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I commend Raftery et al in their recent editorial on concussion
assessment in sport, in particular rugby's response on this matter (1).
Undoubtedly one of the major issues facing sport is the lack of clarity
and consistency in identifying concussions on the field; a symptom of the
deficiencies in the last output from the Concussion in Sport Group (the
However, while a c...
However, while a commendable effort, on reading the article I am
anxious about contradictions in the detail provided on World Rugby's
protocol, which I believe are an oversight by the authors.
Specifically, while clearly defining much needed indications for
immediate and permanent removal from play ('Criteria Set 1'), the authors
then suggest that these criteria confirm concussion 'unless proven
The inclusion of the get out clause, 'unless proven otherwise',
without qualification or expansion is, I believe, an error and does not
reflect my understanding of rugby's HIA process. As it is written, Raftery
et al are proposing that a player can sustain a blow to the head, be
knocked unconscious or suffer a seizure or display tonic posturing or
display any of the other Criteria 1 signs, but later might be 'cleared'
of having sustained a brain injury via subjective post-match testing.
The natural conclusion from this being a player can be KO'd on
Saturday after a knee to the head, but apparently 'proven' not concussed
in subsequent, after match and fallible tests and be back in training or
play 2 days later.
To my knowledge there are no tests that can unequivocally and
confidently 'prove' a player is not concussed, as suggested. I would
expect the authors are aware of that, and did not intend the draft to
suggest a protocol that allows players with elements in Criteria Set 1 to
be later cleared of brain injury in this way.
Unfortunately, unless this is clarified, then there is a danger of
promoting the false belief that a robust and infallible test is in current
practice that can 'prove' a player has not sustained a brain injury
despite being knocked unconscious after a blow to the head. The
alternative is the current working definition of 'concussion' needs
1. Raftery et al. It is time to give concussion an operational definition:
a 3-step process to diagnose (or rule out) concussion within 48 h of
injury: World Rugby guideline. Br J Sports Med 2016;doi:10.1136/bjsports-
2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on
concussion in sport: the 4th International Conference on Concussion in
Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-8.