Name: symptoms of traumatic brain injury.[1] It is

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Name:Leah FalveyStudentNumber: 110302501ModuleCode: MX3007ModuleTitle: Physical Activity, Exercise, and Sports MedicineLecturer:Dr. Éanna FalveyWordCount:  2,025            Contents                                                                                                                     Page1.Introduction                                                                                                           32.Summary of main findings                                                                                  33.Critique3.1 General Considerations                                                                          43.

2 Population                                                                                                53.3 Data Collection                                                                                        53.4 Study Design                                                                                            63.5 Validity of Results                                                                                   75.Conclusions                                                                                                            76.References                                                                                                             9             1.

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Introduction The 5th ConsensusStatement on Concussion in Sport first defines sport related concussion broadlyas, “…representing the immediate and transient symptoms of traumatic braininjury.1 It is further defined as “…a traumatic brain injuryinduced by biomechanical forces.”1 Concussion results in animpairment of neurological function with a range of clinical symptoms that mayor may not include loss of consciousness.1Awareness of concussion has increased, however the nuances of the injuryare poorly understood.2 Estimates show that those affected byconcussion in the U.S.

range from 1.6 to 3.8 million annually.

2 Concussionis a very topical area that has garnered much media attention of late.34It is unsurprising as it is linked to chronic traumatic encephalopathy,neurodegenerative disease and long-term cognitive deficits.5 6 78Rugby is a high intensity sport that is linked to head injury, with concussion”…commonly reported during match play.

“9 It is imperative thatthose involved in the game; players, coaches, referees, and medical staff havea comprehensive knowledge of concussion injury so that concussion can beprevented, recognised and managed. Pitch side assessment isa “key component” in evaluating concussion injury.1 The Sport ConcussionAssessment Tool (SCAT-5) has been developed, informed by evidence basedresearch, for recognising concussion symptoms, assessing players, and forreturn to play guidelines.1 There has been research into player’sknowledge and attitudes as well as coaches, parents, and referees.101112Research has focused on knowledge of rugby coaches and referees in theprofessional game, rather than the amateur game.13 The aim of thiscritical review is to assess a study which measures concussion knowledge incoaches and referees involved in the amateur game in Welsh Rugby Union (WRU) .142. Summary of mainfindings Thiscross-sectional study gathered information from 333 coaches and 283 refereesinvolved in amateur WRU, in both youth and adult clubs.

Its main findings showthat there is a high standard of knowledge among coaches and referees withregards concussion symptom recognition. The mean score for concussion symptomrecognition was 18.6 out of 21 (95% CI 18.4 to 18.7). The mean score for returnto play guidelines and consequences of concussion knowledge were 11 out of 16(95% CI 11.5 to 11.

8) and 1 out of 6 (95% CI 0.9 to 1.1) respectively. Thereare clear discrepancies in knowledge regarding the prevention of concussion andthe return to play guidelines. Knowledge in these areas were considered poor.

Further,67% of participants held an incorrect belief that headgear protects againstconcussion. There were no significant differences of knowledge between the twogroups, coaches and referees.13 Theauthors outline that concussion management within the amateur game in Walesmust be improved upon and suggest a “multi-faceted educational intervention.”The article is clearly outlined and discussion and arguments in favour offurther education well-structured. The authors take a balanced approach,outlining the strengths and limitations of their study throughout. I will furtherdiscuss these strengths and limitations below.143.Critique 3.

1General ConsiderationsThis study has a clearaim in assessing knowledge and experience of concussion among WRU coaches andreferees involved in the amateur game. The authors outline clearly thenecessity for such a study by highlighting the “steadily increasing” incidenceof concussion within rugby over the last decade.14 There has beenevidence of under-reporting of concussion injury by athletes.1516Therefore the recognition by referees, coaches and medical staff is imperativeas “…diagnosis currently hinges on the subjective identification of theclinical signs and symptoms.”14 The authors outline thatonly two previous studies have looked at concussion knowledge in referees.1718Rule 23 of the World Rugby Union Laws state that if a player has a suspectedconcussion, the player “…must be immediately and permanently removed from theplaying area.”19 The referee may decide under rule 21 and 22 thatthe player is injured and must leave the field to be medically examined.

19As an impartial arbiter on the pitch, the referees’ knowledge andmanagement of concussion needs to be of a high standard. Assessing theknowledge of referees in this study will contribute significantly to the bodyof knowledge on concussion. The findings of thisstudy will help inform guidelines and education with regard concussion.

Further, highlighting of these issues and raising awareness of concussion willcontribute to the prevention, recognition, and management of head injury insport. Increasing the knowledge of key participants in sport will aid themedical profession in providing rapid recognition and management of symptoms.This article has contributed to my own knowledge of concussion. The article hasalso highlighted to me some key gaps in knowledge of coaches and referees whichwill be worth considering when participating in sports as well as when dealingwith those involved in sport in my future career.

I will now criticallyassess this paper in the four following areas; population, data collection,study design and validity of results.3.2PopulationInclusion and exclusioncriteria are not explicitly defined but the population is defined as all knownqualified rugby union coaches (n=1,843) and referees defined as ‘all eligibleparticipants’ (n=420). While it is likely that referees are registered with theWRU, ‘all eligible participants’ could be construed as ambiguous and a clearinclusion or exclusion criteria is preferable.

A possible issue with each populationis that in the amateur set-up, there may be some unregistered participantsinvolved. A way around this could be to contact clubs to get contact details ofall those involved in coaching and refereeing. The number of registered rugbyplayers in Wales is 83,120.20 The ratio of 45:1, players:coachesappears to be a reasonable size.A difficulty encounteredby the authors of this research was the response rate. A total of 621questionnaires were returned.

19% response rate from coaches (n=337) and 68%response rate from referees (n=284). The authors acknowledged that the poorresponse rate from coaches hindered the validity of the data. However it isworth noting that compared to similar studies, this is the largest sample sizeof rugby coaches surveyed with respect to concussion knowledge and experience.Previous studies have had samples of 12 and 267 coaches respectively.1318Future studies should aim to improve the sample size by introducing measures toimprove response rates.3.

3Data CollectionThe authors’ methods ofdata collection involved accessing emails from governing bodies, the WRUcoaching development department for coaches and the WRU’s National MatchOfficial’s Manager. Emails were sent out with a hyperlink to access thequestionnaire. Consent was required from all responders and those who did notconsent were not able to engage in the survey. There have been concerns aboutreduced response rate to email questionnaires.21 However as thepopulation becomes more ‘internet savvy’ studies suggest that it is the moreeffective mode of data collection compared to postal survey.22 Someconsiderations may be that not all people check their emails regularly, or manypeople will disregard an email based survey due to lack of time. To improveemail response the authors could consider offering an incentive for completion oroffer paper-based questionnaires delivered through club management. The authors categorisedthe questionnaire as confidential rather than anonymous.

This could be afurther reason for low response rates from coaches. While the authors statethat it was made clear that the responses were not traceable, it is possiblethat coaches are afraid that their responses could traceable back to themthrough personal postcode. There also is an issue of selection bias regarding responders.The responders to the survey may be those who are more likely to engage in safepractice and conscious of improving their education with regards to concussion.

 3.4Study DesignThis was a cross-sectionalstudy of rugby coaches and referees in the amateur welsh rugby union. Ethicalapproval was obtained from the Cardiff School of Sport’s research ethicscommittee.

Some of the benefits of a cross-sectional study include that it is easyto complete, cheap and fast. It can also measure multiple factorssimultaneously. For this topic, it is the appropriate means of gatheringinformation. Several other studies assessing concussion experience andknowledge have also used cross-sectional study design.1011121314Some limitations of this design is that it is susceptible non-response bias andthe sample size needs to be sufficiently large to determine prevalence. These limitationshave been outlined above.The self-reported natureof the study is one of its primary limitations. There may be selection bias interms of those who responded but also recall bias in terms of how the questionswere answered.

Recall bias may be evident regarding results on removing aplayer with suspected concussion from play. 93% of coaches reported they wouldremove a player with suspected concussion from play immediately as per guidelines.1However 40% of coaches reported witnessing another coach pressure a potentiallyconcussed player to stay on the pitch. 28% of coaches reported witnessingmedical staff being pressured into allowing a potentially concussed player stayon the pitch. It is also possible that the 81% of non-responding coaches couldbe less compliant with concussion measures and these non-responders may providean explanation for the discrepancy in results.The questionnaire wasbased on a paper-based survey and adapted for an email-based survey.

Thequestionnaire instrument was not validated. This was acknowledged, and a pilotstudy was conducted to test the instrument. Each questionnaire was adapted withspecific questions relevant to coaches and referees but questions on recognisingsymptoms of concussion, consequences of concussion, return to play guidelines,and headgear usage were identical. The questionnaire was included in the studyand a reference to the original questionnaire it was based on also provided.These factors help in ensuring the study is repeatable. 3.5Validity of resultsThe results were clearlyoutlined in the results section. A graph outlined the results of coaches versusreferees in recognising the true symptoms of concussion.

Knowledge of return toplay guidelines would have been well illustrated in a graph but were not provided.The conclusions drawn by the authors reflect the analysis carried out and unequivocallystate limitations experienced. The primary concern with regards validity ofresults is the poor response rate from the coaches’ population (19%). Theauthors of this study highlight that this is a concern and acknowledge that theresults of the study with regards coaches may be compromised as a result. As discussedabove, subsequent studies should develop measures to increase the response rate.The authors outline theneed for further research. It is recommended that the same questions onrecognition of symptoms, prevention and return to play knowledge should be appliedto other groups – medics and physios involved with teams, players, and parentsof youth players. Validation of the survey instrument would provide further strengthto the validity of results.

4.Conculsions The overall validity ofthis study based on the EBL Critical Appraisal checklist is 86%.23As this is greater than 75%, I can state that the study is valid.

Overall thisarticle presented a clear and structured presentation of this research and abalanced and informed discussion of their results. The primary weakness of thestudy is the poor response rate of coaches. The population score was 67%according to the EBL guidelines. A score of less than 75% indicates that thereliability of data relating to this area is poor. The authors were aware ofthese weaknesses and highlighted their concerns regarding these results.Understandably there areconcerns regarding the long term effects of concussion, particularly in thewake of the much reported experience of NFL players and long term effects of concussion.242526A protocol for assessing long term effects of concussion in retired rugby unionplayers has been established in the UK.27 Further studiesconfirming long term effects will undoubtedly support the importance ofpreventing, recognising, and managing concussion in rugby.

By completing this study,the authors have contributed to raising awareness of concussion in sport. Thisstudy provides evidence that further education in concussion is required forcoaches and referees in rugby. The authors provide a clear framework for thestudy to be repeated in other regions and across other sports where concussionis a concern.

                 5.References 1 McCrory P, MeeuwisseW, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ,Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016.Br J Sports Med. 2017 Apr 26:bjsports-2017.2 MaegeleM. Traumatic brain injury in 2017: exploring the secrets of concussion.

TheLancet Neurology. 2018 Jan 31;17(1):13-5.3 Concussionin sport: 72 children attend Dublin hospital with head injuries from sport injust six months, Irish Independent, 7th July 2017 accessed at https://www.independent.

ie/irish-news/concussion-in-sport-72-children-attend-dublin-hospital-with-head-injuries-from-sport-in-just-six-months-35999695.htmlon 29-01-174 Concussionin sport: Five sports gather to discuss head-injury prevention, BBC News, 20thJuly 2017 accessed at

com/sport/rugby-union/40675605on 29-01-175 Broglio SP, Moore RD,Hillman CH. A history of sport-related concussion on event-related brainpotential correlates of cognition. International Journal of Psychophysiology.2011 Oct 1;82(1):16-23.6 Tagge CA, Fisher AM,Minaeva OV, Gaudreau-Balderrama A, Moncaster JA, Zhang XL, Wojnarowicz MW,Casey N, Lu H, Kokiko-Cochran ON, Saman S. Concussion, microvascular injury,and early tauopathy in young athletes after impact head injury and an impactconcussion mouse model.

Brain. 2018 Jan 18.7 Stein TD, Alvarez VE,McKee AC. Concussion in chronic traumatic encephalopathy. Current pain andheadache reports.

2015 Oct 1;19(10):47.8 Lehman EJ, Hein MJ,Baron SL, Gersic CM. Neurodegenerative causes of death among retired NationalFootball League players. Neurology. 2012 Nov 6;79(19):1970-4.9 Gardner AJ, IversonGL, Williams WH, Baker S, Stanwell P. A systematic review and meta-analysis ofconcussion in rugby union.

Sports medicine. 2014 Dec 1;44(12):1717-31.10 Cusimano MD, ZhangS, Topolovec-Vranic J, Hutchison MG, Jing R. Factors affecting the concussionknowledge of athletes, parents, coaches, and medical professionals. SAGE openmedicine. 2017 Mar 3;5:2050312117694794.

11 O’Connell E, MolloyMG. Concussion in rugby: knowledge and attitudes of players. Irish Journal ofMedical Science (1971-). 2016 May 1;185(2):521-8.

12 Delahunty SE,Delahunt E, Condon B, Toomey D, Blake C. Prevalence of and attitudes aboutconcussion in Irish schools’ rugby union players. Journal of school health.

2015 Jan 1;85(1):17-26.13 Fraas MR, CoughlanGF, Hart EC, McCarthy C. Concussion knowledge and management practices amongcoaches and medical staff in Irish professional rugby teams. Irish Journal ofMedical Science (1971-). 2015 Jun 1;184(2):425-30.

14 Griffin SA, RansonC, Moore I, Mathema P. Concussion knowledge and experience among Welsh amateurrugby union coaches and referees. BMJ open sport & exercise medicine. 2017Sep 1;3(1):e000174.

15 Conway FN, DominguesM, Monaco R, Lesnewich LM, Ray AE, Alderman BL, Todaro SM, Buckman JF.Concussion Symptom Underreporting Among Incoming National Collegiate AthleticAssociation Division I College Athletes. Clinical journal of sport medicine:official journal of the Canadian Academy of Sport Medicine. 2018 Jan.16 Meier TB, BrummelBJ, Singh R, Nerio CJ, Polanski DW, Bellgowan PS. The underreporting ofself-reported symptoms following sports-related concussion. Journal of scienceand medicine in sport.

2015 Sep 1;18(5):507-11.17 King D, Hume P,Clark T. First-aid and concussion knowledge of rugby league team management,administrators and officials in New Zealand. NZJ Sports Med. 2010Apr;37(2):52-68.18 White PE, Newton JD,Makdissi M, Sullivan SJ, Davis G, McCrory P, Donaldson A, Ewing MT, Finch CF.

Knowledge about sports-related concussion: is the message getting through tocoaches and trainers?. Br J Sports Med. 2013 Sep 14:bjsports-2013.19 Laws of the Game,Rugby Union, accessed at 25-01-1720 World Rugby Websiteaccessed at 26-01-17 21 Sebo P, MaisonneuveH, Cerutti B, Fournier JP, Senn N, Haller DM.

Rates, delays, and completenessof general practitioners’ responses to a postal versus web-based survey: arandomized trial. Journal of medical Internet research. 2017 Mar;19(3).22 McMaster HS,LeardMann CA, Speigle S, Dillman DA. An experimental comparison of web-push vs.paper-only survey procedures for conducting an in-depth health survey ofmilitary spouses. BMC medical research methodology. 2017 Dec;17(1):73.

23 Glynn L. A criticalappraisal tool for library and information research. Library Hi Tech. 2006 Jul1;24(3):387-99.24 Mez J, Daneshvar DH,Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML, Solomon TM,Nowinski CJ, McHale L, Cormier KA. Clinicopathological evaluation of chronictraumatic encephalopathy in players of American football. Jama. 2017 Jul25;318(4):360-70.

25 Alosco ML, TripodisY, Jarnagin J, Baugh CM, Martin B, Chaisson CE, Estochen N, Song L, Cantu RC,Jeromin A, Stern RA. Repetitive head impact exposure and later-life plasmatotal tau in former National Football League players. Alzheimer’s : Diagnosis, Assessment & Disease Monitoring. 2017 Jan 1;7:33-40.26 Amen DG, WilleumierK, Omalu B, Newberg A, Raghavendra C, Raji CA.

Perfusion neuroimagingabnormalities alone distinguish National Football League players from a healthypopulation. Journal of Alzheimer’s Disease. 2016 Jan 1;53(1):237-4127 Gallo V, McElvennyD, Hobbs C, Davoren D, Morris H, Crutch S, Zetterberg H, Fox NC, Kemp S, CrossM, Arden NK.

BRain health and healthy AgeINg in retired rugby union players,the BRAIN Study: study protocol for an observational study in the UK. BMJ open.2017 Dec 1;7(12):e017990. 

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