Evaluation of World Rugby's concussion management process: results from Rugby World Cup 2015

Objective To evaluate World Rugby's concussion management process during Rugby World Cup (RWC) 2015. Design A prospective, whole population study. Population 639 international rugby players representing 20 countries. Method The concussion management process consisted of 3 time-based, multifaceted stages: an initial on-pitch and/or pitch-side assessment of the injury, a follow-up assessment within 3 hours and an assessment at 36–48 hours. The initial on-pitch assessment targeted obvious signs of concussion, which, if identified, lead to a ‘permanent removal from play’ decision and a diagnosis of concussion. If the on-pitch diagnosis was unclear, a 10-min off-pitch assessment was undertaken for signs and symptoms of concussion leading to a ‘suspected concussion with permanent removal from play’ or a ‘no indication of concussion with return to play’ decision. Evaluations at 3 and 36–48 hours postmatch lead to diagnoses of ‘confirmed concussion’ or ‘no concussion’. Medical staff's decision-making was supported during each stage by real-time video review of events. Players diagnosed with confirmed concussion followed a 5-stage graduated-return-to-play protocol before being allowed to return to training and/or competition. Results Players were evaluated for concussion on 49 occasions, of which 24 resulted in diagnoses of concussion. Fourteen players showing on-pitch signs of concussion were permanently removed from play: 4 of the 5 players removed from play following off-pitch medical room evaluation were later diagnosed with a confirmed concussion. Five players not exhibiting in-match signs or symptoms of concussion were later diagnosed with concussion. The overall incidence of concussion during RWC 2015 was 12.5 concussions/1000 player-match-hours. Conclusions This study supports the implementation of a multimodal, multitime-based concussion evaluation process to ensure that immediate and late developing concussions are captured

King-Devick concussion test performs poorly as a screening tool in elite rugby union players: a prospective cohort study of two screening tests versus a clinical reference standard

BACKGROUND: The King-Devick (KD) test is an objective clinical test of eye movements that has been used to screen for concussion. We characterised the accuracy of the KD test and the World Rugby Head Injury Assessment (HIA-1) screening tools as methods of off-field evaluation for concussion after a suspicious head impact event. METHODS: A prospective cohort study was performed in elite English rugby union competitions between September 2016 and May 2017. The study population comprised consecutive players identified with a head impact event with the potential to result in concussion. The KD test was administered off-field, alongside the World Rugby HIA-1 screening tool, and the results were compared with the preseason baseline. Accuracy was measured against a reference standard of confirmed concussion, based on the clinical judgement of the team doctor after serial assessments. RESULTS: 145 head injury events requiring off-field medical room screening assessments were included in the primary analysis. The KD test demonstrated a sensitivity of 60% (95% CI 49.0 to 70) and a specificity of 39% (95% CI 26 to 54) in identifying players subsequently diagnosed with concussion. Area under the receiver operating characteristic curve for prolonged KD test times was 0.51 (95% CI 0.41 to 0.61). The World Rugby HIA-1 off-field screening tool sensitivity did not differ significantly from the KD test (sensitivity 75%, 95% CI 66 to 83, P=0.08), but specificity was significantly higher (91%, 95% CI 82 to 97, P<0.001). Although combining the KD test and the World Rugby HIA-1 multimodal screening assessment achieved a significantly higher sensitivity of 93% (95% CI 86% to 97%), there was a significantly lower specificity of 33% (95% CI 21% to 48%), compared with the HIA-1 test alone. CONCLUSIONS: The KD test demonstrated limited accuracy as a stand-alone remove-from-play sideline screening test for concussion. As expected with the addition of any parallel test, combination of the KD test with the HIA-1 off-field screening tool provided improved sensitivity in identifying concussion, but at the expense of markedly lower specificity. These results suggest that it is unlikely that the KD test will be incorporated into multimodal off-field screening assessments for concussion at the present time

Guidelines for community-based injury surveillance in rugby union

Objectives The vast majority of rugby union (‘rugby’) participants are community-based players; however, the majority of injury surveillance studies reported relate to the elite, professional game. A potential reason for this dearth of studies could be the perceived difficulty of using the consensus statement for injury recording at the community level. The aim of this study was to identify areas where the consensus statement could be adapted for easier and more appropriate implementation within the community setting. Design Round-table discussion Methods All community-based injury surveillance issues were discussed during a 2-day facilitated round-table meeting, by an 11-person working group consisting of researchers currently active in rugby-related injury surveillance, sports medicine and sports science issues. The outcomes from the meeting were summarised in a draft guidance document that was then subjected to an extensive iterative review prior to producing methodological recommendations. Results Each aspect of the rugby-specific consensus statement was reviewed to determine whether it was feasible to implement the standards required in the context of non-elite rugby and the resources available within in a community setting. Final recommendations are presented within a community-based injury report form. Conclusions It is recommended that whenever possible the rugby-specific consensus statement for injury surveillance studies be used: this paper presents an adapted report form that can be used to record injury surveillance information in community rugby if suitable medical support is not available

The accuracy and reproducibility of video assessment in the pitch-side management of concussion in elite rugby

Objectives To investigate the accuracy and reliability of side-line video review of head impact events to aid identification of concussion in elite sport. Design Diagnostic accuracy and inter-rater agreement study. Methods Immediate care, match day and team doctors involved in the 2015 Rugby Union World Cup viewed 20 video clips showing broadcaster’s footage of head impact events occurring during elite Rugby matches. Subjects subsequently recorded whether any criteria warranting permanent removal from play or medical room head injury assessment were present. The accuracy of these ratings were compared to consensus expert opinion by calculating mean sensitivity and specificity across raters. The reproducibility of doctor’s decisions was additionally assessed using raw agreement and Gwets AC1 chance corrected agreement coefficient. Results Forty rugby medicine doctors were included in the study. Compared to the expert reference standard overall sensitivity and specificity of doctors decisions were 77.5% (95% CI 73.1–81.5%) and 53.3% (95% CI 48.2–58.2%) respectively. Overall there was raw agreement of 67.8% (95% CI 57.9–77.7%) between doctors across all video clips. Chance corrected Gwets AC1 agreement coefficient was 0.39 (95% CI 0.17–0.62), indicating fair agreement. Conclusions Rugby World Cup doctors’ demonstrated moderate accuracy and fair reproducibility in head injury event decision making when assessing video clips of head impact events. The use of real-time video may improve the identification, decision making and management of concussion in elite sports

The accuracy and reproducibility of video assessment in the pitch-side management of concussion in elite rugby

Objectives To investigate the accuracy and reliability of side-line video review of head impact events to aid identification of concussion in elite sport. Design Diagnostic accuracy and inter-rater agreement study. Methods Immediate care, match day and team doctors involved in the 2015 Rugby Union World Cup viewed 20 video clips showing broadcaster’s footage of head impact events occurring during elite Rugby matches. Subjects subsequently recorded whether any criteria warranting permanent removal from play or medical room head injury assessment were present. The accuracy of these ratings were compared to consensus expert opinion by calculating mean sensitivity and specificity across raters. The reproducibility of doctor’s decisions was additionally assessed using raw agreement and Gwets AC1 chance corrected agreement coefficient. Results Forty rugby medicine doctors were included in the study. Compared to the expert reference standard overall sensitivity and specificity of doctors decisions were 77.5% (95% CI 73.1–81.5%) and 53.3% (95% CI 48.2–58.2%) respectively. Overall there was raw agreement of 67.8% (95% CI 57.9–77.7%) between doctors across all video clips. Chance corrected Gwets AC1 agreement coefficient was 0.39 (95% CI 0.17–0.62), indicating fair agreement. Conclusions Rugby World Cup doctors’ demonstrated moderate accuracy and fair reproducibility in head injury event decision making when assessing video clips of head impact events. The use of real-time video may improve the identification, decision making and management of concussion in elite sports