Question for Physiotherapists

NRL head injury management
Welcome to Orthosports Question for Physiotherapists June 2025. This month Dr Paul Annett discusses the NRL decision making behind the head injury process.
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QUESTION | I have been watching the NRL and am interested in the decision making process behind the head injury process. Could you explain it to me?
The NRL initiated the ISB (Injury Surveillance Bunker) just prior to the 2022 season. It was introduced to ensure the safe and accurate management of in game head injury, improving the immediacy of player removal from the field for head trauma and assisting the Club Medical Officer (CMO) in the management of game day concussion. One of the predictors of outcome and recovery is the rapid diagnosis of a concussion event, and a prompt removal of a player from the field as quickly as possible. Any delays in these steps gives less favourable outcomes.
I have been working in the ISB from its commencement, along with Dr John Best and Dr Leigh Golding, and a collection of other Sports Physicians and experienced sports doctors.
The purpose of the ISB is to use detailed video analysis to determine potential severity of an in-game head trauma or concussive force transmitted to the head. It is a system purely based on video signs noted and not a definitive diagnosis of concussion, which must be made with an accurate clinical assessment by the CMO. This is not to be confused with simply observing a heavy tackle or impact between players, which may look spectacular, but does not lead to clear video signs of concussion and mandate player removal from the field.
Logistically the ISB is located in a television studio in Redfern in Sydney, in conjunction with the video referee bunker. The ISB is made up of 5 people. There is a medical officer, 2 ‘spotters’ and 2 technical supports. The spotters are experienced and well-trained rugby league people (ex-players, physiotherapists, exercise physiologists). One spotter’s job is to watch the game continually and ‘tag’ any potential head impacts for more detailed analysis. These incidents will then be further scrutinized, with the second spotter and 1 of the technical supports providing the best of a series of multiple video angles (up to 12 camera angles), delivered to the medical officer, who ultimately decides whether the incident requires a classification or is deemed non-significant. In any one game of rugby league there may be numerous incidents of contact around the head, most of which do not require categorization. The second technician communicates with a sideline assistant at the ground, where there is video set-up for the CMO to review any incidents that occur. CMO review of the video footage is mandatory for any reportable incidents.
There are 2 main classification groups that the ISB works with – a Category 1 and a Category 2 concussion.
Category 1 signs indicate that the player has concussion and must be immediately removed from the field. They are not to be allowed to return to play on that day, irrespective of symptom recovery during the game.
Category 1 signs include:
- Lying motionless (suspected loss of consciousness)
- Motor incoordination (ataxia or stumbling)
- Impact seizure
- Tonic posturing
- Lack of protective Action (Player becomes floppy)
- Blank or vacant look
Category 2 signs indicate the potential for concussion. When identified the player must be removed from the field and taken for a SCAT 6 assessment by the CMO. If the player passes this within an allocated 15minute time-frame, then they are free to return to the field of play.
Category 2 signs include:
- Lying motionless (>2, but <5 seconds) in the context of a head injury (possible LOC)
- Possible impact seizure
- Possible tonic posturing
- Possible motor incoordination
- Slow to stand (15 seconds)
In addition, if it is noted that the player doesn’t look right, looks dazed, shakes head, opens and closes eyes quickly, this may indicate category 2 symptoms.
A category 3 has also been devised which is designated as a ‘trainer check’. In these cases, there may have been a significant head impact although without clear category 1 or 2 signs. The ISB will ask the CMO to have the orange shirt trainer perform an on-field assessment of the player. If there are any concerns (such as failing orientation or Maddocks questions or any disturbance of balance) then the player can be upgraded to a category 2 by the trainer and removed for a SACT 6 assessment.
It has been determined that over the last 3 years the introduction of the ISB has led to a more rapid removal of players from the field. This is particularly for category 2 incidents where the player will be regularly removed in under 60 seconds. From a personal perspective the ISB has been a worthwhile initiative. I can recount numerous incidents, particularly in category 2 concussion, where both the head contact and subsequent signs were sufficiently obscured only to be noted on a single camera angle, which ultimately led to a player being removed from the field and subsequently failing the SCAT 6 assessment. As a result, there has been a clear improvement in the level of player safety with respect to immediate concussion management and potentially reducing the likelihood of developing long term issues such as CTE (chronic traumatic encephalopathy).



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Previous Question for Physiotherapists:
Dec-2020 | Wrist Ganglions | Dr Kwan Yeoh |
Oct/Nov-2020 | Medial Meniscal Root Tears | Dr Doron Sher |
Sep-2020 | Lumbar Stress Fractures | Dr Paul Annett |
Aug-2020 | Frailty and Healthy Ageing | Dr John Best |
Jul-2020 | Thumb – Collateral Ligament Tear | Dr Kwan Yeoh |
Jun-2020 | Shoulder Instability | Dr Doron Sher |
May-2020 | Hallux Rigidus | Dr John Negrine |
Mar/Apr-2020 | Achilles Tendon Ruptures | Dr Todd Gothelf |
Feb-2020 | Distal Biceps | Dr Doron Sher |
Nov-2019 | Clavicle Fracture Internal Fixation | Dr Doron Sher |
Oct-2019 | Femoracetabular Impingement (FAI) | Dr Paul Mason |
Sep-2019 | Imaging for Acute ACL Injuries | Dr Doron Sher |
Aug-2019 | Joint Relocation | Dr Paul Annett |
Jul-2019 | Guyon canal surgery | Dr Kwan Yeoh |
Jun-2019 | Whats new in ACL reconstruction 2019 | Dr Doron Sher |
May-2019 | Cuneiform Fracture | Dr Todd Gothelf |
Apr-2019 | Flexor Tendon Injuries | Dr Kwan Yeoh |
Mar-2019 | Chronic Exertional Compartment Synd | Dr Paul Annett |
Feb-2019 | Achilles Tendon Rupture | Dr John Negrine |
Nov-2018 | Low Back Pain | Dr Paul Mason |
Sep-2018 | Concussion part 2 | Dr John Best |
Jul-2018 | Concussion part1 | Dr Paul Annett |
Jun-2018 | Thessaly & McMurray Test | Dr Doron Sher |
May-2018 | AC Joint | Dr Doron Sher |
Apr-2018 | Arthritis of the fingers | Dr Kwan Yeoh |
Feb-2018 | CLAVICLE fractures | Dr Doron Sher |
Oct-2017 | ACL Grafts | Dr Doron Sher |
Sep-2017 | Forefoot pain | Dr John Negrine |
Aug-2017 | Wrist Ganglion | Dr Kwan Yeoh |
Jul-2017 | Anterolateral Ligament Reconstruction | Dr Doron Sher |
Jun-2017 | Scapholunate ligament | Dr Kwan Yeoh |
Apr-2017 | Knee Brace – ACL Reconstruction | Dr Doron Sher |
Mar-2017 | Sesamoid fractures | Dr Kwan Yeoh |
Feb-2017 | Plantar Fasciitis | Dr Todd Gothelf |
Nov-2016 | Sternoclavicular Joint | Dr Doron Sher |
Oct-2016 | Proximal Humerus Fractures | Dr David Lieu |
Sep-2016 | Wrist Fractures | Dr Kwan Yeoh |
Aug-2016 | Patella Instability | Dr Doron Sher |
Jul-2016 | Snowboarders ankle | Dr Todd Gothelf |
May-2016 | Cortisone Injections | Dr Paul Annett |
Apr-2016 | Shoulder Instability_1 | Dr Ivan Popoff |
Mar-2016 | Exercise after TKR | Dr Doron Sher |
Dec-2015 | Scaphoid OA | Dr Kwan Yeoh |
Nov-2015 | Greater Tuberosity Fractures | Dr Doron Sher |
Oct-2015 | Stress Fractures | Dr Paul Annett |
Sep-2015 | Boxers Fractures | Dr Kwan Yeoh |
Aug 2015 | Resistance Training | Dr John Best |
July 2015 | LARS Ligament | Dr Ivan Popoff |
Jun-2015 | Distal Biceps | Dr Doron Sher |
May-2015 | Latarjet procedure | Dr Jerome Goldberg |
Apr-2015 | TFCC Questions | Dr Kwan Yeoh |
Mar-2015 | Acute Ankle Sprains | Dr Todd Gothelf |
Nov-2014 | PRPP | Dr Paul Annett |
Oct-2014 | Driving After Surgery | Dr Doron Sher |
Sep-2014 | Distal Biceps Rupture | Dr Doron Sher |
Aug-2014 | Ankle Sprain | Dr Todd Gothelf |
Jun-2014 | Patella Dislocation | Dr Doron Sher |
May-2014 | Shoulder Instability | Dr Todd Gothelf |
Apr-2014 | De Quervains | Dr Kwan Yeoh |
Mar-2014 | Acromio-clavicular joint injuries | Dr Todd Gothelf |
Feb-2014 | Chronic Knee Pain | Dr Paul Annett |
Dec-2013 | Foot and Ankle Questions | Dr John Negrine |
Oct-2013 | Rotator Cuff Repair | Dr Todd Gothelf |
Sep-2013 | ACL Reconstruction | Dr Doron Sher |
Jul-2013 | Slipped Upper femoral epiphysis | Dr Rod Pattinson |
May-2013 | Skiers thumb | Dr Kwan Yeoh |
Apr-2013 | Bakers_Cyst | Dr Ivan Popoff |
Mar-2013 | Tibial Osteotomy vs UKR | Dr Doron Sher |
Feb-2013 | ALIF success rate | Dr Andreas Loefler |
Jan-2013 | Lisfranc Injuries | Dr Todd Gothelf |
Nov-2012 | Anterior Spinal Fusions | Dr Andreas Loefler |
Oct-2012 | MCL Injuries | Dr Doron Sher |
Sep-2012 | Compartment Syndrome | DrPaul Annett |
Aug-2012 | Carpal tunnel | Dr Kwan Yeoh |
July-2012 | Anterior Process Calcaneus Fx | Dr Todd Gothelf |
Jun-2012 | Tenodesis vs Tenotomy | DrJeromeGoldberg |
May-2012 | Osteoarthritis in the young active patient | Dr Doron Sher |
Apr-2012 | Syndesmosis Sprain | Dr Todd Gothelf |
Mar-2012 | Triangular Fiocartilage Injuries | Dr Kwan Yeoh |
Jan-2012 | Shoulder Replacement Older Population | Dr Jerome Goldberg |
Dec-2011 | Wrist Fracture | Dr Kwan Yeoh |
Nov-2011 | Adductor Tendon Tear | Dr Paul Annett |
Oct-2011 | Navicular Pain | Dr Todd Gothelf |
Sep-2011 | OCD Lesion | Dr Doron Sher |
Aug-2011 | Metal on Metal Hip Replacements | Dr Andreas Loefler |
July-2011 | Femoral Neck Stress Fract (Pt 2) | Dr John Best |
Jun-2011 | Femoral Neck Stress Fractures | Dr John Best |
May-2011 | PCL Injury Part 2 | Dr Doron Sher |
Apr-2011 | PCL Injury Part 1 | Dr DoronSher |
Mar-2011 | Prolotherapy Autologous Blood Injections | DrPaul Annett |
Feb-2011 | Shoulder Impingement | Dr Todd Gothelf |
Dec-2010 | Does Chondral Grafting Work | DrDoron Sher |
Nov-2010 | Shoulder Immobilisation-Dislocation | Dr Jerome Goldberg |
Sep-2010 | SLAP Lesions Stable Shoulder | Dr ToddGothelf |
Jul-2010 | Ankle Sprains | Dr Todd Gothelf |
Jun-2010 | Dislocation After THR | Dr Peter Walker |
May-2010 | Acupuncture Muscle Strength Programmes | Dr Paul Annett |
April-2010 | Full Thickness Rotator Cuff Tears | Dr JeromeGoldberg |
Mar-2010 | Skiing after TKR | Prof Warwick Bruce |
Feb-2010 | Fractures of the Clavicle | Dr John Trantalis |
Jan-2010 | Osteoarthritis of the Knee | Dr Doron Sher |
Dec-2009 | Fifrth Metatarsal Fractures | Dr Todd Gothelf |
Nov-2009 | Partial Rotator Cuff Tears | Dr Todd Gothelf |