Yes, but why?

Alex Donaldson, Research Fellow,

Other Contributors:

November 04, 2011

Dear Editor

Re. Stephanie J Hollis, Mark R Stevenson, Andrew S McIntosh, et al. Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players. Br J Sports Med published online June 24, 2011. doi: 10.1136/bjsm.2011.085332.

We read with interest the findings of this investigation by Hollis et al.(1) The conclusion that there is a clear failure of translation and implementation of concussion return-to-play regulations within community rugby is well supported by the data presented in the study. The next obvious question is why?

In a recent survey of community rugby union coaches undertaken in the same Australian state as the research by Hollis et al, 23% of community coaches (14 of the 62 coaches who answered the question) reported that they were not aware of, or were unsure of their awareness of, the Australian Rugby Union (ARU) concussion guidelines. This is despite the fact that all rugby union coaches in Australia must be SmartRugby accredited and the SmartRugby training program includes written information with a clear statement that "a player who has suffered concussion shall not participate in any match or training session for a minimum period of three weeks from the time of injury, and may only do so when symptom free and declared fit after proper medical examination".(2)

Other results from this survey indicated that of the 44 coaches who were aware of the guidelines and responded to further questions, 59% did not think that the guidelines were very effective in preventing injuries (rating of 3 or less on a 5 point scale) and 25% either did not or were not sure if they had informed their players about the guidelines in the previous season. In addition, 23% of coaches reported that they had not adhered very well (rating of 3 or less on a 5 point scale) to the ARU concussion guidelines in the previous season and that 45% of the players they coached had not adhered very well to these guidelines.

There may be many reasons why there is poor compliance among community players with the ARU return-to-play regulations following concussion. Perhaps community level sports participants and coaches are influenced more by what they see and hear about concussion in professional sport in the media than they are by the policies and procedures promoted by sports' governing bodies.(3) Increasingly, policy translation and implementation is being considered both an art and a science(4) and perhaps the strategies used by the International Rugby Board (IRB) and the ARU to support translation and implementation of the return-to-play regulations were not well designed or planned. One suspects this is a contributing factor when the IRB concussion guidelines are 12 pages long, divided into two stages which contain three tables and three diagrams, the smallest of which contains 13 steps connected by 14 arrows.(5) Certainly, within an ecological framework of influences on behaviour of individuals,(6) our preliminary research suggests that one possible reason for lack of player compliance with the ARU return-to-play regulations is that the message has not reached all community level community rugby coaches (an acknowledged influence on participant behaviour),(7) and even those whom it has reached do not always believe in the effectiveness of the intervention nor do they adopt it with fidelity.


1. Hollis SJ, Stevenson MR, McIntosh AS, Shores EA, Finch CF. Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players. Br. J. Sports Med. 2011. Published Online First: 24 June 2011 doi:10.1136/bjsm.2011.085332.

2. Australian Rugby Union. ARU SmartRugby: Confidence in contact. A guide to the SmartRugby program, Not dated: page 36.

3. McLellan TL, McKinlay A. Does the way concussion is portrayed affect public awareness of appropriate concussion management: the case of rugby league. Br. J. Sports Med. 2011;45(12):993-96.

4. Finch CF. No longer lost in translation: The art and science of sports injury prevention implementation research. Br. J. Sports Med. 2011. Published Online First: 22 June 2011 doi:10.1136/bjsports-2011-090230

5. International Rugby Board. Putting players first: IRB Concussion Guidelines: International Rugby Board, 24 May 2011. Available from Accessed 11 September 2011

6. Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br. J. Sports Med. 2010;44(13):973-78.

7. Emery CA, Hagel B, Morrongiello BA. Injury prevention in child and adolescent sport: Whose responsibility is it? Clin. J. Sport Med. 2006;16(6):514-41.

Conflict of Interest:

None declared

Conflict of Interest

None declared