Concussion is a traumatic brain injury resulting in a disturbance of brain function. There are many symptoms of concussion, common ones being headache, dizziness, memory disturbance or balance problems.
Loss of consciousness, being knocked out, occurs in less than 10% of concussions. Loss of consciousness is not a requirement for diagnosing concussion.
Typically standard brain scans are normal.
Concussion can be caused by a direct blow to the head, but can also occur when blows to other parts of the body result in rapid movement of the head, e.g. whiplash type injuries.
Concussions can happen at any age. However, children and adolescent athletes:
Athletes with a history of two or more concussions within the past year are at greater risk of further brain injury and slower recovery and should seek medical attention from practitioners experienced in concussion management before return to play.
It should be noted that the symptoms of concussion can present at any time but typically become evident in the first 24-48 hours following a head injury.
If any of the following signs or symptoms are present following an injury the player should be suspected of having a concussion and immediately removed from play or training.
Any one or more of the following visual clues can indicate a concussion:
Presence of any one or more of the following signs and symptoms may suggest a concussion:
Failure to answer any of these questions correctly may suggest a concussion:
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, using appropriate emergency management procedures.
Once safely removed from play, the injured player must not be returned to activity that day and until they are assessed medically.
If a neck injury is suspected, the player should only be removed by emergency healthcare professionals with appropriate spinal care training.
Team mates, coaches, match officials, team managers, administrators or parents who suspect a player may have concussion MUST do their best to ensure that the player is removed from the field of play in a safe manner.
Athletes with a suspected concussion:
If ANY of the following are reported, then the player should be transported for urgent medical assessment at the nearest hospital:
In all cases of suspected concussion, it is recommended that the player is referred to a medical or healthcare professional for diagnosis and guidance, even if the symptoms resolve.
Rest is the cornerstone of concussion treatment. This involves resting the body - ‘physical rest’ - and resting the brain - ‘cognitive rest’. This means avoidance of:
This complete rest should be for a minimum of 24 hours.
Before restarting activity, the player must be symptom free at rest. Medical or approved healthcare provider clearance is recommended before restarting activity.
Children and adolescents should be managed more conservatively. World Rugby recommends children and adolescents should not play or undertake contact training for a minimum of 2 weeks following cessation of symptoms. Students must have returned to school or full studies before recommencing exercise.
After the minimum rest period AND if symptom free at rest, a graduated return to play (GRTP) programme should be followed.
A graduated return to play (GRTP) programme is a progressive exercise programme that introduces an athlete back to sport in a step wise fashion. This should only be started once the athlete is symptom free and off treatments that may mask concussion symptoms, for example drugs for headaches or sleeping tablets.
The GRTP programme consists of six distinct stages:
Under the GRTP programme, the player can proceed to the next stage only if there are no symptoms of concussion during rest and at the level of exercise achieved in the previous GRTP stage.
If any symptoms occur while going through the GRTP programme, the player must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms.
World Rugby recommends that a medical practitioner or approved healthcare professional confirm that the player can take part in full contact training before entering stage 5.
Minimum rest period
Complete body and brain rest without symptoms
Light aerobic exercise
Light jogging for 10-15 minutes, swimming or stationary cycling at low to moderate intensity. No resistance training. Symptom-free during full 24-hour period
Increase heart rate
Running drills. No head impact activities
Non-contact training drills
Progression to more complex training drills, e.g. passing drills. May start progressive resistance training
Exercise, coordination, and cognitive load
Full contact practice
Normal training activities
Restore confidence and assess functional skills by coaching staff
Return to play
It is recommended that, in all cases of suspected concussion, the player is referred to a medical professional for diagnosis and guidance as well as return to play decisions, even if the symptoms resolve.
A comprehensive medical concussion evaluation may include:
Each of these is useful in contributing to a diagnosis and return to play decision but no one test stands alone in determining return to play.