Head Injuries & Concussion in Rugby League - Media Position Statement
The RFL follows the Berlin (2016) Consensus Statement on Concussion in Sport which is considered best practice.
All professional rugby league games have at least one doctor who is IMMOFP (Immediate Medical Management on the Field of Play) qualified, many have two and some Super League games have four doctors in attendance. All physiotherapists, sports rehabilitators and therapists also undergo the same training. In addition, the RFL runs CPD events for practitioners in the sport, usually three a year which have included CPD on concussion.
The RFL has a set of Medical Standards which form part of the Operational Rules and can be found on the RFL website, amongst other things these cover the game’s concussion rules and protocols. Compliance with the Standards is monitored by RFL staff.
The RFL has two Clinical Groups, the Advisory Group, made up of practitioners in the sport, and the Effectiveness Group, made up of representatives of the game’s stakeholders including the RLPA. The Groups consider Medical Standards and Best Practice in the game and make recommendations to the RFL.
The RFL has delivered a number of workshops to professional players to educate them about concussion and medical staff provide ongoing information and advice. In addition, information is provided at meetings and by circulars to ensure that Head Coaches and club CEOs are informed and aware of their responsibilities.
Stakeholders within the game are also educated on the risk to Players health and the game through the meeting and forums which they attend.
All professional players have to set a CogState (multi-faceted cognitive test) baseline prior to contact training each season, the RFL has access to this system to monitor its use. This baseline is used in the GRTP (Graduated Return to Play) protocols to ensure players have recovered from a concussion. The organisation is due to move to CogniGram in the coming months, which provides a modern updated version of the system which is more accessible and user friendly.
Players must be removed from play (or training) if diagnosed with concussion OR if they have any signs or symptoms of concussion OR if the medical staff suspect may have concussion. If medical staff are unsure a concussion assessment must be carried out.
A Concussion Assessment allows a player with a suspected concussion to be removed from play for 15 minutes to be assessed by a doctor using standardised tests and clinical judgement. During that time the player can be replaced by a free interchange.
Pitchside Review System
All Super League clubs and full-time clubs in the Championship have a Pitchside Review System which allows medical staff to review play at the side of the pitch if there is a potential concussion not visible by the medical staff.
All concussion or potential concussions (in matches and training) have to be reported to the RFL. In addition, the RFL monitors information received from the Match Review Panel (MRP) and Match Commissioners (MCs), both groups receive training from the Chief Medical Officer.
The MRP and MCs report any incidents where either a player was taken off for a concussion assessment (which allows the RFL to ensure that the appropriate return to play protocols are followed) or where they had concerns that a player should have been taken off for an assessment (any such incidents are then reviewed and if necessary education and/or compliance action taken). Before a player Returns to Play the player has to be signed off by a doctor in writing to the RFL.
Graduated Return to Play
All players follow a Graduated Return to Play (GRTP) protocol as set out in the Medical Standards with minimum time periods and a gradual increase in the intensity of exercise. However, some players will take longer than the minimum to work through their GRTP as a player cannot start GRTP until he is symptom free and can only move onto the next stage of the GRTP if he is symptom free at that level of exercise.
Any player who has a second or subsequent concussion or a difficult concussion with prolonged recovery must see a concussion specialist and be cleared to Return to Play. The player receives a copy of the specialist’s report.
The RFL has systems in place to monitor compliance and any potential breach would initially be reviewed by the Chief Medical Officer with a system including options from peer review, reflective clinical review and potentially compliance action. Compliance action is taken where any breach of the rules takes place, but also against any individual who undermines the concussion policy and/or process.
On field interventions
Whilst it would be impossible to eliminate all concussion in sport, steps have been taken to reduce or if possible, prevent risk. The Match Officials this year have issued yellow cards for punches to the head –an instant punishment which is detrimental to the team may assist in reducing the forceful direct contact of a punch to the head.
The use of the free interchange to allow for a Head Injury Assessment (HIA) is in place to allow Clubs to take the time to deliver the medical attention required for possible concussive injuries, without having to use an interchange. Although Clubs may find ways to use this to their advantage, Clubs are encouraged to use this for the intention it was introduced for. Compliance action can be taken where Clubs abuse and undervalue the process.
The Laws Committee regularly discuss and consider steps which seek to reduce contact with the head. These discussions feed through to Match Review Panel, Operational Rules Tribunal, Coaches and Match Officials. The nature of contact with the head is considered with a range of charges available to the Panel.
Injury Audit and Research
The injury audit is underway with Leeds Beckett University (recently transferred over from the University of Bolton). Leeds Beckett are also reviewing the clips provided on a weekly basis from the Match Review Panel to assess tackle technique leading to contact with the head. The University of Leeds via Jon Greenwell have made an informal concussion research proposal to the RFL which would provide Rugby League specific follow up support for clubs. Whilst funding resource is not available for significant research projects, we do monitor the ongoing trials and outcomes from other similar sports and informative research in this area.
The RFL Community Game Concussion Rules and protocols mirror those in Rugby Union providing consistency for recreational players in both sports.
First Aid Provision
All clubs must register their first aiders on LeagueNet before playing fixtures. All community games must have a first aider present which is monitored by match officials who have been instructed not to allow a game to take place unless a first aider is present.
First Aid Standards
The RFL has a set of First Aid Standards which form part of the Operational Rules Tiers 4-6 which can be found on the RFL website, amongst other things these cover the game’s concussion rules and protocols.
The RFL’s Clinical Groups also consider the First Aid Standards.
The RFL’s Emergency First Aid course includes a section on concussion. For those that have undertaken First Aider training from another provider we have a concussion module on Our Learning Zone for First Aiders to undertake. The RFL website includes advice for players, parents, first aiders and coaches and the RFL has concussion posters supplied to all clubs.
The Coach Education programme includes a section on concussion and match officials have been given a basic awareness through an online tool.
Education sessions have been rolled out to the major playing leagues and to other groups and information is included in newsletters and conferences.
There is no system of concussion assessments in the community game, if there is any suspicion that a player has suffered a concussion they must be removed from the field of play and can’t return until they have completed their Graduated Return to Play protocol.
Graduated Return to Play
The GRTP protocols in the community game have longer periods at each stage as the GRTP is not being monitored by a club doctor and do not have the benefit of a CogState baseline. All players are recommended to be signed off by their GP at the end of their GRTP.
Community clubs have to submit concussion reports which are logged on LeagueNet which automatically generates an advice email to the player.
Insurance is annually reviewed with insurance companies now requesting information on concussion cases. We provide quarterly reports on concussion cases so they can review how many concussion cases there have been and check if the protocols are adhered to. The insurers have also visited Community Clubs to check their training and awareness and record keeping. As such the RFL’s insurers are aware of the work that the sport has done in minimising issues arising as a result of head injuries and whilst the marketplace for getting this type of insurance has become ever more challenging, there is recognition of the work that has been done in this area, which has allowed the level of insurance to be maintained.
The policy the RFL currently has in place is comprehensive and effectively operates on an employer’s liability basis if the claim was brought against the Club and on a public liability basis if the claim was brought against the RFL.
The insurance is on a “losses occurring” basis rather than on a “claims made” basis – this means the insurance that would cover any claim(s) made would be the insurance policy that was in place at the time of the incident/injury i.e., if a player brought a claim for injuries caused as a result of playing between 2000 and 2005, it would be the policy in place at that period.