Sideline assessment of concussion and return to play – are we practising what we preach?
October 27, 2011 9 Comments
The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.
The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.
Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.
He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.
The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.
Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’
Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’
What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines – see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’
In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.
Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.
The Rugby Law blog was particularly vociferous on these events.
For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.
Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?
CJSM would like to hear your experiences and opinions.
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About Chris Hughes
Clinical Journal of Sport Medicine Blog 
Thanks for an insightful discussion on the issue of return-to-play after concussion in rugby union. As a sports injury prevention researcher with a particular interest in the translation of safety evidence and policy into practice at the community level of sport, I find these examples of non-compliance with organisational safety policy at the elite level very challenging. For an international rugby union player to be able to return to play in the same game after a suspected concussion incident displayed scant regard for the IRB Concussion Guidelines which clearly state that “Players suspected of having concussion must be removed from play and must not resume play in the match.”
Recently published research by Hollis et al1 has highlighted how poorly the IRB guidelines are translated into action in community rugby in Australia with the median number of days before players returned to play following concussion being three despite the IRB 21-day stand-down regulation following concussion. Most players (78%) did not receive return-to-play advice post-concussion, and of those who received correct advice, all failed to comply. In addition, it has recently been suggested that what viewers see on TV in regard to the management of concussion in professional sport is often contradictory to the policies and messages being put forward by the governing bodies for these sports.2
If the IRB does indeed believe that concussion must be taken extremely seriously to safeguard the long term welfare of players, then it must ensure that all players at international level set the right example to community level participants by not returning to play in the same game in which a concussion event is suspected. Community sport does not have the resources necessary to ensure sideline assessment of suspected concussed players by a properly qualified and recognised neurological specialist and such public displays of non-compliance to safety policy at the international level only serves to compound this problem.
1. Hollis SJ, Stevenson MR, McIntosh AS, Shores EA, Finch CF. Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players. Br. J. Sports Med. 2011.
2. McLellan TL, McKinlay A. Does the way concussion is portrayed affect public awareness of appropriate concussion management: the case of rugby league. Br. J. Sports Med. 2011;45(12):993-96.
If there was no visible blood injury then presumably an attempt to see if concussion would settle
Against guidelines as highlighted above and puts player at higher risk of developing significant pathology once the “diagnosis” of concussion was made
Are there unique pressures in rugby where often play is not stopped and clinician on pitch as game continues ? Does the ongoing action drive a concussed player on ?
Is there a difference in football where game stopped before I can go on ?
I have worked professionally in both sports and do believe that in rugby it can be more challenging because of this factor .
I think that’s a really good point, Mike.
Does anyone else think that stopping play to allow the medical team to assess a head injury would improve clinical assessment and decision making, player compliance with medical advice, and clinical outcomes? I’m not aware of any studies looking at this in sport. Another call for some more injury prevention research? Any takers?!
Stopping the play and making the assessment can be easily done likewise I have also had to try and assess the player with the game going on around me at the same time. I do it in amateur rugby league . What is the problem is the coaching staff wanting players back on the field so that they can win. I know of many Dr.’s (medical) who have been told “put them back on or I will find someone who will” by coaches. Likewise I have been told by many coaches to put the player back on or lose my role at the team. As I have not I have three life bans from clubs and have been told I am not wanted with certain teams as I wont “play the game” and am “turning the players soft”.
Take last night’s Four Nation’s rugby league game. First tackle and Jordan James was knocked out and it was shown on many replays that he was unconscious even before he hit the ground, when they went to stand him up he was very unsteady on his feet and the commentators even said he should not be back on as he was concussed yet he was back in the game 40 mins later. Was that pressure from the coach to put the player back on? Was it the medical provider (They always have sports medicine recognized medical officer’s with International teams) who decided there was no concussion? Who knows but the focus at the professional level should be liability.
If a player suffers a concussion in a game and they are returned who suffers the long term damage – not the coach or medical provider, the player and their family. Surely if the coach or medical provider was made to be financially liable for any other effects from medical decisions when returning a professional player to the field under 10 days from the effects of a concussion then we would not have this problem on the international stage. Likewise with the non-professional level of sports participation. I have had players assessed at the sideline and in hospital as being concussed, see their own Dr 2 days later and been cleared to return to play and then the next game they take another head injury and I am left fighting for their life. Who is responsible for having cleared the player and allowing them to return to the field.
Something to ponder
Even now, I recall that incident as I was watching that part of the game with my family. Interesting that they thought that what happened to Parra did not look good and he looked like he was seriously affected by the incident.
Like other responders to the initial blog, I, too, am concerned with the very mixed messages that this sort of incident and its media coverage is sending to the non-professional players. Usually, the broad community sports participant does not see what goes behind the scenes with elite player performance and so gets an incorrect impression of what can be done to prevent injuries of any type (think about the well-designed and intensive training programs; allied health support before, after and during a game; nutrition advice and psychological support services; carefully chosen equipment and gear of the latest technological standards; fine manicuring of playing fields for high performance games, etc.)
One could view this rather as ignorance bred from omission due to a complete absence of any obvious good role modelling in media and other coverage of sport. In a recent commentary (http://www.monash.edu.au/news/show/is-it-time-for-a-new-breed-of-professional-sport-role-model) I argued that we now need high-profile sports role models who can advocate for injury prevention, and talk about what they do to reduce their own risks. There is too much emphasis on just want went wrong for those who did get injured – why don’t we hear about what those who do not get injured did to ensure that?
This concussion incident, on the another hand, leads to incorrect and misleading information being provided to community sports participants, because there is a very obvious, and visual, demonstration of prevention/management practice that is contrary to the best evidence and guidelines for action.
I wonder which is worse – not telling or showing community sports participants about what is done to prevent injuries or doing and showing something that is contrary to all evidence and which is not appropriate?
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it was very interesting and informative.