Health Care Professionals General Information
Summary
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The welfare of the player both short and long term must always come first
Concussion is a functional disturbance of the brain
All Health Care Professionals (HCPs) involved in rugby must be able to
RECOGNISE concussion
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Players with suspected concussion must be REMOVEd from play
The treatment for concussion is physical and cognitive rest
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All players must be allowed to RECOVER before returning to play. Complications
can occur if a player is returned to play before complete recovery.
All players with diagnosed or suspected concussion must undergo a graduated
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RETURN to play.
1. Background
What is concussion?
Concussion is a functional disturbance of the brain without any associated structural
pathology (as visible using current scanning technology) that results from forces transmitted
to the brain (either directly or indirectly) (1). It is generally considered part of the spectrum of
Traumatic Brain Injury (TBI) and has been described diagrammatically as shown in Figure 1.
Glasgow Coma Scale
“Minimal” Mild ?
Sports Concussion
Mod
Severe
Moderate
Mild
GCS ≤ 8
GCS 9-12
GCS 13-15
Teasdale et al Lancet 1974; ii 81-4
Figure 1: Spectrum of Traumatic Brain Injury
Severe
The Glasgow Coma Scale (GCS) is commonly used to both assess the severity of brain
injury and to serially monitor patients following TBI (2). THE GCS is used to classify TBI as
follows:
Mild; GCS = 13 - 15
Moderate; GCS = 9 - 12
Severe; GCS = <8
Typically in rugby, players who sustain a concussion have a GCS score of 13 - 15 at the
time of medical assessment and therefore fall into the mild end of the injury severity
spectrum. The clinical features usually appear rapidly after injury and resolve spontaneously
over a variable timescale.
Although the pathophysiology of concussion remains poorly understood, the current
consensus is that it reflects a disturbance of brain function rather than a structural injury (1).
Research in animal models of concussion suggests that linear acceleration or rotational
shearing forces may result in short‐lived neurochemical, metabolic or gene‐expression
changes (3).
Current State of Knowledge
In November 2012, the Fourth International Consensus Conference on Sports Concussion
was held in Zurich. The presentations made at this conference are available from
http://f-marc.com/concussion2012/.
The Consensus Statement from this conference was published in 2013 and is available to
download from the HCP area of rfu.com/concussion.
The consensus statements produced from these meetings provide the most up‐to-date
knowledge on concussion in sport, as well as outlining the current best practice
management guidelines.
The International Rugby Board (IRB) is actively involved in these Consensus Conferences
and the subsequent Statements, and reviews its Regulations and Guidelines in accordance
with them
How common is concussion in Rugby Union?
Concussion is a relatively common injury in Rugby Union with the overall incidence rate
reported as 3.9 concussions per 1000 player hours in the professional game(4) and 1.2
concussions per 1000 player hours in the adult amateur game (5).
We do recognise however that there is probably a degree of under-reporting in these
studies.
Comparative concussion rates presented at the 2012 Sports Concussion Consensus
Conference (6) are as shown in the following table:
Sport
Horse racing (Amateur)
Concussion rate per
1000 player hours
95.2
Horse racing (Jumps)
25.0
Horse racing (Flat)
17.1
Boxing (professional)
13.2
Australian football (professional)
4.2
Rugby union (professional)
3.9
Ice Hockey (NHL)
1.5
Rugby union (amateur)
1.2
Soccer football (FIFA)
0.4
NFL football (NFL)
0.2
According to the NHS Choices website (www.nhs.co.uk) the three main causes of
concussion are:
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being involved in a road accident
accidental trip or fall
taking part in sporting or other recreational activities
The site makes it clear that “Most doctors would argue that the physical benefits of
regularly taking part in these sports outweigh potential risks associated with
concussion. But this is only if you (or your child) wear appropriate equipment, and are
supervised by a suitably trained referee, umpire or trainer with experience in diagnosing and
treating concussion.”
What are the potential complications following concussion?
Concussion is a functional injury without structural damage; consequently, the changes are
temporary and recover spontaneously if managed correctly. The recovery process however,
is variable from person to person and injury to injury.
Whilst most cases of concussion recover uneventfully within 10‐14 days of injury, a number
of complications or adverse outcomes have been reported:
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Impaired performance; impaired cognition and slowed reaction times may result in
impaired performance. (7)
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Increased injury risk; slowed reaction times may predispose the individual to an
increased risk of injury, including repeated concussion (8,9)
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Acute progressive diffuse cerebral oedema, often referred to as “second impact
syndrome”; this is a controversial issue with a small number of case reports and a
possible association with repeated head trauma, and youth players may be more
susceptible (10, 11)
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Prolonged symptoms; this is a long recognised complication of mild traumatic brain
injury (12, 13). Prospective cohort studies monitoring clinical recovery following
concussion demonstrate 5‐10% of concussed athletes take longer than 10 days to
recover and <1% have true “post-concussion syndrome” (i.e. symptoms lasting >3
months) (14, 15)
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Depression and other mental health conditions; there is a long established link
between head injury and risk of clinical depression later in life (15)
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Chronic Traumatic Encephalopathy; recently there has been an association shown
between encephalopathy and playing elite American football (16 - 20). This is an
association and no causal link has been establishment.
There may a genetic predisposition (3, 21) or other risk factors associated with
participation in certain professional sports that have yet to be identified. There are
cross‐sectional studies reporting lower cognitive performance in subjects with
previous concussions compared to controls (22), and some athletes demonstrate
persistent cognitive deficits post‐concussion (23).
The current expert consensus is that premature return to play may be a key factor in
predisposing the athlete to poorer outcomes following a concussive injury (1). This is the key
reason for the introduction of the current management strategies
2. Prevention
Concussion can be prevented and all those involved with rugby teams should advise
management and coaching staff of the importance of prevention. Ideally we all want to
prevent concussions occurring and although it may not be possible to stop them happening
altogether, there are some measures that can be taken during rugby training and games that
have the potential to reduce the number of concussions that we see:
1. Ensure the playing or training area is safe, and the risk of serious head injury
occurring is reduced:
a. Check ground conditions - do not play or train if the ground is frozen solid or
rock hard due to drought
b. Ensure all posts and barriers on or close to the pitch are protected with
appropriate padding
2. Ensure correct tackle technique is coached and performed consistently by all players.
If the head of the tackler hits the ball carrier there is a significant risk of concussion
and/or neck injury.
Coaches should therefore ensure that all players are able to perform correct tackle
technique consistently, and they should be corrected immediately if they do not.
3. Explain the dangers of high, tip and spear tackles, and penalise them immediately if
they occur. Similarly with tackling players in the air, jumping to catch the ball from
kicks or lineouts.
Falling from height increases the risk of concussion and neck injuries. In young
players in particular, a zero tolerance approach should be taken.
Protective Equipment
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Rugby Head Guards; DO NOT protect against concussion. They do protect against
superficial injuries to the head such as cuts and grazes. This has been
demonstrated in a number of research studies now (24 - 27).
There is some evidence to suggest that they may increase risk taking behaviours in
some players (24, 28).
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Mouth Guards/Gum Shields; do not protect against concussion either although they
are strongly recommended in all players as they do protect against dental and facial
injuries (29 - 32).
3. Management of Suspected Concussion during the Game
HCPs are pivotal to the correct management of concussion in rugby. As such all must be
able to recognise a suspected concussion on the field of play and be able to evaluate the
player appropriately. Concussion can only be formally diagnosed by a Registered Medical
Practitioner (1).
When initially attending players with a suspected concussion on the pitch it must not be
forgotten to apply basic first aid/immediate care principles (i.e. Safe approach, Airway,
Breathing, Circulation). Appropriate care must be taken of the player’s cervical spine, which
may have also been injured particularly with a significant mechanism of injury, such as if
there is a high velocity of impact or collision with a hard body part e.g. head to knee or hip
impact.
On rare occasions what appears initially to be a concussion may be something more serious
such as a structural injury. HCPs must be alert for the following “Red Flags” and if more
serious injury is suspected then the player sent to hospital IMMEDIATELY in an ambulance
(absolute indications).
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Immediate confirmed and/or prolonged loss of consciousness (anything other than
momentary)
Seizures
Neurological signs
Persistent vomiting or increasing headache post‐injury
Deterioration of conscious state post‐injury (e.g. increased drowsiness)
Neck pain or spinal cord symptoms
Obvious skull fracture (CSF rhinorrhoea/otorrhoea) or significant facial trauma
Children with concussion
Consideration should also be given to immediate hospital transfer in the following
situations:
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Development of new symptoms
Prolonged confusion (>15 minutes)
Adolescents (16‐18 years old) with concussion
High risk patients (e.g. known bleeding disorders)
Where there is difficulty with assessment or uncertain follow‐up (e.g. no responsible
adult supervision)
Overall, if there is any doubt, the player should be referred to hospital.
NHS Guidelines on referral to hospital following a head injury are available at
http://publications.nice.org.uk/head-injury-cg56 (NICE Clinical Guideline 56 – The early
management of head injuries (Issue date September 2007)
.
Recognition and diagnosis of concussion
Any player who is seen to receive a blow to the head or have the potential for force
transmission to the head, should be observed for the symptoms and signs of concussion.
Circumstances that should alert a practitioner include the following:
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Tackled player – blow to head from shoulder, arm, knee or head of another player.
Head hitting ground or whiplash when tackled from height.
Tackling player – blow due to head in wrong position of blow from head from
shoulder, arm, knee or head of another player.
Ruck - blow to head from shoulder, arm, knee or head of another player
Lineout - blow to head from shoulder, arm, or head of another player. Head hitting
ground or whiplash when falling from height.
Dangerous Play – collision
Foul Play - punch
While the symptoms and signs can be vague there are certain ones that enable the
diagnosis of concussion to be made immediately, these include:
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Confirmed loss of consciousness (assessed as response to Verbal or Pain stimulus
on AVPU scale used in pre-hospital immediate care and ATLS)
Tonic posturing
Convulsions
Other common signs and symptoms of concussion include the following (1):
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Cannot remember things that happened before and/or after the injury
Headache
Dizziness
Feel dazed, “dinged” or stunned - A blank stare/glassy eyed, “the lights are on but
nobody is at home”, seems slow to answer questions or follow directions
Loss of vision, seeing double or blurred, seeing stars or flashing lights
Ringing in the ears
Sleepiness
Stomach ache, stomach pain, nausea, vomiting
Poor coordination or balance, staggering around or unsteady on feet
Slurred speech
Poor concentration
Strange or inappropriate emotions (i.e. laughing, crying, getting angry easily)
Feeling generally unwell
Not playing as well as expected
If the diagnosis of concussion is confirmed then the player MUST BE REMOVED from play
immediately and not be returned to play on the day.
Adult players, who have had a complete neurological examination, are improving following
their injury and have a competent person looking after them, may be allowed home. These
players and their caregiver (e.g. spouse, parent, partner etc…) should be given clear and
practical instructions, particularly regarding:
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Symptoms and signs to look for
Action to take if deterioration occurs
Abstinence from alcohol medication use, physical exertion
Not driving. A player who has been concussed should not drive until fully recovered.
Timing of medical follow up.
Players must be followed up after a concussive injury; to monitor progress in the early
stages of their injury, and for medical clearance before they return to full contact training or
game play. Concussion assessment tools such as the SCAT3 (available to download from
the resources section of rfu.com/concussion) are very useful in enabling regular objective re‐
assessment of concussed players. Whilst most symptoms appear rapidly following a
concussive incident, some symptoms may be delayed and the diagnosis should be
suspected in any player that presents with these symptoms following a collision or direct
trauma to the head or neck.
Questioning close relatives, especially parents or guardians in the case of children and
adolescents, is often valuable. Any report that the individual ‘does not seem right’ or ‘is not
him/herself’ following a head injury, is strongly suggestive of a concussive injury.
If you are providing pitch side medical or first aid cover and you suspect concussion in a
player YOU MUST draw this to the attention of the team coach or officials. Allowing a player
to continue to play increases the risk of more severe, longer lasting concussion symptoms,
as well as increases their risk of other injury:
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You should not let them return to play that day
You should not let them be left alone
You should make sure they are seen by a doctor as soon as possible that day
You should not let them drive
All Health Care Professionals providing First Aid or Immediate Care cover at sports events
are required by their Professional Regulating Body and their Insurance Provider, to have
undergone specific training in this. The following courses developed for practitioners
involved in rugby are available from the RFU. Other more generic courses are available.
 RFU Emergency First Aid Course (rfu.com/firstaid)
 RFU Immediate Care in Sport Course (rfu.com/icis)
Professional Rugby Concussion Trial
There is currently a trial taking place in the Aviva Premiership and other professional
competitions/leagues under an IRB dispensation, where a player with suspected concussion
is removed from the pitch to be assessed and if cleared to do so may return to play. It is
important to recognise that this has been introduced because of concerns that players were
remaining on the pitch when concussed.
The doctors who conduct the assessments specialise in the assessment, diagnosis and
management of concussion. Any player who is diagnosed as having concussion is not
permitted to return to play. Only those who are formally assessed as not having concussion
are allowed to return to play. Even then, these players are re-assessed after the game and
subsequently carefully monitored by the club medical teams.
Clinical features that may raise concerns of structural head injury
Any deterioration in clinical condition following a head injury must prompt a re-evaluation and
the following should alert the HCP to refer the player to hospital immediately:
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Drowsiness when normally awake or cannot be awoken
A headache that is getting worse
Weakness, numbness or decreases in coordination and balance
Repeated vomiting or prolonged nausea
Slurred speech, difficulty speaking or understanding
Increasing confusion, restlessness or agitation
Loss of consciousness
Convulsions
Clear fluid coming out of ears or nose
Deafness in one or both ears
Problems with eyesight
Clinical features of concussion typically resolve within 10‐14 days of injury.
Any deterioration in clinical state during or after this time, in particular worsening headache,
nausea or vomiting, or deterioration in conscious state, should raise suspicion of a structural
head injury and warrant urgent investigation.
Similarly, structural head injury should be kept in mind in any case where symptoms persist.
4. Management of the Concussed Player
Once concussion has been diagnosed their Health Care Professional should manage their
care pathway, liaising with coaches and parents as appropriate.
Concussion Assessment Tools
There are a number of tools which are available which can help HCPs manage players with
concussion:
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Pocket SCAT3 .
This simple tool can be utilised on‐field or on the side line to assess a player with
suspected concussion. For a more detailed assessment, the player should be moved
to a quiet room, away from the field of play (e.g. change rooms, medical room etc.)
for a detailed neurological examination and use of the full SCAT3.
Sport Concussion Assessment Tool (SCAT3).
The international consensus statement on the management of concussion in sport
recommends the use of the Sport Concussion Assessment Tool (SCAT3) to facilitate
assessment of athletes following a concussive injury.
Sport Concussion Office Assessment Tool (SCOAT).
The SCOAT has been developed from SCAT by concussion specialists in South
Africa (33). It is designed for use in the clinic setting and provides a structured
approach and record of concussion management.
Imaging
Following an uncomplicated concussion, conventional imaging techniques such as skull x‐
ray, CT brain scan and magnetic resonance brain imaging (MRI) are typically normal (1).
More sophisticated imaging such as Functional MRI is available in some centres, which may
show functional abnormalities in players with concussion (1).
Estimating the severity of injury and Recovery
Over the years, numerous concussion severity scales have been proposed. The main
objective of these scales has been to try to identify grades of concussion severity or
increased potential for adverse outcomes, which will guide management.
Many of the more popular scales, such as the Cantu classification system (34) and Colorado
guidelines (35) have focussed on the presence and duration of LOC to estimate injury
severity and guide return to sport.
Traditionally, the depth and duration of LOC have been shown to correlate with moderate to
severe traumatic brain injury (GCS < 13) only (2), however, studies on concussion in sport
have consistently demonstrated that brief LOC does not reflect injury severity or predict time
to recovery (36‐39).
Predicting severity based on initial presentation has been recognised as problematic and the
International Concussion Consensus Group have therefore moved away from these
predicative severity grading systems (e.g. mild, moderate or severe or grade 1, 2, and 3
concussion) towards an initial objective measure based combination of symptom checklist,
physical examination and cognitive assessment (1) and a number of modifying factors which
have been associated with longer duration of symptoms or increased risk of adverse
outcomes following concussive injury (1).
These ‘modifying’ factors are summarised below.
Factor
Symptoms
Signs
Sequelae
Temporal
Threshold
Age
Co‐ and pre-morbidities
Medication
Behaviour
Sport
Modifier
High number, long duration (>10 days) and/or high severity
Prolonged loss of consciousness (>1 min), amnesia
Prolonged concussive convulsions*
Frequency ‐ repeated concussions over time
Timing ‐ injuries close together in time
‘Recency’ ‐ recent concussion or traumatic brain injury
Repeated concussions occurring with progressively less
impact force or slower recovery after each successive
concussion
Child and adolescent (<18 years old)
Migraine, depression or other mental health disorders,
attention deficit hyperactivity disorder, learning disabilities,
sleep disorders
Psychoactive drugs, anticoagulants
Dangerous style of play
High risk activity, contact and collision sport, high sporting
level
*Concussive convulsions or impact seizures are occasionally observed following concussion
in sport. These are usually brief in duration (less than 1 minute) and range from tonic
posturing to full tonic‐clonic seizures. Brief concussive convulsions are benign, with no
adverse clinical outcomes (39). Consequently, investigations are not required, anti‐epileptic
treatment is not indicated and prolonged absence from sport is not warranted in the majority
of cases.
The presence of a ‘modifying’ factor should lead the practitioner to take a more conservative
approach; including a more detailed assessment and slower time to return to sport by
extending each stage of the Graduated Return to Play protocol. Consideration should also
be given to involving other practitioners in a multi‐disciplinary team approach. This may
include review by a neuropsychologist and formal neuropsychological testing and/or referral
to a doctor with expertise in managing concussive injuries (e.g. Sport and Exercise
Medicine, Neurology or Neuropsychology Specialists).
5. Recovery and Return to Play
The decision regarding the timing of return to play following a concussive injury is a difficult
one to make. Expert consensus guidelines recommend that players should not be allowed to
return to competition until they have recovered completely from their concussive injury (1).
Currently however there is no single gold standard measure of functional brain disturbance
and therefore objective measurement of recovery following concussion. Instead, clinicians
must rely on clinical judgment. In practical terms this involves a comprehensive clinical
approach, which may include the following:
a)
b)
c)
d)
e)
A period of cognitive and physical rest to facilitate recovery;
Monitoring for recovery of post‐concussion symptoms and signs;
The use of neuropsychological tests to estimate recovery of cognitive function;
Graduated return to activity with monitoring for recurrence of symptoms, and
A final medical clearance including full neurological examination before resuming full
contact training and/or playing.
Cognitive and Physical for Recovery
Rest is the mainstay of treatment in concussion. Physical activity, physiological stress (e.g.
altitude and flying) and cognitive loads (e.g. school work, videogames, computer use) can all
worsen symptoms and possibly delay recovery. Individuals should be advised to rest from
these activities in the early stages after a concussive injury, especially whilst symptomatic. A
pragmatic approach needs to be taken as complete avoidance of these activities is
impracticable. Restriction and monitoring should be employed to gauge a level which does
not exacerbate symptoms.
Similarly, the use of alcohol, narcotic analgesics, anti‐inflammatory medication, sedatives or
recreational drugs can exacerbate symptoms, delay recovery or mask deterioration and
should also be avoided. Specific advice should also be given on avoidance of activities that
place the individual at risk of further injury (e.g. driving, operating heavy machinery).
Monitoring Recovery
Monitoring of post‐concussion symptoms and signs can be facilitated by the use of the
SCAT3 (1). This tool, although not formally validated yet, provides a standardised method of
evaluating individuals following a concussive injury. Given that the SCAT3 has been
designed as an overall assessment tool, some of its components (e.g. Maddock's Questions,
Glasgow Coma Score) are only useful in the acute setting following a concussive injury and
have no real value in monitoring recovery.
The most important components for follow up are the graded symptom checklist, tests of
balance and cognitive assessment.
Use of neuropsychological tests to estimate recovery of cognitive function
Cognitive deficits associated with concussion are typically subtle and may exist in a number
of domains. Common deficits following concussion include; reduced attention, ability to
process information, slowed reaction times, and impaired memory. The use of
neuropsychological tests reduces the reliance on subjective symptoms, which are known to
be poorly recognised and variably reported. It is important to recognise that subtle cognitive
deficits have been observed to remain even after symptom scores have returned to baseline
(41).
There are a number of levels of complexity of cognitive testing, including:
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Basic ‘paper‐and‐pencil’ evaluation (e.g. SCAT3 and SCOAT)
Screening computerised cognitive test batteries
Formal neuropsychological testing
Formal neuropsychological testing remains the clinical best practice standard for the
assessment of cognitive function (42) but is often not easily accessible. Formal testing is
logistically impractical for routine use following concussive injuries but is recommended in
any case where there is uncertainty about recovery or in difficult cases (e.g. prolonged
recovery). Many NHS Trusts provide Minor TBI outpatient clinics that can be accessed via
Emergency Departments or direct GP referrals.
Computerised cognitive tests provide a practical alternative for the assessment of cognitive
recovery following a concussive injury. A number of screening computerised cognitive test
batteries have been validated for use following concussion in sport and are readily available.
These include test platforms such as CogState Sport (www.cogstate.com/go/Sport) and
ImPACT (www.impacttest.com). Computerised tests allow quick and reliable screening of
cognitive function following concussive injury. The tests are best interpreted by comparison
to the individual’s own pre‐injury baseline and for this reason; preseason/baseline screening
testing should be encouraged. In situations where a baseline does not exist, the test result
can still be utilised with the results compared to population normative data, plus the test can
be repeated to identify when the individual’s performance stabilises. This approach should
be combined with a more conservative Graduated Return to Play plan.
Basic paper‐and‐pencil cognitive tests can be used to provide an estimate of cognitive
function (e.g. SCAT3). Again, the use of these tools should be combined with a conservative
return to play approach and careful monitoring of symptoms as the player progresses
through their Graduated Return to Play programme.
Overall, it is important to remember that neuropsychological testing is only one component of
assessment, and therefore should not be the sole basis of management decisions.
Neuropsychological testing does not replace the need for a full history and
clinical/neurological examination.
Balance Testing
It has become apparent that balance testing is an important and validated part of concussion
assessment. Published studies using both sophisticated force plate technology, as well as
less sophisticated clinical balance tests (e.g. Balance Error Scoring System (BESS)), have
identified balance deficits which last up to 72 hours following sport-related concussion.
Balance testing therefore provides a useful tool for objectively assessing the motor domain
of neurologic functioning and should be considered a reliable and valid addition to the
assessment of athletes suffering from concussion, particularly where symptoms or signs
indicate a balance component (43-49). Simple clinical balance testing is included in the
Pocket SCAT3, SCAT and SCOAT resources.
Baseline Testing
Pre-participation health questionnaires should include concussion related questions
including the following:
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Number
Frequency
Severity
Recovery
Presence of modifying factors e.g. mood disorders, learning difficulties, migraine etc.
The role of baseline testing using SCAT, computerised neurocognitive assessments,
remains unclear. No studies have shown that the use of these provides better outcomes.
The reliability of pre-season baseline testing is also controversial and for most tests it is
unknown. It is thought that baseline testing may be more important in those with a past
history of concussion, pre-existing modifying factors, and sports with a high incidence of
concussion (1)
Graduated return to Play
Following a concussive injury, players should undergo a Graduated Return to Play (GRTP)
once clinical features have resolved and cognitive function returned to ‘normal’. Details on
the GRTP are provided in the Return to Play Guide (rfu.com/concussion). When considering
return to play, the player should be off all medications both at the commencement of
programme and at the final medical assessment. A more conservative approach with and
extended GRTP should be used in the following circumstances:
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Children and adolescents.
Cases where there is any uncertainty about the player’s recovery
“if in doubt sit them out”
Final medical clearance before resuming full contact training and/or playing
A player who has suffered from a concussive injury must not be allowed to return to play
before having a medical clearance. In accordance with current consensus guidelines, there
is no mandatory period of time that a player must be withheld from play following a
concussion.
6. Youth Players
The developing brain differs physiologically from the adult brain. There is evidence that
younger athletes take longer to recover following a concussive injury than adults and that
return to play on the day of the injury is more likely to lead to subsequent cognitive
deterioration. Severe complications (e.g. diffuse cerebral swelling) although rare, are also
more likely. Consequently, a more conservative approach is recommended in all concussed
players under18 years of age, regardless of the level of competition in which they participate
(1, 50-61).
The potential impact of concussion on the education of young players is an important factor.
In addition, their behaviour and performance in the academic setting should be considered
as part of their assessment of recovery. Subtle deficits may become apparent in the
classroom setting, and where possible liaison with teachers/academic staff should be
included.
7. Gender
There is some evidence that there are gender differences in concussion and a more
conservative approach should also be considered in female players (62-64).
8. Pressure from Players, Parents and Coaches
Experience shows that there may be pressure from the player themselves, their parent, and
or their coach to return to play as soon as possible “for that crucial game”. This pressure
must be resisted and the time taken to explain why it is important to follow the guidelines.
This will usually result in the pressure being withdrawn. If however the advice is ultimately
rejected then you are advised to record the advice and if possible obtain a signature to verify
that this advice has been given and has been rejected by the individual.
Knowledge about concussion in the UK general public is low and the potential seriousness
of the condition is generally underestimated, and even a personal experience of concussion
may yield a false sense of security (65).
9. Research
For those interested in research around this subject, please register with and follow the IRB
supported International Rugby Research Network (www.irbsciencenetwork.com;
@IRBRugbyScience)
10. Resources
Available from the HCP section of rfu.com/concussion:
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2008 Consensus Statement
Pocket SCAT
SCAT 3
SCOAT
Plus: RFU Immediate Care in Sport Course rfu.com/icis
4th International Consensus Conference on Concussion in Sport Presentations
http://f-marc.com/concussion2012/
IRB Education Site www.IRBplayerwelfare.com
Computer based concussion assessments (the RFU does recommend or endorse any of the
following and individuals should make their own assessment on the suitability of these
products):
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CogState (www.cogstate.com)
ImPACT (www.impacttest.com)
International Rugby Research Network (www.irbsciencenetwork.com)
11. LINKS
NHS Services
There are a number of NHS services or resources that HCPS may find useful:
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
NHS Direct (www.nhsdirect.nhs.uk)
NHS Choices (www.nhs.uk)
Specialist Minor Head Injury Clinics. (www.nhs.uk/service-search)
NICE Guidelines (http://publications.nice.org.uk/head-injury-cg56)
United States CDC Concussion Education website (www.cdc.gov/concussion)
Other Services
Headway, the brain injury charity specialise in providing advice,
support and rehabilitation services to individuals and their
families following a head injury.
We would like to thank them for their work with us on developing
these resources and their support of our awareness campaign.
(www.headway.org.uk)
Headway’s head injury advice leaflet is also available from the resources section of
rfu.com/concussion.
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These RFU Concussion resources have been developed based on the Zurich Guidelines
published in the Consensus Statement on Concussion in Sport, and adapted for rugby by
the International Rugby Board
The information contained in this resource is intended for educational purposes only
and is not meant to be a substitute for appropriate medical advice or care. If you
believe that you or someone under your care has sustained a concussion we strongly
recommend that you contact a qualified health care professional for appropriate
diagnosis and treatment. The authors have made responsible efforts to include
accurate and timely information. However they make no representations or warranties
regarding the accuracy of the information contained and specifically disclaim any
liability in connection with the content on this site.