Patrick McGrann1, Louise Keating2
1RCSI physiotherapy student
2School of Physiotherapy, RCSI
Royal College of Surgeons in Ireland Student Medical Journal 2012;5: 33-38.
Background: There is currently much discussion in the sports medicine literature and mainstream media regarding diagnosing and managing concussion and the appropriate criteria to guide return-to-play decisions. In amateur sport, the chartered physiotherapist is often the primary healthcare professional present at sporting events. At present, there is no research to guide management of the concussed player by physiotherapists, which negatively impacts the consensus of concussion management.
Objective: To identify current knowledge and clinical practice patterns (assessment and management) regarding concussion in sport among Irish chartered physiotherapists.
Methods: Members of Chartered Physiotherapists in Sports and Exercise Medicine with active email addresses (n=370) were invited to participate in an online cross-sectional survey consisting of four sections: demographics; knowledge; assessment; and, management of concussion.
Results: A 26% (n=95) response rate was achieved. Of the participants, 35.8% (n=34) were aware of the current Concussion in Sport consensus statement. The mean score for knowledge about concussion was 61.6% (σ=11.1%) and mean score for management of concussion was 81.2% (σ=13.0%). There was no correlation between years of experience and knowledge scores (p=0.45) or management scores (p=0.86). Similarly, years of sports physiotherapy experience did not correlate with knowledge scores (p=0.91) or management scores (p=0.82).
Conclusion: Respondents have a high level of knowledge regarding the assessment and management of concussion. It is important that sporting bodies regularly update their guidelines and that chartered physiotherapists look for future Concussion in Sport consensus statements as research in concussion continues to evolve.
In recent years, concussion has become a focus of sports medicine literature and sporting organisations due to its adverse effect on brain function and the potential long-term complications of injury.1,2 Concussion is a complex pathophysiological process induced by traumatic biomechanical forces.3
The incidence of concussion in sports, especially collision sports, is well documented.4,5 The last decade has witnessed the production of a number of national and international consensus statements and guidelines.3,6 Since 2001, the Concussion in Sport (CIS) Group has led the way in creating an internationally recognised consensus statement for the assessment and management of sport-related concussion.3,6-8 Other sporting organisations have subscribed to the CIS consensus statements, or have made modifications to the recommendations to suit a particular sport.3,8-13 These modifications have led to a difference of opinion among organisations, clinicians and researchers.
The clinical implementation of any consensus statement is important. If an athlete is concussed, these guidelines determine if he/she needs to be removed from play to prevent further injury and provide the management protocol for a safe return to play.14 One study demonstrated that two-thirds of athletic trainers (ATs) (n=336) working in the USA were unfamiliar with the current CIS statement.15 The proposed reason for this was poor dissemination of the statement in AT educational programmes. It is clear that even with the recent focus on concussion in sport, the dissemination and implementation of current consensus statements is not reaching all relevant groups.
To date, there has been no study about the knowledge and management of the concussed athlete by physiotherapists. As such, the impact of consensus statements in this group of professionals is unknown. The aim of this study is to determine the extent of Irish chartered physiotherapists’ current knowledge and clinical practice patterns (assessment and management) regarding concussion in sport.
A cross-sectional survey, distributed online, was conducted using a self-administered original questionnaire.
Members of the Chartered Physiotherapists in Sports and Exercise Medicine (CPSEM), a clinical interest group of the Irish Society of Chartered Physiotherapists (ISCP), were surveyed, as they are involved in the frontline management of players.
An original questionnaire (see Appendix) was created, as an established tool could not be found in the published literature. Guidelines from international medical and sporting organisations were reviewed with the 2008 Consensus Statement on Concussion in Sport used as the gold standard.3 There were four sections in the survey: demographic information; knowledge of concussion; assessment of concussion; and, management of concussion.
In the knowledge section, scores were calculated and compared with each respondent’s years of experience. Identification of a correct answer (agree or strongly agree) scored one point and incorrect answers or ‘I don’t knows’ scored zero, yielding a potential maximum score of 19 and a minimum of zero. In the management section, five questions were used to assess management of concussion, giving a maximum score of 10 and a minimum of zero. Respondents were asked to rank a list of signs and symptoms of concussion from most common to least common (1=most common, 12=least common). Signs and symptoms not related to concussion were included in the list to identify respondents’ ability to distinguish unrelated signs and symptoms from those associated with concussion.
The survey was anonymous and the participants could not be identified at any stage of the process. During the study, all electronic data were stored securely, password-protected on the RCSI server and on a password-protected computer. After the project, all data were stored in a locked filing cabinet in the office of the project supervisor, Louise Keating, in the School of Physiotherapy, RCSI, and will be kept for five years. It will then be destroyed in compliance with Data Protection Guidelines.16
Ethical approval for this study was granted by the Research Ethics Committee of the Royal College of Surgeons in Ireland. Permission was granted by the chairperson of the CPSEM to access their membership database (2010/2011) through the CPSEM secretary. Once ethical approval was granted, an email was sent to each CPSEM member with an active email address (n=370). Consent was implied by completing the questionnaire. Participants were informed that data collected would remain anonymous. Two reminder emails were sent. All participants were offered a copy of the study results upon completion.
The data was analysed using Statistical Package for Social Science version 18.0 for Microsoft Windows. Descriptive statistics and Pearson’s test were used.
A response rate of 34% (n=124) was achieved over a four-week period. Of the 124 responses received, 95 respondents had completed all four sections, giving a valid response rate of 26%. Data from the 29 respondents with incomplete questionnaires were excluded.
Demographics of the respondents
More than twice as many females (67.6%; n=64) than males (32.6%, n=31) responded, and 61.2% (n=60) of respondents had at least three years of experience in sports physiotherapy (Table 1). Most respondents worked in more than one sport (n=90), with the greatest numbers in: Gaelic football (53.7%; n=51); rugby (33.7%; n=32); and, hurling/camogie (32.6%; n=31) (Table 2). During competitive sporting events, 47.7% (n=41) of respondents reported always being present field side.
Knowledge of concussions
Nine questions were used to assess respondents’ knowledge of concussion and clinical guidelines. Of the respondents, 55.8% (n=53) agreed that use of ‘simple’ and ‘complex’ terminology to describe concussion is correct. Another 51% (n= 48) answered that depression should not affect concussion management, while 22.1% (n=21) did not know the answer.
Of the respondents, 46.3% (n=44) were aware of the 2011 International Rugby Board (IRB) guidelines, while 37.9% (n=36) were aware of the 2007 Gaelic Athletics Association (GAA) guidelines and 35.8% (n=34) of the 2008 CIS statement. Respondents ranked dizziness/balance instability as the most common sign or symptom of concussion and stomach pain as the least common (Table 3). The mean score for the knowledge section was 11.7 out of 19 (σ=2.1).
Assessment of concussions
Orientation questions were the most widely used sideline tool for the assessment of concussion (82.1%; n=78). Only 15.8% (n=15) used the Standardised Assessment of Concussion (SAC). During play, 90.5% (n=86) of respondents reported not always having sufficient time for appropriate assessment.
Management of concussions
The mean score achieved on questions regarding the management of concussion was 8.1 out of 10 (σ=1.3). Physiotherapists led the implementation of treatment protocol for a concussed player in nine out of the 12 sporting categories.
The role of experience in the knowledge and management of concussion
No correlation was found between years of experience and knowledge scores (r= -0.078, p=0.45), and years of experience and management scores (r= -0.019, p=0.86). Similarly, no correlation was found between years of sports physiotherapy experience and knowledge scores (r= -0.012, p=0.91), and between years of sports physiotherapy experience and management scores (r= -0.024, p=0.82).
Of the Irish physiotherapists surveyed, 35.8% (n=34) of respondents knew of the current CIS consensus statement, compared with 33.6% (n=336) of ATs in the United States and 44.4% of medical officers in the English football league.3,10 Two sports that respondents worked in, Gaelic football and hurling/camogie, had constructed their guidelines directly from the 2006 CIS statement.8,11 Other sports, such as rugby and soccer, updated their guidelines directly from the current CIS statement.3,12 In this survey, respondents reported being more aware of other sporting body guidelines – 37.9% (n=36) for GAA guidelines and 46.3% (n=44) for IRB guidelines – than of the current CIS statement.11,12 This exemplifies the negative impact that a delay in the dissemination of guidelines by sporting bodies could have on the management of a concussed player in that sport.
The mean score for knowledge of concussion achieved by respondents was 11.7 (61.6%, σ=11.1%), and for management of concussion was 8.1 (81.2%, σ=13.0%). The high management score achieved by respondents could reflect the fact that the respondents were the primary lead in concussion treatment in nine out of 12 sports. The lower knowledge score may reflect the use of the current CIS statement to construct the survey.3 Changes and additions were made to the 2006 CIS statement in generating the current CIS statement, including: abandonment of the description of concussion as simple or complex; introduction of the Sports Concussion Assessment Tool 2 (SCAT 2) test; modifying factors for return-to-play management; and, consideration of special populations.3,8 The 2007 GAA guidelines, modified from the 2006 CIS statement, pre-dated the current CIS statement and do not include these elements.8 The correct answers for some of the questions – particularly whether it was appropriate to define a concussion as ‘simple’ or ‘complex’ (56.0% incorrectly responded) and whether depression was a modifying factor in management (51% incorrectly answered; 22.1% did not know the answer) – required knowledge of the current CIS statement.3 Therefore, incorrect answers from respondents may have simply been due to a lack of updated information. This finding has important implications, as the GAA Medical, Scientific and Welfare Committee will be updating its guidelines again this year, according to GAA senior physiotherapist R. Carolan (personal communication, August 2011).
Standard orientation questions were the most widely used tool by respondents to assess concussion in players (82.1%, n=78). However, according to the CIS statement, orientation questions have been shown to be unreliable in sporting situations compared with memory questions.3 The vast majority of respondents reported not always having sufficient time for appropriate assessment during play. In the future, sporting organisations may need to ensure that adequate time is provided for effective sideline examination.
It was originally hypothesised that knowledge and management scores would correlate with experience in physiotherapy and sports physiotherapy. However, no correlation between knowledge and experience was found, suggesting that CPSEM members are generally consistent in their knowledge and application of consensus-based clinical practice irrespective of experience.
The low response rate encountered in this study may be due to the timing of survey dissemination, which may have coincided with holidays or the changing of membership. It may also be that recipients not currently involved in ‘pitch-side’ physiotherapy may have thought that they were not meant to be included in the study group. Non-response bias is a methodological problem in cross-sectional surveys, which adversely affects the reliability and validity of results.17 This study limitation might have been overcome by a random survey of non-respondents.
A second study limitation was that the original questionnaire used has not been demonstrably validated. The survey might have been
improved by the addition of more questions to assess knowledge of concussion. In this study, the questionnaire was piloted by three chartered physiotherapists. No major issues were identified, but one respondent found the pitch-side management question to be difficult due to lack of field experience. In order to be used in future research, a more comprehensive questionnaire should be developed and verified as an accurate gauge of participants’ knowledge.
Physiotherapists work in a number of contact and non-contact sports. They often lead the treatment of concussion on the sidelines and are thus tasked with consistently providing best evidence-based practice for injured players.
This study found that there is little awareness of the current consensus statement within the physiotherapy community (35.8%, n=34), as more therapists are accessing sporting body guidelines rather than the CIS statement directly.3 No correlation was found between years of experience in physiotherapy or sports physiotherapy and knowledge or management of concussion, suggesting that a standard of care is maintained among chartered physiotherapists. A survey should be undertaken to identify the extent to which the dissemination of concussion guidelines occurs at the undergraduate level.
Results of this survey indicate that physiotherapists preferentially consult specific sporting body guidelines for the management of concussion rather than the CIS consensus statement. This puts an important responsibility on the regulating bodies to regularly disseminate changes to concussion guidelines.
- Glang A, Koester M, Beaver S, Clag J, McLaughlin K. Online training in sports concussion for youth sports coaches. Int J Sports Sci Coach. 2010;5(1):1-12.
- Putukian M, Aubry M, McCrory P. Return to play after sports concussion in elite and non-elite athletes. Br J Sports Med. 2009;43(Suppl. I):i28–i31.
- McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. 2009;43(Suppl. 1):i76-90.
- Lincoln A, Caswell S, Almquist J, Dunn R, Norris J, Hinton R. Trends in concussion incidence in high school sports; a prospective 11-year study. Am J Sports Med. 2011;39(5);958-63.
- Haseler C, Carmont M, England M. The epidemiology of injuries in English youth community rugby union. Br J Sports Med. 2010;44:1093-9.
- Alla S, Sullivan J, McCrory P, Hale L. Spreading the word on concussion: citation analysis of summary and agreement, position and consensus statements on sports concussion. Br J Sports Med. 2011;45:132-5.
- Aubry M, Cantu R, Dvorak J et al. Summary and agreement statement of the first international conference on concussion in sport, Vienna. Br J Sports Med. 2001;36:3-7.
- McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J et al. Summary and agreement statement of the 2nd international conference on concussion in sport, Prague. Br J Sports Med. 2006;39:196-204.
- American Academy of Neurology. Position Statement on Sports Concussion. 2010.
- Canadian Academy of Sports Medicine. ThinkFirst-SportSmart Concussion Education and Awareness Program. 2005.
- Gaelic Athletic Association. Position statement on Concussion in Gaelic Games. 2007.
- International Rugby Board. IRB Concussion Guidelines. 2011.
- National Collegiate Athletic Association. Concussion Management Plan. 2010.
- Sullivan S, Schneiders A, McCrory P, Gray A. Physiotherapists’ use of information in identifying a concussion: an extended Delphi approach. Br J Sports Med. 2007;42;175-7.
- Covassin T, Elbin R, Stiller-Ostrowski J. Current sport-related concussion teaching and clinical practices of sports medicine professionals. J Athl Train. 2009;44(4):400-4.
- Data Protection Act (2004) [Internet]. Accessed December 10, 2011. Available from: http://www.icta.mu/documents/laws/dpa.pdf.
- Knoll L, Felten M, Ackermann D, Kraus T. Non-response bias in a surveillance program for asbestos-related lung cancer. J Occup Health. 2011;53(1):16-22.