Post-concussion return-to-play: Perceptions of roles,responsibilities and guideline implementation among community club rugby stakeholders in South Africa

Abstract

Concussions are an inherent part of rugby; however, subsequent concussions can be decreased by following the appropriate post-concussion return-to-play (RTP) protocols. The aim of this study was to compare stakeholders’ perceptions regarding their roles and responsibilities in terms of the implementation of post-concussion RTP in community club rugby in the Western Cape, South Africa. The results of a post-concussion RTP implementation questionnaire revealed limited knowledge of the recommended 6-stage BokSmart™ RTP protocol among players. Although not essential that players have knowledge of this protocol, this can be indicative of coaches’ disregard of the importance of communicating concussion knowledge. Coaches were identified as having a major role to play in post-concussion RTP, being responsible for monitoring matches and training sessions for concussion. They were also considered the most knowledgeable stakeholders on post-concussion return-to-play guidelines. Yet, coaches and administrative staff demonstrated a relatively low ability to advise on when to safely return to play. Only two thirds of coaches and a third of administrative staff were found to implement the recommended protocol, while less than half of medical staff and only a third of coaches demonstrated the ability to implement the protocol correctly, revealing inadequate knowledge. Hence, the study underscored the significance of education focusing on the practical implementation of post-concussion RTP protocols within community club rugby.

Keywords

Mild traumatic brain injury,rugby football

Introduction

Rugby Union (hereafter referred to as rugby), has a high occurrence of injuries due to the physical demands and the frequent contact between opposing players.^1–3 Up to 30% of rugby injuries are to the head and neck, and the risk of concussion is high. Concussed players need to complete a return-to-play (RTP) protocol and receive medical clearance before returning to play.^4–6 Players with a history of concussion have been found to be more susceptible (between 3 to 6 times more) to sustaining secondary concussions with aggravated symptoms and longer recovery times.^7–9 These subsequent concussions could be a result of premature RTP and indicate that complete clinical recovery had not been achieved.¹⁰ More emphasis should be placed on post-concussion RTP implementation,¹¹ given the high incidence of concussions in rugby and the information coming to light regarding the associated health issues if not managed correctly.¹² The misunderstanding and incorrect implementation of RTP guidelines can lead to questionable management of players throughout the process.¹⁰ Finch et al. and White et al. express concern regarding the translation of concussion guidelines to non-elite and community sport populations. Ensuring that information reaches target audiences through implementing the preferred method of learning of each stakeholder is referred to as knowledge transfer.^13,14 While a shared responsibility among stakeholders (players, coaches, administrative staff, and medical staff) has been advocated by previous literature to ensure the safe RTP of players,^12,15 differences in perceptions have been reported throughout the rugby community structure.¹²

To ensure player welfare, World Rugby and BokSmart™ have developed concussion management recommendations.³ However, the practical application and enforcement of these recommendations present a challenge. A strong emphasis of the BokSmart program is concussion education, which focuses on the 6Rs of concussion management: Recognise, Remove, Refer, Rest, Recover, and Return. This approach, which includes implementing a post-concussion RTP protocol, has proven to be a challenging issue for clinicians. Although the exercises prescribed at certain timeframes have proven beneficial,^15,16 the prescribed level of exercise appears to be vague.¹⁷ If implemented correctly, players should not report concussion symptoms after any stages of the RTP protocol and if symptoms were to re-occur, they should revert to the previous stage.¹⁸ After RTP protocol has been fully adhered to, players are mandated to be evaluated and cleared by a medical doctor or licensed health care professional.¹⁹

Although the number of concussion educational programmes focusing on knowledge and attitude have increased, knowledge among stakeholders has been found to be one of many areas of concern.⁷ Previous research has deemed that, although athletes had knowledge of the risks of concussion, their actions were not in line with their knowledge, hence shifting the focus in research to investigating concussion attitude.²⁰ The BokSmart safety program which developed educational initiatives in South Africa for preventing catastrophic rugby injuries, has a keen focus on concussion. In South Africa, all coaches and referees are requested to attend a bi-annual face to face BokSmart™ safety course and coaches and referees are tasked to deliver the preferred best-practices for injury prevention to their players.¹⁷ This responsibility of disseminating the information was found lacking by a study which indicated that only 21% of community players were aware of the general RTP guidelines.²¹ Brown et al.²² mention a possible resistance by older coaches, referees and players to adopt safety programmes such as BokSmart™, which could explain the weak dissemination of post-concussion RTP information. The ultimate aim of BokSMart™ is try to improve player behaviour (not knowledge) through ongoing education of coaches and referees. Clacy et al. has highlighted the importance of teammates in identifying potential concussions. As identification of an injury requires both knowledge and behaviour, World Rugby and BokSmart’s general awareness campaigns are aimed at all stakeholders, including players.¹² Viljoen et al., further highlighted that in a country like South Africa where medical assistance on the field during a rugby training and matches is scarce, the players themselves can play a pivotal role in reporting possible concussions to their coach or the referee.²³ It has also been reported that, previously, misconceptions have existed among coaches regarding when players can safely return to play.²⁴ For instance, a previous study found that when coaches were asked to indicate the requirements for allowing players to RTP on the same day, 97% of them replied that it was allowed when the player says he is symptom free and ready to play.¹⁴

Furthermore, players have previously underreported symptoms in order to return to play, which warrants concern as players should not return to play on the same day of a game or practice.²⁵ Mathema et al. investigated adult rugby and found that 80% of the medical staff reported feeling pressured by coaches or players to allow players to continue playing regardless of concussion symptoms.²⁵ It is for this reason that medical doctors or licensed health care professionals should advise players’ families, and most of all coaches, on how to manage post-concussion RTP.²² A multidisciplinary team of stakeholders should be responsible for identification of symptoms, initial management, and RTP protocol implementation.²⁶ The aim of this study was to compare stakeholders’ perceptions of their roles and responsibilities regarding the implementation of post-concussion RTP in community club rugby in the Western Cape, South Africa.

Material and methods

Study design

The study utilised a quantitative cross-sectional study design in which a paper-based questionnaire was completed in person during the 2018 rugby season. The post-concussion RTP implementation questionnaire was designed by the researchers and was based on available literature on post-concussion RTP, general RTP, and suggestions from 6 local and international rugby experts in the field of concussion and rugby. Ethical approval was obtained from the Human Research Ethics Committee at Stellenbosch University (Sport-2017-0241-170).

Participants

The participants in the study comprised 408 community club rugby stakeholders (players, coaches, administrators and medical staff) with an mean age of 27.1 years (SD 11.1) and an mean of 11.7 (SD 7.5) years of experience in their respective roles. The inclusion criteria entailed that the stakeholders had be associated with a community rugby club. All 89 rugby clubs registered with the Western Province Rugby Union (WPRU) had been contacted to participate in the study; however, only 14 agreed to participate. The overall response rate, determined by dividing the total number of questionnaires received by the number of projected stakeholders, was 4%.

Questionnaire

The post-concussion RTP implementation questionnaire aimed to determine the post-concussion RTP guidelines implementation and to explore how the different stakeholders in community club rugby perceived their roles and responsibilities in this regard. Prior to the data collection for the main study, a pilot study was conducted with the aim of determining face validity and whether any questions could be misunderstood or misinterpreted. The post-concussion implementation questionnaire was based on relevant literature on post-concussion RTP. The current study utilised two processes to determine the validity of the questionnaire. Part 1 of the process entailed sending the initial questionnaire to 6 experts (n = 6) in the field of rugby and concussion for feedback, which was then incorporated into the questionnaire. Concerning face validity, it was established by the experts that the questions and questionnaire measured the desired concept of post-concussion implementation. Part 2 of the validity test involved 15 participants (pilot study) in the field of rugby completing the questionnaire finalised in part 1. The feedback from the pilot study was screened to determine whether any technical aspects needed to be addressed or whether questions had to be added or removed (Part 2). The participants of the pilot study were stakeholders (players, coaches, medical staff and administrative staff) from community club rugby who did not form part of the current study. After completion of the questionnaire, pre-set questions were administered to the participants, which inquired about the general interpretation of questions in the questionnaire. Minor adjustments were made to the questionnaire based on the feedback. Upon completion of these two processes, the questionnaire was considered valid. The post-concussion RTP questionnaire aimed to investigate two themes, namely (1) Implementation of post-concussion RTP (Questions 1 to 8) and (2) Post-concussion RTP roles and responsibilities (Questions 9–17).

Data collection procedure

The club representatives were contacted telephonically and a date and time for each data collection session was determined. The questionnaires (Supplemental Appendix A) were available in English and completed in-person at each one of the community clubs. A member of the research team was in attendance to provide clarity on the questions where needed. The purpose of the study was explained to the participants (in-person) before commencing with the data collection. Hereafter, demographic information and informed consent were obtained and the questionnaire was completed.

Data analysis

Statistica version 13.5 (Dell Inc, Tulsa, OK, USA) and Excel (Microsoft® Corporation, Redmond, WA, USA) were utilised to analyse the data. Descriptive statistics, such as the mean, frequency and standard deviation were used. The data were expressed as percentages and frequencies to summarise the score of each question. Regarding post-hoc analysis, responses to the first Likert-scale question (Question 1) was compared between the groups using one-way analysis of variance (ANOVA) with Fisher least significant difference test. Responses to the remaining questions were compared between the groups using cross tabulation and generalised Fischer exact test.

Results

Implementation of post-concussion RTP

Implementation of post-concussion RTP stakeholder responses (Question 1–8) are presented in Table 1.

Table 1.

Implementation of post-concussion RTP stakeholder responses (Question 1–8).

Questions	Response(s)	Player f(%)	Coach f(%)	Administrative staff f(%)	Medical staff f(%)
Question 1: Do you believe that you have the ability to assist a concussed player on when it is safe to Return-to-Play?	Strongly disagree	66(19)	5(14)	2(13)	0(0)
	Disagree	100(29)	9(26)	3(20)	0(0)
	Neutral	81(24)	6(17)	2(13)	3(38)
	Agree	69(20)	13(37)	8(53)	2(25)
	Strongly Agree	25(7)	2(6)	0(0)	3(38)
Question 2: Do you know whether the organisation (community) you belong to performs any preseason screening such as computerised brain function testing or measuring of baseline symptoms for concussion?	Not sure	152 (42)	6(16)	3(21)	2(25)
	Yes	154(46)	8(22)	0(0)	4(50)
	No	41(12)	22(61)	11(79)	2(25)
Question 3: Do you have knowledge of any concussion tools, which can be used in the assessment of an injured player?	Not sure	74(22)	8(23)	3(21)	0(0)
	Yes	132(38)	17(49)	6(43)	8(100)
	No	137(40)	10(28)	5(36)	0(0)
Question 4: Are any of the following immediate (sideline) concussion assessments/tests currently being implemented within your community? (you may mark more than one)	Not sure	126(38)	12(35)	5(35)	4(50)
	Physical signs	106(32)	12(35)	8(57)	6(75)
	Balance assessments	79(34)	11(32)	5(36)	4(50)
	None	59(18)	6(18)	2(14)	0(0)
	SCAT3/5	27(8)	2(6)	1(7)	4(50)
	Computerized brain function test	13(4)	1(3)	1(7)	2(25)
Question 5: Following a concussion, is there a mandatory period of time a player should rest?	Not Sure	50(14)	3(8)	1(7)	0(0)
	Yes	271(79)	31(86)	12(86)	8(100)
	No	21(6)	2(6)	1(7)	0(0)
Question 5.1: If you answered yes to the above question, what is it?	24–48 h	15(5)	1(3)	0(0)	0(0)
	3–5 days	26(9)	1(3)	0(0)	0(0)
	5–7 days	34(12)	3(10)	0(0)	1(14)
	8–10 days	120(42)	22(71)	8(72)	2(29)
	30 days	46(16)	2(6)	2(18)	0(0)
	>30 days	40(14)	2(6)	1(9)	4(57)
Question 6: Does the organisation you belong to have records of player medical history/injury history?	Not sure	155(45)	13(36)	2(14)	2(25)
	Yes	107(31)	12(33)	6(43)	5(63)
	No	80(23)	11(31)	6(43)	1(12)
Question 6.1: If you answered yes, do you know whether the organisation uses the medical history information in the event of a suspected concussion?	Not sure	93(52)	9(39)	3(30)	3(38)
	Yes	55(31)	7(30)	5(40)	4(40)
	No	30(17)	7(30)	3(30)	1(12)
Question 7: Are any of the following concussion return-to-play guidelines implemented at your community/team?	None	53(16)	6(17)	3(21)	0(0)
	Not sure	179 (53)	7(19)	6(43)	2(25)
	6 Stage	99(30)	23(64)	5(36)	6(75)
	Buffalo Treadmill	6(2)	0(0)	0(0)	0(0)
Question 8: Which grading system of concussion is currently implemented at your community/team?	None	60 (18)	12(33)	6(43)	1(13)
	Not sure	253(75)	20(56)	4(29)	3(38)
	Colorado	4(1)	0(0)	0(0)	0(0)
	Case-by-case	17(5)	4(11)	4(29)	1(13)
	Glasgow coma scale	2(1)	0(0)	0(0)	3(38)

%: percentage; AS: administrative staff; C: coaches; f: frequency; MS: medical staff; P: players.

Table 2.

Roles and responsibilities in the post-concussion RTP process stakeholder responses (Question 9–17).

Questions	Response(s)	Player f(%)	Coach f(%)	Administrative staff f(%)	Medical staff f(%)
Question 9: Within your organisation, what category does the medical team fall into?	Not sure	142(42)	11(31)	5(36)	0(0)
	Designated	154(46)	17(47)	7(50)	7(88)
	Assigned	41(12)	8(22)	2(14)	1(13)
Question 10: In your opinion, should a concussed player be assessed by either a medical doctor or registered healthcare professional (Biokineticist/ Physiotherapist/First aid) before returning to full contact?	Not sure	44(13)	0(0)	1(7)	0(0)
	Yes	296(87)	35(97)	13(93)	8(100)
	No	1(0)	1(3)	0(0)	0(0)
Question 11: Within your organization, are players assessed by either a medical doctor or registered healthcare professional (Biokineticist/ Physiotherapist/First aid) before returning to full contact?	Not sure	108(33)	3(8)	5(36)	1(13)
	Yes	189(57)	27(75)	8(57)	7(88)
	No	34(10)	6(17)	1(7)	0(0)
Question 12: Who within your organization, do you believe should have knowledge of return-to-play guidelines? (can mark more than one)	Player	168(50)	22(61)	6(43)	6(75)
	Coach	249(74)	32(88)	11(79)	8(100)
	Specialist coach	163(49)	21(58)	4(29)	6(75)
	Medic	253(76)	29(81)	9(64)	8(100)
	Physiotherapist	205(61)	23(64)	7(50)	7(88)
	Biokineticist	149(44)	16(44)	3(21)	6(75)
	Doctor	254(73)	24(67)	7(50)	7(88)
	Administrative staff	63(19)	19(53)	7(50)	2(25)
	Referee	121(36)	11(31)	7(50)	6(75)
Question 13: Player A is diagnosed with a concussion, please rank (from 1 to 6) the following activities in the order that you believe they should be performed before returning to play?	Correct	50(22)	10(37)	2(29)	2(40)
	Incorrect	177(78)	17(63)	5(71)	3(60)
Question 14: Have you participated in the BokSmart educational training program within the last 5 years?	Yes	116(35)	33(92)	13(93)	4(50)
	No	218(65)	3(8)	1(7)	4(50)
Question 15: Have you attended any other educational seminars or training programs?	First aid	100(69)	19(68)	5(63)	4(67)
	BokSmart Medic	45(31)	10(36)	5(63)	2(33)
	Cardiopulmonary-resuscitation	18(13)	2(7)	2(25)	0(0)
	Paramedics	10(7)	0(0)	1(13)	0(0)
	Basic Life Support	26(18)	3(11)	2(25)	1(17)
Question 16: Which stakeholder in your organization, ensures that the concussed player is ready to return-to-Play?	Player	71(22)	4(11)	2(16)	0(0)
	Coach	173(53)	20(56)	7(54)	0(0)
	Specialist coach	86(26)	4(11)	1(8)	0(0)
	Medic	166(50)	13(36)	3(23)	3(38)
	Physiotherapist	130(40)	14(39)	4(31)	2(25)
	Biokineticist	89(27)	6(17)	0(0)	0(0)
	Doctor	182(55)	21(58)	6(46)	6(75)
	Administrative staff	22(7)	4(11)	2(15)	0(0)
	Referee	38(12)	1(3)	1(8)	1(13)
Question 17: Who within your organization is responsible for monitoring matches and practises for injuries and possible concussions?	Player	61(18)	1(3)	1(7)	0(0)
	Coach	233(71)	28(80)	9(64)	4(50)
	Specialist coach	131(40)	13(37)	2(14)	2(25)
	Medic	157(48)	15(43)	6(43)	5(63)
	physiotherapist	128(39)	14(40)	5(36)	6(75)
	Biokineticist	71(22)	10(29)	1(7)	1(13)
	Doctor	113(34)	11(31)	2(14)	2(25)
	Administrative staff	53(16)	17(49)	6(43)	0(0)
	Referee	40(12)	2(6)	0(0)	1(13)

%: percentage; AS: administrative staff; C: coaches; f: frequency; MS: medical staff; P: players.

In response to Question 1 (Do you believe that you have the ability to assist a concussed player on when it is safe to Return-to-Play), 28% of the stakeholders indicated that they disagreed with the statement. When comparing the responses of the different stakeholders, the medical staff scored the highest compared to players (p < 0.01) and coaches (p = 0.03).

In response to Question 2 (Do you know whether the organisation (club) you belong to performs any preseason screening such as computerised brain function testing or measuring of baseline symptoms for concussion?), a high proportion of administrative staff (79%) and coaches (61%) indicated that concussion baseline testing was not conducted for players (p < 0.01). While all the medical staff responded to Question 3 (Do you have knowledge of any concussion tools which can be used in the assessment of an injured player?) in the affirmative, only half of both coaches (49%) and administrative staff (43%) responded in this way (p < 0.05).

Significant differences in responses by stakeholders were reported for Question 4 (Are any of the following immediate (side-line) concussion assessments/tests currently being implemented within your club?). The SCAT 3/5 (p = 0.01) and physical signs (p = 0.01) tests were indicated to be the forms of assessment used by stakeholders. Whereas medical staff reported that in assessing concussion they relied predominantly on physical signs (75%) and SCAT 3/5 (50%), only a third (35.12%) of coaches counted on physical signs and very few coaches (5.88%) preferred using the SCAT 3/5.

While no significant differences were reported in the responses of the stakeholders for Questions 5, 6, 6.1 and 10, the remainder of questions were deemed statistically significant (p < 0.05). Question 7 (Are any of the following concussion return-to-play guidelines implemented at your club/team?) indicated the following differences among the stakeholders: Decisions on which RTP protocol should be followed, more specifically with the use of the 6-stage RTP protocol (p < 0.01), as well as players reporting ‘unsure’ (p < 0.01) proved significant. Only 30% of the players, 64% of the coaches and 36% of the administrative staff indicated that they were implementing the 6-stage RTP protocol. Regarding Question 8 (Which grading system of concussion is currently implemented at your club/team?), 75% of the players, compared to 56% of the coaches and 38% of the medical staff, indicated that they were ‘not sure’ (p < 0.05). In summary, statistically significant differences were found when the stakeholders were compared throughout Questions 1, 2, 3, 4, 7 and 8 (p < 0.05).

Post-concussion RTP roles and responsibilities

Post-concussion RTP roles and responsibilities stakeholder responses (Question 9-17) are presented in Table 2. Responses to Question 9 (Within your organisation, what category does the medical team fall into?) indicated that 88% of the medical staff, 50% of the administrative staff, 47% of the coaches and 46% of the players believed that the medical staff is appointed by the club (designated) (p < 0.05). The two main categories in community rugby clubs within the Western Province firstly are the “designated” category, where the medical staff is appointed by the club for the duration of the season, the staff who forms part of the support staff on training and match days. Secondly there is the “assigned” category where the medical staff is employed by a company that provides a service to the club on match days. In reference to Question 11 (Within your organisation, are players assessed by either a medical doctor or registered healthcare professional (Biokineticist/Physiotherapist/First aid) before returning to full contact?), 87.5% of the medical staff, compared to 57% of the administrative staff and 57% of the players (p = 0.02) answered in the affirmative. Regarding Question 12 (Who within your organisation do you believe should have knowledge of return-to-play guidelines?), only the role of administrative staff proved to be statistically significant. Of the coaches 53% and of the administrative staff 50% indicated that administrative staff’ should have knowledge of the guidelines. The players, however, did not agree as 81% of them did not select the administrative staff (p < 0.01). Question 16 (Which stakeholder in your organisation ensures that the concussed player is ready to return to play?) yielded that coaches (p < 0.01), specialist coaches (p < 0.01) and biokineticists were significant stakeholders. For this question, coaches were selected by 53% of the players, by 56% of the coaches and by 54% of the administrative staff but not selected by any of the medical staff. Specialist coaches (p = 0.01) and biokineticist (p < 0.01) were, however only selected by a quarter of all players (26% and 27% respectively) but not selected by the rest of the stakeholders. Regarding Question 17 (Who within your organisation is responsible for monitoring matches and practises for injuries and possible concussions?), 18% of the players (p = 0.01) indicated themselves, whereas the highest proportion (48%) of the administrative staff (p < 0.01) indicated that the coaches were responsible.

Discussion

The main finding of the study was that, although coaches were perceived by others as the stakeholders with the greatest responsibility regarding post-concussion RTP, their implementation of RTP was found to be lacking. In 2017, New Zealand Rugby conducted a survey with 416 high school players who reported that they received the majority of their concussion education information from the coach, and felt the most comfortable disclosing their symptoms to their coach. ²⁷ While it is recognised that there are many stakeholders who are important to each aspect of the concussion management pathway, the stakeholders with the largest capacity to make an on-field impact are players, coaches and referees in the community rugby. This is demonstrated by only two-thirds of coaches selecting the 6-stage BokSmart RTP protocol and only 37% of them being able to successfully arrange the steps of the protocol. In the first question, only 43% of coaches indicated that they agreed or strongly agreed that they could assist concussed players on when to RTP. Medical staff displayed the highest perceived ability to assist a concussed player on when to safely RTP. Patricios et al.²⁸ state that ‘when’ to return to play post-concussion is a challenge faced by all medical staff. Viljoen et al. argue that in a community setting, the coaches and referees are most often the first responders and need to have the ability to recognise the signs of concussion and remove a potentially concussed player from the field.²⁹ The next step in the process is then to refer the potentially concussed player to the medical professional.¹⁹

Regarding the responsibility of identification, medical staff indicated the highest knowledge of concussion tools, followed by coaches and administrative staff. The medical staff are the only stakeholders who are authorised to assess concussed players before allowing them to initiate the RTP process.¹⁹ Most of South Africa’s rugby playing population consists of amateur players. Only a limited proportion of amateur clubs and schools offer medical assistance – which is limited to matches – mostly due to a lack of funding and resouces.²³ Therefore the focus of the BokSmart™ safety program in South Africa currently leans towards educating coaches and referees to recognise concussion signs and symptoms and to remove concussed players from the field.²³ In a country where medical assistance on the field during a rugby match is scarce, the players themselves can play a pivotal role in reporting possible concussions to their coach or the referee.³⁰ When asked to specify the concussion assessments, ‘physical signs’ were reported as the most common assessment by medical and administrative staff and coaches. While it is vital that assessments such as SCAT 3/5 are conducted by medical staff in conjunction with symptom and balance assessments, only 50% of the medical staff in the current study selected the SCAT 3/5 as an additional assessment method. This score was, however, higher than previously reported by Clacy et al. who found that as little as 18% of the medical staff would use formal measures such as the SCAT 3/5 to assess concussion.²⁹

Mandatory post-concussion rest periods were selected by all the medical staff, who were cautious with 57% selecting a greater than 30-day stand-down period. Similarly, most coaches and administrative staff believed that there are mandatory rest periods and a period of 8–10 days was selected by 71% of coaches and 72% of administrators. BokSmart™ advocates a 1-week minimum rest period followed by a minimum 5-day RTP protocol for players 19 years and older.¹⁹ Any player younger than 19 must adhere to 14 days of complete rest where after they can commence with the 5-day RTP protocol. The medical staff were, therefore, more conservative regarding stand-down periods in comparison to the coaches and administrative staff. This could imply that coaches and administrative staff, who are directly involved at clubs, place a greater emphasis on match outcomes and player attendance than safety, or are not as conservative as medical staff in this regard. Brown et al.¹⁹ advise that medical staff and coaches should consider educating players on the dangers of premature RTP.

When asked which of the post-concussion RTP protocols should be followed, 50% of the players and slightly fewer of the administration staff in the current study reported being unsure. Yet, 64% of the coaches selected the BokSmart™ 6-stage RTP protocol. Previous research by Brown et al.¹⁹ found that the 6-stage RTP protocol was the safest measure. Coaches need to attend a compulsory BokSmart™ workshop bi-annually, which covers the post-concussion RTP protocol to be followed in the event of a concussion. What warrants serious concern, though, is that the workshop only entails a viewing of a ±4 hours standardised DVD on safety and a discussion between coaches and referees, facilitated by a certified BokSmart™ trainer. Implementing the RTP protocol on a player is therefore not practically demonstrated in person but rather through video.

Responses were quite divided regarding the category into which the medical staff at the organisations fall. Many of the medical staff and less than half of the players indicated that they belonged to the clubs. This discrepancy could be a determining factor when potentially concussed players are searching for follow-up advice from medical staff. Players must be assessed by medical staff to commence with the RTP protocol, as well as before returning to full contact training.¹⁹ Most stakeholders indicated that they believed concussed players should be cleared by medical staff before returning to play, whereas only 50% of the participants reported that players were in fact cleared. This reflects previous research done by Brown et al.¹⁹ who found that only 50% of youth-week players sought out medical clearance before RTP.

The players predominantly believed that the medical staff and coaches should have the knowledge of RTP guidelines, whereas the coaches, administrative staff and medical staff all identified the coaches as the main stakeholders required to have knowledge of RTP guidelines. The study by Viljoen et al., looked at the dissemination of concussion knowledge in South African schools and reported that health care providers played the biggest role in providing this information so it would be good to see this discussed in context of the BokSmart program.²³ Hollis et al.¹¹ concur that coaches and medical staff are perceived to be the most relied upon stakeholders regarding RTP decisions. Recently, medical staff and referees were also found to have the highest level of knowledge of concussion among community rugby stakeholders.^7,31,32 In a study by Sye et al., New Zealand coaches scored 74% for concussion knowledge, ranking third after referees and medical staff.⁷ In recent studies by van Vuuren et al.³¹ (community rugby – club level) and Salmon et al.³² (community rugby – school level) also revealed that coaches scored significantly higher than other stakeholder for concussion knowledge and attitude. The finding from the studies is unsurprising as coaches in South Africa and New Zealand are required to attend an bi-annual rugby safety workshop which includes a concussion education component, while players receive no direct concussion education similar to that. This highlights the need for coaches in community rugby clubs to be comfortable with the immediate management, during the recovery process and post-concussion RTP information players may need for a confirmed or suspected concussion. The potential for coaches to address this gap through the provision of information post-concussion and during the recovery process would warrant its inclusion in coaches’ concussion education.

The 6-stage RTP protocol is recommended by BokSmart™ and World Rugby to be implemented in the event of a concussion. Although being identified by coaches as the most used protocol, the order of the 6 stages was only successfully answered by a third of coaches, which warrants concern. Previous research by Hollis et al.¹² has indicated that inadequate knowledge of concussion could hinder the correct implementation of the post-concussion RTP protocol. However, there are still opportunities for improvement for coaches’ concussion knowledge. The low referral rate of players to immediate care following a loss of consciousness needs to be addressed in future SARU educational initiatives.³² The current study indicated that coaches in community rugby have the highest perceived responsibility to uphold post-concussion RTP. Half of the players, coaches and administrative staff identified coaches as responsible in the assessment of whether a player is ready to RTP post-concussion. The study by Salmon et al.³² revealed that 71% of high school players surveyed in the study reported that they received concussion information from their coach. Coaches were also the most identified stakeholders responsible for monitoring matches and training for concussions.

Practical application

The results of the current study can inform future concussion education initiatives within community club rugby. The study has identified the important need to provide ongoing concussion education (at different stages of the season), including the BokSmart™ 6Rs for concussion, to community club rugby stakeholders. Furthermore, the study suggests that BokSmart™ should regularly update their online content (website, Facebook, Twitter and YouTube) to assist community club rugby stakeholders. For coaches, recommendations include continued bi-annual coach education and emphasis on the pivotal role coaches play in post-concussion RTP management through their dissemination of concussion information, and the recognition, removal, and referral of symptomatic players, particularly when a loss of consciousness occurs during training and match-play.

Limitations of the study

Limitations to the current study included a low response rate from the stakeholders, which makes generalising to the community rugby population problematic. A further limitation could be that the questionnaire failed to provide context of the current struggles in community club rugby. Majority of the community rugby clubs within the Western Province struggle financially thus making it difficult to appoint medical staff with a higher qualification, and rather choosing an entry first aider with a level 1 qualification. Consequently, these financial difficulties which prevent these community club players to access private General Practitioners and private hospitals when sustaining a concussion. Limitations also include the sample size of the medical staff, as well as the variance in the type of medical staff, which should be specified in future studies.

Conclusion

In conclusion, coaches were most frequently identified as having a major role to play in post-concussion RTP. Yet, results regarding the implementation of RTP concluded that coaches and administrative staff demonstrated relatively low perceived ability to assist others on when it was safe to RTP. Coaches were also identified by the majority of the participants to be responsible for monitoring matches and training sessions for concussion, as well as having knowledge of post-concussion RTP guidelines. However, of great concern is that only two thirds of the coaches and a third of the administrative staff indicated implementing the 6-stage RTP protocol, the recommended protocol by BokSmartTM and World Rugby. Furthermore, the correct 6-stage protocol was identified by less than half of medical staff and 37% of the coaches, which indicates a low level of correct implementation. Although 92% of the coaches and 93% of the administrative staff had participated in BokSmart within the last 5 years, the participants demonstrated inadequate knowledge to implement RTP protocols. Future research should focus on assessing the practical application of RTP guidelines by the stakeholders.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Wilbur Kraak

Supplemental material

Supplemental material for this article is available online.

References

Fuller

Ashton

Brooks

, et al. Injury risks associated with tackling in rugby union. Br J Sports Med 2010; 44: 159–167.

Gardner

Iverson

Williams

, et al. A systematic review and meta-analysis of concussion in rugby union. Sports Med 2014; 44: 1717–1731.

Fraas

Burchiel

A systematic review of education programmes to prevent concussion in rugby union. Eur J Sport Sci 2016; 16: 1212–1218.

Kaux

Julia

Delvaux

, et al. Epidemiological review of injuries in rugby union. Sports 2015; 3: 21–29.

Roberts

Trewartha

England

, et al. Concussions and head injuries in English community rugby union match play. Am J Sports Med 2017; 45: 480–487.

Wallace

Covassin

Lafevor

Use of the stepwise progression return-to-play protocol following concussion among practicing athletic trainers. J Sport Health Sci 2018; 7: 204–209.

Sye

Sullivan

McCrory

High school rugby players’ understanding of concussion and return to play guidelines. Br J Sports Med 2006; 40: 1003–1004.

Castile

Collins

McIlvain

, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005–2010. Br J Sports Med 2012; 46: 603–610.

Zuckerman

Kerr

Yengo-Kahn

, et al. Epidemiology of sports-related concussion in NCAA athletes from 2009-2010 to 2013-2014: incidence, recurrence, and mechanisms. Am J Sports Med 2015; 43: 2654–2662.

10.

Carson

Lawrence

Kraft

, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician 2014; 60: 310–315.

11.

Hollis

Stevenson

McIntosh

, et al. Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players. Br J Sports Med 2012; 46: 735–740.

12.

Clacy

Sharman

Goode

, et al. Responsibilities in the prevention of concussion in community rugby union. Procedia Manuf 2015; 3: 1173–1180.

13.

Finch

Donaldson

A sports setting matrix for understanding the implementation context for community sport. Br J Sports Med 2010; 44: 973–978.

14.

White

Newton

Makdissi

, et al. Knowledge about sports-related concussion: is the message getting through to coaches and trainers? Br J Sports Med 2014; 48: 119–124.

15.

Sabini

Nutini

Return-to-play guidelines in concussion: revisiting the literature. Phys Sports Med 2014; 42: 10–19.

16.

Leddy

Willer

Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep 2013; 12: 370–376.

17.

Leddy

Wilber

Willer

BS.

Active recovery from concussion. Curr Opin Neurol 2018; 31: 681–686.

18.

Leddy

Baker

Kozlowski

, et al. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med 2011; 21: 89–94.

19.

Brown

Abrahams

Burger

, et al. 2015. Return-to-play after concussion, a pragmatic approach. Available at:https://www.springboks.rugby/media/04zbkmfn/rtp-a-pragmatic-approach.pdf (accessed 12 August 2019).

20.

Chrisman

Quitiquit

Rivara

FP.

Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013; 52: 330–335.

21.

Walker

SP.

Concussion knowledge and return-to-play attitudes among sub elite rugby union players. S Afr J Sports Med 2016; 27: 50–54.

22.

Brown

Verhagen

Van Mechelen

, et al. Coaches’ and referees’ perceptions of the BokSmart injury prevention programme. Int J Sports Sci Coach 2016; 11: 637–647.

23.

Viljoen

Schoeman

Brandt

, et al. Concussion knowledge and attitudes among amateur South African rugby players. S Afr J Sports Med 2017; 29: 1–6.

24.

Griffin

Ranson

Moore

, et al. Concussion knowledge and experience among Welsh amateur rugby union coaches and referees. Br Med J Open Sport Exerc Med 2017; 3: 174.

25.

Mathema

Evans

Moore

, et al. Concussed or not? An assessment of concussion experience and knowledge within elite and semi-professional rugby union. Clin J Sport Med 2016; 26: 320–325.

26.

Pabian

Oliveira

Tucker

, et al. Interprofessional management of concussion in sport. Phys Ther Sport 2017; 23: 123–132.

27.

Salmon

Mcgowan

Sullivan

, et al. What they know and who they are telling: concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players. J Sports Sci 2020; 38: 1585–1594.

28.

Patricios

Ardern

Hislop

, et al. Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations. Br J Sports Med 2018; 52: 635–641.

29.

Clacy

Goode

Sharman

, et al. A knock to the system: a new sociotechnical systems approach to sport-related concussion. J Sports Sci 2017; 35: 2232–2239.

30.

Clacy

Goode

Sharman

, et al. A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union. Appl Ergon 2019; 80: 256–264.

31.

van Vuuren

Welman

Kraak

Concussion knowledge and attitudes amongst community club rugby stakeholders. Int J Sport Sci Coach 2020; 15: 297–305.

32.

Salmon

Romanchuk

Sullivan

, et al. Concussion knowledge, attitude and reporting intention in rugby coaches and high school rugby players. Int J Sport Sci Coach 2021; 16: 54–69.