Ir J Med Sci DOI 10.1007/s11845-014-1137-9

ORIGINAL ARTICLE

Concussion knowledge and management practices among coaches and medical staff in Irish professional rugby teams M. R. Fraas • G. F. Coughlan • E. C. Hart C. McCarthy



Received: 11 November 2013 / Accepted: 5 May 2014 Ó Royal Academy of Medicine in Ireland 2014

Abstract Background Self-reported concussion rates among U-20 and elite rugby union players in Ireland are 45–48 %. Half of these injuries go unreported. Accurate knowledge of concussion signs and symptoms and appropriate management practices among coaches and medical staff is important to improve the welfare of players. Aims Examine concussion knowledge among coaches, and management techniques among medical staff of professional Irish rugby teams. Methods Surveys were administered to 11 coaches and 12 medical staff at the end of the 2010–2011 season. Results Coaches demonstrated an accurate knowledge of concussion with a good understanding of concussion-related symptoms. Medical staff reported using a variety of methods for assessing concussion and making return-toplay decisions. Reliance on subjective clinical methods was evident, with less reliance on objective postural stability performance.

M. R. Fraas (&) Department of Communication Sciences and Disorders, Western Washington University, 516 High Street, Bellingham, WA 98225-9171, USA e-mail: [email protected] M. R. Fraas  E. C. Hart Department of Communication Arts and Sciences, Elmhurst College, Chicago, USA G. F. Coughlan  C. McCarthy Medical Department, Irish Rugby Football Union, Dublin, Ireland E. C. Hart Department of Psychology, The Chicago School of Professional Psychology, Chicago, IL, USA

Conclusions Overall, the coaches in this investigation have accurate knowledge of concussion and medical staff use effective techniques for managing this injury. On-going education is needed to assist coaches in identifying concussion signs and symptoms. It is recommended that medical staff increase their reliance on objective methods for assessment and return-to-play decision making. Keywords Concussion  Rugby  Coaches knowledge  Medical management  Ireland

Introduction Rugby union is a popular sport in Ireland with over 150,000 registered participants across all levels of play [1]. Owing to the physical contact nature of the game, rugby players are at risk of sustaining concussion. Subsequently, the need for accurate concussion knowledge and access to appropriate management techniques by those responsible for ensuring the well-being of players stands to reason. Two recent investigations have examined self-reported concussion rates among Irish rugby union players. Baker and colleagues surveyed U-20 Irish rugby union players and observed that up to 48 % reported a history of sustaining at least one concussion during the season [2]. Similarly, Fraas and colleagues [3] found that 45 % of elite players in professional Irish rugby union reported concussion during the 2010–2011 season. Of those IRFU players, 32 % had more than one concussion [3]. The self-reported rates of concussion found in these two studies are higher than those found in other countries where rugby union is a popular sport. For example, elite-level rugby union players in South Africa, Australia, and New Zealand have reported concussion rates of 5–23 % per season [4–6]. Of concern,

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44–47 % of concussions sustained by players in Ireland are not reported to coaching or medical staff [2, 3]. Players cited several reasons for failing to report their concussions, which included: not knowing the injury was a concussion; not thinking the injury was serious enough; and thinking that concussions are part of the game [3]. This reasoning demonstrates a lack of knowledge, and illustrates the importance of educating players on how to recognize concussion and the potential risks associated with failure to report their injuries. Baker et al. found that if players were to report their concussion to someone, the majority (65 %) would do so to coaches and physiotherapists [2]. The authors go on to cite this as evidence of the importance of coaching and medical staff having accurate awareness of concussion signs and symptoms, and access to appropriate medical services to manage player injury [2]. However, investigations outside of Ireland have found that coaches, in particular, lack knowledge of concussion symptoms or subsequent concussion outcomes, and are uninformed about appropriate concussion management practices [7–9]. In addition, recent reports indicate that medical personnel rely more frequently on subjective clinical examination and player selfreport of symptoms [10, 11] than on a more comprehensive concussion management approach that includes objective baseline and post-injury neurocognitive and balance testing [12, 13]. Therefore, the purpose of this investigation was to determine the degree of knowledge of concussion signs and symptoms, and appropriate concussion management techniques among professional Irish rugby coaches. In addition, the study examined the concussion management practices of their medical staff.

obtained and the surveys were administered. The surveys took approximately 10–15 min to complete. The completed surveys were collected and returned to the investigators. Two separate surveys were developed for this investigation. The survey distributed to coaches was similar to those used in previous investigations [8, 10] and were intended to determine how coaches perceive concussion and their understanding of the signs and symptoms of concussion. The survey administered to medical staff was developed based on findings from previous investigations examining concussion management practices [7, 8, 10, 11]. Both surveys asked participants to focus their responses in relation to the 2010–2011 rugby union season. Descriptive information and statistical analyses were conducted using SPSS software (SPSS, Chicago, IL) with an a priori significance level set at p \ 0.05. The coaches’ data were analysed using Spearman correlation to determine whether a relationship existed between years coaching, history of concussion, attendance at a concussion workshop, and knowledge of concussion signs and symptoms. Analysis of the medical staff data included Pearson correlations between age, years of experience (total and in rugby union), and education and the number of concussions evaluated during the 2010–2011 season. In addition, the preferred methods of concussion assessment, as well as return-to-play decision-making, were rank ordered and the means were compared using non-parametric measures (Kendall’s W test) in an effort to determine the level of agreement among the medical staff.

Results Coaches

Methods This study was conducted following international ethical guidelines for biomedical research involving human subjects as outlined in the 1964 declaration of Helsinki and the World Health Organization [14]. Institutional Review Board approval was granted by the Elmhurst College Institutional Review Board prior to the commencement of the study. Participants for this investigation included coaches and medical staff from four professional rugby teams in Ireland. Managers for each team were contacted to schedule times to meet with the coaches and medical staff and distribute the surveys at the end of the 2010–2011 season (June 2011). Surveys were administered to the coaches and medical staff during a team meeting held at each team’s respective training ground in an attempt to maximize response rates. The study was explained to the participants, following which signed informed consent was

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Eleven coaches representing three of the four teams participated in this investigation. Not all coaches responded to all survey questions, therefore, the results are relative to the valid responses. Two head coaches (18.2 %) and nine assistant coaches (81.8 %) were an average of 37.1 ± 7.6 years of age with an average of 14.7 ± 12.5 years of coaching experience. One had a secondary education (9.1 %), three had some college education (27.3 %), six had a college degree (54.5 %), and one had a doctoral degree (9.1 %). Two (18.2 %) coaches had attended a class or course on concussion. All but one coach (90.9 %) had a history of concussion. The coaches were asked to indicate whether a history of concussion increases the risk of another injury. The majority reported that it did (N = 9, 66.7 %). Three coaches (N = 11, 27.3 %) indicated that having your ‘‘bell rung’’ is part of the game and not cause for concern. All coaches (N = 11, 100 %) acknowledged that loss of

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consciousness was not a prerequisite for a concussion diagnosis. Furthermore, the coaches accurately identified additional concussion signs and symptoms, with a few exceptions (Table 1). When asked about assessing concussion, the coaches indicated that they would be in agreement with baseline testing if it lead to better informed medical decisions (N = 11, 100 %) and quicker return to play decisions (N = 10, 100 %). The coaches’ indicated that the components of a baseline assessment should include: symptom report (N = 9, 88.9 %), neurocognitive examination (N = 11, 100 %), balance assessment (N = 7, 85.7 %), magnetic resonance imaging (MRI) (N = 8, 75 %), and computed tomography (CT) (N = 7, 14.3 %). The majority of coaches support rest (N = 11, 72.7 %), followed by exercise without contact to the head (N = 11, 27.3 %) as the best course of recovery following concussion. None of the coaches supported the use of neuroimaging or prescription medication as methods lending to the recovery process. When asked who was the best trained to determine a players readiness to return to play, the majority of coaches indicated that it was the team doctor (N = 11, 81.8 %), followed by the player (N = 11, 18.2 %). In addition, the majority of coaches indicated that a player was ready to return to play when they were asymptomatic (N = 11, 90.9 %), followed by when the player no longer had a headache (N = 11, 9.1 %). Only one coach admitted to pressuring a concussed player to return to play (N = 11, 9.1 %). None of the coaches indicated that they had actually returned a concussed player to play. Correlational analysis between years coaching, concussion injury history, and concussion signs and symptoms did not reveal any significant relationships (p \ 0.05). Medical staff Twelve medical staff representing all four professional rugby teams participated in this investigation. Not all medical staff completed all aspects of the survey. Therefore, the data presented are relative to the number of valid responses. The participants were an average of 35.7 ± 7.4 years of age with an average of 11.6 ± 6.9 years of experience with professional rugby union teams. Four of the medical staff participants had a Bachelor’s degree (33.3 %), five had a Master’s degree (41.2 %), one had a doctorate degree (8.3 %), and two had a medical degree (16.7 %). The medical staff estimated that they assessed a total of 52 concussions during the 2010–2011 season. The mean number of concussions assessed by each participant was 5.2 ± 4.7. Pearson correlation analysis was used to examine the relationship between age, education, total years of medical staff experience, and years of experience

Table 1 Coaches knowledge of concussion signs and symptoms Sign/symptom

Yes

No

Drowsya

10

1

91

Nauseaa

11

0

100

0

11

100 100

Eat more Dizziness/Loss of balance

a

% Correct

9

0

Hyperactive/High energy

1

8

89

Difficulty hearing

4

5

56 89

Excited/Happy

1

8

10

1

91

Fatiguea

8

1

98

Frustration

5

4

44

Talk more Impatient

3 4

6 5

67 56

Headachea

Difficulty concentratinga

11

0

100

Nervousnessa

3

6

33

Calm

1

8

89

Sleep morea

7

2

78

Slowed down feelinga

9

1

90

Elation

1

8

89

11

0

100

11

0

100

Mentally dazeda a

Confusion a

Commonly acknowledged signs and symptoms of concussion

Table 2 Preferred concussion assessment methods among IRFU medical staff Assessment

Rank (N)

Clinical examination

1 (11)

Symptom checklist

2 (10)

Neurocognitive testing: computerized

3 (10)

Standardized assessment of concussion (SAC)

4 (10)

Concussion grading scale (CGS)

5 (10)

Balance error scoring system (BESS)

6 (10)

Neurocognitive testing: paper and pencil

7 (10)

N number of respondents

in rugby union on the number of concussions evaluated annually. There was a significant relationship between the medical staff’s age and the number of concussions evaluated annually (r = 0.74, p = 0.014); CI 95 % [0.29, 0.92]. In addition, there was a significant relationship between number of years of experience in rugby union and the number of concussions evaluated annually (r = 0.73, p = 0.018); CI 95 % [0.27, 0.92]. There was no significant relationship between the total years of medical experience (r = 0.54, p = 0.11) or education (r = 0.25, p = 0.48) and the number of concussions evaluated. There was consensus among the medical staff regarding the practice of baseline testing players prior to the start of the rugby

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Ir J Med Sci Table 3 Return-to-play decision-making methods preferred among IRFU medical staff Methods Symptom checklist

Rank (N) 1 (11)

Neurocognitive testing: computerized

2 (11)

Clinical examination

3 (11)

Recommendation from a medical doctor (MD)

4 (11)

Concussion grading scale (CGS)

5 (10)

Standardized assessment of concussion (SAC)

6 (10)

Balance error scoring system (BESS) Neurocognitive testing: paper and pencil

7 (10) 8 (10)

Computerized tomography/magnetic resonance Player self-report

9 (10) 10 (10)

N number of respondents

union season (N = 11, 91 %). In addition, rank order analysis (Kendall’s W test) indicated moderate agreement among the participants regarding what measures should constitute an adequate concussion assessment [W (N = 9) = 0.59, p \ 0.05]. Table 2 lists the rank-ordered concussion assessment preferences among medical staff participants. The participants return-to-play decision-making preferences were also rank ordered (Kendall’s W test) to determine agreement among participants. Again, moderate agreement was observed among the participants [W (N = 10) = 0.57, p \ 0.05]. Table 3 lists the rankordered return-to-play decision-making preferences among medical staff participants. When making return-to-play considerations, the medical staff participants reported being pressured by both players (N = 10, 88.3 %) and by coaching staff (N = 9, 75.0 %).

Discussion This is the first investigation conducted in Ireland to examine the knowledge of concussion symptoms, as well as the management practices held by its professional rugby union coaching and medical staff. Overall, the findings suggest that the knowledge and management practices among these coaches and medical staff are consistent with current recommendations [15, 16]. The coaches in this investigation were asked to provide an indication of their knowledge of concussion signs and symptoms. Overall, the coaches were knowledgeable about concussion signs and symptoms, and means of effective concussion management, despite the fact that only two coaches (18.2 %) had previously attended a class or course on concussion. For example, contrary to the findings from McLeod and colleagues who found that 42 % of coaches believed loss of consciousness was a requirement for a

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concussion [17], all of the coaches in this study indicated that loss of consciousness is not a requirement. It is interesting to note that all coaches indicated that they had sustained a previous concussion. O’Donoghue and colleagues found that coaches who had a personal history of concussion were significantly better at recognizing concussion signs and symptoms than coaches without a history of concussion [8]. The methods for diagnosing a concussion were accurately identified by the coaches, with the exception of the inclusion of neuro-imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) (75 %). Broglio et al. reported similar findings with their cohort of Italian soccer coaches [10]. Neuroimaging (CT and MRI) is currently limited in the ability to diagnose concussion due to the fact that the injury is the result of functional rather than structural changes in the brain [10, 18]. However, the coaches in this study did not indicate the use of neuroimaging to guide the course of recovery. Instead, they reported that rest was the best method for effective recovery from concussion, and that the medical staff are the best trained for making return to play decisions. These findings concurred with previous investigations [10, 12, 16]. The coaches were 78–100 % accurate in identifying other signs and symptoms associated with concussion, except for nervousness (33 % accurate), which has also been shown to be inaccurately identified among Italian soccer coaches [10]. Furthermore, 28 % of the coaches continue to believe that having your ‘‘bell rung’’ is part of the game and no cause for concern. An additional 33 % failed to recognize that a history of a concussion increases the risk for a second injury. Given that many players fail to report their concussions because they feel that having your bell rung is part of the game [3], and that nearly 50 % of players who do report their concussions do so to their coach [2], it is imperative that coaches maintain and constantly update their knowledge of these issues. As some head injuries occur without the presence of physical lacerations or symptoms, recognition and knowledge of other concussive symptoms (such as nervousness, or ‘‘having your bell rung’’) by coaches is important to avoid returning a concussed player to competition. However, some symptoms may not be fully present immediately after the injury, and game-time pressures may arise, making a coach’s decision-making process difficult. For this reason, it is recommended that coaches attend regular concussiontraining workshops to obtain up to date knowledge on concussion signs and symptoms, and an understanding of appropriate concussion management. Numerous other investigations have also advocated further concussion education for coaches [7, 8]. Attendance at concussion workshops has been found to increase coaches’ knowledge about concussion management practices [8] and increase coaches’ ability to identify concussion signs and symptoms

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[7]. The majority of the coaches in this study (81.8 %) indicated a desire for formal concussion training. Medical staff The purpose of including medical staff in this investigation was to evaluate the overall concussion assessment and management practices. The medical staff reported implementing a variety of methods for assessing concussion with the primary reliance on subjective measures of concussion assessment including a clinical examination and symptom checklist. There was some preference among medical staff for relying on objective measures such as computerized neurocognitive testing and the standardized ssessment of concussion tool (SCAT). Similarly, medical staff indicated employing a variety of subjective and objective methods to determine a player’s ability to return to play. Most notable were reliance on clinical examination, symptom checklist, and computerized neurocognitive testing. However, recent investigations have reported that neurocognitive function and, in particular, postural stability have been found to persist for days following the resolution of concussion symptoms [19, 20]. Therefore, it appears that more emphasis should be placed on methods of concussion assessment that measure cognitive functioning and postural stability. The medical staff reported assessing a total of 52 concussions during the 2010–2011 season. However, Fraas et al. [3], who examined the rate of concussion among IRFU players from the same teams as the participants in the current investigation, reported that 92 self-reported concussions were sustained during the 2010–2011 rugby union season. This would indicate that players do not always report their concussion leading to fewer concussions being identified and managed by the medical staff. This is not an uncommon phenomenon in rugby union or other sports. In a recent investigation of Italian soccer players, Broglio et al. [10] found that more than half (62 %) of player concussions go unmanaged by medical staff. This investigation has a number of limitations that are inherent to conducting survey research. First of all, the sample sizes for both the coaching staff and the medical staff are small. In addition, we were only able to collect data from coaches representing three out of the four professional clubs. We attempted to maximize those involved by attending meetings at team training grounds. Despite these issues, the majority of coaches and medical staff affiliated with these teams were surveyed.

Conclusions This is the first investigation to examine the concussion knowledge of coaches and the management practices of

medical staff working with professional rugby teams in Ireland. There was an accurate knowledge of concussion among coaches and effective management of concussion among medical staff working in the professional game. Continued education of coaching staff to better identify concussion and the increased reliance on objective methods for managing concussion will improve player safety and inform more reliable return-to-play decision-making. The Irish Rugby Football Union has been providing education programmes in rugby-specific first aid, to include concussion modules, in their SAFE–Rugby programme [21] over the last 3 years, which is available to both professional and amateur rugby personnel. An improved understanding of both the temporary neuropathological changes that may occur, as well as the clinical symptoms that can arise, even several hours post injury, is prompting an increased vigilance of head injury management in rugby [16]. The international rugby board (IRB) has recently updated the concussion regulations and developed a concussion module on the player welfare area of the IRB website [22]. Objective, as well as subjective diagnosis and assessment techniques (symptom checklist, neuropsychological testing, and postural stability), in addition to pre-season baseline testing of all players is strongly recommended for all players participating in rugby union [12, 16]. Such protocols will allow medical and non-medical personnel to better recognize concussion and assist in making wellinformed return-to-play decisions. Conflict of interest

Dr. Fraas has nothing to disclose.

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Concussion knowledge and management practices among coaches and medical staff in Irish professional rugby teams.

Self-reported concussion rates among U-20 and elite rugby union players in Ireland are 45-48%. Half of these injuries go unreported. Accurate knowledg...
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