Highlights • Return-to-play time in concussed Rugby Union players depends on the presentation of symptoms at 2 and 72 h after injury. • When symptoms worsen between the time of injury and 3 days post, return-to-play time is significantly longer than when symptoms improve or remain stable. • Balance and cognitive function in the 72 h after injury are not associated with delayed recovery time. • Individualized management of concussed players is possible with stratification based on initial symptom presentation using standardized screening tools. Abstract Background Return to play (RTP) in elite rugby is managed using a 6-stage graduated RTP protocol, which can result in clearance to play within 1 week of injury. We aimed to explore how symptom, cognitive, and balance presentation and evolution during concussion screens 2 h (head injury assessment (HIA) 2) and 48 h (HIA3) after injury were associated with time to RTP) to identify whether a more conservative graduated RTP may be appropriate. Methods A retrospective cohort study was conducted in 380 concussed rugby players from elite men's rugby over 3 consecutive seasons. Players were classified as shorter or longer returns, depending on whether RTP occurred within 7 days (allowing them to be considered to play the match 1 week after injury) or longer than 8 days, respectively. Symptom, cognitive, and balance performance during screens was assessed relative to baseline (normal or abnormal) and to the preceding screen (improving or worsening). Associations between sub-test abnormalities and RTP time were explored using odds ratios (OR, longer vs. shorter). Median day absence was compared between players with abnormal or worsening results and those whose results were normal or improving. Results Abnormal symptom results during screens 2 h and 48 h after concussion were associated with longer return time (HIA2: OR=2.21, 95% confidence interval (95%CI): 1.39-3.50; HIA3: OR=3.30, 95%CI: 1.89-5.75). Worsening symptom number or severity from the time of injury to 2 h and 48 h post-injury was associated with longer return (HIA2: OR=2.49, 95%CI: 1.36-4.58; HIA3: OR=3.34, 95%CI: 1.10-10.15. Median days absence was greater in players with abnormal symptom results at both HIA2 and HIA3. Cognitive and balance performance were not associated with longer return and did not affect median days absence. Conclusion Symptom presentation and evolution within 48 h of concussion were associated with longer RTP times. This may guide a more conservative approach to RTP, while still adhering to individualized concussion management principles.
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