{"id":9887,"date":"2021-08-31T18:30:06","date_gmt":"2021-08-31T17:30:06","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=9887"},"modified":"2021-08-31T18:32:50","modified_gmt":"2021-08-31T17:32:50","slug":"why-reinforcing-good-practice-around-head-bumps-and-re-thinking-what-makes-us-go-ouch-could-benefit-player-welfare-in-rugby","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2021\/08\/31\/why-reinforcing-good-practice-around-head-bumps-and-re-thinking-what-makes-us-go-ouch-could-benefit-player-welfare-in-rugby\/","title":{"rendered":"Why reinforcing good practice around head #BUMPs and re-thinking what makes us go \u2018#OUCH\u2019 could benefit player welfare in rugby"},"content":{"rendered":"

In 2008, research showed that 58% of players diagnosed with concussion after the game had remained on the field after their head injury event(1,2). Since then, we have seen a paradigm shift not only in terms of how head injuries are viewed across the rugby landscape, but also in terms of the processes put in place to maximise player welfare. As the scientific knowledge in this area has evolved, rugby has evolved with it, whilst there remains work to be done, it should at least be acknowledged that more recent research has shown that the proportion of players subsequently diagnosed with concussions not being removed at the time of their injury has reduced to less than 10%(3).<\/p>\n

One such player welfare initiative in place today across elite adult rugby that has contributed to these improvements is the Head Injury Assessment (HIA) protocol*. The HIA is a structured assessment protocol (using real-time video to support clinical assessment) that allows medical staff to manage head impact events where the initial diagnosis may be unclear and to differentiate between possible, suspected and confirmed concussions. (4). The off-field assessment is sensitive and specific (90% & 87% respectively) comparable to the use of MRI to diagnose rotator cuff tears. The diagnostic accuracy is improved by clinical judgement. (3)<\/p>\n

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Most people involved in rugby, will recognise that there are several \u2018criteria 1\u2019 signs that if observed require immediate and permanent removal (IPR) of the player, as they are automatically considered to be concussed. Generally, these clinical signs (which can be broadly summarised by the acronym #BUMP<\/strong>), account for between 30-50% of concussions. These\u00a0are clinical signs<\/strong>, but in elite rugby to support recognition of a clinical sign there are also identified\u00a0visible or video signs<\/strong>. For instance, loss of consciousness is supported by the following visible or video signs – falling without protection and lying motionless for more than 5 seconds<\/em>. The visible or video signs support the recognition of a clinical sign. For most experienced doctors and therapists working in elite rugby, the clinical decision making and communication around these IPR events could be considered a straightforward part of the job. The task can be difficult for those early in their careers.<\/p>\n

Dealing in shades of grey<\/strong><\/p>\n

However, as with most things in life, not everything is quite as \u2018black and white\u2019. Though guidance exists as to who should be removed for an in-match HIA through \u2018category 2\u2019 clinical and\/or video criteria (which are based on empirical research and summarised in Figure 1), more tricky in practice is determining whether a player (who has not exhibited any criteria 1 signs) needs to be taken for a HIA (and a temporary replacement made). Though there is little debate around the removal of players who demonstrate evidence of #BUMPs, some of the language used as part of the \u2018category 2\u2019 criteria can be interpreted quite subjectively and, from experience, with a degree of variation. One medic\u2019s interpretation of an \u2018injury event witnessed with potential to result in a concussive injury\u2019 <\/em>or a \u2018head impact where diagnosis not immediately apparent\u2019 <\/em>could theoretically and practically be very different to another\u2019s.<\/p>\n

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Figure 1. <\/strong>Criteria 2 Video\/Visual Signs. World Rugby<\/p>\n

In order to further improve the consistency of decision making and to make the process as effective as possible, World Rugby, Premiership Rugby and the Rugby Football Union (RFU) have been intensively collecting and analysing HIA data from multiple data streams for a number of years. Whilst the HIA protocol has been widely accepted and supported as a significant development from a player welfare perspective, a few important clinical questions have consistently surfaced:<\/p>\n