The balancing act - Physiotherapists’ experiences of managing rugby-related concussion in the community

ABSTRACT

Background

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP) to improve management at the community level. Physiotherapists play an important role in the CMP.

Objective

This study explored physiotherapists’ experiences in the management of community rugby-related concussion as part of the CMP.

Methods

We adopted a pragmatic, descriptive qualitative approach to explore perceptions of twenty-four physiotherapists involved in the CMP. Thematic analysis was used to analyze data.

Results

Four themes represented participants’ experiences: 1) ‘walking the tight rope between player welfare and performance’ described the balancing act between different attitudes and priorities of the various rugby stakeholders; 2) empowering physiotherapists’ authority and responsibilities, described the influence of physiotherapists’ authority within the team and concussion management responsibilities; 3) multi-directional communication, described the role of communication between multiple stakeholders; and 4) the influence of context, which included the complexity of concussion, concussion knowledge of the physiotherapists and team, resource support for the physiotherapist, and access to a medical doctor.

Conclusion

Physiotherapists had positive attitudes toward the CMP and are well-positioned to play an active role in the pathway. Priorities of other stakeholders, authority of the physiotherapist and the communication flow influences physiotherapists’ ability to optimally manage players with concussion.

KEYWORDS:

• Concussion
• physiotherapists
• rugby union

Acknowledgments

The authors acknowledge Drs: Stephen Kara, Theo Dorfling, Chris Reid, Helen Fulcher, Patrick McHugh, Warren Groarke, Andrew Webster, Wendy Gush and Mrs. Emma Wicks who were a part of the GP advisory group who helped develop the New Zealand Rugby Concussion Assessment Protocol and New Zealand Rugby Concussion Assessment Tool and for their contributions to this project. The authors acknowledge the physiotherapists from the high schools and clubs who volunteered to participate. We would also like to thank the Provincial Rugby Unions who agreed to participate in the study and for their assistance with the recruitment of schools and clubs. Funding for this study as part of New Zealand Rugby’s National Concussion Initiative was provided by Accident Compensation Corporation through the RugbySmart program.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Sampling and Data Collection

As part of the broader project, data were collected in three geographically and socioeconomically diverse regions/provincial unions (PU) in NZ to facilitate diversity in views and access to resources such as sport medicine professionals and concussion clinics. Within each PU, rugby administrators in male and female rugby playing schools and premier-level community clubs were contacted to identify teams, from which; App managers, school contacts, coaches, players, parents and nurses were invited to participate in the study. To be eligible, participants must have been involved in the NZR CMP. Additionally, physiotherapists and GPs involved with the CMP within the four unions were invited to participate. Participants were contacted via phone/e-mail and informed of the goals of the study. If they wished to participate, a date and time was scheduled for the interview. Written informed consent was obtained prior to the start of the interviews. Interviews lasted between 30-75 minutes.

Interviews and focus groups were conducted face-to-face, by one of six researchers experienced in qualitative methods. In line with the pragmatic nature of the study, mini focus groups were conducted in instances where individual interviews were not possible due to scheduling or time constraints. One research assistant was present during each focus group/interview to take field notes. The interview team consisted of one male and five female researchers, all involved in the implementation of the CMP. To ensure consistency between interviewers, experienced qualitative researchers (SW/AC) conducted a training session with the interviewers prior to the interviews. Additionally, interviewers and the research assistant met weekly with the research team to reinforce interview consistency, the use of probing questions and paraphrasing to confirm understanding.

Semi-structured interview questions were developed by our inter-disciplinary research team, pilot tested and altered according to feedback.

The interview schedule included the following questions:

• (1) How was your overall experience of the concussion initiative we piloted this season with your team?

Probing: For example, the good, the bad, highlights, things that stand out for you or things that you found hard to deal with …

• (2) If there is one thing we could change to improve your overall experience with your team, what would it be?

• (3) Using the infographic here we are going to break the steps of the concussion initiative into 5 parts. For each part tell us: 1) what went well; 2) what didn’t; and 3) how we could improve:

• (a) Pre-season baseline testing

1. What went well?

2. What didn’t go well?

3. How could we improve your experience?How could we improve your experience?

• (b) Did you have any players that you thought sustained a suspected concussion this season?

1. Can you walk us through what happened after this?

2. Did you log the concussion in the app?

3. Were there things that you found really helpful after it happened?

4. How could we improve your experience?

Probing: Did you log it on the App, if you didn’t logged it on the App can you tell why, Did you feel supported through this process or were there pressures challenges from other stakeholders

• (c) Did you refer your players to a GP after the suspected concussion?

1. Did you have discussion with your players on how the GP visit went?

2. Did you feel that your player got all the information they needed from the GP?

3. How do you think we could we improve this experience for you and your player?

• (d) After your player saw the doctor for their concussion diagnosis was there anything you did with the player around education or their recovery process?

1. Did you support or provide any information about return to work/school?

2. Can you tell me what you did to get them back to rugby after their concussion?

3. Do you remember when they returned to contact training?

4. Did you feel supported taking your player through the GRTP and GRTL process?

5. How could we improve your experience?

• (e) Medical clearance visit

1. How did the player report this GP visit went?

• (ii) Did you feel your player got all the information they needed from the GP?

• (iii) Did you receive any communication after the player had been cleared?

• (iv) How could we improve your experience?

• (5) How did you feel about returning players to contact training/playing?

• (6) How did you feel about returning players to school or work?

• (7) Anything else you would like to share about your experience?

Rigor and Trustworthiness

A study-specific approach to rigor and trustworthiness was adopted (Burke, 2016; Smith and McGannon, 2018). The interview team was involved in the implementation of the CMP and was thus known to the participants. It was our experience that the existing rapport and mutual understanding between the interviewers and the participants contributed to the depth of data. Nonetheless, it is possible these prior relationships may have affected what participants felt comfortable to share regarding their experience. For this reason, every effort was made to create a comfortable environment that encouraged unrestricted sharing of experiences.

Regular team meetings were held during the analysis phase to test assumptions and evaluate coherence in interpretation. Regarding saturation, we believe that there is always potential for new insights as long as data continues to be collected (Braun and Clarke, 2019; Low, 2019). Instead, our focus was on gaining context-sensitive insights from participants that we considered to be critical role players and key informants, as well as on a rigorous, iterative analysis process (Braun and Clarke, 2019).

Notes

1. Organizational structures that work with NZR, to manage and provide services to clubs and schools in their region.

Additional information

Funding

This work was supported by the The Accident Compensation Corporation [RugbySmart]; New Zealand Rugby Foundation [Rugby Research Grant]; World Rugby [Player Welfare Grant].