Discussion

This study, the first to assess concussion knowledge in community sport in Australia, involved two popular sports with a considerable risk of concussive injury.3 The results demonstrated that surveyed AF and RL C+STs had relatively good general knowledge about concussion, which is consistent with findings from other sporting contexts.10 ,12 There was no difference across the two football codes, but STs displayed a small but significantly better knowledge than coaches, particularly in RL. The differences between C+STs is not surprising given that the STs’ major role is to recognise and manage sports injuries, while the coaches’ main role is to govern play and training activities.17 It could also possibly be explained by better education of coaches in AF, compared to RL.

For all other survey components, there were no differences between team roles, possibly reflecting the existing high level of coach education in the two football codes studied. Approximately one–quarter of both C+STs failed to recognise the increased risk of another concussion following an initial concussion. This is consistent with findings in Italian soccer coaches,8 but inconsistent with a study of Canadian minor hockey coaches.11 This suggests that further efforts are needed to properly educate C+STs about concussion risk and the rationale for strict return-to-play protocols.

Concussion usually results in functional disturbances rather than structural injury to the brain so standard structural neuroimaging typically does not detect postconcussion brain abnormalities.7 However, a significant proportion of C+STs incorrectly believed that postconcussion brain scans show damage to the brain, consistent with a previous study of Canadian minor hockey coaches.11 Further, more than a third of respondents believed or were uncertain about whether being knocked unconscious always causes permanent damage to the brain, consistent with other New Zealand studies.18 ,19 Combined, these results suggest that C+STs have misconceptions about the impact that concussion has on the structure of the brain. Such beliefs might detract from the importance that C+STs place on proper concussion management, especially if they believe that ‘the damage is already done’. It will be important to strengthen messages that all concussed players should undergo adequate recovery.

A relatively small proportion of both C+STs correctly recognised that younger players typically take longer to recover from concussion than adults, with most indicating that they were uncertain about this. This knowledge gap may reflect limited involvement with younger players. Moreover, at the time of this study, the AFL and NRL guidelines referred to the management of adults. As now recognised in the 2012 International Consensus Statement on Concussion in Sport, the management of children requires specific guidelines, and understanding the differences between adult and childhood concussion management is paramount for messages aimed at the community level.2

There was also uncertainty and misconception about the long-term impact of concussion on player health and well-being. A lack of understanding of potential long-term complications of concussion may lead to inadequate management and premature return to play. It is critical that C+STs receive adequate and up-to-date education regarding the potential impact of concussion on a player's long-term health and emotional well-being.

One of the most common misconceptions held by respondents, particularly coaches, was that wearing headgear can prevent concussion. This misconception is frequently reported4 ,11 despite there being no substantial evidence that headgear will prevent or reduce concussion.7 ,20 This misconception should be redressed as a priority since well-intentioned efforts by C+STs could misdirect community club resources for very little gain. Moreover, C+STs need to have a clearer understanding of this issue to present a confident, informed response to pressure from parents or other members of the community, to mandate helmet use.

Finally, there is a misconception among the majority of coaches and a significant proportion of STs that players can return to normal training once they are symptom free. Although remaining symptom free is a crucial component of the AFL and NRL return-to-play guidelines, the guidelines also stipulate that players should return-to-play gradually, using a stepwise approach. As coaches have a major role in ensuring this, their lack of understanding about this key tenet is concerning.

On a positive note, the once common misconception9 that a concussion can only occur with a loss of consciousness appears to have been dispelled. This finding is supported by recent studies involving other sports.8 ,11

Coaches and sports trainers generally had a good knowledge of concussion signs and symptoms, in contrast to Italian soccer coaches.8 A large majority identified the cognitive signs and symptoms such as memory loss and confusion, and were aware of most of the physical symptoms such as blurred vision and headache. However, fewer identified low energy and sensitivity to noise as physical symptoms of concussion. Consistent with another study of coaches,9 ‘trouble falling asleep’ was the most under-recognised, which is not surprising given that it is not an acute symptom of concussion. Fewer respondents identified the emotional signs and symptoms of concussion, compared to the other symptom groups perhaps reflecting the more subtle and ambiguous nature, less frequent reporting, delayed onset and the high prevalence of these symptoms in the general community. It would seem sensible to educate C+STs on recognising the emotional signs and symptoms of concussion, particularly since players may not voluntarily report such symptoms themselves.

The AFL and NRL concussion guidelines clearly stated that any player who has suffered a concussion should not be allowed to return-to-play in the same game. The guidelines also warn against being swayed by the opinion of the player, trainers, coaching staff or others suggesting premature return-to-play. Nearly one-fifth of all respondents indicated that it would be appropriate for a player to return-to-play on the day they suffer a concussion if they no longer show any signs or symptoms of concussion. It seems that the ‘no return-to-play on same day’ message has not yet fully reached the target audience. Importantly, the majority of C+STs indicated that they thought that it would be appropriate for a player to return-to-play on the same day they suffer a concussion if the doctor says they are ready to play. This finding highlights the important role GPs and club doctors play in the management of concussion and the influence they can have over return-to-play decisions. Importantly, it also emphasises why general practitioners (GPs) need to be educated about ‘best practice’ concussion management.

According to the AFL and NRL concussion guidelines, all players with concussion or a suspected concussion need an urgent medical assessment (with a registered medical doctor). More than a third of respondents failed to recognise that a player who has a suspected concussion should be referred to a medical doctor ‘as soon as possible, regardless of symptoms’. Approximately one-fifth suggested that players with a concussion should be referred to a medical doctor if they lost consciousness, even if only for a moment, and 10% indicated that players should be referred to a doctor if their symptoms have not improved within an hour. This highlights the need to renew efforts to reinforce the message that all players with a concussion should be assessed by a medical doctor.

Finally, while the majority of C+ST correctly identified that the most important factor during a player's rehabilitation following a concussion is that they remain symptom free, a quarter of respondents indicated that avoiding contact training drills until the very end of their rehabilitation was the most important factor. While this response reflects some understanding of the gradual, stepwise approach to return-to-play recommended in the AFL and NRL concussion guidelines, it suggests that they do not understand the underlying purpose of the stepwise approach. It would be valuable to clarify to C+STs that it is recommended that players return-to-play gradually and that contact drills are postponed until the end to ensure that players remain symptom free throughout their recovery and to make it easier to return them to a non-symptomatic state if their symptoms were to recur.

There are some limitations associated with this study. Invitation to participate in the survey was distributed widely but it is not known how representative of all target group members the final set of survey responses are. The large sample size however helps to minimise potential responder bias. On the other hand, the statistical significance of some of the apparently small differences between C+STs was quite substantial and this probably reflects the relative large sample size.

As a self-report survey, the views expressed by the respondents could not be validated. The survey did not collect information about prior awareness or use of sport-specific guidelines. As such, it was not possible to determine whether these guidelines have been useful in potentially increasing knowledge about how to recognise/manage concussion.

In summary, this paper describes the current concussion knowledge of AF and RL C+STs in relation to messages contained in the previously disseminated concussion management guidelines by the two sports governing bodies. The identified gaps in knowledge and misconceptions should be addressed to enable C+STs to manage players with a concussion more appropriately.