Translating Guidelines for the Diagnosis and Management of Sports-Related Concussion Into Practice

Unintended consequences - A qualitative exploration of baseline testing in community rugby concussion management

OBJECTIVES

Understanding key stakeholders' perceptions around the value of baseline testing, as well as barriers or facilitators experienced as part of the process, may assist with the decision-making process of whether to implement baseline testing in community sport. This study explored coaches', players' and physiotherapists' perceptions of the perceived value, barriers and facilitators of baseline testing as part of New Zealand Rugby's (NZR) community concussion initiative.

DESIGN

The study employed a pragmatic, qualitative descriptive design.

METHODS

Semi-structured interviews were used to explore participants' perceptions. In total, 73 individual interviews were conducted. The sample consisted of 36 players, 13 coaches and 24 physiotherapists involved in NZR's concussion management pathway. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis.

RESULTS

In terms of perceived value, baseline testing was reported to play a role in i) facilitating a positive concussion culture; ii) positive perceptions of rugby and player safety and iii) enhancing concussion management as part of the pathway. Barriers and facilitators of the baseline testing process included i) stakeholder buy-in as critical driver of the process and ii) contextual and operational factors. Although contextual and operational challenges exist, these participants, as key stakeholders in the process, perceived the value of baseline testing to be more important than the barriers experienced.

CONCLUSIONS

The value of baseline testing extends beyond concussion assessment and management, by enhancing community concussion awareness, attitudes and player safety. The findings of this study may assist in the decision-making process around inclusion of pre-season baseline testing in community rugby.

The balancing act - Physiotherapists' experiences of managing rugby-related concussion in the community

BACKGROUND

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP) to improve management at the community level. Physiotherapists play an important role in the CMP.

OBJECTIVE

This study explored physiotherapists' experiences in the management of community rugby-related concussion as part of the CMP.

METHODS

We adopted a pragmatic, descriptive qualitative approach to explore perceptions of twenty-four physiotherapists involved in the CMP. Thematic analysis was used to analyze data.

RESULTS

Four themes represented participants' experiences: 1) 'walking the tight rope between player welfare and performance' described the balancing act between different attitudes and priorities of the various rugby stakeholders; 2) empowering physiotherapists' authority and responsibilities, described the influence of physiotherapists' authority within the team and concussion management responsibilities; 3) multi-directional communication, described the role of communication between multiple stakeholders; and 4) the influence of context, which included the complexity of concussion, concussion knowledge of the physiotherapists and team, resource support for the physiotherapist, and access to a medical doctor.

CONCLUSION

Physiotherapists had positive attitudes toward the CMP and are well-positioned to play an active role in the pathway. Priorities of other stakeholders, authority of the physiotherapist and the communication flow influences physiotherapists' ability to optimally manage players with concussion.

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders.

Concussion injury management, perception, and knowledge in amateur field hockey

Background

Field hockey has a high risk for sports-related concussion (SRC) injuries due to the speed and intensity of the game, current rules, field surfaces and equipment composition. Head injuries are the second most common reported injury and up to 75% of SRCs go unreported or undetected. This increases the subsequent injury risk, long-term health consequences and prolonged injury recovery.

Objectives

This study aimed to examine the prevalence of SRC in hockey players within the Southern Gauteng Hockey Association (SGHA) premier league. Concussion knowledge and attitudes of hockey players, coaches, umpires, and officials were also investigated.

Methods

A partially mixed sequential dominant status design (QUANT-qual) was used, divided into two phases. In Phase One hockey players, coaches, umpires, and technical officials (n=119) completed a modified RoCKAS-ST questionnaire. In Phase Two, a focus group discussion with umpires (n=3) and interviews with coaches (n=3) were conducted.

Results

Injuries to the shoulder, neck, head, and face were reported from stick use (n=98); ball use (n=102) and collisions (n=187). Only 19% of hockey players were diagnosed with SRC, indicating that many of these injuries were undetected or not reported. Responses from the focus group discussion and interviews indicated that coaches, umpires, and officials felt they had insufficient knowledge of SRC.

Conclusion

The recognition and management of on-field injuries require improvement to enhance the injury detection system.

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial

OBJECTIVES

To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs.

METHODS

Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care.

RESULTS

A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites.

CONCLUSIONS

Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05095012.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines

Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

Barriers and facilitators to the management of mental health complications after mild traumatic brain injury

Background:

Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI.

Methods & results:

Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains.

Conclusion:

Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

Best practice recommendations call for family doctors to proactively screen for and treat mental health problems that might arise after a mild traumatic brain injury (mTBI) (also known as a concussion). However, previous studies show that these recommendations are not followed consistently. The authors aimed to find reasons why this is not happening by interviewing 11 family doctors. The authors found that family doctors are mostly unaware of resources to guide their practice, are unsure about their role in mental health management, and experience difficulties in referring their patients to specialists for mental health care. Actively providing family doctors with knowledge and tools that help them initiate mental health care, as well as a structure for mental health referrals after mild traumatic brain injury, would help doctors apply best practice recommendations.

Preventing Concussions From Foul Tips and Backswings in Professional Baseball: Catchers' Perceptions of and Experiences With Conventional and Hockey-Style Masks

OBJECTIVE

To understand catchers' preferences for mask type and perceptions regarding safety, comfort, and fit, and determine whether mask type is correlated with self-reported concussion and related symptoms after impacts from foul tips or backswings.

DESIGN

Cross-sectional study.

SETTING

Survey of active baseball catchers.

PARTICIPANTS

Professional baseball catchers.

INTERVENTION

From May 1, 2015, to June 30, 2015, an online survey was administered in English and Spanish to all Major and Minor League catchers (n = 836).

MAIN OUTCOME MEASURES

Survey items addressed the type of mask routinely and previously used (conventional or hockey style); brand and material (steel or titanium); perceptions regarding safety, comfort, and fit; and experiences with concussions.

RESULTS

The sample consisted of 596 catchers of which 26% reported being diagnosed with a concussion. Some concussions occurred from non-baseball activities, such as car accidents or off the field incidents. For those that occurred playing baseball, 35% resulted from a foul tip. Once catchers entered professional baseball, the use of a conventional mask rose significantly: 71% of catchers reported wearing conventional-style masks, and 30% hockey-style masks at the time the survey was conducted (P < 0.05). Both conventional and hockey-style mask wearers significantly selected hockey-style masks as providing better overall safety and protection than conventional masks (P < 0.05).

CONCLUSIONS

This research supports foul tips as an important cause of concussion in catchers and provides important information about preferences among catchers for masks that are not perceived as the safest and strongest. Future research should supplement these data by conducting laboratory testing to determine which masks are stronger and by collecting qualitative data to explore why some players are more likely to wear a mask type that they perceive as offering less safety or protection.

Is It Time to Give Athletes a Voice in the Dissemination Strategies of Concussion-Related Information? Exploratory Examination of 2444 Adolescent Athletes

OBJECTIVE

The objective of the research was to screen male and female adolescent athletes on their concussion educational histories and preferred future methods of education in terms of educational messenger, modality, and concussion-related areas of interest.

DESIGN

Cross-sectional survey.

SETTING

Examination setting within the classroom.

PARTICIPANTS

Adolescent male (n = 1854) and female (n = 590) athletes aged 12 to 18 years.

MAIN OUTCOME MEASURES

To explore the concussion educational histories and preferred future methods of education in Irish male and female adolescent athletes.

RESULTS

19.7% (n = 482) of the sample received education in the past 12 months. Male athletes had a significantly higher rate of previous education than female athletes (41% vs 17%). The methods used in previous educational interventions are failing to match the interests of the athletes. Sex played a significant role in the preferred educational methods, as male and female athletes had significant differences in their choice of educational messenger, modality, and concussion-related areas of interest.

CONCLUSIONS

The current disparity in previous concussion education rates between male and female adolescent athletes should be addressed. Forthcoming research should explore the efficacy of tailoring knowledge translation strategies to match the specific needs of the recipient.

Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby

The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.

Australian Football League concussion guidelines: what do community players think?

Background

Preventing concussion in sport is a global challenge. To assess community-level adult male Australian Football players’ views on following the Australian Football League's (AFL) concussion guidelines.

Methods

3 focus groups, each comprising 6 players from 1 regional league, were conducted until saturation of issues raised. Discussions followed a semistructured script and were audio-recorded and transcribed verbatim. Thematic analysis was conducted by 2 coders independently.

Results

Identified advantages of the guidelines included highlighting the seriousness of concussion; changing the culture around playing with concussion and shifting return-to-play decision responsibility from players to others. Disadvantages included players being removed from play unnecessarily; removal of players’ rights to decide if they are fit to play and players changing their behaviours to avoid being removed from play. Identified facilitators to guideline use included local league enforcement; broad information dissemination and impartial medically trained staff to assess concussion. Identified barriers to guideline use included players’ desire to play at all costs; external pressure that encouraged players to return to play prematurely; and inconvenience and cost.

Conclusions

Players generally understand that the AFL concussion guidelines protect their long-term welfare. However, their desire to play at all costs and help their team win is a common barrier to reporting concussion and adhering to guidelines. Leagues should take a lead role by mandating and enforcing the use of the guidelines and educating coaches, game day medical providers and players. The return-to-play component of the guidelines is complex and needs further consideration in the context of community sport.

Injuries in Australian Rules Football: An Overview of Injury Rates, Patterns, and Mechanisms Across All Levels of Play

CONTEXT

The nature of Australian rules football (Australian football) predisposes both unique and common injuries compared with those sustained in other football codes. The game involves a combination of tackling, kicking, high-speed running (more than other football codes), and jumping. Two decades of injury surveillance has identified common injuries at the professional level (Australian Football League [AFL]).

OBJECTIVE

To provide an overview of injuries in Australian rules football, including injury rates, patterns, and mechanisms across all levels of play.

STUDY DESIGN

A narrative review of AFL injuries, football injury epidemiology, and biomechanical and physiological attributes of relevant injuries.

RESULTS

The overall injury incidence in the 2015 season was 41.7 injuries per club per season, with a prevalence of 156.2 missed games per club per season. Lower limb injuries are most prevalent, with hamstring strains accounting for 19.1 missed games per club per season. Hamstring strains relate to the volume of high-speed running required in addition to at times having to collect the ball while running in a position of hip flexion and knee extension. Anterior cruciate ligament injuries are also prevalent and can result from contact and noncontact incidents. In the upper limb, shoulder sprains and dislocations account for 11.5 missed games per club per season and largely resulted from tackling and contact. Concussion is less common in AFL than other tackling sports but remains an important injury, which has notably become more prevalent in recent years, theorized to be due to a more conservative approach to management. Although there are less injury surveillance data for non-AFL players (women, community-level, children), many of these injuries appear to also be common across all levels of play.

CLINICAL RELEVANCE

An understanding of injury profiles and mechanisms in Australian football is crucial in identifying methods to reduce injury risk and prepare players for the demands of the game.

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.

Concussion management in United States college sports: compliance with National Collegiate Athletic Association concussion policy and areas for improvement

BACKGROUND

In 2010, the National Collegiate Athletic Association (NCAA) adopted its Concussion Policy and Legislation, which applies to more than 450,000 collegiate athletes annually. To date, there has been no examination of school-level compliance with the NCAA Concussion Policy.

PURPOSE

To examine whether stakeholders at NCAA schools report that their school has a concussion management plan and whether existing plans are consistent with the NCAA policy. Also examined were stakeholders' perceptions regarding concussion management at their institution and possible areas for improvement.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Surveys were sent by e-mail to coaches, sports medicine clinicians, and compliance administrators at all 1066 NCAA member institutions. Surveys asked population-specific questions about institutional concussion management. Individuals (N=2880) from 907 unique schools participated in this survey.

RESULTS

Most respondents (n=2607; 92.7%) indicated their school had a concussion management plan. Most schools had all (82.1%) or some (15.2%) respondents indicate a concussion management plan was present. When asked to indicate all individuals who could have final responsibility for returning athletes to play after a concussion, 83.4% selected team doctor, 72.8% athletic trainer, 31.0% specialist physician, 6.8% coach, and 6.6% athlete. Most respondents (76.1%) indicated that their institution had a process for annual athlete concussion education; 91.2% required athletes to acknowledge their responsibility to report concussion symptoms. Nearly all respondents (98.8%) thought their school's concussion management plan protected athletes "well" or "very well." Top categories suggested for improvement included better coach education (39.7%), increasing sports medicine staffing (37.2%), and better athlete education (35.2%).

CONCLUSION

Although a large majority of respondents indicated that their school has a concussion management plan, improvement is needed. Compliance with specified components (eg, annual athlete education) lags behind the presence of the plan itself, and stakeholders had suggestions for areas in which improvements are needed. Increasing scientific evidence supporting the seriousness of concussion underscores the need for the NCAA to use its regulatory capabilities to ensure that athletes' brains are safe.