must not intentionally charge or obstruct an opponent
who has just kicked the ball.
Sanction: The non-offending team may choose to take the penalty kick either at the place of
infringement, where the ball lands or or where it was next played
Place of infringement. If the infringement takes place in the kicker’s in-goal, the penalty kick is
taken 5 metres from the goal line in line with the place of infringement but at least 15 metres from
the touchline.
The non-offending team may also choose to take the penalty where the ball lands or is next played
before landing and at least 15 metres from the touchline.
Where the ball lands. If the ball lands in touch, the mark for the optional penalty kick is on the
15-metre line, in line with where it went into touch. If the ball lands, or is next played before
landing, within 15 metres of the touchline, the mark is on the 15-metre line opposite where the
ball landed or was played.
If the ball lands in the in-goal, in touch-in-goal, or on or over the dead ball line, the mark for the
optional penalty kick is 5 metres from the goal line, in line with the place where the ball crossed
the goal line and at least 15 metres from the touchline.
130723 SG IRB Player Welfare -­‐ Head Injuries Page 16 of 47 Protecting Players from Head Injuries If the ball hits a goal post or crossbar, the optional penalty kick is awarded where the ball lands on
the ground.
(p) Flying Wedge and Cavalry Charge. A team must not use the ‘Flying Wedge’ or the ‘Cavalry
Charge’.
Sanction: Penalty kick at the place of the original infringement.
‘Flying Wedge’. The type of attack known as a ‘Flying Wedge’ usually happens near the goal line,
when the attacking team is awarded a penalty kick or free kick.
The kicker tap-kicks the ball and starts the attack, either by driving towards the goal line or by
passing to a team-mate who drives forward. Immediately, team mates bind on each side of the
ball carrier in a wedge formation. Often one or more of these team mates is in front of the ball
carrier. A ‘Flying Wedge’ is illegal.
Sanction: Penalty kick at the place of the original infringement.
‘Cavalry Charge’. The type of attack known as as a 'Cavalry Charge' usually happens near the
goal line, when the attacking team is awarded a penalty kick or free kick. Either a single player
stands some distance behind the kicker, or attacking players form a line across the field some
distance behind the kicker.
These attacking players are usually a metre or two apart. At a signal from the kicker, they charge
forward. When they get near, the kicker tap-kicks the ball and passes to a player who had started
some distance behind the kicker.
Sanction: Penalty kick at the place of infringement
(q) Advantage may be played for acts of foul play, but if the offence prevents a probable try, a
penalty try must be awarded.
(r) For an offence reported by an assistant referee a penalty kick may be awarded where the
offence occurred, or advantage may be played.
(s) All players must respect the authority of the referee. They must not dispute the referee’s
decisions. They must stop playing at once when the referee blows the whistle except at a kick-off
or at a penalty kick following admonishment, temporary suspension, or send-off.
Sanction: Penalty kick
130723 SG IRB Player Welfare -­‐ Head Injuries Page 17 of 47 Protecting Players from Head Injuries APPENDIX 2 REGULATION 12. PROVISIONS RELATING TO PLAYERS’ DRESS
For all matches, Unions, Associations, Rugby Bodies, Clubs, Players and
Persons must ensure that the provisions relating to Players’ dress, set out
in this Regulation, and the specifications set out in Schedule 1, are
complied with in full. The Council may, from time to time, supplement,
amend and/or modify, in whole or in part, the provisions relating to
Players’ dress set out in this Regulation and/or the specifications set out
in Schedule 1.
Below are the two IRB Approved Clothing labels. Both are valid and on
display on the IRB Player Welfare website (www.irbplayerwelfare.com).
IRB Approved Clothing Labels 130723 SG IRB Player Welfare -­‐ Head Injuries Page 18 of 47 Protecting Players From Head Injuries 3 Requirements – Headgear 3.1 Ergonomics Headgear should be designed and constructed to minimise discomfort for the wearer. All normal playing movements shall not be impeded by wearing the headgear. 3.2 3.2.1 Construction Construction Materials It is the manufacturer’s responsibility that all materials used in the construction of the headgear should not be significantly affected by ultra-­‐violet radiation, water, dirt, perspiration, toiletries, household soaps and detergents. All materials coming into contact with the wearer’s body will not be of the type known to cause skin disorders and shall not cause abrasion of either the wearer or other players. 3.2.2 Padding Materials Padding materials must be homogeneous padding facing towards the wearer should be the same texture, hardness and density as that facing the opponent). Foam padding of sandwich construction is not allowed. 3.2.3 Finish Headgear shall be so constructed that it is unlikely to cause any injury to the wearer or other players during play. There shall not be hard or sharp edges, seams, buckles or other items on the surface of the product that could harm the wearer or other players during normal use. 3.3 3.3.1 Design Zones of Coverage The headgear must have zones of coverage that cover the crown, temple, forehead (sweatband area) and ear areas. The zones of coverage shall fulfil the requirements of the impact performance specification (Section 3.4.1) and have a maximum padding thickness of 10mm+2mm tolerance band plus an additional allowance of 1mm on each side for fabric. The typical dimensions of the zones of coverage are given in Table 1. Areas outside designated zones of coverage do not have to meet impact requirements but must be of soft foam or leather and be less than or equal to 5mm in thickness. Where this overall thickness consists of padded material covered by fabric, 0.5 cm is the maximum measured thickness for the combination of the uncompressed padding and the fabric. The fabric can contribute up to a maximum measured thickness of 1 mm on each side of the padding. All padding materials must have a density not greater than 45 kg/m3 + 15 kg/m3 tolerance band. Table 1. Typical Dimensions of Zones of Coverage for Headgear Dimensions
XXS mm
XS mm
S mm
M mm
L mm
XL mm
XXL mm
130603 SG IRB Player Welfare -­‐ Head Injuries Page 19 of 47 Protecting Players From Head Injuries B
56
58
63
70
75
75
75
C
81
85
89
97
104
106
108
D
132
136
140
147
155
158
160
E
50
50
50
50
50
50
50
F
> 25
> 25
> 25
> 25
> 25
> 25
> 25
G*
25
to
30
25
to
30
25
to
30
25
to
30
25
to
30
25
to
30
25
to
30
*see Ear Aperture section 3.3.2
130603 SG IRB Player Welfare -­‐ Head Injuries Page 20 of 47 Protecting Players From Head Injuries Figure 1. Typical zones of Coverage for Headgear Sizes are based on the following: Table 2. Head sizes Diameter
(cm)
50
51
52
53
54
55
56
57
58
59
60
61
62
63
Size
6¼
6⅜
6½
6⅝
6¾
6⅞
7
7⅛
7¼
7⅜
7½
7⅝
7¾
7⅞
XXS
XS
S
M
L
XL
XXL
3.3.2
Ear Aperture The ear aperture of the headgear shall have a linear dimension (G) not less than 25mm and not more than 30mm. It may have a cross mesh or similar design characteristic but this must not significantly affect the hearing of the wearer. Where a cross mesh is used, the linear dimension of any ear apertures shall not exceed 30 mm. 3.3.3 Vision Horizontal field: the headgear shall provide peripheral vision clearance of at least 105° to each side of the longitudinal vertical line (median plane) when the headgear is positioned in accordance with the Manufacturer’s Instructions (see Figure 2). Vertical field: the headgear shall provide peripheral vision clearance of 25° above the Apex plane when the headgear is positioned in accordance with the Manufacturer’s Instructions. Vision will not be hindered below the Apex plane (see Figure 3). 130603 SG IRB Player Welfare -­‐ Head Injuries Page 21 of 47 Protecting Players From Head Injuries Figure 2. Horizontal Field of Vision Requirement Figure 3. Vertical Field of Vision Requirement 130603 SG IRB Player Welfare -­‐ Head Injuries Page 22 of 47 Protecting Players From Head Injuries 3.3.4 Ventilation It is the manufacturer’s responsibility to provide for adequate ventilation in the headgear design. 3.3.5 Retention System The retention system should be attached so that the headgear remains in its normal position during play. The chin strap that secures the headgear should be affixed to both sides of the headgear and pass under the lower jaw in close proximity to the jaw and the neck. The minimum width of the chin strap shall be 15 mm. Buckles or similar hard fixings may not be used. Rubber buttons or Velcro® type fixing materials are acceptable. 3.4 Performance Requirements 3.4.1 Impact Attenuation When tested in accordance with the procedures specified in Section 4.3, the peak acceleration of impacts delivered to test locations shall not be less than 200g. 3.4.2 Retention System Strength When tested in accordance with Section 4.4, the strap should stay intact and closed when loaded with a 7 kg mass but should fail when strained dynamically by an additional mass of 10 kg allowed to fall through 300mm. 3.4.3 Retention System Effectiveness When tested in accordance with the procedures specified in Section 4.5 the headgear may shift but not roll off the wearer’s head when initially subject to a static load of 3 kg followed by an additional dynamic load exerted by a 4 kg load falling through 175mm. 4. Test Methods and Procedures – Headgear 4.1 Sampling Three (3) test specimens of each size shall be submitted by Manufacturers, complete with ‘Information supplied by the Manufacturers’ (see section 9). Two specimens shall be used for impact attenuation testing at the various conditions and one for retention system testing. 4.2 Conditioning of Specimens Prior to impact testing, one specimen will be exposed to ambient conditions and another to high temperature conditions as follows: (i) Ambient Temperature -­‐ one sample is conditioned by exposing it to a temperature of 20°C +/-­‐ 2°C and relative humidity condition of rh60% +/-­‐ 5% for a period of between 4 and 24 hours. (ii) High Temperature -­‐ the second is conditioned by exposing it to a temperature of 50°C +/-­‐2°C and relative humidity condition of rh60% +/-­‐ 5% for a period of between 4 and 24 hours. All testing shall be conducted within 5 minutes of removal from the conditioning environment. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 23 of 47 Protecting Players From Head Injuries 4.3 Impact Attenuation Testing 4.3.1 Principle The headgear is mounted on the test headform so that the headform can be oriented in different positions and dropped onto a flat impact surface. The acceleration and time history of the impact are recorded using a tri-­‐axial accelerometer and appropriate instrumentation. Peak acceleration and time duration data obtained using the methods specified in Section 4.3.4 are used to determine the impact characteristics of the headgear. 4.3.2 Apparatus The apparatus for the impact attenuation test shall consist of the following (also see Figure 4): Headforms – All headforms used will be to EN 960, be of metal and have a low resonance frequency (but not lower than 3kHz). Anvil – the anvil shall consist of a flat steel surface of diameter 130mm +/-­‐3mm and not have a resonance frequency liable to affect measurements. The centre of mass of the drop head form shall lie over the centre of the anvil. Guide Assembly – a headform shall be attached to a free fall or rail guided drop assembly carriage by an adjustable mounting or other means that will allow impacts to be delivered at any prescribed point on the headgear. Accelerometer – a set of three accelerometers in a three axis array are mounted at or close to the centre of gravity of the test headform when the headform is mounted in the free fall carriage assembly. Impact Recording and Displaying Instrumentation – the impact shall be recorded and displayed on a storage oscilloscope with specified deflection factors, sweep speed per division and bandwidth for each of the accelerometers and be capable of resolving the gmax of the headform. Equivalent instrumentation capable of recording, displaying and storing the impact signal from the accelerometers shall meet this requirement. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 24 of 47 Protecting Players From Head Injuries Figure 4. Typical apparatus for Impact Testing of Headgear 4.3.3 Reference Testing A flat MEP (modular elastomer programmer) reference surface will be used measuring 150mm diameter, 25mm thick mounted on a matching steel base. The headform will be dropped onto the MEP impact surface from a distance 300mm +/-­‐ 5mm. Resolved gmax values recorded by the accelerometer on three successive drops shall lie within +/-­‐ 10g of the mean. 4.3.4 Impacting The headgear is matched for best fit to the testform according to the manufacturers recommendations. Each headgear is impacted where additional padding has been applied within the specified zones of coverage (crown, forehead and temple/sweatband areas). An energy level of 13.8J will be used for impact. This is equivalent to the ‘J’ headform falling through 300mm. The height of fall will be adjusted for each headform mass. Note: Mass of headforms used are A -­‐ 500 mm -­‐ 3.1Kg ± 0.10 E -­‐ 540 mm -­‐ 4.1Kg ± 0.10 J -­‐ 570 mm -­‐ 4.7Kg ± 0.14 M -­‐ 600 mm -­‐ 5.6Kg ± 0.16 O -­‐ 620 mm -­‐ 6.1Kg ± 0.18 The impact zones will be: 130603 SG IRB Player Welfare -­‐ Head Injuries Page 25 of 47 Protecting Players From Head Injuries Once, where crown padding is provided. Twice where forehead padding is provided. Twice where temple padding is provided. Figure 5. Impact locations on Headgear 4.3.5 Calculations Maximum acceleration The maximum peak acceleration is calculated by measuring the perpendicular distance to the trace baseline from the midpoint of the resultant trace at maximum excursion and multiplying by the sensitivity factor. The sensitivity factor is defined as g per division deflection of the trace. 4.3.6 Duration of Impulse Determine the duration of the pulse by measuring the total width of the trace along the 150g line in milliseconds. 4.4 Retention System Testing – Strength 4.4.1 Principle The chin strap of the headgear is subjected to two loads. The first a static load of 7 kg to which the strap will not open or break. The second is an additional load which falls dynamically to apply a sudden downward load causing the strap to open or break. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 26 of 47 Protecting Players From Head Injuries 4.4.2 Apparatus A suitable set-­‐up is shown in Figure 6. The headgear is positioned on a test headform (to EN 960 and without hair). A support is provided for the headform. A vertical guide assembly with anvil is attached below the headgear with two round pins of diameter 12mm and 76mm apart (between centres). The total mass of the guide assembly with anvil is 7 kg +/-­‐ 0.02 kg. A drop weight of 10 kg +/-­‐ 0.02 kg can be moved up the guide assembly and dropped onto the anvil in a substantially frictionless fall through a distance of 300 mm +/-­‐ 5 mm. Figure 6. Apparatus for Test of Retention System Strength 4.4.3 Procedure The headgear is mounted on the test headform and the retention system is adjusted so the headgear is securely positioned. The guide assembly is attached to the chin strap of the headgear. The mass falling through 300mm to the guide assembly anvil exerts a dynamic force under which the strap fails. If the strap fails under the static load, it will be deemed ‘failed’. If the strap fails when additionally subjected to the dynamic load it will be deemed ‘passed’. If the strap does not fail under both static and dynamic load it will be deemed ‘failed’. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 27 of 47 Protecting Players From Head Injuries 4.5 Retention System Testing – Effectiveness 4.5.1 Principle The headgear positioned on a headform is subjected to a tangential force at the rear edge of the headgear in a forward direction. The resulting shock places a rotational load on the headgear. The headgear may be shifted but must not roll off. Figure 7. Typical Apparatus for Retention System Effectiveness 4.5.2 Apparatus A typical apparatus is shown in Figure 7. The headform (to EN 960 without hair) is mounted on a stand in the upright position. To this is fitted the headgear according to manufacturers instructions. A vertical guide assembly weighing 3 kg +/-­‐ 0.02 kg in total is attached via a cable or strapping* to a hook which attaches to the rear of the headgear. A drop weight of 4 kg +/-­‐ 0.02 kg can be moved up the guide assembly and dropped onto the anvil in a substantially frictionless fall through a distance of 175 mm +/-­‐ 5 mm. *Note: The cable or strapping shall be of a material having an elongation of no more than 5mm per 300mm when loaded with a 22 kg weight in the free hanging position. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 28 of 47 Protecting Players From Head Injuries 4.5.3 Procedure The headgear is mounted on the headform and the retention system adjusted so as to obtain the best fit. The hook is attached to the rear of the headgear to which is attached the guide assembly weighing 3 kg. The drop weight of 4 kg falls through 175mm +/-­‐ 5mm before it hits the anvil. The headgear may be shifted but must not roll off the headform. The retention system is readjusted and the test is repeated one more time. If the headgear rolls off, the test will be deemed a fail 130603 SG IRB Player Welfare -­‐ Head Injuries Page 29 of 47 Protecting Players From Head Injuries Appendix 3 MEMORANDUM To: Referees Citing Commissioners Judicial Officers Non-­‐legal Judicial Committee Members From: Paddy O’Brien, IRB Referee Manager Tim Gresson, IRB Judicial Panel Chairman Date: 8 June 2009 Subject: Dangerous Tackles In 2007, the IRB Council approved a Laws Designated Members Ruling which essentially made it clear that tackles involving a player being lifted off the ground and tipped horizontally and were then either forced or dropped to the ground are illegal and constitute dangerous play. At a subsequent IRB High Performance Referee Seminar at Lensbury referees were advised that for these types of tackles they were to start at red card as a sanction and work backwards. Unfortunately these types of tackles are still being made and the purpose of this memorandum is to emphasize that they must be dealt with severely by referees and all those involved in the off-­‐field disciplinary process. Attached is a recent decision of the Judicial Officer Jannie Lubbe SC, in which the differences between the application of the red card test by referees and judicial personnel is highlighted. In our view, this decision correctly highlights that the lifting of players in the tackle and then either forcing or dropping them to the ground is dangerous and must be dealt with severely. To summarise, the possible scenarios when a tackler horizontally lifts a player off the ground: • The player is lifted and then forced or “speared” into the ground. A red card should be issued for this type of tackle. • The lifted player is dropped to the ground from a height with no regard to the player’s safety. A red card should be issued for this type of tackle. • For all other types of dangerous lifting tackles, it may be considered a penalty or yellow card is sufficient. Referees and Citing Commissioners should not make their decisions based on what they consider was the intention of the offending player. Their decision should be based on an objective assessment (as per Law 10.4 (e)) of the circumstances of the tackle. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 30 of 47 Protecting Players From Head Injuries Appendix 4 A M E N D E D M E M O R A N D U M TO: Referees Citing Commissioners Judicial Officers Non legal Judicial Committee Members FROM: Paddy O’Brien, IRB Referee Manager Tim Gresson, IRB Judicial Panel Chairman DATE: 4 August 2011 SUBJECT: (i) DANGEROUS TACKLES (HIGH TACKLES) and (ii) DANGEROUS GRASPING OF NECK AND/OR HEAD AREA OF PLAYER NOT IN POSSESSION OF THE BALL ___________________________________________________________________ NOTE: THIS MEMORANDUM REPLACES THE MEMORANDUM OF 21 JANUARY 2011 RELATING TO DANGEROUS TACKLES (HIGH TACKLES) ___________________________________________________________________ This is a further memorandum in relation to Dangerous Tackles and the illegal taking out of players who are not in possession of the ball. Law 10.4(e) in relation to Dangerous Tackles provides as follows: A player must not tackle an opponent early, late or dangerously. A player must not tackle (or try to tackle) an opponent above the line of the shoulders even if the tackle starts below the line of the shoulders. A tackle around the opponent’s neck or head is dangerous play. A stiff-­‐arm tackle is dangerous play. A player makes a stiff-­‐arm tackle when using a stiff-­‐arm to strike an opponent. Playing a player without the ball is dangerous play. A player must not tackle an opponent whose feet are off the ground. High Tackles: At an IRB Medical Seminar held in November 2010 at Lensbury the results of studies by the Rugby Football Union and New Zealand Rugby Football Union concluded that most injuries in Rugby in the elite Game are now occurring as a result of high tackles. The participants generally recognised that tackles above the line of the shoulders have the potential to cause serious injury and noted that a trend had emerged whereby players responsible for such tackles were not being adequately sanctioned. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 31 of 47 Protecting Players From Head Injuries Dangerous Grasping: A further trend has recently emerged in the Game whereby players not in possession of the ball are being grasped and/or grabbed by an opponent in and around the neck and/or head area, principally in an effort to clear out players from the breakdown. While such behaviour does not come under the definition of a tackle, as no ball carrier is involved nevertheless, it is dangerous play under Law 10.4(e) and/or Law 10.4(f) (playing an opponent without the ball). The purpose of this revised Memorandum is to emphasise that as with tip tackles, (see Memorandum of 8 June 2009) this type of dangerous play must be dealt with severely by Referees and all those involved in the off-­‐field disciplinary process. As with other types of Illegal and/or Foul Play, depending on the circumstances of the high tackle or the illegal and dangerous taking out of players not in possession of the ball, the range of sanctions can extend from a penalty kick to the player receiving a red card. An illegal high tackle to the head and/or neck area of the opponent (in particular involving a ‘stiff arm’ or swinging arm), bears all the hallmarks of an action which should result in a yellow card or a red card being seriously considered. The grasping and twisting of the neck and/or head area of a player to effect either a tackle or to clear out a player not in possession of the ball should also be regarded as constituting serious Illegal and/or Foul Play and Match Officials and Judicial Personnel have a responsibility to ensure that the appropriate action is taken by them. Referees and Citing Commissioners should not make their decisions based on what they consider was the intention of the offending player. Their decision should be based on an objective assessment (as per Law 10.4(e) and Law 10.4(f)) of the overall circumstances of the tackle or the clear out. Paddy O’Brien Tim Gresson 1 This was the subject of the earlier Memorandum of 21 January 2011, now replaced by this Memorandum of 4 August 2011. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 32 of 47 Protecting Players From Head Injuries Appendix 5 Extract from Trial TMO Protocol related to Potential Acts of Foul Play 4. Potential acts of foul play 4.1. The match officials may suggest that the referee refers the matter to the TMO for review if they observe an act of foul play where: • They may have only partially observed an act or acts of foul play • They are unsure of the exact circumstances • The views of the match officials reporting the act(s) of foul play differ • There is doubt as to the appropriate sanctions to be applied 4.2. If the referee agrees to refer the matter to the TMO he will indicate that he wishes the TMO to review the potential act(s) of foul play and to make a recommendation as to the appropriate sanction(s). 4.3. In reviewing the potential offence the TMO must use the criterion on each occasion that the infringement must be clear and obvious especially where sanctions may apply where a player is removed from the field of play either temporarily or permanently. 4.4. The other match officials may utilise the in stadium screens (where available) to form a judgement in this matter. In accordance with Law 6.A.4, the referee will remain the sole judge of fact and Law during a match. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 33 of 47 Protecting Players From Head Injuries Appendix 6 The Role of the Citing Commissioner 17.9 Matches where a Citing Commissioner is appointed 17.9.1 Citing Commissioners shall be entitled to cite a Player for any act(s) of Foul Play which in the opinion of the Citing Commissioner warranted the Player concerned being Ordered Off. 17.9.2 Citing Commissioners may cite Players for an act(s) of Foul Play where such act(s) may have been detected by the referee or assistant referee and which may have been the subject of referee action. A Citing Commissioner may not cite a Player for an act(s) of Foul Play in respect of which the Player has been Ordered Off save where the Ordering Off is as a result of two yellow cards. A Player in that situation may also be cited for the act(s) of Foul Play which resulted in either or both yellow card(s). 17.9.3 Citing Commissioners may cite a Player if he has been Temporarily Suspended. Such citing may be made in respect of the incident(s) for which the Player was Temporarily Suspended or otherwise. 17.9.4 Citing Commissioners shall act independently of the Disciplinary Committee or Judicial Officer and of the Match Officials of a Match or other Citing Commissioners. 17.9.5 Citing Commissioners may be in attendance at the Match for which they are appointed. Where a Citing Commissioner is not present at the Match, there shall be a suitably qualified and experienced Citing Commissioner Liaison Officer in attendance at the Match who is able to provide the Citing Commissioner in accordance with the applicable timeframe with the relevant information and back-­‐up required to assist the Citing Commissioner with his duties. 17.10 Union referral to Citing Commissioner 17.10.1 Where a Citing Commissioner has been appointed, the Union or other affiliated organisation responsible for the management of either participating team in a Match shall not have the power to cite a Player for Foul Play but may refer any incident of alleged Foul Play to the Citing Commissioner for consideration. Such incident shall ordinarily be referred to the Citing Commissioner within 12 hours of the Match in which the incident is alleged to have occurred. 17.10.2 A Citing Commissioner's decision as to whether a Player should be cited, whether as the result of an incident referred to him or otherwise, shall be final. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 34 of 47 Protecting Players From Head Injuries Appendix 7 Regulation 17 Discipline -­‐ Sanctions IRB SANCTIONS FOR FOUL PLAY (REGULATION 17)
Law No.
Description
Entry Point Based on Scale
of Seriousness of the
Player’s conduct, which
constitutes the offending –
Lower End (LE),
Mid Range (MR),
Top End (TE).
Maximum
Sanction
10.4(s)
10.4(m)
Verbal Abuse of Match Officials
LE – 6 weeks
MR – 12 weeks
TE – 18+weeks
52 weeks
10.4(s)
10.4(m)
Threatening Actions or Words
at Match Officials
LE – 12 weeks
MR – 24 weeks
TE – 48+ weeks
260 weeks
10.4(s)
10.4(m)
Physical Abuse of Match
Officials
LE – 24 weeks
MR – 48 weeks
TE – 96+ weeks
Life
10.4(a)
Striking another Player with a
hand, arm or fist
LE – 2 weeks
MR – 5 weeks
TE – 8+ weeks
52 weeks
10.4(a)
Striking another Player with the
elbow
LE – 2 weeks
MR – 5 weeks
TE – 9+ weeks
52 weeks
10.4(a)
Striking with knee
LE – 3 weeks
MR – 8 weeks
TE – 12+ weeks
52 weeks
10.4(a)
Striking with head
LE – 4 weeks
MR – 10 weeks
TE – 16+ weeks
104 weeks
10.4(b)
Stamping/Trampling on an
Opponent
LE – 2 weeks
MR – 5 weeks
TE – 9+ weeks
52 weeks
10.4(c)
Kicking an Opponent
LE – 4 weeks
MR – 8 weeks
TE – 12+ weeks
52 weeks
130603 SG IRB Player Welfare -­‐ Head Injuries Page 35 of 47 Protecting Players From Head Injuries Law No.
Description
Entry Point Based on Scale
of Seriousness of the
Player’s conduct, which
constitutes the offending –
Lower End (LE),
Mid Range (MR),
Top End (TE).
Maximum
Sanction
10.4(d)
Tripping an Opponent with the
foot/leg
LE – 2 weeks
MR – 4 weeks
TE – 8+ weeks
52 weeks
10.4(e)
Dangerous tackling of an
Opponent including early or
late and including the action
known as the “stiff arm tackle”
LE – 2 weeks
MR – 6 weeks
TE – 10+ weeks
52 weeks
10.4(e)
Dangerous tackling of an
Opponent including a tackle or
attempted tackle above the line
of the shoulders even if the
tackle starts below the line of
the shoulders
LE – 2 weeks
MR – 6 weeks
TE – 10+ weeks
52 weeks
10.4(f)
Holding, pushing or obstructing
an Opponent not holding the
ball, by a Player who is not in
possession of the ball, except
in a scrum, ruck or maul
LE – 2 weeks
MR – 4 weeks
TE – 6+ weeks
52 weeks
10.4(f)
10.4(k)
Dangerous charging or
obstructing or grabbing of
Opponent without the ball,
including shouldering
LE – 2 weeks
MR – 5 weeks
TE – 10+ weeks
52 weeks
10.4(g)
Dangerous charging or
knocking down an Opponent
with the ball, including
shouldering
LE – 2 weeks
MR – 5 weeks
TE – 10+ weeks
52 weeks
10.4(h)
A player must not charge into a
ruck or maul. Charging
includes any contact made
without use of the arms, or
without grasping a player
LE – 2 weeks
MR – 5 weeks
TE – 10+ weeks
52 weeks
10.4(i)
Tackling, tapping, pushing or
pulling an Opponent jumping
for the ball in a lineout or in
open play
LE – 3 weeks
MR – 6 weeks
TE – 12+ weeks
52 weeks
130603 SG IRB Player Welfare -­‐ Head Injuries Page 36 of 47 Protecting Players From Head Injuries Law No.
Description
Entry Point Based on Scale
of Seriousness of the
Player’s conduct, which
constitutes the offending –
Lower End (LE),
Mid Range (MR),
Top End (TE).
Maximum
Sanction
10.4(j)
Lifting a Player from the ground
and either dropping or driving
that Player’s head and/or upper
body into the ground whilst the
Player’s feet are off the ground
LE – 4 weeks
MR – 8 weeks
TE – 12+ weeks
52 weeks
10.4(k)
Causing a scrum, ruck or maul
to collapse
LE – 2 weeks
MR – 4 weeks
TE – 8+ weeks
52 weeks
10.4(m)
Testicle grabbing or twisting or
squeezing
LE – 12 weeks
MR – 18 weeks
TE – 24+ weeks
208 weeks
10.4(m)
Biting
LE – 12 weeks
MR – 18 weeks
TE – 24+ weeks
208 weeks
10.4(m)
Contact with the Eye(s) or the
Eye Area
LE – 12 weeks
MR – 18 weeks
TE – 24+ weeks
208 weeks
10.4(m)
Spitting at Players
LE – 4 weeks
MR – 7 weeks
TE – 11+ weeks
52 weeks
10.4(m)
Verbal abuse of Players based
on Religion, Race, Colour, or
National or Ethnic Origin,
sexual orientation or otherwise
LE – 4 weeks
MR – 8 weeks
TE – 16+ weeks
52 weeks
10.4(m)
Any other acts (not previously
referred to) which are contrary
to good sportsmanship
LE – 4 weeks
MR – 7 weeks
TE – 11+ weeks
52 weeks
10.4(m)
Hair pulling or grabbing
LE – 2 weeks
MR – 4 weeks
TE – 6+ weeks
52 weeks
In respect of offences not referred to in Appendix 1 above, appropriate sanctions may be imposed at the discretion of the relevant Judicial Officer, Disciplinary Committee, Appeal Officer and/or Appeal Committee (as the case may be). 130603 SG IRB Player Welfare -­‐ Head Injuries Page 37 of 47 Protecting Players From Head Injuries Notwithstanding the Sanctions in Appendix 1 and/or the provisions of Regulation 17.19 in cases where the player’s actions constitute mid range or top end offending for any type of offence which had the potential to result and, in fact, did result in serious/gross consequences to the health of the victim, the Judicial Officers and/or Disciplinary Committees may impose any period of suspension including a suspension for life. Guidance to Disciplinary Committees and Judicial Officers Regulation 17 also provides guidance to Disciplinary Committees and Judicial Officers in applying sanctions taking into consideration the assessment of the seriousness of foul play and how aggravating and mitigating factors affect the sanctions applied. The following is a relevant extract from Regulation 17. Assessment of seriousness of the Foul Play 17.19.2 Disciplinary Committees or Judicial Officers shall undertake an assessment of the seriousness of the Player’s conduct that constitutes the offending and categorise that conduct as being at the lower end, mid range or top end of the scale of seriousness in order to identify the appropriate entry point for consideration of a particular incident(s) of Foul Play where such incident(s) is expressly covered in Appendix 1. The assessment of the seriousness of the Player’s conduct shall be determined by reference to the following features: (a) whether the offending was intentional or deliberate; (b) whether the offending was reckless, that is the Player knew (or should have known) there was a risk of committing an act of Foul Play; (c) the gravity of the Player’s actions in relation to the offending; (d) the nature of the actions, the manner in which the offence was committed including part of body used (for example, fist, elbow, knee or boot); (e) the existence of provocation; (f) whether the Player acted in retaliation and the timing of such; (g) whether the Player acted in self-­‐defence (that is whether he used a reasonable degree of force in defending himself); (h) the effect of the Player’s actions on the victim (for example, extent of injury, removal of victim Player from the game); (i) the effect of the Player’s actions on the Match; (j) the vulnerability of the victim Player including part of victim’s body involved/affected, position of the victim Player, ability to defend himself; (k) the level of participation in the offending and level of premeditation; (l) whether the conduct of the offending Player was completed or amounted to an attempt; and (m) any other feature of the Player’s conduct in relation to or connected with the offending. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 38 of 47 Protecting Players From Head Injuries Based on the assessment of the offence(s) under consideration against the above features of offending, the Disciplinary Committee or Judicial Officer shall categorise the act of Foul Play as being at the lower end, mid range or top end of the scale of seriousness of offending and identify the applicable entry point as set out in Appendix 1. 17.19.3 For offences categorised at the top end of the scale of seriousness of offending, the Disciplinary Committee or Judicial Officer shall identify an entry point between the period shown as the top end for the particular office and the maximum sanction in Appendix 1.1 Aggravating Factors 17.19.4 Having identified the applicable entry point for consideration of a particular incident, the Disciplinary Committees or Judicial Officers shall identify any relevant off-­‐field aggravating factors and determine what additional period of suspension, if any, above the applicable entry point for the offence should apply to the case in question. Aggravating factors include: (a) the Player’s status generally as an offender of the Laws of the Game;2 (b) the need for a deterrent to combat a pattern of offending in the Game; and (c) any other off-­‐field aggravating factor(s) that the Disciplinary Committee or Judicial Officer considers relevant and appropriate. Mitigating Factors 17.19.5 Thereafter, the Disciplinary Committee or Judicial Officer shall identify any relevant off-­‐
field mitigating factors and determine if there are grounds for reducing the period of suspension and subject to Regulations 17.19.6 and 17.19.7 the extent, if at all, by which the period of suspension should be reduced. Mitigating factors include the following: (a) the presence and timing of an acknowledgement of culpability/wrong-­‐doing by the offending Player; (b) the Player’s disciplinary record and/or good character; (c) the youth and inexperience of the Player; (d) the Player’s conduct prior to and at the hearing; (e) the Player having demonstrated remorse for his conduct to the victim Player including the timing of such remorse; and 1
2
The plus sign against each top end period suspension denotes this entitlement and flexibility.
The Player’s disciplinary record in all competitions and (as appropriate) in other sports during his playing career
from the age of 18 shall be considered by a Disciplinary Committee or Judicial Officer. In any case in which the
Disciplinary Committee or Judicial Officer establishes that the Player has previously been found by a Judicial
Officer and/or Disciplinary Committee to have committed any act of Foul Play and/or Misconduct then the
Disciplinary Committee or Judicial Officer in imposing any sanction on the Player may in fixing that sanction
take account of such offending as an aggravating factor.
130603 SG IRB Player Welfare -­‐ Head Injuries Page 39 of 47 Protecting Players From Head Injuries Appendix 8 Rugby Ready References to Head Injury Prevention •
•
•
•
•
Pre Participation -­‐ Special attention should be given to players with a history of concussion The tackle -­‐ Keeping the eyes open, position the head behind or to one side of the ball carrier -­‐ never position the head in front of the ball carrier Mouth guards -­‐ It is strongly recommended that all players should wear a mouth guard during practice sessions and matches. A good mouth guard protects the teeth and surrounding soft tissue and can prevent a broken jaw. Since mouth guards became compulsory in New Zealand in 1997 there has been a 47% reduction in Rugby-­‐related dental claims. Mouth guards made from a dental mould generally provide the best protection. A mouth guard needs to be replaced every season to ensure it provides the best protection. Scrum caps and head guards -­‐ Headgear can help prevent soft tissue injuries to the head and ears. Headgear must be fitted properly. There is no evidence that headgear provides protection against concussion. Injury Management -­‐ Inclusion of Regulation 10 in RR 130603 SG IRB Player Welfare -­‐ Head Injuries Page 40 of 47 Protecting Players From Head Injuries Appendix 9 REGULATION 10. MEDICAL 10.1 Concussion 1 10.1.1 Concussion must be taken extremely seriously. The IRB Concussion Guidelines set out the procedures for the management of; (i) Players diagnosed with concussion by an appropriately qualified person (as applicable in the relevant jurisdiction); or (ii) Players suspected of having concussion. The IRB Concussion Guidelines (available on www.irbplayerwelfare.com) shall be updated from time to time in accordance with best medical practice. 10.1.2 All Players diagnosed with concussion during a Game or training must; (i) be removed from the field of play and not return to play or train on the same ay; and (ii) complete the graduated return to play protocol described in the IRB Concussion Guidelines. 10.1.3 All Players who are suspected of having concussion during a Game or training at which there is no appropriately qualified person (as applicable in the relevant jurisdiction) present to diagnose concussion; (i) must be removed from the field of play and not return to play or train on the same day; and (ii) should be reviewed by an appropriately qualified person (as applicable in the relevant jurisdiction) and diagnosed as having concussion or not; and (iii) in any case must complete the graduated return to play protocol described in the IRB Concussion Guidelines. 10.2.4 The IRB Concussion Guidelines highlight the heightened risk of concussion and its complications in children and adolescent (less than 18 years of age) Players. Extra caution must be taken to prevent such Players returning to play or continuing playing or training if any suspicion of concussion exists. 1
Concussion is a complex process caused by trauma that transmits force to the brain either directly or indirectly and results in temporary impairment of brain function.. A Player can sustain a concussion without losing consciousness. Concussion is associated with a graded set of clinical signs and symptoms that resolve sequentially. Concussion reflects a functional rather than structural injury and standard neuro-­‐imaging is typically normal. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 41 of 47 Protecting Players From Head Injuries Appendix 10 IRB PSCA PROCEDURES & DEFINITIONS INTRODUCTION In 2012 the International Rugby Board (IRB) introduced the Pitchside Suspected Concussion Assessment (PSCA) process into elite Rugby Union. This process was introduced to improve the pitch side management of concussion and specifically to address the consistency with which concussed players were removed from the field of play at the time of concussive injury. A preliminary trial has been undertaken since August 2012 and an analysis of Coach, Player and Physician feedback regarding this preliminary trial suggests that the introduction of the PSCA has improved initial concussion management. This is supported by data indicating that 17.5% more players are being removed from the field of play following a suspected head injury using this PSCA Process, as compared with Rugby World Cup 2011 data. Before outlining the PSCA process it is critical that all medical staff recognize the following a) Clinical suspicion should always overrule a ’normal’ result from any concussion assessment tool including the PSCA b) Players who have a head injury and have concussion excluded should always be monitored for deterioration or an evolving concussion. This applies to all players returning to play following a negative PSCA The PSCA has been developed for the elite level of the Game who are supported by experienced health care professionals. The IRB recognising that the science around concussion is evolving will be supporting continued research and auditing of this PSCA tool and process to improve the validity and sensitivity of this tool and process. PROCESS OVERVIEW The PSCA Process involves more than the use of the PSCA Tool used sideline. It includes a) PSCA 01 Tool (side line)-­‐ Each suspected concussive episode will be assessed pitch side using this standardised assessment tool (PSCA 01 Tool). This tool is a multi-­‐modal tool that assesses symptoms, cognitive function and balance in the injured athlete b) PSCA 02 Tool (post game) -­‐ All players who have been removed from the field of play for a head injury assessment and have either a confirmed or excluded concussion (PSCA negative) will be required to have a post-­‐game, same day SCAT 3 (PSCA 02 Tool) completed prior to leaving the stadia. c) PSCA 03 Tool (follow up) -­‐ this Tool will be used to assess players at 36-­‐48 hours post-­‐
incident. This assessment incorporates a Symptom Assess Form (SAF) and each team's preferred concussion follow-­‐up tool (e.g. Cogsport, Impact, SCAT 3, Headminder etc .) PSCA 01 Tool (side line) 130603 SG IRB Player Welfare -­‐ Head Injuries Page 42 of 47 Protecting Players From Head Injuries Below are definitions, explanations and procedures that will assist the person(s) who will be responsible for undertaking a PSCA pitchside. Definition 1 A player will be assumed to have a concussion and must be removed from further participation in a Game if they have any of the following: 1. Confirmed loss of consciousness (see definition below) 2. Tonic posturing as confirmed by the Team Doctor 3. Traumatic convulsion 4. One "Column One" response in the PSCA 01 Tool 5. The Team Doctor clinically diagnoses a concussion despite a negative PSCA Definition 2 Confirmed loss of consciousness can only be made by a medically trained person following a neurological assessment using the following definition -­‐ "a player has a confirmed loss of consciousness if he/she is not responding to orders and not moving apart from reflex movement such as tonic posturing and convulsions". Note: This is an equivalent to a player being assessed as P (pain) or U (unresponsive) on AVPU scale (see below for full AVPU Scale description) Definition 3 A PSCA can be requested by the Team Doctor, Match Day Doctor or the referee if any of the following are witnessed: • Suspected Loss of Consciousness (see definition below) • Ataxia (unsteady on feet) • Disorientated or confused • Player appears to have been "dazed, dinged or had their bell rung" • Inappropriate behaviour • Other symptoms or signs suggesting a suspected concussion Definition 4 A "suspected" LOC is defined as a situation where a Team Doctor, MDD or referee thinks that there may have been a LOC. In this "suspected" LOC scenario, LOC has not been confirmed by a medically trained person directly observing that there is no response to orders and no movement apart from reflex movement. TV observation of a potential LOC by either a medically trained person or other is considered a "suspected" LOC as a neurological assessment of the player would not have been completed. 130603 SG IRB Player Welfare -­‐ Head Injuries Page 43 of 47 Protecting Players From Head Injuries Appendix 11 Terms and Conditions for Participation in the Pitch Side Concussion Assessment Trial
1.
The International Rugby Board (“IRB”) Executive Committee has authorised an extension of
the Pitch Side concussion Assessment (“PSCA”) Trial for the period August 2012 to
December 2013. The PSCA Trial was initiated by the IRB around the IRB Junior World
Championship and Trophy tournaments in June 2012 and the results of the trial suggested that
the Trial should be extended for a further period.
2.
The objective of the extension of the PSCA Trial is to (i) build upon the aims of the original
IRB PSCA Trial which was to improve the pitch side care of Concussion for elite Rugby
Players and (ii) to obtain valid and authoritative data in sufficient numbers to undertake
scientifically robust research which will aid the long terms assessment of the impact of
Concussion and Concussion related injuries in Rugby.
3.
Participation in the Trial is only permitted with the express approval of the IRB Chief
Medical Officer and Head of Technical Services and subject to a written commitment to
comply with the Terms and Conditions for Participation in the PSCA Trial (the “Trial
Conditions”).
4.
The PSCA Trial data and outcomes shall be monitored and assessed by the PSCA Working
Group under the auspices of the IRB Chief Medical Officer.
5.
All participating Unions, tournament organisers and other bodies authorised to participate in
the PSCA Trial (the “Participants”) shall do so in respect of specified and agreed
competitions, events, leagues and/or championships (“Competitions”) only and not to the
entirety of the events they run or control save as specifically approved by IRB.
6.
Participants partake in the PSCA Trial in respect of their Competition(s) at their own risk and
in full knowledge and agreement with the Trial Conditions having obtained medical input and
taken all due care to inform themselves, their members and participants of the objectives of
the PSCA Trial, the risks and further obtained all the requisite consents and authorisations
required, all in accordance with applicable laws.
7.
In respect of the outcomes and data arising from the implementation of the PSCA Trial by
Participants, all Participants hereby agree as follows:
a. To participate fully in the IRB coordinated research on Concussion and Concussion
related injuries;
b. To appoint a Competition Coordinator who will be responsible for coordinating the
collection and collation of all data emerging from their Competition(s) for PSCA
research and its provision to the IRB in accordance with the collection procedures
notified by IRB;
c. To use IRB approved paperwork for data collection under the PSCA Trial;
d. To use an IRB approved IT data collection system (when available), and to provide all
PSCA Trial related data from its Competition(s) via such data collection system (where
available);
130603 SG IRB Player Welfare -­‐ Head Injuries Page 44 of 47 Protecting Players From Head Injuries e.
To undertake formal introductory educational sessions for all medical practitioners
(including Team doctors and Match doctors) and referees and to disseminate information
in relation to the data collection under the PSCA Trial in their Competitions for coaches
and Players utilising IRB templates for these activities.
8.
The PSCA Trial presumes the attendance of a Match doctor at every Match in the relevant
Competition. If a Match doctor is not present at any Match in the Competition, the
Participant must identify to the IRB the system they have in place that will provide oversight
of the Team doctors’ PSCA decisions and provide any additional details the IRB may require.
9.
The Participant acknowledges and agrees that all data provided by or on its behalf to the IRB
pursuant to the PSCA Trial shall upon transfer become the property of IRB. The Participant
recognises and undertakes to procure that its members and participants recognise that the data
made available by it or on its behalf to the IRB pursuant to the PSCA Trial is the exclusive
property of IRB and hereby assigns to IRB and undertakes to procure that the members and
participants assign to the IRB ownership of any such data provided pursuant to the PSCA
Trial. For the avoidance of doubt the Participant shall be granted a perpetual license by IRB to
utilise any data it has provided pursuant to the PSCA Trail for its own medical research
purposes should it so request.
10.
The Participant acknowledges and agrees as follows and shall procure the written agreement
of its members for the use of the data in the manner prescribed below:
a. That the data provided by Participant may constitute personal data and be subject to legal
protections under applicable national data privacy laws.
b. The data shall be made available to authorised IRB, medical and research personnel for
the purposes of medical research into Concussion and Concussion related injuries and/or
as further set out in these Trial Conditions.
c. Such data will be held in electronic form and may be made available to authorised
persons or parties, including research laboratories and institutions located outside the
country where the data originated. In some other countries, data protection and privacy
laws may not be equivalent to those in the country of the Participant; and
d. By signing the Trial Conditions you will release IRB, as well as relevant research
persons, agencies and institutions to whom the data is provided from all claims,
demands, liabilities, damages, costs and expenses that you may have arising in
connection with the processing of the data provided in relation to the PSCA Trial
through any data collection system.
11.
The IRB confirms that:
a. Such persons and/or bodies who receive the data will not disclose any of the data other
than to those persons within their organisation who require it for the identified purposes.
b. Strong technological, organisational and other security measures shall be applied to
maintain the security of the data contained in any data collection system.
12.
The Participant shall not publish any data, findings our outcomes from its participation in the
PSCA Trial without the prior written approval of the IRB Medical Officer.
130603 SG IRB Player Welfare -­‐ Head Injuries Page 45 of 47 Protecting Players From Head Injuries 13.
The Participant shall upon request provide written evidence to the IRB that the participation
by the Participant and/or its members in the PSCA Trial in connection with their
Competition(s) does not affect the insurance cover of Players affiliated to the Participant.
14.
The Participant shall obtain a signed consent from all Players and team members (including
but not limited to coaching and medical personnel) involved in their Competition(s) where the
PSCA Trial has been authorised such that each every person: (a) acknowledges and agrees to
their participation in the PSCA Trial; (b) agrees to the provision of PSCA Trial data to the
IRB including in accordance with paragraph 9 and 10 above, and (c) accepts any risks and/or
outcomes associated with participating in the PSCA Trial. The Participant shall provide
copies of such consents to the IRB upon request.
15.
The Participant hereby indemnifies and holds harmless the IRB and all of the IRB’s
associated entities, officers, employees, agents and/or representatives and the officers,
employees, agents and/or representatives of its associated entities in respect of any direct or
consequential loss (which expression shall include, but not be limited to, loss of anticipated
profits, loss of anticipated savings and all other economic loss), claim, cause of action,
demand and/or liability, including without limitation arising directly or indirectly as a result
of any third party action, in relation to any injury and/or incident and/or other matter
connected with its participation in the PSCA Trial or use of its data as part of the PSCA Trial
by any person representing the Participant and/or its Players or team members affiliated
directly or indirectly to the Participant.
16.
Where necessary, the Participant shall provide an appropriate indemnity to its members
participating in the PSCA trial (including but not limited to clubs, Rugby Bodies and/or
teams, as appropriate), affiliated directly or indirectly to the Participant in respect of any loss,
claim, cause of action, demand and/or liability, including without limitation arising directly or
indirectly as a result of any third party action, in relation to any injury and/or incident and/or
other matter connected with their participation in the PSCA Trial or use of their data as part of
the PSCA Trial.
17.
These Trial Conditions shall be interpreted in accordance with English law and subject to the
jurisdiction of the English courts.
Signed by an authorised signatory on behalf of the Participant:
Name of Participant organisation: ______________________________________________________
Name of Competition(s) subject to the PSCA Trial: _______________________________________
Name of authorised signatory: _________________________________________________________
Position: _____________________
Signature: ________________________________________
Date: ________/_________/ 2012
130603 SG IRB Player Welfare -­‐ Head Injuries Page 46 of 47 Protecting Players From Head Injuries Appendix 12 Haddon Matrix summarising the Prevention and Treatment Strategies established by the IRB to manage head injuries Time Pre Match •
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Prevention Strategies Prevention and Treatment of Head Injuries in Rugby Physical Management IRB Rugby Ready: Equipment, • Law 10.4: Dangerous Play & Misconduct environment and emergency plan • Regulation 10 Goalpost Padding • Education and Guidance to Match Officials Gum Shields • IRB Training Programmes Artificial turf: head impact criteria Laws of the Game Use of headgear Rugby Ready Coaching Match Officials Strength & Conditioning Match Day Medical Staff • IRB Medical Conference • Working Group on Concussion • Match Day Medical Staff (MDMS) Education programme • IRB Player Welfare website • IRB research programme Medical facilities available at • PSCA protocol match venues Television Match Official facilities Availability of external medical facilities for injured players •
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Project on the long term effects of concussion Judicial Framework Concussion -­‐ Graduated Return to Play Protocol (GRTP) •
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Human The IRB ‘Core values’ for Rugby Dissemination of information to coaches regarding proper technique and its importance in injury prevention Match Officials apply Laws TMO for foul play referrals Citing officer identifies incidents of dangerous play during the game Match officials performance monitored Game Analysis by Game Analysts used to identify trends that may be leading to increased risk of injury and thus to alterations in Law or Regulation GRTP managed by healthcare professionals Player sanctions for dangerous play 130603 SG IRB Player Welfare -­‐ Head Injuries Page 47 of 47