Rugby’s temporary substitution for head injury assessment adopted into law

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Rugby’s temporary substitution for head injury assessment adopted into law

World Rugby has adopted temporary substitution for head injuries at the elite level into Law 3.10, further underscoring the governing body’s commitment to evidence-based research driving player welfare enhancements for players at all levels of the sport.

World Rugby’s number-one priority is player welfare and any clear signs or symptoms of concussion or suspected concussion – at all levels of the game – must result in the immediate and permanent removal of players from the playing or training environment as highlighted within the organisation’s #RecogniseAndRemove education campaign.

At the elite level of the game, a global trial has enabled temporary substitution for a head injury assessment (HIA) when it is unclear if the player has a suspected concussion. Following overwhelmingly positive results, this trial will officially become law, effective from 1 August, 2015.

The temporary substitution time period has proven successful in assisting medical staff to assess and make an informed decision regarding the removal of players when suspected concussion is not clear. The entire process includes strict side-line assessment based on the best available evidence and rigid follow-up procedures.

This HIA tool combines cognitive, balance and memory tests and is derived from the SCAT 3 recommended by the experts from the Zurich Concussion Consensus Group to assist medics in making the correct decision following a head impact. World Rugby is the first sport to use access to an on-field law to obtain post-injury management compliance resulting in improved diagnostic accuracy of concussion and improved player safety.

World Rugby Chief Medical Officer Dr Martin Raftery said: “World Rugby’s number-one priority is player welfare and allowing temporary substitution for head injury has proven to be a massive step forward in protecting our elite players following a head injury.

“As someone who has been involved as a team doctor in elite sport for more than 25 years, I firmly believe that medical management of concussion in rugby has never been stronger. Law changes, pitch-side and post-injury management, combined with greater education and awareness are ensuring that we continue to put our players first.”

Research has underpinned the HIA process throughout. Prior to the temporary substitution, 56 per cent of players with a confirmed concussion remained on the field following their injury. Now that figure is less than 12 per cent (British Journal of Sports Medicine, 2014).

Raftery added: “World Rugby is committed to the best-possible standards of care for our players and the research suggests that increased rates of reported concussion are largely due to the changing culture around recognition and diagnosis. Our mission is to reduce that 12 per cent further with concussion education, prevention and research, and our message to the global rugby community is clear – recognise and remove.”

World Rugby’s commitment to progressing concussion education, prevention, education and research is reflected in the adoption of mandatory education for players, coaches, referees and medics, an untoward incident system review and innovative player welfare standards for Rugby World Cup and all World Rugby events.


For further information on World Rugby’s concussion education programmes and public guidance visit

Editors’ notes

  • Before 2012 medical staff were diagnosing concussion on the run and on the pitch
  • August 2012 to July 2013 – Introduction of Pitch-Side Concussion Assessment (PSCA) which included a five-minute temporary substitution
  • August 2013 to May 2014 – More rigid and standardised post-game follow up procedures
  • August 2014 to date – Name changes from PSCA to HIA and the HIA tool has been enhanced. The enhanced tool, containing more assessments, required increased time to complete so the time for temporary substitution period was increased from five to 10 minutesHIA principles
  • Any clear or suspected symptoms of concussion MUST result in immediate and permanent player removal
  • If the signs or symptoms of concussion are unclear then a player can be removed for an HIA, which is a 10-minute off-field assessment – the HIA does not diagnose concussion, it identifies a suspected concussion
  • If a player is suspected of concussion, following a pitch-side assessment supported by the HIA, they are removed permanently from the match
  • Any player who undertakes an HIA (irrespective of the result) must undertake further clinical assessments supported by the a SCAT 3 immediately after the match and again at 36 and 48 hours
  • Any player with a confirmed concussion must undertake a supervised graduated return to play protocol to manage safe return to competitionKey HIA findings
  • Less than 12 per cent of players with a confirmed concussion remained on the field following their injury. Prior to the HIA, 56 per cent of concussed players returned to play following their injury
  • The HIA process (temporary substitution, pitch-side tool plus follow up process) is playing a predominant role in changing culture in the sport towards concussion and is a major factor behind increased reported concussion rates in the elite game
    #RecogniseAndRemove concussion education
    World Rugby’s #RecogniseAndRemove online concussion education modules were completed by almost 13,000 members of the public and doctors across 180 nations in 2014. Completions of the interactive concussion education module at, which is available in 11 languages, included 7,311 members of the public, 3,534 completions by non-rugby doctors, 1,391 completions by match day doctors and 693 completions by elite team medical staff, underscoring rugby’s commitment to change concussion culture.

    The online programme is a key strategy of World Rugby’s holistic approach to concussion awareness and education, which also includes mandatory face-to-face education and training for players, coaches, team management and team doctors, guidance for general public and educational posters in multiple languages and the social media-driven #RecogniseAndRemove educational video featuring stars of men’s and women’s rugby.

    Concussion education is also included as mandatory modules within World Rugby’s Rugby Ready programme, which has been rolled out to almost 200,000 members of the rugby family globally.

    Rugby World Cup 2015 Player Welfare Standards – Concussion

    a) All teams must have appropriately-qualified and HIA-educated doctor at all such Matches as defined in the World Rugby HIA concussion guidelines
    b) All medical staff and team staff must adhere to the immediate and permanent removal criteria for players following a head injury that suggests a confirmed or suspected concussion
    c) All medical staff and team staff must adhere to temporary removal from the field of play criteria that indicate when a HIA assessment should be completed
    d) All players and team staff must have completed concussion education within the year prior to their first participation each season. The minimum content of this education is set out in the World Rugby HIA concussion guidelines
    e) Annual baseline concussion testing on all players participating in such matches, as a minimum using the tools as set out in the World Rugby HIA concussion protocols
    f) Annual risk stratification of all players participating in such matches to support concussion management on an individual basis. This concussion risk stratification may be undertaken as set out in the World Rugby HIA concussion guidelines and/or as appropriate in accordance with medical practice in the relevant jurisdiction;
    g) All competitions or tournaments must monitor the implementation and compliance of the HIA protocol in such matches and, as requested, promptly provide feedback to World Rugby on overall or individual case compliance within 10 days of request
    h) Union or tournament organisers must ensure that rules require all persons involved in the tournaments and/or matches to comply with Law 3.10 ii and this Regulation 10 and set out that any non-compliance therewith constitutes a breach of such rules as a strict liability offence by, as a minimum, the relevant team’s medical staff, team manager and head coach as the persons primarily responsible for the welfare of the players in their team, and any relevant players and/or other persons. The union or tournament organiser’s rules must also stipulate that the club, rugby body and/or union responsible for the team shall be vicariously liable for any proven breach of such rules by its personnel. Unions and tournament organisers must institute proceedings and impose appropriate sanctions in the event of any such breaches. Unions and tournament organisers must provide World Rugby with a summary of any such cases and, upon request, all supporting documentation and information.

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