RFU concussion advice: ‘recognise, remove, recover and return’

Unless you’ve been in hibernation, you can’t have failed to notice the general discussions taking place around the issue of concussion in sport. It’s an issue that’s cropped up across a number of different sports over the course of the summer, from rugby and football to cycling and athletics.

What has particularly concerned the various sporting authorities is the effect of concussion of young sportsmen and women. Repeated studies show that whilst the incidence of concussion in professional rugby is more commonplace than in the amateur game, the general consensus appears to be that concussion injuries in rugby do not occur more frequently than in other sports.

Never the less, the RFU has been sufficiently concerned about the matter to carry out its own extensive research into the subject. To that end it has recently published the advisory document – ‘Don’t be a Headcase. Stop! Check for concussion.’

Macclesfield Rugby Club thought that it might be useful to give a brief description of the new report outline the information which the RFU is making available for healthcare professionals, officials, coaches, players and parents and supporters.

Concussion – the facts

What is concussion? Is it serious?

Concussion is a disturbance of the normal working of the brain but without there being any structural damage. Most people who sustain a concussion do not require any treatment as they normally get better by themselves and recover quickly, but for some the symptoms may last for days, weeks or in rare cases even longer.

Are concussion injuries more serious for young players?

We need to be more cautious with young players. Because the child or adolescent brain is still developing, there is particular concern that concussion can have more of an impact on the brain, and a second concussion occurring before recovery of the first results in prolonged symptoms that can have a significant impact on the child.

Can more serious conditions appear like concussion?

Although extremely rare in sport, a blow to the head (direct or indirect) may first appear to be concussion, when in reality there is something more serious going on; such as bleeding or swelling in or around the brain. Sometimes the symptoms of a more serious brain injury do not occur for several hours or days after the initial injury has taken place. If not recognised, these injuries can have very serious consequences.

What about repeated concussions?

Because there is considerable variation in the initial effects of concussion, and spontaneous recovery is often rapid, this can increase the potential for players to ignore concussion symptoms at the time of injury or return to play before they’ve fully recovered. There are, therefore, concerns that repeated concussion – particularly before full recovery – could shorten a player’s career, significantly interfere with their academic performance, and may have some potential to result in permanent neurological impairment.

How common is concussion in rugby?

It is hard to say how common concussion is as players often don’t admit to being concussed or there isn’t someone who can correctly diagnose concussion available at the time. The incidence of concussion injuries also varies depending on the level of play. Studies in professional rugby have shown that it occurs at a rate of about 3.9 per 1000 player hours, (i.e. one concussion in every six games among all the players involved) whereas studies at amateur adult level suggest that concussion occurs at a rate of about 1.2 per 1000 player hours (i.e. one in every 21 games).

What is rugby doing about concussion?

Over the years there have been a number of specific initiatives within rugby, and an ongoing programme of player, coach and official training and education which all contributes to the prevention of concussion, including:

  • Laws: http://www.rfu.com/thegame/laws
  • Regulations: http://www.rfu.com/Home/TheGame/Regulations
  • Guidelines: the RFU has been involved in and contributed to the development of current international guidelines on concussion management in sport and specifically in rugby, with the IRB. These guidelines have been developed utilising international research evidence and expert opinion and underpin what we develop in this area.
  • Concussion awareness and education targeting players, coaches and officials:http://www.rfu.com/managingrugby/firstaid/injuries/concussion
  • Coach education:http://www.rfu.com/takingpart/coach/coachdevelopmentprogrammes
  • First aider education: www.rfu.com/firstaid
  • Health care professional education:http://www.rfu.com/managingrugby/firstaid/coursesandguidelines/icis
  • Professional player testing

 

The RFU’s advice:

The general rule that the RFU is advising everyone in rugby to follow is the Recognise-Remove-Recover and Return principle:

  • 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 involved in rugby must be able to recognise concussion
  • Players with suspected concussion must be removed from play
  • The treatment for concussion is physical and cognitive rest
  • 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 return to play

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.

The RFU has also issued the following specialist advice for healthcare professionals, officials, coaches and players and families.

Health Practitioners

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). It is generally considered part of the spectrum of traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) is commonly used to both assess the severity of brain injury and to serially monitor patients following TBI. 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. 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.

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.

Coaches

Coaches probably have the most important role in the prevention and management of concussion. Research has shown that young players in particular rely on their coach to provide information on concussion and are influenced most in their behaviour towards concussion by their coach. All coaches should be able to recognise suspected concussion and are in the best position to remove the player from play

Match Officials

Match officials have an important role in the prevention and management of concussion. Through the correct and consistent application of the laws of the game they are able to influence players and their coaches’ behaviour towards concussion. At certain games, there may not be a coach, so the match official’s role becomes more significant.

If you suspect concussion you should ask for the player to be assessed and/or removed from play right away. Continuing to play increases their risk of more severe, longer lasting concussion symptoms, as well as increasing their risk of other injury. Even if a player is cleared to play by a team doctor and you are concerned that they continue to show signs or symptoms of concussion you should remind the doctor of their responsibilities to the player and you are within your rights, under Law 3.9, to remove the player from the game.

If the referee decides – with or without the advice of a doctor or other medically qualified person – that a player is so injured that the player should stop playing, the referee may order that player to leave the playing area. The referee may also order an injured player to leave the field in order to be medically examined.

Players and parents

Players are responsible for their health and should take concussion seriously. Failing to follow the guidance provided) can have significant and sometimes serious consequences resulting in:

  • Playing careers and enjoyment of the game being affected
  • Long term health being affected
  • Work and/or academic studies being affected
  • Play well, perform well
  • Although it may not be possible to stop all concussions happening, there are some measures players can take that could potentially reduce the number of concussions:
  • Ensure the playing or training area is safe, and the risk of serious head injury occurring is reduced.
  • Check ground conditions – do not play or train if the ground is frozen solid or rock hard due to drought.
  • Ensure all posts and barriers on or close to the pitch are protected with the appropriate amount of padding.
  • Ensure correct tackle technique is performed consistently. If the head of the tackler hits the ball carrier there is a significant risk of concussion and/or neck injury. You should therefore ensure that you are able to perform correct tackle technique consistently.
  • Do not engage in dangerous play such as high, tip and spear tackles. Similarly do not tackle players in the air i.e. when jumping to catch the ball from kicks or lineouts. Falling from height increases the risk of concussion and neck injuries.

Protective equipment

Rugby head guards do not protect against concussion. They do protect against superficial injuries to the head such as cuts and grazes though, however, there is some evidence to suggest that head guards may increase risk taking behaviours in some players. Mouth guards/gum shields do not protect against concussion either although they are strongly recommended for all players as they do protect against dental and facial injuries.

If supporters would like more information on the subject of concussion in rugby, then they should register with, and follow the IRB-supported International Rugby Research Network.

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