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Concussions in Rugby: Don’t be “foggy” about what’s not such a mild head injury

Part 2 By Mark Waller BSc (Physio) Wits

Management of a concussion is very important. The player needs to be monitored closely for 24 hours after the injury as symptoms can fluctuate and new symptoms can arise. If any “red flag” symptoms arise after the injury the player should be taken to the hospital as soon as possible for medical assessment and the possibility of a CT scan or MRI. The problem that is present during a concussion is that there is an energy crisis in the brain, therefore the most suitable and effective management of concussions is to have complete rest – cognitive and physical. This would include no work that requires concentration, reading or writing. The individual should also be exposed to as minimal amounts of light and sound as possible and should also try limit their screen time.

The player and parents should be given advice regarding the concussion when they go home after the match. This would include instructions of no alcohol intake, no driving, and no anti-inflammatory medication. When medically stable and a few hours after the injury the player can be given light pain killers such as Paracetamol. Once a concussed individual is medically cleared, sleep is encouraged as this will allow for the most amount of rest which is what is needed. If the player has issues with waking up, they need to be taken to a hospital immediately. Once the player has completed their instructed period of rest and are symptom free, they will begin a specific and recommended return to play protocol.

This Gradual Return to Play (GRTP) protocol is recommended by BokSmart and World Rugby and is used across the country and world in returning athletes back to the playing field safely. The programme includes six stages, to progress to the next stage a player needs to complete the current stage, symptom free and be symptom free for 24 hours afterwards. If the player experiences symptoms, they need to return to the previous stage (Boksmart , 2019).

The initial stage is the recommended amount of rest (14 days for players younger than 18 and a minimum 7 days for players older than 18) and if they are symptom free, they move onto stage two and then onwards. Stage two brings in light aerobic training, this can be light walking on the treadmill, or the stationary bike for 20 minutes. Stage three brings in more sport specific training and more moderate aerobic exercises. It can include certain running drills, and more rugby-like scenarios and the aerobic training can be pushed to 30 mins. Stage four is contact free training and can include passing, kicking and decision-making scenarios, resistance training can be incorporated.

Following contact free sessions, the fifth stage of the GRTP programme will be contact training sessions, this is back to ordinary training sessions and then finally if the player is able to complete all previous sessions without any symptoms during or 24 hours after each stage, they are cleared for game time and return to play. For a player to move onto stage five he/she needs to get medical clearance beforehand. According to the suggested time of rest and for each stage to be completed with 24 hours of monitoring before the next stage, the minimum time out before returning to play would be day 12 post injury for players 18 years and older (7 days rest and 4 days for the stages) and day 19 for players younger than 18 years of age (14 days + 4) (Boksmart , 2019) . Regarding school rugby, it is not only ‘return to play’ that is important but also a ‘return to learn’ protocol is important. The brain is in an energy crisis during a concussion, and it needs to be in a complete state of rest in order to recover. Initially the player needs to have at least 24 - 48 hours of complete cognitive rest, this includes no school, learning, homework or studying.

The player should be exposed to minimal amounts of bright lights as possible and screen time should be kept as low as possible. Once the player has rested and are symptom free, the player can progress to adding gentle short periods of cognitive work, this can include watching TV for a bit, listening to an audiobook or even doing some drawing if it doesn’t trigger symptoms. If comfortable and no symptoms arise, short periods of schoolwork can be attempted at home and the duration is increased as tolerated.

If the child is able to complete one hour of schoolwork at home comfortably for successive days, they will then progress to returning to school on a modified schedule. A modified schedule would include shorter lessons, longer breaks and shorter days for example with less writing and reading. The final step of being able return to full normal school routine is possible once the child has completed all previous steps comfortably (Childrens Hospital of Philadelphia , 2022).

Once an individual has a concussion it becomes even more dangerous for them to have a second concussion. Medical research has shown that incidents of mild traumatic brain injuries put the individual at risk of developing serious conditions later in life.

Post-Concussion Syndrome (PCS) can arise, and this results in the individual suffering from concussion symptoms way after the suggested 7-10 day period, the individual can suffer for weeks and months and even up to a year with the side effects of a concussion (Ledreux, et al., 2020).

Concussions and even more so multiple concussions are shown by medical research to be linked to increased chances of developing menta/cognitive conditions such as dementia and Alzheimer’s, with a mild traumatic brain injury being linked to a possible 30% increase in risk of developing Alzheimer’s (Dekosky, et al., 2010).

The third article in this series covers prevention of concussions. Debbie Cameron Physiotherapy is passionate about school sport and specifically the prevention of sports injuries. To book an appointment, contact Chantal or Michelle on 031 765 8898.


Boksmart , 2019. Referees/Coach's On the Field Concussion Guideline. [Online] Available at: [Accessed April 2022].

Childrens Hospital of Philadelphia , 2022. Return to Learn After a Concussion. [Online] Available at: [Accessed April 2022].

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).

Hrysomallis, C., 2016. Neck Muscular Strength, Training, Performance and Sport Injury Risk: A Review. Sports Medicine, 46(8).

Ledreux, A. et al., 2020. Assessment of Long-Term Effects of Sports-Related Concussions: Biological Mechanisms and Exosomal Biomarkers. Frontiers in Neuroscience, Volume 14.

McCroy , P. et al., 2017. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Brittish Journal of Sport medicine, 51(11).

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).

World Rugby, 2019. INNOVATIVE RUGBY WORLD CUP 2019 DRIVES BEST-EVER PLAYER WELFARE OUTCOMES. [Online] Available at: [Accessed April 2022].

World Rugby, 2021. Concussion Guidelines. [Online] Available at: [Accessed April 2022].

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