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Language: English

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Concussion Reporting and Return to Play over Two Years for an Amateur Women’s Rugby Union Team in New Zealand

Doug King^{1, 2, 3, 4*},  Patria A Hume^{1, 4, 5}, Trevor N Clark^{1, 6}, Karen Hind^{1, 7}, Natalie Hardaker¹ 

¹Faculty of Health and Environment Science, Sport Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Auckland, New Zealand
²School of Science and Technology, University of New England, Armidale, NSW, Australia
³School of Sport, Exercise and Nutrition, Massey University, New Zealand
⁴Traumatic Brain injury Network (TBIN), Auckland University of Technology, Auckland, New Zealand
⁵Faculty of Health and Environment Science, National Institute of Stroke and Applied Neuroscience (NISAN), Auckland University of Technology, Auckland, New Zealand
⁶International College of Management Sydney, Manly, New South Wales, Australia
⁷Department of Sport and Exercise Sciences, Durham University. United Kingdom

Received Date: October 09, 2020; Accepted Date: October 16, 2020; Published Date: October 26, 2020

^*Corresponding author: Doug King, Emergency Department, Hutt Valley District Health Board, Private Bag 31-907, Lower Hutt, New Zealand. Email: dking30@une.edu.au

Citation: King D, Hume PA, Clark TN, Hind K, Hardaker N (2020) Concussion Reporting and Return to Play over Two Years for an Amateur Women’s Rugby Union Team in New Zealand. Adv Ortho and Sprts Med: AOASM-134.

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Abstract
Objective: To quantify injury reporting and return to play in an amateur women’s rugby union teams in New Zealand.

Methods: A two-year (2019-2020) retrospective study was undertaken using an online medical history questionnaire for two amateur women’s domestic rugby union, club-based teams (n=79). The number of concussions reported, concussions medically diagnosed, memory loss, prolonged symptoms (>10 days), returned in the same game and number of concussions reported to the coach in amateur women’s rugby union teams in New Zealand were all quantified by player positional group.

Results: The combined total of 83 prior concussions for the two seasons resulted in 2.1 ±1.2 prior concussions per person (i.e. ~1 concussion per year).Only two-thirds of previous concussions (68.7%) were reported to team management. A quarter of concussed players reported prolonged (>10 days) symptoms and 7.2% returned to the same game after the concussive event. Within the cohort 16% of previous concussions were reportedly not medically assessed and 32% of the players with a medically diagnosed concussion did not report the concussion to the coach.

Discussion: Players are still returning to the game even though medically diagnosed as having sustained a concussion. There were more concussions sustained by forwards than backs player positions. The player-coach relationship seems to be an important contributing factor for both injury reporting and for providing supportive communication in encouraging safety behaviors.

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Introduction
      Rugby union (hereafter referred to as rugby) is a full contact collision sport played in over 200 countries with over 8.5 million registered players worldwide [1]. Played over two 30 to 40 minute halves interspersed with a 10-minute rest interval, [2] rugby matches are characterized with frequent bouts of both high-intensity (e.g. running, tackling, rucks, mauls, passing and sprinting) and low intensity (e.g. jogging and walking) intermittent activities [2]. Rugby is a physical contact sport and players are exposed to repetitive collisions. While this is an integral part of the game [3], in means there is an inherent higher risk of injury [4].

      Over recent years, rugby has increased in popularity with over 2 million women participating under the same rules as their male counterparts at both community and elite level [5]. Although females participate in match activities under the same rules as males, females reportedly have lower physiological indices (e.g. reduced speed and less agility, lower muscular power, lower estimated maximal aerobic power) when compared with males [6]. Differences in injury profiles are evident across sports including; basketball [7], football [8], handball [9], rugby league [10] and also in individual sports track & field, cross country & road running [11, 12].

      Concussions (also known as mild traumatic brain injuries) are a frequent occurrence in rugby [13]. A growing body of evidence [14-16] has consistently shown that female athletes experience greater symptom severity and take longer to recover from concussions than male athletes. Studies reporting on concussion injuries in male rugby union identified that the incidence was relatively low varying from 0.2 [17] to 4.3[18] per 1,000 playing hours, and 3.8 [19] to 5.7 [20] per 1,000 athlete exposures. However, more recently concussion has been identified to be the most commonly reported injury in professional male rugby union in England [21]. Concussions are associated with cognitive, behavioral and physical impairment of affected players [22]. Best practice management of concussion is the shared responsibility of the management team and the players themselves [23]. For players who continue to play with a concussion, or return to play prematurely, there is an increased risk of sustaining a more severe brain injury. Delayed concussion reporting and diagnosis is associated with a prolonged recovery time [24]. Additionally, it has been identified that sustaining a concussion increases the risk of non-concussive injuries, [25] while those with repeated concussive injuries have been linked with an increased risk of depression,[26] mild cognitive impairment [27] and neurodegenerative disease [28] in later life. However, there is a paucity of research in the longitudinal effects of concussion in women.

      There are differences in the way that male and female athletes experience sports related concussion. Some studies [11, 29, 30] have shown that in sex comparable sports female athletes have a higher incidence of concussion; particularly during matches/game play [30, 31]. The highest volume of data reflecting this pattern is in soccer and ice hockey [30]. However, a systematic review and meta-analysis [32] specifically investigating rugby union (rugby-15s) revealed a higher overall incidence of concussion in the men's game; 4.7 per 1,000 player match hours during match-play and 0.1 per 1,000 practice hours during training. The incidence of concussion in women's rugby-15s was 0.6 per 1,000 player match hours. Training incidence for females was not reported in the study. The conflicting results observed across different studies may be sport specific or may be a reflection of the different level of medical support available between the men’s and women’s game in rugby. Better medical support allows improved identification and reporting of concussion.

      It has been suggested that female athletes report a higher incidence of sport related concussion due to (1) weaker neck muscles resulting in less protection against a potentially concussive blow; [29] (2) smaller axonal diameter in female brains making them more susceptible to damage during injury;[33] and(3) female athletes are more honest and more likely to report their concussion [31]. A greater understanding of the true incidence of concussion in female sport and the underlying mechanisms is needed to inform effective sex specific preventative interventions and rehabilitation protocols.

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Aim: This study aimed to quantify concussion reporting and return to play in amateur women’s rugby union teams in New Zealand.

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Methods
Participants and Ethical Approval

      A two-year (2019-2020) retrospective study was undertaken. The participant sample was derived from two New Zealand amateur women’s domestic rugby union, club-based teams (n=79; 26.1 ±7.2 yr.; 1.65 ±0.75 m; 87.3 ±15.8 kg) (see Table 1). Prior to the start of the competition season, all players provided written informed consent to participate in the research and all procedures were approved by the institutional ethics committee.

Pre-Season Medical Questionnaire

      Players completed an online medical history questionnaire specifically developed for this study (www.surveygizmo.com). It was based upon a previously utilized questionnaire, [34] pertaining to player demographic data (age, player position, playing experience, height, weight and ethnicity), medical and injury history. Specific focus was placed on player concussion history over the last two seasons (e.g. number, medical assessment, symptom recall).  To aid recall of post-concussive events (e.g. post-concussion syndrome, depression etc.) a 22-item concussion symptom scale was provided for players to complete online.

Statistical Analysis

      All data collected were entered into a Microsoft Excel spread sheet and analysed with SPSS v22.0.0. The number of concussions reported, concussions medically diagnosed, memory loss, prolonged symptoms (>10 days), returned in the same game and concussions reported to the coach were quantified by player positional group. Independent t-tests were used to assess differences in baseline data. The reliability or internal consistency of the questionnaire was assessed by estimating Cronbach’s alpha (α) coefficient [35, 36]. An alpha coefficient for an internally consistent scale should be at least 0.70 [37]. Internal reliability of the questionnaire was confirmed by a Cronbach’s α of 0.79 [38].

A one-sample chi-squared (χ²) test was used to determine whether the observed reported concussion frequency was significantly different from the expected concussion frequency by competition year and for total concussions recorded. Players were divided into player roles (e.g. Forwards; Backs) and player positional groups (i.e. Front-Row Forwards [FRF], Back-Row Forwards [BRF], Inside Backs [ISB]; Outside Backs [OSB]). Risk ratios (RR’s) were used to compare concussion data across groups. The RR’s were assumed to be significant at p<0.05.

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Results
      Over the study, Forwards were significantly older (27.9 ±8.0 yr. vs. 23.2 ±4.7 yr.; t₍₄₂₎=2.8; p=0.0086) and heavier (92.8 ±16.2 kg vs. 79.2 ±10.9 kg; t_(4.5)=4.1; p<0.0001) than Backs (see Table 1).Over half of the players (50.6%) reported they had previous concussions in the last two seasons and the majority (84.3%) of concussions were reportedly medically assessed (see Table 2). Sixty eight percent (68.7%) of previous concussion were reported to team management, a quarter of players with a diagnosed concussion (26.5%) reported prolonged (>10 days) symptoms and 7.2% were reported to have returned the same game after the concussive event. There was a combined total of 83 prior concussions reported resulting in a mean of 2.1 ±1.2 prior concussions per-person. Backs had significantly more reported concussions medically assessed (RR: 1.8 [95% CI: 1.5-2.2]; p=0.0404) than Forwards in 2020.

      Back-Row Forward’s reported less previous concussions (38.1%) but they also reported fewer concussions medically assessed (77.8%) and reported fewer previous concussions to the coach (66.7%) than the other playing groups (see Table 3). When compared with the other player groups, Back-Row Forward’s reported significantly fewer previous concussions with memory loss than Front-Row Forward’s (RR: 3.4 [95% CI: 1.1 to 10.3] p=0.0438), Inside Back’s (RR: 4.8: [95% CI: 1.6 to 14.3; p=0.0069) and Outside Back’s (RR: 5.8 [95% CI: 2.0 to 17.1; p=0.0024). Outside Backs reported significantly more prior concussions (RR: 1.9 [95% CI: 0.1 to 3.2]; p=0.0138) and reportedly had significantly more medically assessed (RR: 2.2 [95% CI: 1.2 to 4.2]; p=0.0136) than Front-Row Forward’s in 2020.

Table 1: Player age, height, body mass and years playing experience for backs, forwards and total players for the 2019 and 2020 women’s rugby union competitions in New Zealand. Data reported by number of players and mean with standard deviation.Table 2: Number of concussions reported, concussions medically assessed, memory loss, prolonged symptoms, returned in the same game and concussions reported to the coach for an amateur women’s rugby union team in New Zealand by player role and total for the team. Data reported as number of players with concussions, number of concussions recalled, percentage of reported concussions and mean and standard deviation of concussions per player with concussion.Table 3: Number of concussions reported, concussions medically assessed, memory loss, prolonged symptoms, returned in the same game and concussions reported to the coach for an amateur women’s rugby union team in New Zealand by player positional group. Data reported as number of players with concussions, number of concussions recalled, percentage of reported concussions and mean and standard deviation of concussions per player with concussion.

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Discussion
      This retrospective study documented the reported number of concussions in a previous two-year period of amateur women rugby union players from two club-based teams in New Zealand. The principal findings of this study identified: (1) Over half (50.6%) of the player’s reported previous concussions in the previous two-years; (2) For those players that reported a previous concussion there was a mean of 2.1 concussions per-person; (3) The majority (84.3%) of reported concussions were medically diagnosed; (4) Two thirds (68.7%) were reported to team management; and (4) a quarter of players with a concussion (26.5%) reported prolonged (>10 days) symptoms.

       Just over half of the players reported a previous concussion; this may be an underestimate of the true incidence due to low player awareness of what a concussion is, pressure from teammates, significant others and team management to continue to play and the player’s own desire to remain in the game at the time of the injury [39-41]. A previous study [39] with a similar cohort has highlighted a lack of awareness among players; the majority (80.2%) of concussed players did not recognize that they had suffered a concussion.

      As previously identified, between 12% and 53% of players would not report their most recent concussion [42]. This could also be due to not wanting to miss game/training, let team down or lose place on team. Another reason for the non-reporting may be related to lack of knowledge to the risks and potential consequences of concussion or that the players do not think that the injury is serious enough to warrant medical attention [41]. The finding that 16% of previous concussions within this cohort were reportedly not medically diagnosed and 32% of the players with a concussion did not report this to the coach falls within this range. This may be related to being “in the zone” [43] when playing or if the players are uncertain if the signs and symptoms are due to concussion or other factors such as dehydration or illness [44].

      Another aspect that may also influence the decision to report a concussion can be an increase in external pressures on the player from peers, the coach and family members [40]. In terms of pressure from teammates and team management, this can be delivered directly or indirectly and may be explicit or implied in how they perceive the team environment, how they interact with the team management and to what extent they identify with the team [40]. The player-coach relationship is an important contributing factor for both injury reporting and in supportive communication in encouraging safety behaviors [40]. This also extends to implicit non-verbal messages such as playing on with an injury being seen as a valued team behavior [45].

      The concussion incidence of 2.1 prior concussions per-person over the previous two-year period is a concern in terms of long term player health and wellbeing and a shortened playing career. Retired professional players that reported a history of one or two concussions over their career were reported to be 1.5 times more likely to be diagnosed with common mental disorders (CMD) (i.e. symptoms of distress, anxiety and depression, sleep disturbance, or substance abuse/dependence). In addition, professional male players (football, ice hockey, rugby union) with three or more previous concussions were three times more likely to report CMD [46, 47]. For those players with a history of six or more sports-related concussions over their playing career, the risk of CMD was five-fold when compared with those players with no reported prior concussions [46, 47]. Two players in the current cohort did report a total of six concussions in the previous two-year period. Although the studies conducted on the risk of symptoms of CMD in conjunction with sport-related concussions have been undertaken in male professional sports-participants, there is support for women having an increased susceptibility to, and potential risk for, protracted recoveries from sports-related concussion [29]. There is a need for more female specific data to better understand the true incidence of concussion in female sport and the underlying mechanisms for a prolonged recovery and the potential for longitudinal symptoms of CMD.

      Knowledge of and attitudes towards concussions and their management has been reported to be sub-optimal in the rugby environment among coaches, referees, medical staff and more importantly in the players [48]. In 2001, New Zealand Rugby (NZR), in partnership with the Accident Compensation Corporation (ACC), launched Rugby Smart [49]. Rugby Smart is a nationwide compulsory rugby-specific injury prevention programme delivered annually to provide the delivery of injury prevention interventions to the NZR community [50]. A key aspect of Rugby Smart is the concussion management protocols that are included for coaches, players and medical staff.

      The NZR, as part of the National Concussion Initiative, developed a concussion management pathway (CMP) to assist with the identification, management and return-to-play (RTP) following concussive injury [51]. The CMP can be utilized by the team manager, physiotherapist or parent if the team has someone willing to accept this role. Female teams often have a lower level of support and access to a trained health professional or team supporter able to observe for and manage concussive injuries. However, in the absence of such support, the results of this study do highlight considerable opportunity for sporting bodies and sports clubs to provide education on the potential severity of the injury if left untreated and therefore the importance of learning how to recognize concussion and what to do.

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Conclusion
      There is a need to increase education for players and coaches in female rugby on how to recognize concussion and remove from play.  In parallel further female specific research is needed to understand the true incidence of concussion and the underlying mechanism for prolonged recoveries. Players are returning to the game early even though medically diagnosed as having sustained a concussion. Concussion injury reporting and return to play after concussion diagnosis needs to be improved for amateur women’s rugby union in New Zealand.

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