Are Irish Sporting Organisations Neglecting the Safety of Their Athletes? A Narrative Review on Concussion Return-to-Play Protocols

M. Beakey1, C. Blake2, S. Tiernan3, K. Collins4

1Department of Science, Institute of Technology, Tallaght, , . 2University College Dublin, School of Public Health, Physiotherapy and Sports Science, Health Sciences Centre, Belfield, Ireland 3Department of Engineering, Institute of Technology, Tallaght, Dublin, Ireland 4Gaelic Sport Research Centre, Institute of Technology, Tallaght, Dublin, Ireland

Review article Review article

ABSTRACT

Introduction: Concussion can vary in presentation and requires an individualised clinical assessment and so, it is imperative that the appropriate return to play (RTP) protocols are administered to facilitate the safe recovery of an athlete prior to their return to sport. A 2014 report by the Houses of the Oireachtas (Parliament) Joint Committee on Health and Children (JCHC) proposed several recommendations to tackle issues with current concussion management policies in Ireland. Aims: The aim of this narrative review is to provide an in depth comparative analysis of Irish sporting organisations’ concussion RTP protocols and to assess their compliance with the JCHC’s recommended RTP proposals. Materials & Methods: Fifteen organisations were eligible for review under the inclusion criteria. Information on their RTP protocols was gathered from their official websites and through direct communication with relevant representatives from each organisation. Results: Whilst the majority of the RTP protocols bear resemblance to recent international consensus guidelines, there is a lack of consistency, clarity and detail across the approaches. Key areas in the RTP management of an athlete appear neglected; essential domains are underdeveloped for athletes, coaches and parents such as instructions pertaining to cognitive rest, return-to-learn (RTL), return-to-work (RTW) accommodations and the impact of concussion modifiers. Conclusion: The findings of this review weigh heavily in favour of the establishment of a specialised national “Sports related Concussion (SRC) Taskforce” to regulate the management of concussion in Ireland. Further research needs to be undertaken to evaluate the efficacy of an educational intervention in the graded return-to-play (GRTP) of an athlete.

Keywords: Concussion management, return to play (RTP), sporting organisations, taskforce

Correspondence to: Mark Beakey, MSc, Department of Science, Institute of Technology, Tallaght, Dublin 24, D24 FKT9, Ireland. Email address- [email protected]

Volume 3, Issue 2, March 2016 41 INTRODUCTION Irish culture has always valued the participation in sporting activities with 45% of the population taking part in either a team or individual sport annually.1 Unfortunately, the inherent physical nature of many popular Irish sports carries with it the underlying risk of injury for the athletes. It is incumbent therefore on sporting organisations to ensure that the safest possible conditions are in place for their athletes. Sports-related concussion (SRC) has become a major health burden, affecting an estimated 3.8 million athletes every year in the United States alone, with a significant percentage of these concussions going unreported.2 Over the last 50 years, concussion has garnered substantial interest within the scientific community, however, there has been considerable variability in the definition of concussion within the literature.3 Recently in Berlin, the Concussion in Sport Group (CISG), a panel of international experts at the 5th International Conference on Concussion in Sport were tasked with providing an operational definition for concussion. They described concussion as “a traumatic brain injury that is defined as a complex patho-physiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature”.4 In the absence of a gold-standard diagnostical measure, many clinical questions remain unanswered including the exact recovery and appropriate commencement of return to play (RTP) guidelines. Therefore, the decision to allow an athlete to return to their sport following a concussive diagnosis is based heavily on subjective opinion rather than objective evidence. Following a concussion, if an athlete returns to play before the brain has fully recovered, they are at a heightened risk of exacerbating their symptoms and delaying their recovery.5 If an athlete receives additional brain trauma in their premature return to sport, they may be susceptible to long term cognitive impairment6 and even mental illness and neurodegenerative disease, although current research on the latter is inconclusive.7 In rare cases, further significant trauma to a concussed brain may lead to rapid cerebral oedema known as second impact syndrome (SIS) resulting in probable death or a permanent life altering debilitation.8 The ambiguity in recovery, results in a difficult determination by clinicians as to whether an athlete has recovered or is still suffering the effects of a concussion. Thus, a conservative RTP protocol should be recommended by clinicians and implemented by sporting organisations to minimise the potential risk of severe health complications, especially for younger athletes who are more vulnerable to concussion and its negative effects.4 Major sporting and health organisations worldwide have called for the implementation of a standardised concussion RTP framework for all athletes. However, within this RTP model, these experts have instructed a multidisciplinary concussion management team (CMT: medical staff, teachers/work colleagues, coaches and parents) to take an individualised and tailored approach to the treatment program for each injured athlete.2,5,9 Therefore, if the treatment of the athlete is to be of the highest standard of care, the members of the CMT must have an open dialogue and be appropriately qualified and competent in making RTP decisions. RTP protocols are not in place to test if a concussed athlete can tolerate physical exertion, rather they are to test an athlete’s current health to see if it safe for them to return to their chosen sport.10

HOUSES OF THE OIREACHTAS JOINT COMMITTEE ON HEALTH AND CHILDREN (JCHC)

In December of 2014, Houses of the Oireachtas Joint Committee on Health and Children (JCHC)11 released a report on how to tackle the problem of concussion in . The committee highlighted key issues and provided the following recommendations for Irish sporting organisations: 1. The guidelines put forward by the Concussion in Sport Group (CISG)5 at the 4th International

42 European Journal of Sports Medicine Conference on Concussion in Sport in 2012 should be implemented across all the sports disciplines at all ages and levels. 2. Sporting organisations and schools need to be more proactive with SRC with emphasis on the younger athletes. 3. A more consistent approach among all sporting organisations and educational bodies in the RTP management of SRC is required. 4. There needs to be an improved accessibility of resources including concussion clinics and specialised medical staff. 5. The recording of concussion incidents should be compulsory in all clubs and educational institutions. 6. In collaboration with the sporting organisations and educational institutions, the government needs to establish a “Taskforce on SRC” to address the current problems and to implement the Committee’s recommendations.11

To allow the CMT to effectively manage a concussion, sporting organisations must provide accesible and detailed concussion management and RTP protocols for their members to adhere to.12 In Ireland, there has been limited research evaluating the concussion management policies in place for athletes. There is an innate risk of concussion in all sports, however the risk is heightened in physical and combat sports such as mixed martial arts, boxing, horse racing and rugby.2,4,11 Therefore, increased emphasis on concussion management is necessry for organsiations that govern inherently violent and dangerous forms of sporting activity, particularly if they have a large number of youth members. The aim of this narrative review is to provide an in depth comparative analysis of Irish sporting organisations concussion RTP protocols and to assess their compliance with the JCHC’s recommended concussion management proposals.

MATERIALS & METHODS Information pertaining to the concussion RTP protocols was gathered through public material available on the official websites of the relevant sporting organisations under review. An appropriate representative of each organisation was also contacted to ensure an accurate depiction of the protocols collected. Irish sporting organisations: 1) which are recognised as the National Governing Body (NGB) or National Regulatory Body of their respective sport(s) by and/or Federation of Irish Sport and 2) which govern sport that is categorised as “contact and/or collision based”, or that carry an increased risk of head injury or concussion, were eligible for review.

RESULTS After review, fifteen sporting organisations met the inclusion criteria (See Table 1). Of these organisations, no concussion management policy or RTP protocols were found for Gymnastics Ireland (GI),13 (RLI),14 (CyI)15 and the Irish Ice Hockey Association (IIHA)16 and thus, were excluded from the review.

Compliance with the International Concussion in Sport Group (CISG) There is considerable variation in the current RTP guidelines of Irish sporting organisations. Notwithstanding those variations, the organisations do stand unanimous on some important international concussion management recommendations by the CISG4,5 and in doing so are in align with the recommendations put forward by the JCHC.11

Volume 3, Issue 2, March 2016 43 TABLE 1. Irish Sporting Organisations Under Review

Irish Sporting Organisation Sport(s) Played Within the Organisation Athlete Status

Gaelic Athletic Association (GAA)17 Gaelic Football, Hurling, Camogie & Handball Amateur Football Association of Ireland Soccer Professional & Amateur (FAI)18 Irish Rugby Football Union Rugby Union, Sevens Rugby, Tag & Professional & Amateur (IRFU)19 Touch Rugby

Rugby League Ireland (RLI)14 Rugby League Professional & Amateur Irish Martial Arts Commission Aikido, Sambo, Karate, Tai Chi, Tang Soo Do, Amateur (IMAC)20 Taekwondo, Kickboxing, Wushu, Muaythai, Kung Fu, Ninjutsu & Kendo Irish Athletic Boxing Association Boxing Amateur (IABA)21 Irish American Football Association American Football Amateur (IAFA)22

Irish Turf Club (ITC)23 Horse Racing Professional & Amateur

Horse Sport Ireland (HSI)24 Carriage Driving, Dressage, Endurance, Amateur Eventing, Harness Racing, Hunting, Mounted Games, Para-equestrian, Polo, Polocrosse, Reining/Western, Showing, Show Jumping, Side Saddle, TREC, Vaulting

Basketball Ireland (BI)25 Basketball & Wheelchair Basketball Amateur

Hockey Ireland (HI)26 Amateur

Gymnastics Ireland (GI)13 Olympic Disciplines: (Women’s Artistic Amateur Gymnastics (WAG), Men’s Artistic Gymnastics (MAG), Trampoline Gymnastics (TRA) & Rhythmic Gymnastics (RHY). Non-Olympic: Disciplines (Acrobatic Gymnastics (ACRO), Tumbling Gymnastics (TUM), Gymnastics for All (GFA) & Sports Aerobics (AERO))

Cycling Ireland (CyI)15 Road, Off road (MTB), Track, Paracycling, Amateur BMX, Leisure/Sportive & Cyclo-cross

Cricket Ireland (CI)27 Professional & Amateur Irish Ice Hockey Association Ice Hockey Amateur (IIHA)16

They advocate; 1. Any player suspected of suffering a concussion must be removed from play. 2. No RTP on the same day as initial concussive trauma. 3. Clinical diagnosis of concussion is required. 4. Medical clearance should be obtained prior to RTP.

44 European Journal of Sports Medicine 22 qualifies for the 365-day suspension” incial union affiliated under CI. arring for a period of 365 days after the the boxer having received heavy blows to st Suspension was 90 days, the repeat LOC <1min: 90 days LOC >1min: 180 days Two LOC <90 days: 90 days* Three <365 365 days** from both physical and cognitive activity” 22 (19+ yrs) (5-18 yrs) TV, PC use, music etc." 12 days (16-18 yrs) 7 days (16-18 yrs) PC use, music etc” 7 days (18+ yrs)N/A 20 days (5-18 yrs)21 days (20+ yrs)6 days (<19 yrs) 23 days (5-20 yrs) 24-48 hours 23 days (5-18 yrs)30 days 14 days (20+ yrs) N/A 14 days (5-18 yrs) 24-48 hours 14 days (5-20 yrs) “No sports, exertions, minimal TV, PC use, music etc” “Complete physical and mental rest without symptoms” 30 days21 days (18+ yrs) 14 days 10 days 23 days (<18 yrs) N/A15 days21 days (20+ yrs) 14 days (18+ yrs) "No sports, exertions, minimal 30 days 23 days (<20 yrs) 14 days (<18 yrs) 10 days21 days (20+ yrs) “Complete physical and mental rest with symptoms” 15 days6 days (19+ yrs) 23 days (5-20 yrs) N/A 14 days (20+ yrs) 23 days (<16 yrs) 30 days 14 days (<20 yrs) 14 days (20+ yrs) “The treatment for uncomplicated concussion is REST, 5 days 14 days (5-20 yrs) 24 hours (19+ yrs) 10 days 14 days (<15 yrs) “Complete physical and cognitive rest” N/A No LOC: 30 days “No sports, exertions, minimal TV, 5 days 10 days “No activity, complete cognitive and physical rest” “No activity, complete cognitive and physical rest” 27 20 21 19 22 17 24 18 23 26 25 suspension will be 180 days. If the first was days, new 365 days.” *“If during a period of 90 days after boxer’s suspension for KO, the boxer is knocked out second time by referee due to the head then boxer may not take part in boxing or sparring for a period of 90 days after second occurrence. If fir IMAC CI*** HI third occurrence. Any combination of knockouts or RSCHs (Referee Stops Contest-Head) that equal three under these circumstances Sporting Organisation Adult Minimum Time Out from PlayGAA FAI IRFU Youth Minimum Rest Requirement AdultIAFA ITC HSI YouthBI Minimum Rest Description **“If during a period of 365 days the boxer suffers third knockout from head blows, then he may not take part in boxing or sp ***The concussion management information for (CI) was gathered through the Leinster Union (LCU), a prov IABA TABLE 2. Concussion Management Information Provided by Irish Sporting Organisations

Volume 3, Issue 2, March 2016 45 Recording of a such as headache tablets, anti-depressants and/or sleeping medication and caffeine" for pain" is especially important (and " … … day etc to work, college or school as soon possible” sometimes difficult) in an amateur sport where most players will want to return to school work, increase breaks during medications prescribed by their doctor" activity "Occasionally there is a need for gradual "It is essential that players only take N/A N/AN/AN/A"Players with prolonged recovery should be assessed and managed by health care providers (multi- "Occasionally there is a need for gradual disciplinary) with experience in "Occasionally there is a need for gradual return return to school work, increase breaks during sports-related concussions" "It is essential that players only take medications prescribed by their GP/ school day etc. (upon medical advice). N/A "It is essential that players only take Students may have difficulty concentrating" N/AN/A N/A N/AN/A physician" N/A N/AN/A N/AN/A N/A"Players with prolonged recovery should N/Abe assessed and managed by health N/Acare providers (multi-disciplinary) with N/A return to school work, increase breaks during school day etc (on medical advice). Students experience in sports-related concussions" "Symptoms may be masked by medications may have difficulty concentrating" medications prescribed by their doctor" “REST, from both physical and cognitive N/A N/A N/A N/A N/A N/A N/A "Take prescribed medications or paracetamol N/A N/A N/A Yes Yes Yes N/A 20 21 19 22 17 24 18 23 26 25 27 IRFU HSI HI IMAC CI Sporting Organisation Prolonged RecoveryGAA FAI Academic/Work Considerations Pharmacological TherapiesIABA IAFA ITC Concussion BI TABLE 3. Concussion Management Information Provided by Irish Sporting Organisations Cont.

46 European Journal of Sports Medicine In addition, the graduated return-to-play (GRTP) guidelines proposed by the CISG are utilised by each organisation apart from IABA,21 who do not incorporate a GRTP in their guidelines. The Irish Turf Club23 and Horse Sport Ireland24 also include neuropsychological testing in their GRTP protocols as recommended by the CISG.4,5

DISCUSSION Cognitive and Physical Rest In recent years, cognitive and physical rest have been consistent international guidelines for the management of concussion among athletes with a more conservative approach advocated for adolescent and youth athletes.2,4,5,9,12 As concussion is an individual and dynamic injury, the recommended period of cognitive and physical rest is difficult to standardise and should be tailored to the specific athlete.12 The FAI18 and IABA21 do not give a specific length of time for their period of cognitive rest for an athlete suffering a concussion. The FAI advocate commencing a GRTP protocol once the player is asymptomatic and the IABA implement a mandatory 30-day suspension of physical exertion with no reference to a cognitive rest period. Other organisations have cognitive and physical rest periods in their RTP protocols ranging from 24 hours to 14 days in adults and 5 days to 14 days in youth athletes (See Table 2). The concept of “physical” rest is uncomplicated in its interpretation. The understanding of what constitutes “cognitive” rest can be more challenging.28 In all the protocols under review, the proposed cognitive rest period is ambiguous and offers minimal direction on how the athlete can achieve reserved cognitive stimulation. “Complete cognitive and physical rest”19,22-25,27 and "no sports, exertions, minimal Television, PC use, music etc”17,20,26 are common instructions provided by the organisations for athletes during their period of rest. If sporting organisations simply just prescribe full cognitive and physical rest without including more specific insight or direction, they may endanger the health and well-being of the concussed athlete especially when these periods of rest are for a significant length of time.29 Without adequate oversight, an athlete may be subjected to unsafe practices of strict rest such as cocoon therapy which may not only exacerbate concussive symptoms and delay recovery,30 but also may increase their risk of anxiety and depression due to social isolation and an amplified fixation on their injury.31 Physical de-conditioning32 and a fall in academic standing33 are also potential consequences of an ill-designed rest period. Although recommended by the organisations, a large percentage of concussed players will not be evaluated by a trained medical professional.34 If concussion management guidelines are not precise, detailed and appropriate in their description, athletes may be given incorrect and harmful treatments by undereducated members of their CMT.5 Recommendations on the best current practices for treating SRC in the first few days following the clinical diagnosis are outside the scope of this study. However, it is evident that a more collaborative approach is warranted among the Irish sporting organisations to deliver uniform and evidence based guidelines to safely manage injured athletes.

Return to Learn (RTL)/Return to Work (RTW) SRC can affect an athlete in their academic or work environment.33 After suffering a concussion, athletes should undergo an individualised graded RTL/RTW protocol prior to carrying out any physical exertion.33 There are several proposed interventions on how to manage athletes returning to school/college35 yet research on employees RTW following concussion is limited. Despite its importance to the concussion management process, there were only brief and vague mentions of academic considerations in a few RTP protocols under review.17,20,26.27 No mention was given to

Volume 3, Issue 2, March 2016 47 work accommodations for employees suffering from SRC in any of the concussion RTP protocols under examination (See Table 3). The ambiguous recommendations in their protocols provide no clear guidance on how to deal with a concussed athlete in these environments. It is irresponsible of the organisations, for example, to advocate “complete physical and cognitive rest”19,22-25,27 for considerable periods of time for athletes suffering from concussion while providing no reasonable guidance on how this period of rest may affect the athlete in their school or work environment.36 If no direction is provided by the organisation itself, teachers, parents and the athletes themselves will struggle to handle the concussion appropriately. Each athlete diagnosed with a concussion should undergo an individualised program of graded return, facilitated by their CMT.5 Therefore, it is imperative that sporting organisations work together along with schools/employers, parents and medical staff to ensure they are consistent and uniform in their message to the athlete. Having clear and standardised requirements in their RTP protocols is the first step in achieving this goal.

Concussion Modifiers Implementing an individualised concussion management plan is necessary in regard to several modifying factors that may affect, not only the frequency and severity of a concussion but also the time an athlete requires to recover from the injury.37 After a concussion diagnosis, thorough assessment of an athlete should be carried out to identify the presence or absence of certain concussion modifiers to allow a targeted RTP protocol to be developed and implemented.4 Age, gender, type of sport, level of play, concussion history and specific injury characteristics such as symptom occurrence, severity and duration are common examples of concussion modifiers present in athletes that need to be evaluated to allow suitable RTP guidelines to be established.37 The presence of co-morbidities and the pre-morbid condition of an athlete also may have a profound effect on the recovery from concussion. For instance, athletes who have a history of migraine, insomnia or suffer from a mental health or hyperactive disorder may have a prolonged recovery time.4,5 Less than half of the sporting organisations give mention to concussion modifiers with varying explanations and level of content (See Table 4). IABA21 centre their concussion management policy around a fighter being ‘knocked out’ and experiencing a LOC. LOC is the only concussion modifier mentioned and all other concussive symptoms and modifiers are not included in their suspension criteria for concussed fighters. LOC only occurs in a fraction of concussions and brief LOC (<1min) is not supported as a concussion modifier as it is not an accurate predictor of concussion severity. However, more caution needs to be taken with prolonged LOC (>1min).5 IABA are relying heavily on an archaic understanding of concussion being synonymous with LOC. Adaptation to the current evidence is warranted with a provision for a more detailed RTP policy for their boxers and coaches. The IAFA22 record all concussion incidents and use a player’s concussion history in their RTP decision making process. They state, "Should a player receive concussion a second time in one season, they must sit out the rest of the season" (See Table 4), despite no scientific evidence supporting this notion. The fear of missing out on training and game time acts as a barrier to honest self-reporting of concussion among athletes.38 Their decision to enforce a rigid ‘two strikes and you’re out’ general RTP protocol, without room for individual assessment, is concerning and may be contributing to a lack of open disclosure. The stark reality is that an athlete may be willing to hide their concussion and risk playing symptomatic in the hope of avoiding a long-term stint on the sidelines.34

Accessibility of Information

As alluded to in the report by the JCHC,11 the accessibility of specialised concussion clinics

48 European Journal of Sports Medicine TABLE 4. Information on Concussion Modifiers

Sporting Organisation Concussion Modifiers

GAA17 "Medical personnel should be mindful of modifiers when managing a player’s concussive injury" "Symptoms: Number, Duration (>10 days), Severity Signs: Prolonged loss of consciousness (LOC) (>1min), Amnesia Sequelae- Concussive convulsions Temporal: Frequency – repeated concussions over time? Timing – injuries close together in time? ‘Recency’ – recent concussion or traumatic brain injury Threshold-Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Age- Child and adolescent (<18 years) Comorbidities and premorbidities- Migraine, depression or other mental health disorders, attention deficit hyperactive disorder (ADHD), learning disabilities (LD), sleep disorders Medication- Psychoactive drugs, anticoagulants Behaviour-Dangerous style of play Sport- High risk activity, contact with collision sport, high sporting level"

IMAC20 "There are some groups in which concussion may be particularly dangerous: young players, non- elite and female" "Players with two concussions within 12 months/ history of multiple concussions should be assessed and managed by health care providers (multi-disciplinary) with experience in sports- related concussions"

IAFA22 "Should a player receive concussion a second time in one season, they must sit out the rest of the season"

HSI24 "Recovery may be slower among older adults, young children, and teens"

CI27 “It is extremely important to note that if concussion is not properly managed, especially in young players, serious and long-term consequences may ensue”

HI26 "Children; are more susceptible to concussion take longer to recover have more significant memory and mental processing issues. are more susceptible to rare and dangerous neurological complications, including death caused by a second impact syndrome." "Players with; a second concussion within 12 months a history of multiple concussions unusual presentations or prolonged recovery should be assessed and managed by health care providers (multi-disciplinary) with experience in sports-related concussions."

and trained staff is limited in Ireland. It is imperative sporting organisations provide free, comprehensive and readily available information on SRC to any concerned member of the public. The current level of information provided is fractured among the sporting organisations in Ireland (See Tables 2 & 3). Only the IRFU19 deliver specific information on concussion for different members of the CMT with educational videos and specialised contact details dedicated to

Volume 3, Issue 2, March 2016 49 concussion. The FAI,18 IAFA22 and BI25 offer no documents outlining their concussion management plan. Although, HSI24 provide a document on their “Rules and Regulations”, they offer no detail on a GRTP protocol for an athlete suffering a concussion. Limited material is provided on important areas of managing a concussion such as use of pharmacological therapies or how to deal with prolonged concussive symptoms (See Table 3). There is no information provided on concussion management and RTP by nearly half of the organisations being examined. The lack of transparent information was emphasised in a recent study of Irish parents where 70% do not believe clubs or schools have appropriate protocols in place to treat and manage concussion successfully.39 The organisations must consider how members at the lower levels of sporting participation on a nationwide scale, such as volunteer coaches, can access the relevant material necessary to effectively aid in the safe management of concussion.40

Future Recommendations In agreement with the JCHC, the management of SRC in Ireland needs a more standardised and collaborative approach among the sporting organisations. A SRC “Taskforce”, acting as a regulatory body, should be created to oversee the management of concussion and RTP guidelines among schools and sporting bodies. The “Taskforce”, comprised of representatives from sporting, medical and educational backgrounds, should examine the best methods for creating a collaborative national concussion management policy and RTP framework with clearly defined milestones (See Figure 1). Their national policy and SRC guidelines should be made freely available online. This information should be clear, comprehensive and relatable to each sporting organisation within Ireland. Other key responsibilities of the Taskforce should include an annual evaluation of sporting organisations, knowledge and attitude assessments of athletes and staff, overseeing the competence and adherence levels to their concussion management policies and the establishment of a national concussion-reporting database for the mandatory logging of all SRC incidents. The formation of specialised concussion clinics to care for athletes and the public who are suffering prolonged negative effects of concussion should also be a main goal of the Taskforce. The current information provided by Irish sporting organisations is fractured and lacking in clarity, detail or direction. The contradictory information can lead to ambiguity among the recipients. There is a need for not only standardised RTP framework but also standardised concussion information. As it is common for athletes to participate and have interests in many sports in Ireland, it is important that they are being provided with a uniform message on SRC. There is a responsibility on the sporting organisations to provide their members with accessible and detailed information on SRC to ensure adequate care for the athletes. This review highlights the inconsistent levels of information provided on important areas of RTP protocol including physical and cognitive rest, recording of a concussion, “red flag” symptoms, pharmacological therapies, concussion modifiers, prolonged recovery and academic/work considerations. The sporting organisations should continually update their RTP protocols and the information they provide to meet current international consensus guidelines.4 Educating athletes on SRC is a vital aspect in effective concussion identification, management and prevention.41 Targeted interventions can improve their knowledge, reporting intentions and accentuate the best methods of recovery.40 As an athlete’s concussive symptoms resolve, it is a prime opportunity for the concussion Taskforce to implement a mandatory educational intervention as part of the GRTP protocol. The intervention should aim to assess athlete’s knowledge and barriers to reporting. It should also address a number of areas relative to their own sport and age group such as myths and misconceptions regarding protective equipment, tackling technique, effect of concussion on athletic performance, academic/work considerations and dangers of concealing symptoms. A possible solution is to develop a concussion education examination where

50 European Journal of Sports Medicine FIGURE 1. Development of a SRC Task Force and The Proposed Associated Network

an athlete must obtain a certain level of knowledge before being allowed complete the GRTP protocol and return to their sport. The examination could be adapted for different ages and sports and could be delivered in a variety of modalities at the request of the athlete.

Limitations

No concussion management guidelines or RTP protocols were found for GI,13 RLI,14 CyI,15 and the IIHA16 and thus a review of their organisations cannot be undertaken. The information on the concussion RTP protocols of the Irish sporting organisations was gathered from their respective websites and through communication with a representative of each organisation and therefore may under-represent their actual protocols in place. Nevertheless, it reiterates the lack of transparency and accessible information for members of the CMT who may rely on such outlets to improve their knowledge and management of concussion.

SUMMARY Irish sporting organisations need to address several issues in their concussion return-to-play (RTP) protocols. Currently, they provide substandard instruction on how to manage a concussed athlete. There is a lack of consistency and accessible information available on applying cognitive and physical rest, the impact of concussion modifiers and structuring the return-to-learn (RTL)/return- to-work (RTW) of the athlete. A specialised concussion ‘Taskforce’ should be established to oversee the concussion management of athletes in Ireland. Implementing concussion educational interventions in the RTP protocols should also be considered.

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52 European Journal of Sports Medicine 23. Irish Turf Club and Irish National Hunt Steeplechase Committee. Rules of Racing and Irish National Hunt Steeplechase Rules. 2015. 24. & Medical Equestrian Association Ireland. Medical Equestrian Association Ireland Concussion Guidelines. 25. [Internet]. [cited 2017 Jan 19]. Available from: http://www.basketballireland.ie/concussion/ 26. . Irish Hockey Concussion Guidelines. 2014. 27. Leinster Cricket. Concussion Guidance for Non-Medical Persons. 2017 28. Renjilian CB, Grady MF. Concussion. In: Fundamentals of Pediatric Surgery. Cham: Springer International Publishing; 2017. p. 119–27. 29. Johnson RS, Provenzano MK, Shumaker LM, Valovich-Mcleod TC, Welch Bacon CE. The Effect of Cognitive Rest as Part of Post-Concussion Management for Adolescent Athletes: A Critically Appraised Topic. J Sport Rehabil. 2016; 30. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015;135(2):213–23. 31. Karlin AM. Concussion in the pediatric and adolescent population: “Different population, different concerns.” PM R. 2011;3(10 SUPPL. 2):S369–79. 32. Leddy JJ, Kozlowski K, Fung M, Pendergast DR, Willer B. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome : Implications for treatment. NeuroRehabilitation. 2007;22(3):199–205. 33. DeMatteo C, Mccauley D, Stazyk K, Harper J, Adamich J, Randall S, Misiuna C. Post-concussion return to play and return to school guidelines for children and youth: a scoping methodology Post- concussion return to play and return to school guidelines for children and youth: a scoping methodology. Disabil Rehabil. 2015;37(12):1107–12 34. Kerr ZY, Register-Mihalik JK, Kroshus E, Baugh CM, Marshall SW. Motivations Associated With Nondisclosure of Self-Reported Concussions in Former Collegiate Athletes. Am J Sports Med. 2016;44(1):220–5. 35. Cancelliere C, Hincapié CA, Keightley M, Godbolt AK, Côté P, Kristman VL, Stalnacke B, Carroll LJ, Hung R, Borg J, Nygren de Boussard C, Coronado VG, Donovan J, Cassidy D. Systematic Review of Prognosis and Return to Play After Sport Concussion: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3):S210–29. 36. Carson JD, Lawrence DW, Kraft Md SA, Garel A, Snow CL, Chatterjee A, Libfeld P, MacKenzie HM, Thornton JS, Moineddin R, Frémont P. Premature return to play and return to learn after a sport-related concussion: Physician’schart review. Can Fam Physician. 2014;60(6):310–5. 37. Makdissi M, Davis G, Jordan B, Patricios J, Purcell L, Putukian M. Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups? Br J Sports Med. 2013;47(5):314–20. 38. Kroshus E, Baugh CM, Daneshvar DH, Viswanath K. Understanding Concussion Reporting Using a Model Based on the Theory of Planned Behavior. J Adolesc Heal. 2014;54(3):269–74. 39. Headway.ie. 70% of Parents think Schools and Clubs are not protecting children from Dangers of Concussion [Internet]. 2016 [cited 2017 Jan 19]. Available from: http://www.headway.ie/news/2016/10/14/70-of-parents-think-schools-and-clubs-are-not-prot/ 40. Provvidenza C, Engebretsen L, Tator C, Kissick J, McCrory P, Sills A, Johnston M. From consensus to action: knowledge transfer, education and influencing policy on sports concussion. Br J Sports Med. 2013;47(5):332–8. 41. Register Mihalik J, Baugh C, Kroshus E, Y. Kerr Z, Valovich McLeod TC. A Multifactorial Approach to Sport-Related Concussion Prevention and Education: Application of the Socioecological Framework. J Athl Train. 2017;52(3):195–205.

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