Are you a student or a concerned parent observing rugby matches or practices and worrying about the frequency of injuries? It’s perfectly normal to be aware of the risks involved, especially considering the prevalence of concussions, which can have serious consequences, as recent reminders have shown. According to Sports Concussion SA, rugby in South Africa has the highest incidence of concussions among collision team sports, with 10 to 15% of high school players experiencing a concussion each season, and up to 50% experiencing one during their high school playing careers. While these statistics may sound alarming, understanding how to identify, manage, and prevent concussions can make them less daunting. This article aims to provide clarity on the subject, discussing the nature of the injury, how to recognize potential signs, methods of management, and strategies for prevention, including the role of physiotherapists in this process (Sports Concussion SA).

Concussions, categorized as mild traumatic brain injuries, involve trauma to the brain, despite the seemingly trivial label of “mild.” Even in sports discussions, concussions are recognized as significant, defined as “a mild traumatic brain injury as a result of biomechanical forces” (McCroy, et al., 2017). Typically, concussions occur from direct blows to the head, but they can also stem from impacts elsewhere on the body, causing a whiplash effect in the neck (Romeu-Mejia, et al., 2019). In both scenarios, the head undergoes sudden movement, leading to the brain hitting the skull’s bony surface, often rebounding and striking the opposite side—a phenomenon known as Coup-Contrecoup. This rapid acceleration-deceleration motion within the brain tissue affects its white and gray matter differently, generating shearing forces between them. Consequently, nerve fibers stretch and tear, provoking inflammatory responses and triggering an energy crisis in the brain (Romeu-Mejia, et al., 2019).

Concussions are often overlooked, and their signs and symptoms may manifest immediately or days later. These symptoms encompass a range, including headaches, nausea, dizziness, loss of consciousness, double or blurred vision, a sensation of fog, confusion, fatigue, and memory difficulties, among others. It’s crucial to promptly identify these symptoms, as they can overlap with those of other conditions. Studies indicate that the most common symptoms associated with sports-related concussions are headaches, feeling mentally slowed down, fatigue, dizziness, and experiencing pressure in the head (van Tonder, et al., 2021).

Boksmart” is a South African rugby organization and safety initiative, dedicated to addressing rugby’s medical concerns, particularly focusing on concussions. They stress the importance of awareness among coaches, teammates, parents, and medical personnel regarding the potential for concussions in rugby. Whenever a player appears to sustain a head injury from a blow, tackle, or landing on the head/neck, immediate assessment for concussion is essential. The medical team or appropriate personnel should stabilize the player’s head and neck area. Observing concussion symptoms and obtaining feedback from the player is crucial, with symptoms such as headache, fogginess, or a dazed appearance warranting suspicion of concussion. Players showing certain “red flag” symptoms, including severe neck pain, deteriorating consciousness, seizures, persistent vomiting, increasing confusion, slurred speech, limb numbness/tingling, or ongoing double vision, must be removed from play immediately and taken for hospital assessment or neuroimaging (World Rugby, 2021).

“Maddocks Questions” are a set of inquiries utilized by Boksmart and World Rugby to aid in identifying potential concussions. The evaluator asks the injured player questions about the current venue, the last score, the opposing team, the current half, the opponent from the previous game, and the outcome of the last game. Players should answer these questions promptly and accurately without hesitation. Adhering to the “Recognize and Remove” principle advocated by Boksmart, if a player exhibits one symptom or hesitates or answers one question incorrectly, they should be immediately withdrawn from play. Even if there are no obvious symptoms but the assessor suspects a concussion, the player should still be removed from play. Boksmart’s guideline is clear: “When in doubt, sit them out.”

Managing a concussion is of utmost importance, requiring close monitoring of the player for 24 hours post-injury, as symptoms may fluctuate and new ones may emerge. If any “red flag” symptoms appear, such as worsening consciousness, seizures, or severe neck pain, immediate hospitalization for medical assessment, including the possibility of a CT scan or MRI, is necessary. Concussions trigger an energy crisis in the brain, making complete rest—both cognitive and physical—the most effective management strategy. This entails avoiding activities requiring concentration, reading, or writing, minimizing exposure to light and sound, and limiting screen time.

Upon returning home after the match, players and parents should receive guidance on concussion management, including abstaining from alcohol, refraining from driving, and avoiding anti-inflammatory medication. Once medically stable and several hours post-injury, the player can take mild painkillers like Panado. Adequate sleep is encouraged to facilitate optimal rest. If the player encounters difficulties waking up, immediate hospitalization is warranted. Once the prescribed rest period is completed and the player is symptom-free, they embark on a structured return-to-play protocol recommended by BokSmart and World Rugby. This Gradual Return to Play program consists of six stages, with progression contingent on completing each stage symptom-free and remaining symptom-free for 24 hours thereafter. If symptoms reoccur, the player must regress to the previous stage (Boksmart, 2019).

The initial phase of the Gradual Return to Play (GRTP) protocol mandates a prescribed period of rest, with players under 18 recommended to rest for 14 days and those over 18 for a minimum of 7 days. If symptom-free, players advance to stage two and proceed sequentially. Stage Two introduces light aerobic training, such as walking, treadmill, or stationary biking, for 20 minutes. Stage 3 incorporates more sport-specific training and moderate aerobic exercises, potentially including running drills and rugby-like scenarios, with aerobic training extended to 30 minutes. Stage 4 entails contact-free training, encompassing passing, kicking, decision-making scenarios, and resistance training. Following contact-free sessions, stage 5 reintroduces contact training sessions, resembling regular training. Players are cleared for gameplay and return to play if they complete all preceding stages without symptoms during or 24 hours after each stage. Medical clearance is necessary before advancing to stage 5. Based on the recommended rest period and the requirement for 24-hour monitoring before progressing to the next stage, the minimum time out before returning to play is day 12 post-injury for players 18 and older (7 days rest and 4 days for the stages) and day 19 for players under 18 years old (14 days + 4) (Boksmart, 2019).

In the context of school rugby, not only the return to play but also the return to learn protocol is crucial. Concussions trigger an energy crisis in the brain, necessitating complete cognitive rest for recovery. Initially, players require 24-48 hours of complete cognitive rest, excluding school, learning, homework, or studying. Exposure to bright lights should be minimized, and screen time kept to a minimum. Once symptom-free, players progress to incorporating short periods of gentle cognitive activity, such as watching TV, listening to audiobooks, or engaging in non-triggering activities like drawing. If tolerated well and without symptoms, short periods of schoolwork can be attempted at home, gradually increasing in duration. Progression to a modified school schedule, featuring shorter lessons, longer breaks, and reduced reading and writing, occurs once the child comfortably completes one hour of schoolwork at home for successive days. Full return to the normal school routine is achievable once the child completes all preceding steps comfortably (Children’s Hospital of Philadelphia, 2022).

Experiencing a concussion heightens the risk of subsequent concussions, with medical research indicating that individuals who sustain mild traumatic brain injuries are susceptible to developing serious conditions later in life. Post-Concussion Syndrome (PCS) may ensue, prolonging concussion symptoms beyond the suggested 7-10 day recovery period, lasting weeks, months, or even up to a year (Ledreux, et al., 2020). Medical studies demonstrate a correlation between concussions, especially multiple concussions, and an elevated likelihood of developing mental and cognitive conditions like dementia and Alzheimer’s. Mild traumatic brain injury is associated with a potential 30% increase in the risk of Alzheimer’s development (Dekosky, et al., 2010).

Physiotherapy plays a crucial role in concussion management and treatment of associated side effects, addressing coordination, balance, proprioception issues, and aiding in pain management and whiplash complications. Vestibular Ocular Motor screening conducted by physiotherapists assesses and manages players’ vestibular and ocular systems, essential for returning to previous function. Additionally, physiotherapists contribute to injury prevention through preseason risk screening, with research highlighting the effectiveness of neck muscle strengthening in reducing concussion risks (Hrysomallis, 2016). Another preventive measure involves the implementation of pre-activity movement control programs, encompassing balance training, whole-body resistance training, plyometric/explosive training, and controlled rehearsal of rugby-specific maneuvers. Such exercise programs have shown to decrease injury risks, including concussions, among schoolboy rugby players (Hislop, et al., 2017).

All of this highlights the seriousness of concussions within our country’s cherished sport, extending from grassroots to professional tiers. Nevertheless, through efforts such as those spearheaded by World Rugby and initiatives like Boksmart, avenues exist to diminish the likelihood of such severe incidents. Furthermore, the involvement of physiotherapists is evident, whether in preseason conditioning, direct injury care and detection, or implementation of preventive measures such as neck strengthening. This underscores how much of a pivotal role physiotherapists have in addressing this issue comprehensively.



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Dekosky, S., Ikonomovic, M. & Gandy, S., 2010. Traumatic Brain Injury — Football, Warfare, and Long-Term Effects. Minnesota Medicine, 93(12), pp. 46-47.

Hislop, M. et al., 2017. Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. Brittish Journal of Sprts Medicine, 51(15).

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Romeu-Mejia, R., Giza, C. C., Giza, C. C. & Goldman, J., 2019. Concussion Pathophysiology and Injury Biomechanics. Current Reviews in Musculoskeletal Medicine, , 12(2), pp. 105-116.

van Tonder, R. et al., 2021. Presenting features of female collegiate sports-related concussion in South Africa: a descriptive analysis. South African Journal of Sports Medicine, 33(1).

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