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Concussion in Sport: Why parents and coaches need to know the guidelines. Article by Curt Barnes

Curt Barnes, MSc. sports and exercise physiotherapy candidate and article author. Captured in action for The Sharks

The large incidence of concussion and the potential for prolonged adverse effects associated with premature return-to-play has been well established.

[1] Concussion is currently one of the most prominent medical concerns in contact sport at all ages and levels of competition. [2] Currently, the best treatment for concussion appears to be prevention but this has proven to be a daunting task for health professionals, scientists and sport-governing bodies.

[2] Regulations from the International Rugby Board have encouraged rugby union coaches and community players to endorse the following guideline. [1] All players who suffer a concussion do not return-to-play for 3-weeks especially those younger than 19 years old. [1] Players older than 19 years old may return-to-play within 3-weeks if they are symptom free through graduated return-to-play and declared fit by a recognized neurological specialist. [1] Evidence is lacking regarding the effects of legislation on primary, secondary or tertiary concussion prevention. [2] There is a paucity in research in the extent of compliance to these regulations and more so, the extent of their implementation in Australian Rugby Union.

In the available research, a Canadian study detected 33% of ice hockey players who were advised against return to play post-concussion were non-compliant. [1] Furthermore, 80% of the non-compliant players continued to suffer post-concussion symptoms two or more years later. [1] The devastating adverse effects of concussion are noted in three categories; second impact syndrome, post-concussion syndrome and chronic traumatic encephalopathy. [3] Within High School rugby union players, over half reported returning to play without medical clearance and 22% against physician’s orders. [1] Returning to play prematurely post-concussion has been shown to slow reaction time in athletes, leading to an increased risk to re-injury. [1] Furthermore, it can also increase an athletes risk of suffering more severe post-concussion symptoms and lowering cognitive ability, later in life leading to cognitive impairment. [1]

In the current study, an alarming 100% of players who received correct return-to-play advice failed to comply with the 3-week stand-down regulation for return-to-play. [1] This varied with grade (97%) and suburban (91%) adult levels suggesting differences in how return-to-play regulations are implemented across various levels. [1] What is alarming is that when a player sustains a concussion during a rugby game, a decision is made at the time by the coaches and support staff make return-to-play decisions. [1] In the current study, 48% of the players returned to play in the same game that the injury was sustained and 34% did not leave the field at all. [1] Only 22% of players reported being given return to play advice post-concussion and of these, none complied with the return-to-play regulation for returning to either competition or training. [1] It is most commonly the role of clubs, coaches or other support staff to ensure injury prevention measures are in place. [1] With non-compliance to advice being a concern, literature highlights that responsibility for sports safety is shared across different parts of the sports delivery system. [1]

Concussion being a public health concern, surely health professionals should take greater responsibility in regulating the implementation of laws?

With a large volunteer nature in club rugby, implementation and advice strategies remains challenging as players are limited by sideline medical support and the advice given to players by coaches and support staff therefore varies considerably. [1] A 3-week stand-down period post-concussion allows easy and consistent implementation by sporting bodies however, it’s implementation remains questionable. [1] Current recommendations are aligned with the 2008 Zurich Consensus Statement and the American College of Sports Medicine Consensus Statement which recommends a graded and progressive step-wise approach to concussion rehabilitation prior to return to play. [3] These statements emphasize the need for individualized management and complete asymptomatic at rest prior to the three-stage rehabilitation approach of return to play. [3] It is important that any such laws, if passed, must be open to ongoing review and amendment as new scientific knowledge about sports related concussion is discovered and the most effective methods to implement such laws are established. [2]

From a public health perspective, do we really understand how schools and clubs choose to respond to concussion regulations and laws and whether the implementation of these regulations affects concussion knowledge? [4] Furthermore, the extent of concussion education and the resulting concussion knowledge may vary by sport or by urban or rural locations. [4] For what remains a public health concern, how are health professionals taking more responsibility? The counter argument is that many schools and clubs can’t afford health professionals on-site and their presence is largely voluntarily. However, it is by law that every rugby game has a first-aid responder, would educating and empowering these health professionals assist in concussion recognition and removal from the field of play?

Coach concussion knowledge has proven to be high, with majority feeling comfortable in deciding whether an athlete required additional evaluation for concussion. [4] Schools or clubs employ coaches and they thus have the ability to enforce education requirements and adhere to regulations in order to avoid litigation. [4] Despite coaches’ knowledge and confidence in their ability to decide when a player needs further evaluation, how well do they implement this? In high pressure games are coaches’ objective enough to make the correct decisions? Would the threat of litigation against coaches for poor decisions tighten up the adherence to regulations? This emphasizes the importance of health professionals at games to make informed decisions placing the athletes’ health first. Athlete and parent’s concussion education is shown to be more limited with one-third of athletes and more than half of parents not receiving any additional education beyond signing the concussion information form. [4]

Knowledge transfer has been identified as a critical process in concussion education, and to prevent the spread of incorrect information it is pivotal that messages which are regularly being transferred to the general public via online media are in keeping with best-practice knowledge relating to concussion. [5] As a public health issue, it is plausible to infer that the those responsible for adhering to regulations need to engage with the mass media to lead discussion correctly, and better inform the media about this injury. [5] Descriptors of concussion and effect, shared responsibility to have standardized term that influence the correct perception of concussion.

Concussion is currently one of the most prominent medical concerns in contact sport at all ages and levels of competition. There is a poor compliance with return-to-play regulations post-concussion within rugby union from sports governing bodies and athletes. The adverse effects of athletes returning to play too early on game day or post game day following a concussion is well known. Education, awareness and implementation of regulations from clubs, coaches, parents and athletes are critical to ensure compliance. Despite a shared responsibility across the sports administrators, health professionals should take greater responsibility in education and knowledge transfer of concussion.