Concussion tests

[OB..]

[LAWS]If the referee decides – with or without the advice of a doctor or other medically qualified person – that a player is so injured that the player should stop playing, the referee may order that player to leave the playing area.[/LAWS](My emphasis)

 

[Simon]

I missed the bit where the physio was stated to be a fully qualified neurologist.

If I want an opinion on my gas boiler, I don't ask a joiner; if I want an opinion on a head injury, I don't ask a physio.

I am a Neurologist, as well as being an occasional U17 coach and referee and I find it very hard to diagnose concussion. It is very difficult to define what concussion is. It is like pornography in that respect - you cannot define it but you know it when you see it. In practice, I see people in my clinics weeks down the line when they have continuing symptoms, however imaging with MRI is nearly always normal, mean there is something going on at a cellular level beyond the resolution of current imaging technology.

I agree that Na Madrai was right to stand his ground. Our first priority is the safety of the players.

There is a lot of interest in concussion from the US Military and also in NFL. I was at a recent conference when they were discussing what are the best pitch side tests for concussion. Currently the test used is the Pitchside Suspected Concussion Assessment (PSCA), which apparently George Smith passed:

http://www.smh.com.au/rugby-union/u...n-test-after-smith-injury-20130718-2q5o7.html

The PSCA requires a doctor to carry out an assessment:

http://www.irpa-rugby.com/wp-content/uploads/2013/08/130812-PSCA-Procedures-and-Definitions.pdf

As for grassroots where the rest of us are at the moment it is harder. Often the questions from the Sport Concussion Assessment Tool are used:

http://www.olympic.org/Documents/Reports/EN/en_report_1006.pdf

But even these has a medical component.

The talk I went to discussed a new test called the King-Devick Test:

http://kingdevicktest.com

This is a simple pitch side reading test that looks at reading speed. Each player has to have a baseline test and then the test is repeated after the suspected concussion. It is an American test, however it has been tried on New Zealand amateur rugby players:

http://www.ncbi.nlm.nih.gov/pubmed/23374885

Now that there is significant interest here in a number of sports I suspect that there will be a lot of progress made in the next few years. I suspect that there is not going to be one simple answer to assess players as every head injury is different, but I think it is correct to err on the side of caution and exclude any player from continuing playing if it is suspected that they are concussed.

The issue of scanning head injuries is more complicated. Scans will be required on the door in order to detect significant intracranial bleeds. This will be with CT scans, which are X-Ray based and therefore carry a significant amount of ionising radiation exposure.

There are guidelines for A+E departments to decide who needs a CT in minor head injury. These apply to Glasgow Coma Scale (GCS) 13-15, presence of loss of consciousness or amnesia to the Head Injury Event, or Confusion
Major Criteria
(Signs/Symptoms Concerning for Need for Neurosurgical Intervention)
GCS < 15 at 2 hours post-injury - someone who is conscious, obey commands but confused would score 14.
Suspected open or depressed skull fracture
Any sign of basilar skull fracture? (Haemotympanum, Racoon Eyes, Battle’s Sign, CSF oto-/rhinorrhea)
≥ 2 episodes of vomiting
Age ≥ 65 (could apply to the occasional prop still mad enough to play)
Minor Criteria
(Additional Signs/Symptoms That Help Detect All Traumatic Intracranial Processes)
Retrograde Amnesia to the Event ≥ 30 minutes
"Dangerous" Mechanism? (Pedestrian struck by motor vehicle, Occupant ejected from motor vehicle, or Fall from > 3 feet or > 5 stairs.)

These have been validated - but they are still guidelines and the rule is that if there is later deterioration then the patient needs re-assessment, which is why minor head injury advice needs to be given upon discharge from A+E.

 

[crossref]

it would have been interesting if they had gone ahead and attempted the substition.

now, you would have refused to allow the interchange and could show a RC. But as you were refusing the interchange, the person you were RC would have been a non-player so they could still continue with 15 on the pitch ...

 

[crossref]

NM - from your account I think you were perfectly correct.
I have only once had to over-rule a coach and insist a player leaves the pitch. I also received some angry objections and rolling of eyes.
The player himself (an U17) then bounded up and down the touchline to shoe how fit he was.
which lasted about 5 minutes and then he became quiet
then ten minutes later I realised he had been sick, and then he sat down - still in his short and shirts, now shivering, with his head in his hands.

it gave me no pleasure at all when I saw two coaches finally leading him away... obviously not right at all.

did I get an apology? did I buggery.

 

[Browner]

NM - from your account I think you were perfectly correct.
I have only once had to over-rule a coach and insist a player leaves the pitch. I also received some angry objections and rolling of eyes.
The player himself (an U17) then bounded up and down the touchline to shoe how fit he was.
which lasted about 5 minutes and then he became quiet
then ten minutes later I realised he had been sick, and then he sat down - still in his short and shirts, now shivering, with his head in his hands.

it gave me no pleasure at all when I saw two coaches finally leading him away... obviously not right at all.

did I get an apology? did I buggery.

Dear RFU coach Licensing manager
This is what I witnessed ,

I'll leave it to you to decide whether the coaches / physios of team x are deemed a fit &proper person to hold a coach / physio licence. Etc...
Ys
Qualified referee
Cc CB cwo, referee Society secretary, RFU child welfare dept.

For you as well N M ........... X

 

[L'irlandais]

Well done, Na Madrai.

[laws]6.C.2 Those who may enter the playing area The match doctor and the non-playing members of the team may enter the playing area as authorised by the referee.[/laws]

[laws] 6.C.3 Limits to entering the playing area
In the case of injury, these persons may enter the playing area while play continues, provided they have permission from the referee. Otherwise, they enter only when the ball is dead.[/laws]As far as I can see the LoTG don't mention that the coach has the right to enter the field of play, not even if the ball is dead, and certainly not without the referee's permission.
There is this mention :
[laws]6.A.4 The duties of the referee in the playing enclosure (g)
The referee gives permission to each of the coaches to enter the playing area at half-time to attend to their teams during the interval.[/laws]You may allow him on at the interval to attend to his team, but certainly not to interupt the match to give you his opinion. It's a no-no, and he should know better.

If the esteemed gentleman doesn't care all that much about the safety of his underage player, then perhaps he's not fit to be coaching an underage side. (Colts is U19, right?) I wouldn't trust my child to somebody who gets carried away by the heat of the action.

As to carding or threatening to card a member of the coaching staff, it has previously been discussed here on RRF. The general feeling seemed to be the Blazers should deal with it, so the individual is NOT allowed to (even attempt) to interupt the referee during the game. I cannot find the Law which states the referee can request the coach leave the playing enclosure. (Perhaps it covered under the RFU régulations?)

On that note, (RFU regulations) we should be careful on RRF that Reg. 1.10 g)

comments and/or conduct in connection with current and/or anticipated disciplinary proceedings and/or match officiating (or any aspect thereof) which may be prejudicial to and/or impact upon current and/or anticipated disciplinary proceedings and/or which are prejudicial to the interests of the Game and/or any person; or the disciplinary process

constitutes misconduct!

 

[tim White]

NM; well done for spotting it and taking the appropriate action. Particularly well done for sticking by the correct decision in the face of sustained pressure.

Red Card to Player (not technically a red card offence but it would serve the immediate purpose) and Coach (not technically a red card but it would certainly display your intentions) -just submit a simple report to the Society and Disciplinary people as if it was a red card, you might also deem it 'abuse' by the coach. Whatever you decide will certainly make the blazers aware and something will have to be done at this point because you put it in writing.

If not us, then whom? If not now, when? And who said doing the right thing was the same as doing the easiest thing?

 

[Stephen Elliott]

Well done Na Madrai

I don't care if it's not technically correct, but if a coach enters the field of play then you did right to threaten with a red card and show the seriousness to players and spectators. Show me the law that says it's not.

Your management of the situation was impeccable and I would suggest asking your society to write a letter to the coach and his club to remind them of their rights... or lack of them.

 

[Browner]

http://www.rugbydump.com/2014/04/36...eaves-shane-geraghty-ill-for-next-ten-minutes

Is throwing up a sign of concussion, or a sign of stomach upset?
If I knew a player was chundering on the pitch he'd be off .... Is this a overreaction on my part?

 

[Taff]

... Is throwing up a sign of concussion, or a sign of stomach upset?

A less common sympton of concussion apparently. Source: NHS website

The most common symptoms of concussion are:

•headache
•dizziness
•nausea - I'm not sure if this is medical speak for spewing
•loss of balance
•confusion, such as being unaware of your surroundings
•feeling stunned or dazed
•disturbances with vision, such as double vision or seeing 'stars' or flashing lights
•difficulties with memory (see below)

Less common signs and symptoms of concussion include:

•loss of consciousness
•vomiting
•slurred speech
•'glassy eyes' and a vacant stare
•changes in behaviour, such as feeling unusually irritable
•inappropriate emotional responses, such as suddenly bursting into laughter or tears

 

[Shelflife]

If it was after a tackle Id be having a long look at him, we were told at a recent meeting that you can be concussed after a blow to the body as well.

Its hard to pick them all up, missed one yesterday when reffing a final, red were well beaten and red capt shipped a tackle, didnt look too bad and all he wanted to do was get on with the game, seemed more frustrated and upset at the way the game had gone than anything.
After about 2mins he was off, thankfully there were some first/aiders/ambulance service people there to look after him.

Coach was happy to play him, sometimes you think that they will know the player better but I usually prefer to take the decision out of their hands.

 

[leaguerefaus]

To me, my primary role is to referee. If I'm going to order a player off, I'd need to be pretty damn sure he's concussed.

 

[Shelflife]

To me, my primary role is to referee. If I'm going to order a player off, I'd need to be pretty damn sure he's concussed.

Agree with you, this was at u14, sometimes the coaches are more interested in winning the game than looking after the players. Id just hate to be involved in an unfortunate situation.

 

[OB..]

Surely the primary responsibility is Safety? If you (reasonably) suspect concussion, it is unsafe for a player to continue.

 

[tim White]

Surely the primary responsibility is Safety? If you (reasonably) suspect concussion, it is unsafe for a player to continue.

:clap:

If in any doubt -he goes. If I make a mistake in such circumstances I want it to be on the safe side. No-one will know if I was right, everyone will know if I was wrong.

 

[Rushforth]

Surely the primary responsibility is Safety? If you (reasonably) suspect concussion, it is unsafe for a player to continue.

I fully agree that the primary responsibility is safety. However, if a player is out of action both literally (on the ground for whatever reason) and in the sense of not being anywhere near the ball, I can only spend a glance or two and a signal to the "physio" (i.e. water carrier).

Now, that's working on the principle that if it is really serious players will alert me (and they always do, from both sides), but it does mean a delay between "minor" concussion and the time I get there.

If I've been able - out of a couple of glances perhaps, but most likely after a legal accident (bad tackle attempt, etc.) - to determine that the player is looking groggy, then they are off (no genuine doctor at my level, and safety above all).

Fortunately at my level most players have common sense (when not playing at full adrenaline) and anybody who has taken a knock to the head does tend to get shepherded off. What worries me is the intermediate level: not rugby or refereeing skill here, just availability of medics compared to competitiveness of matches.

Players of all levels (back to their skill) will insist that they are fine. After all, they want to play, and if they ARE concussed, they are even less likely to be aware of the issue than other issues.

My opinion only.

 

[Browner]

:clap:

If in any doubt -he goes. If I make a mistake in such circumstances I want it to be on the safe side. No-one will know if I was right, everyone will know if I was wrong.

This is my thinking, but if SG was throwing up on the pitch ( as reported in the press) then its yet another bad example being shown by the elite game. The macho statements that attach to the article add to the problem.

 

[didds]

I may have missed something in the thread so apolgies if this has been said or doesn't actually make sense (no change there then!), but I'd suggest if a player is throwing up then he off for the game, irrespective of concussion. If only because no member of the oppo (or his teammates!) needs to be vomited on, and he is clearly in no fit state to continue anyway.

didds

 

[Browner]

To me, my primary role is to referee. If I'm going to order a player off, I'd need to be pretty damn sure he's concussed.

So, as in this example, after taking a big tackle a player is throwing up for the next 5-10 mins, would that make you sure enough LRA?

 

[leaguerefaus]

So, as in this example, after taking a big tackle a player is throwing up for the next 5-10 mins, would that make you sure enough LRA?

I'm not sure I'd make the leap from throwing up to concussion. I would, however, not allow a player on the field who is vomiting - just as I would not allow a player on the field who is bleeding.