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.

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.

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.

Sport concussion assessment in New Zealand high school rugby players: a collaborative approach to the challenges faced in primary care.

PRIMARY OBJECTIVE: To describe the collaborative development of a New Zealand Rugby Concussion Assessment (NZRCA) for primary care and to provide normative baseline data from a representative group of high school rugby players. METHODS: This study, conducted over the 2018 and 2019 community rugby season where players were baseline tested during the pre- or start of season period. RESULTS: Data were collected from 1428 players (males n = 1121, females n = 307) with a mean age of 15.9 ± 1.4 years. The mean ± SD symptom severity score was 11.3 ± 8.6, the mean number of endorsed symptoms was 8.5 ± 5.3 and the percentage feeling "normal" was 80.2 ± 15.3%. Only 5.3% of players reported no symptoms at baseline. The most common reported were: 'distracted easily' (72.5%), 'forgetful' (68.5%), and 'often tired' (62.6%). None of the participants achieved a perfect score for the SAC50. The majority of participants (89.7%) passed the tandem gait test with a time of 12.2 ± 1.7 seconds. Age, gender, and ethnicity were associated with NZRCA performance; albeit weakly. CONCLUSION: This study provides normative reference values for high-school rugby players. These data will aid healthcare providers in their identification of suspected concussion in the absence of individualized baselines.

Baseline concussion assessment performance of community-based senior rugby players: a cross-sectional study.

OBJECTIVE: To report pre-season baseline concussion assessment performance among senior rugby players and explore associations between assessment performance and player demographics. DESIGN: A cross-sectional study using the New Zealand Rugby Concussion Assessments (NZRCA), comprising symptom, cognitive and dynamic coordination assessments was conducted in the 2018-2019 season. METHODS: Players' baseline assessments were characterised using descriptive statistics; effect sizes (ES) and t-tests were used to explore associations between player demographic characteristics and NZRCA performance. RESULTS: A total of 733 players (11.4% female) aged between 16 and 52 years completed the NZRCA. The median (range) value for symptom severity, endorsed symptoms and "percentage normal" was respectively, 5 (0-40), 5 (0-21) and 90% (30-100%). A perfect standardised assessment of concussion score was achieved by one participant; seven achieved ≥27/30 for immediate recall, and 22 achieved a perfect delayed recall score. Most participants (n = 674, 92%) passed the tandem gait test. Associations between NZRCA performance and gender, concussion history, and Pasifika ethnicity were observed with effect sizes ranging from small (0.18) to large (0.70). Six hundred and twenty-three (85%) participants reported at least one symptom. CONCLUSIONS: The results from this study could help support decision-making by clinicians, improving the management of concussions in the community setting.

Square peg round hole - Time to customise a concussion assessment tools for primary care: The New Zealand experience? A call for a GP-SCAT.

In rugby union concussions are a player welfare concern, particularly in the community game where there is often minimal sideline medical support. New Zealand Rugby (NZR) has three primary goals around the management of concussions in the community game: (1) players with a suspected concussion are removed from the game or training; (2) players are referred into primary care for a diagnosis by a general practitioner(GPs) (doctor in primary care); (3) prior to returning to contact training that they are medically cleared by a doctor. Given their role in the diagnosis and medical clearance of players with a concussion, GPs are a key stakeholder in the concussion management pathway. Thus to ensure that players are safely returning to play, NZR acknowledged the need to better support and engage with GPs. This editorial is an opportunity for NZR to share our experience working collaboratively with GPs in New Zealand to support the diagnosis and medical clearance of players following a rugby-related concussion.

What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players.

The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby's (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR's guidelines. Maori and Pasifika players were less likely to be aware of the guidelines compared to NZ European, Adjusted OR 0.5, p = 0.03. Guideline awareness was significantly higher for those from high decile schools when compared to low (Unadjusted OR 1.63, p = 0.04); however, when ethnicity and school locations were controlled for this became non-significant (Adjusted OR= 1.3, p=0.37). The coach was the key individual for the provision of concussion information and disclosure of symptoms for players. The findings of this study will inform the development and delivery of NZR's community concussion initiative and how these examined factors influence a high school player's concussion knowledge and reporting behaviour.

Can Neck Strength be Measured Using a Single Maximal Contraction in a Simulated Contact Position?

Salmon, DM, Handcock, PJ, Sullivan, SJ, Rehrer, NJ, and Niven, BE. Can neck strength be measured using a single maximal contraction in a simulated contact position? J Strength Cond Res 32(8): 2166-2173, 2018-Neck strengthening has been postulated to potentially reduce the incidence and severity of concussions and neck injuries in collision-based sports. A quick and reliable method to assess neck strength would permit identification of those at risk and tracking of progress after injury. The purpose of this study was to determine if neck strength could be reliably assessed in a simulated contact posture using a single maximal contraction. During a single session, 30 healthy male university students performed 3 maximal voluntary contractions of the neck musculature in each of the following directions: extension (Ext), flexion (Flx), left lateral flexion (LtFlx), and right lateral flexion (RtFlx). To evaluate the reliability of these measures, intraclass correlation coefficients (ICCs) were calculated. The findings revealed a significant effect for direction (p < 0.01), where Ext (234.8 N) tested stronger than Flx (141.0 N), LtFlx (134.5 N), and RtFlx (123.0 N). In addition, Flx tested stronger than RtFlx (p = 0.03). No other differences were observed between LtFlx and RtFlx. When the combined mean values of the trials (1: 151.6 N, 2: 160.0 N, 3: 163.5 N) and the interaction contrast were compared, these were not significant (p = 0.08-1.0), indicating no changes in peak force occurred over the 3 trials. The ICC values for Ext, RtFlx, and LtFlx were all "excellent" (0.91-0.94), whereas Flx demonstrated "good" reliability (0.86). In a simulated contact posture, a reliable measure of peak force was obtained using a single maximal contraction. This may have practical applications for the quick and reliable assessment of contact sport athletes in a position that has functional relevance to their sports.

Neck strength and self-reported neck dysfunction: what is the impact of a season of Rugby Union?

BACKGROUND: Neck strength has been reported to reduce the incidence of concussions and neck injuries. However, little is known about how neck strength changes over a playing season. The aim of this study was to understand the impact a 20-week rugby season has on neck strength, neck pain (NP) and neck stiffness (NS) in a cohort of rugby players, relative to a non-contact control group. METHODS: This prospective cohort study employed a fixed-frame dynamometer to measure neck strength in a simulated contact posture in rugby players (N.=32) and controls (N.=15). During each assessment, participants performed a single maximal voluntary contraction in extension, flexion, left (LtFlx) and right lateral flexion (RtFlx). To quantify neck dysfunction, "current," "average," and "worst" NP and NS were measured using visual analogue scales. RESULTS: Post-season improvements (35.3-59.1 N) in neck strength were observed for the forwards for all measured directions (P<0.01), and were significant when compared to controls. For the backs, improvements were seen in extension, flexion and LtFlx (P=0.01-0.05), with only extension (29.8 N) and flexion (35.14 N) remaining significant when contrasted against the controls. The controls' neck strength remained unchanged over the season. Despite improvements in peak force, NP increased (all three measures) for the forwards (P=0.01-0.04), while only current (P=0.03) and worst NP (P=0.04) increased for the backs. Unexpectedly, NS remained unchanged for the forwards, while backs reported increases for all three measures (P=0.01-0.02). CONCLUSIONS: A season of rugby resulted in neck strength adaptations in the rugby players. Despite these improvements, increased levels of NP and NS were reported.

Reliability of repeated isometric neck strength and endurance testing in a simulated contact posture.

The purpose of this study was to examine the reliability of repeated isometric measurements of neck strength and endurance in a simulated rugby contact posture. Data were collected from healthy active university students (n = 20) over 3 sessions. Each session consisted of a single maximal voluntary contraction (MVC) and endurance trial for extension and flexion. The endurance trials were analyzed to determine the area under the force curve (%AUC) and the time to fatigue (TTF). Reliability was calculated using the SEM and minimal detectable change (MDC). The results revealed that the MVC values for extension were nonsignificant for session (p = 0.21), whereas some session differences were seen for flexion (p = 0.01), where session 1, 115.3 N was less than session 3, 126.4 N (p = 0.03). For %AUC, flexion values (%AUC 86.0) were greater than extension (%AUC 59.4) (p = 0.02). A similar effect was observed for TTF with flexion (125.0 seconds) having significantly greater TTF than extension (86.1 seconds). For peak force, the greatest SEM and MDC were achieved for extension (15.3 and 42.3 N), while flexion produced lower values (11.3 and 31.2 N). In contrast, for the endurance trials, SEM and MDC were greater in flexion than in extension. The findings from this study indicate that the neck musculature can be reliably assessed in a simulated contact posture. For peak force, extension provided more consistent measures across time as there seems to be a learning effect for flexion. Additionally, the SEM and MDC scores provide a useful tool for future assessment of neck strength and endurance.

Exercise therapy for improved neck muscle function in helicopter aircrew.

INTRODUCTION: To address the high prevalence of neck dysfunction in helicopter aircrew, a 12-wk training program was designed to examine the effects on neck muscular strength and endurance. METHODS: Subjects were recruited from Canadian Forces (CF) helicopter aircrew and randomized into either a neck coordination training program (CTP; N = 10), an endurance training program (ETP; N = 11), or a nontreatment control (CON; N = 8). Baseline assessments determined maximal voluntary contraction (MVC) strength and endurance capacity using a submaximal contraction to fatigue at 70% of their MVC for extension, flexion, and left (Ltflx) and right (Rtflx) lateral flexion. The ETP subjects performed dynamic contractions at 30% of their MVC in the four testing directions using a head harness and Thera-band tubing. The CTP consisted of exercises that focused on strengthening the deep cervical musculature using the mass of the head as resistance and progressing to exercises that incorporated the superficial cervical muscles. RESULTS: Post-intervention, the ETP achieved the only statistically significant increase in maximal force when compared to the CON (14.4%). Improved times to fatigue were achieved by the CTP for flexion (26.34 +/- 20.72 s), Ltflx (23.54 +/- 13.94 s), and Rtflx (28.72 +/- 4.88 s). CONCLUSION: The provision of an ETP and CTP resulted in a positive trend toward improved maximal force and muscular endurance. The greatest improvements in endurance and strength were found for those subjects assigned to the CTP treatment. Our research demonstrates the importance of including a designed and supervised training program into the daily routine of helicopter aviators.

Neck pain in military helicopter aircrew and the role of exercise therapy.

Neck pain is a growing aeromedical concern for military forces on an international scale. Neck pain prevalence in the global military helicopter community has been reported in the range of 56.6-84.5%. Despite this high prevalence, historically, research examining helicopter aircrews has focused predominantly on low back pain. A number of recent studies have emerged examining flight-related factors that are hypothesized to contribute to the development of flight-related neck pain. Loading factors such as the posture adopted during flight, use of night vision goggles, and vibration have all been found to contribute to neck pain and muscular fatigue. Prolonged or repeated exposureto these loading factors has been hypothesized to perpetuate or contribute to the development of neck pain. Despite the high number of helicopter aircrew personnel that suffer from neck pain, very few individuals seek treatment for the disorder. The focus of medical personnel should, therefore, be directed toward a solution that addresses not only the issue of muscular fatigue, but the hesitancy to seek treatment. Previous research in military and civilian populations have used exercise therapy as a treatment modality for neck pain and have found improved endurance capacity in the neck musculature and reduced self-reported neck pain.