PREVENTION

IMPLEMENTING A WORLDWIDE CONCUSSION PROGRAMME THE WORLD RUGBY STRATEGY TO SECURE PLAYER WELFARE

– Written by Martin Raftery, Australia and Ross Tucker,

World Rugby, formerly known as the Inter- Rugby’s showcase global event is the Executive, Council and Rugby Committee national Rugby Board, is the global govern- (RWC), which is one of meetings. ing body for , representing the world’s biggest and best-loved major At the 2011 World Rugby Medical more than 7.2 million men, women and chil- sports events. The RWC features the world’s Commission Conference, concussion was dren playing the game across 120 national top 20 fifteen-a-side teams, competing for identified as the number one medical risk member unions, affiliated via six regional the most prestigious prize in the sport, the in rugby. This opinion was supported by associations. . As one of the largest single- previous World Rugby research, which Rugby is a sport for all shapes and sizes sport tournaments worldwide, the RWC concluded that concussion was under- and the variants of the game include 2015 drew crowds of over 2.4 million fans to recognised¹, yet it was still rated in rugby Fifteens, Sevens (which will debut at the Rio games, had a global television audience of among the top five most frequently occurring 2016 Olympic Games), Beach and the non- 780 million and a global social media reach match injuries in the 2009 to 2010 season². contact variants of and Tag. of more than 300 million. World Rugby’s governance respo- World Rugby’s number one priority CONCUSSION INTERVENTIONS AND nsibilities cover both the professional and is player welfare and this is reflected RESULTS community games and is also responsible within the World Rugby Strategic Plan and World Rugby’s concussion programme is for development of the game in emerging confirmed by its position as the number based on activities focused on the following and new markets. one agenda item at all World Rugby four pillars:

50 features posters (in 12 languages), video, Facebook, Twitter and Instagram content that targets the general public. This campaign complements World Rugby’s Rugby Ready programme – a safety awareness programme, completed over 175,000 times since its launch. • Concussion App – in 2015 World Rugby launched its Concussion Guidance App for the general public which is freely available via: www.itunes.apple.com/ gb/app/world-rugby-concussion- management/id1031517215?mt=8 In addition to these interventions, World Rugby has also introduced and enforces compliance with compulsory annual concussion education for all elite team members including players, coaches and

© Dan Mullan/Stringer/Getty Images management staff. In total, more than 250,000 players, coaches, medics and individuals have been 1. Education and awareness • World Rugby Concussion Guidance for educated through these World Rugby 2. Injury management the General Public (in six languages) – interventions. 3. Injury prevention this was developed with the support It should be noted that the above 4. Research of our International Concussion education and awareness initiatives have The key intervention in World Rugby Advisory Group and has been used by been implemented by World Rugby and are driving the worldwide concussion several other sporting federations and complemented by each Union's individual programme has been the introduction of the governments – for example, Scotland– programmes. Head Injury Assessment (HIA) in 2012. This to underpin the development of their highly visible intervention was developed general public education documents. Injury management primarily to improve pitch-side care for • Four Online Concussion Education The key intervention strategy in injury our elite athletes, but it was recognised Modules (in eight languages) – four management has been the introduction from the outset that it would play a critical different educational modules have of the HIA process for the elite game. role in a public awareness programme for been developed, one each for the Introduced in 2012, it was initially known concussion across the entire sport. general public, non-rugby healthcare as the PSCA or Pitch-Side Concussion professionals, non-elite team rugby Assessment, however in 2014, the name of Education and awareness healthcare professionals and elite team this pitch-side tool was changed to the HIA. Since 2012, with the HIA as the rugby healthcare professionals. To date, This intervention has not only provided spearhead for public awareness, World over 20,000 people have completed a worldwide standardisation of pitch-side Rugby has developed written guidelines, these concussion education modules, assessment of head injuries in the elite game, videos and online education modules to with an 83% increase in completions in but it has also led a marketing programme support the dissemination of educational the first 10 months of 2015. This material for the World Rugby Concussion General and awareness messages. The following is available via: www.playerwelfare. Public Awareness Programme. Combined interventions have been key to our public worldrugby.org/concussion with the compulsory education of all team awareness programme and are available • #RecogniseAndRemove Campaign – medical staff, the HIA process has raised the on www.playerwelfare.worldrugby.org/ promoted across World Rugby’s social standard of care within rugby with respect concussion: and digital channels. The campaign to head injuries.

INTERNATIONAL FEDERATIONS TARGETED TOPIC 51 PREVENTION

The introduction of the Player Welfare Standards into the Rugby World Cup Participation Agreement has provided a mechanism for enforcing compliance with Head Injury Assessment protocols

The key and unique levers used to assist Research Medical Officer of World Rugby, who did not with the introduction of – and compliance Another benefit of the introduction of have any voting rights, but chaired these with – the HIA process are discussed later in the HIA process has been the ability to meetings. this paper. identify over 600 videos related to HIA The objective for this group was ‘to Completion of the online elite team game intervention. This video library of investigate the available options for pitch concussion educational module is head impacts events is currently being side assessment of head injury at the compulsory for access and accreditation to analysed to assist in identifying common elite level of the game, recognising that, use the HIA. Since its development in 2012, mechanisms for HIA events. The aim of this at present, rugby is in a unique position it has been completed by over 1450 medical research is to assess whether changes in in world sport, where free interchange of staff worldwide. rugby laws or changes in other areas within players for tactical or injury purposes is At the community level of the game, the game can be identified that will help not allowed under the current laws and the introduction of a 'Blue Card' system is reduce the incidence of head injuries in the regulations’. being trialled in two member unions. The sport. What appeared to be an initial blue card is shown by the referee to any Further research is also currently being impediment to the development of a pitch- player who leaves the field or is required to undertaken into protective materials, in an side assessment for head injury, that is, no leave the field for a suspected head injury. effort to identify preventative interventions. access to a temporary replacement, was to They must receive clearance from a medical become the lever for many benefits that practitioner to return to play. The rationale THE HEAD INJURY ASSESSMENT (HIA) arose from the HIA process. behind this system is that it identifies to PROCESS In 2012, there was agreement across the all spectators and coaches the necessity to At the 2011 World Rugby Medical sport, including working group members, remove a player following a head injury and Commission Conference, it was agreed Unions, teams and medical staff, that highlights the necessity for medical follow- that all player welfare initiatives developed provision of a temporary replacement player up of this injury. must: for head injury assessment was essential. a) improve player welfare or safety In early 2012, the World Rugby Executive Injury prevention b) not undermine the fabric of the game Committee approved a trial law to allow In 2012, World Rugby commissioned c) not be open to tactical manipulation. temporary replacement for a head injury. an independent safety scientist to review With these principles as guidance, in This unanimous decision was obtained all rugby laws and regulations in use early 2012 a working group was established after review of the following information: within the game. The goal was to confirm to investigate and develop a side-line • Research from two independent that safety within the sport with respect assessment process for evaluation and sources, World Rugby Junior World to head injuries was being maximised. management of head injuries in the elite Championship Injury Surveillance³ This review was not limited to only adult game. This resulted in the development and English Rugby Union (RFU) Injury identifying the existence of appropriate of the PSCA tool, later in 2014, to be known as Surveillance4, which confirmed that laws and regulations, but also included the HIA tool. 56% of players with a concussion an assessment of implementation and The working group consisted of medical returned to play following their head compliance by key match officials. This representatives from 5 countries (all had incident. review resulted in strengthening the previous experience as team doctors • Video analysis by the World Rugby recognition and enforcement of the laws at the elite level of the game), a player Game Analysis Department, which and regulations that impact on head representative, two independent (non- showed that during the 2011 RWC, team contact. rugby) concussion experts and the Chief doctors took on average 64 seconds to

52 make a decision, ‘on the run and on EVOLUTION OF THE HIA > Criteria 1 – indications for immediate the field’, regarding a player’s removal In mid-2012, the pitch-side head injury and permanent removal, no pitch- from play following a head impact assessment tool and process, initially side assessment required event. known as the PSCA, but now called the HIA, > Criteria 2 – indications for pitch-side Obtaining a law change for temporary was trialled in the Under 20 Junior World assessment using the standardised replacement for head injury was critical Championship and, following feedback tool. to the pitch-side HIA process, but the regarding logistics, was introduced into The key differences in the 3 phases are most important working group strategic elite adult rugby competitions in both the outlined below: decision was linking access to a temporary northern and southern hemispheres. replacement for head injury to: The HIA has subsequently been Phase 1: August 2012 to July 2013 a) use of a standardised assessment tool through three evolutionary phases and • In this period, the tool was known as a (developed by the HIA Working Group), these are outlined below. It should be Pitch-Side Concussion Assessment or b) compulsory education for all medical highlighted that in Phases 1 and 2, the PSCA. and healthcare practitioners involved in temporary replacement time was limited • The number of Criteria 1 indications on-field head injury management and to 5 minutes as there was concern amongst was three and included confirmed c) compulsory participation of teams who administrators that the temporary concussion, convulsion and tonic access a temporary replacement, in a replacement might be open to tactical posturing. multi-national research programme. manipulation. This concern had been • When Criteria 2 indications were met, These strategic decisions have resulted heightened by an episode of abuse of the a 5-minute temporary replacement in a uniform approach to pitch-side head law for temporary substitution for ‘blood period was allowed for completion of injury management across the world injuries’ in 2009. the PCSA. within rugby, provided the HIA Working All versions of the HIA tool have been • The PSCA was undertaken in the Group with an homogenous cohort for based on the Sport Concussion Assessment medical room or at another agreed research purposes and provided the Tool (SCAT) 25 and SCAT 36, developed by location if the medical room was too far working group with information that has the Concussion in Sports group. The HIA 1 from the field of play. allowed for ongoing improvement in the (pitch-side) tool uses two distinct criteria, • The content of the PCSA included HIA process. each requiring a different action: a symptom checklist, Maddock’s Questions and tandem stance assessment. • Post-game follow-up processes were at the team doctor’s discretion using the follow-up assessment tool (SCAT 2 or computerised neuro-cognitive tool) of that team’s choice. All PSCA data was collected centrally by World Rugby and an official report (not peer-reviewed) was delivered to the working group in late July 2013. This official report identified that the number of players with a confirmed concussion remaining on the field following their injury had dropped from 56% to 12% with the introduction of this pitch-side intervention. Following this report, Version 2 of the PSCA Tool was developed and a more rigid and rigorous post-game follow-up process introduced.

Phase 2: August 2013 to May 2014 • Version 2 of the PSCA Tool was introduced from August 2013. • This included an increase in the number of Criteria 1 indicators from three to five with suspected loss of consciousness © Mike Hewitt/Getty Images Hewitt/Getty © Mike and obvious ataxia being added.

INTERNATIONAL FEDERATIONS TARGETED TOPIC 53 PREVENTION

• Both the 5-minute temporary replace- ment for head injury assessment and the assessment component of the PSCA The number of players with a 1 Tool remained unchanged in this phase. confirmed concussion remaining • A more rigid and standardised post- game follow-up procedure was on the field following their introduced with the implementation of compulsory PSCA 2 (post-game, same- injury droppped from 56% to day assessment – SCAT 3) and PSCA 3 (a 36 to 48 hour assessment) assessments. 12% with the intoduction of this In January 2014, the Phase 1 Scientific Report7 was published in the British Journal pitch-side intervention of Sports Medicine authored by Dr Gordon Fuller. This scientific report: > Confirmed the Phase 1 Official Report findings that the number of players with confirmed concussions of the HIA was strengthened by in the contractual agreement between returning to play following a substituting the Standardised participating teams and the tournament concussive injury had dropped Assessment of Concussion (SAC) owner (World Rugby). This resulted in the from 56% to 12% following the for Maddock’s Questions and the Player Welfare Standards, which covered introduction of the PSCA process. tandem balance test was replaced compliance with HIA processes, being > Identified areas for improvement in by the tandem gait test. legally binding. the PSCA tool and process that were > Time for temporary replacement This intervention was a first for rugby introduced in Phase 3. increased from 5 minutes to 10 and international sport. In May 2014, the Phase 2 Official minutes due to increased activities The World Rugby Executive Committee Report was developed by Paris University, required to be undertaken with the initially adopted the Player Welfare confirming similar results to those obtained new HIA tool. Standards for RWC in 2015 and then in Phase 1 Official and Scientific reports. In May 2014, the World Rugby Executive immediately extended them to all Committee approved an increase in time World Rugby tournaments, and strongly Phase 3: August 2014 to August 2016 allowed for temporary replacement for head recommended their adoption across all elite • Results from the Phase 1 Scientific injury assessment from 5 to 10 minutes. Rugby tournaments. Report and the Phase 2 Official Report Phase 3 research commenced in August At the time of writing, the majority of underpinned changes in the name, 2014 and continues to date. elite tournaments around the world have content and time allowed for the On 1 August 2015, temporary replacement adopted the Player Welfare Standards and temporary replacement. for head injury moved from a trial law the expectation is that these standards will • Phase 3 changes introduced in August within Rugby Union to a permanent law. provide a uniform player welfare standard 2014 included: worldwide. > Name change of pitch-side tool from NEXT STEPS The Player Welfare Standards introduced PSCA to HIA. This name change During the first 3 years of the HIA trial, for the RWC 2015 covered more than reflected that the assessment was enforcement of compliance was difficult as concussion and included the following: an assessment of a head injury, not teams and medical staff in most instances 1. Unions must confirm that team staff are an assessment of a concussion. The were not participating in World Rugby suitably qualified and fully-registered three tools were now referred to as tournaments and therefore were not with the appropriate body in their HIA 1 (pitch-side tool), HIA 2 (post- operating directly within World Rugby’s respective medical fields. game, same day tool) and HIA 3 (36 jurisdiction. The move of temporary 2. Unions and team medical staff must to 48 hour tool). substitution for head injury from a trial law confirm that a pre-tournament medical, > Expansion of Criteria 1 indicators to permanent law resulted in an opportunity mental and physical assessment has (immediate and permanent removal to improve World Rugby’s ability to enforce been completed on all tournament criteria) from five to eleven criteria. compliance. players. > Consolidation of Criteria 2 indicators This improved control over compliance 3. Unions and team medical staff used to identify players requiring was achieved in 2015 by introducing World must confirm that cardiac screening temporary replacement and side- Rugby’s Player Welfare Standards into the including ECG, has been completed on line assessment using the HIA 1 tool. RWC participation agreements. all tournament players. > Change in HIA 1 tool content – the Player Welfare Standards were not 4. Unions and team medical staff must cognitive evaluation component only unique in content, but were included confirm that baseline concussion

54 tests have been completed on all Prior to issuing the medical ac- References players. As a minimum, baseline creditation for the RWC 2015, the 1. Fuller CW, Laborde F, Leather RJ, Molloy SCAT 3 is required and computer educational compliance (online modules MG. International Rugby Board, Rugby neuro-cognitive assessments are and the 2-day Level 2 Immediate Care in World Cup 2007 injury surveillance study. recommended. Rugby course) was confirmed for all 65 Br J Sports Med 2008; 42:452-459. 5. Team medical staff must confirm that team medical and healthcare professional 2. 2009/10 England Rugby Premiership risk stratification for concussion is staff who were allowed admission to the Training & Injury Audit 2009-2010 completed on all players. field of play during a game. In addition, Season Report. 2011 Available from 6. Unions and team medical staff must 77 medical staff, providing immediate https://playerwelfare.worldrugby. confirm that concussion education for care during games, had also completed all org/?documentid=69 all players and team officials has been educational requirements. undertaken and delivered within the 12 The introduction of the Player Welfare 3. Fuller C and Taylor A. Junior World Championship - Injury Surveillance months prior to start of a tournament or Standards into the RWC Participation Summary of Results 2008-2014. Available competition. Agreement has provided a mechanism for from http://playerwelfare.worldrugby. 7. Team medical staff must ensure that enforcing compliance with HIA protocols. org/?documentid=142 players who meet the criteria identified The recommendation from the World Rugby in the HIA Tool and procedures for Executive Committee for the adoption of 4. England Rugby Premiership Injury permanent removal from the field of the Player Welfare Standards in non-World and Training Audit 2010-2011 Season play (Criteria 1) are removed from play Rugby tournaments and competitions Report 2012. Available from https and do not return to play. will support compliance and underpin the http://playerwelfare.worldrugby. 8. Team medical staff must ensure highest standards of medical care for our org/?documentid=75 that players who have sustained athletes. 5. McCrory P, Meeuwisse W, Johnston K, a confirmed concussion follow a Dvorak J, Aubry M, Molby M, Cantu R. graduated return to play protocol, Conclusion Consensus statement on concussion in as outlined in the World Rugby The introduction and delivery of a sport 3rd international conference on Concussion Guidelines. worldwide Concussion Programme in World concussion in sport held in Zurich. Br J 9. Team medical staff must haveRugby has required a collective approach Sports Med 2009; 43:i76-i84. completed the following online World from all national member unions. The 6. Guskiewicz KM, Register-Mihalik J, Rugby education modules: critical steps supporting the success of the McCory P, McCrea M, Johnston K, Makdissi • Match Day Medical Staff – www. programme worldwide included: M et al. Evidence-based approach to playerwelfare.worldrugby.org/ • Formation of a multi-national working revising the SCAT2: introducing the SCAT3. • Concussion Management for Elite group to develop the HIA Tool. Br J Sports Med 2013; 47:289-293. Level Match Day Medical Staff – • Inclusion of external experts in the 7. Fuller GW, Kemp SP, Decq. The www.playerwelfare.worldrugby. development of both the HIA Tool and International Rugby Board (IRB) pitch org/concussion educational materials. side concussion assessment trial: a pilot • Keep Rugby Clean (Anti-doping) – • Use of the elite pitch-side HIA tool as a test accuracy study. Br J Sports Med 2015; www.keeprugbyclean.worldrugby. marketing device for a wider concussion 49:529-535. org/ awareness programme. • Keep Rugby Onside (Integrity) – • Use of access to temporary substitution www.integrity.worldrugby.org/ as a lever for a uniform worldwide 10. On-field healthcare team staff must approach to pitch-side head injury have completed the Immediate Care management and multi-national Martin Raftery M.B.B.S., F.A.C.S.P. in Rugby Level 2 course or equivalent, research. CMO World Rugby within the preceding 3 years. • Recognition that review supported by Australia 11. Unions and teams must agree to research and ongoing assessment of participate in an untoward incident the content of the pitch-side tool was review process, if requested by World essential. Ross Tucker Ph.D., B.Sc. (Med), Post Grad Rugby. • Introduction of Player Welfare Dip. Sports Marketing 12. Team medical staff must acknowledge Standards to enforce compliance with Consultant Sports Scientist World Rugby that the match day doctor under HIA protocols. South Africa Regulation 15, has the final say on • Global public relations approach to Contact: Martin.Raftery@consultant. whether a player can access 15 minute educate players and public at all levels. worldrugby.org temporary substitution for a blood Delivering this worldwide Concussion injury and also if a player is not to return Programme has followed the accepted to play following a head injury or any business model of 'develop, implement, other injury. review, improve and measure.'

INTERNATIONAL FEDERATIONS TARGETED TOPIC 55