Concussion Assessment and Management Practices Among Irish and Canadian Athletic Therapists: An International Perspective

Participants

Athletic therapists in Ireland and Canada who were members of ARTI and the CATA, respectively, were invited to participate in this online, cross-sectional cohort survey study. Membership in these organizations is required by Canada and Ireland to obtain licensure as an athletic therapist and was the sole inclusion criterion for this study. A total of 183 Irish athletic therapists (N.Taaffe, ARTI, written communication, April 2021) and 2090 Canadian athletic therapists (H. DeFazio, CATA, written communication, April 2021) were licensed and eligible to participate at the time of survey distribution. All respondents provided informed consent before starting the survey, and this study was deemed exempt by the Institutional Review Board of the University of Georgia.

Procedures

The survey was administered separately to the ARTI and CATA memberships in February 2021. Each organization sent emails to its members containing a cover letter, an informed consent form, and a web link to complete the online survey from a computer or mobile device. Invitations to participate were also included in each organization's periodical newsletter. Follow-up communications were sent to the memberships at 3 and 6 weeks after the initial survey date, regardless of whether participants had completed the survey.^8,15,16 The survey allowed for only 1 attempt per participant to ensure survey response independence, and all survey items were optional. The survey was active for a total of 8 weeks, and all partially completed surveys were recorded.

Instrumentation

Anonymous web-based surveys were directly adapted from a previously established survey^8,15,16 for Irish and Canadian athletic therapists using an online survey tool (Qualtrics). The survey took 20 minutes on average to complete. Responses to survey items consisted of “Select all that apply,” multiple choice, open-ended, and short-answer item options. Slight changes to the survey were necessary to account for differences in terminology and practice settings between countries to ensure valid survey responses.^8,15,16 We assessed content validity of the surveys to ensure appropriate item construct(s) and clarity. Next, the surveys were piloted among Irish (n = 5) and Canadian (n = 5) athletic therapist colleagues to ensure online survey function and collect open-ended survey feedback. The final survey was then revised based on their feedback and subsequently distributed.

The survey domains consisted of athletic therapists' training and practice backgrounds (degrees earned, years certified as an athletic therapist, years of clinical experience, and employment settings), descriptive data related to concussions sustained and their characteristics for each participant's patient population, clinical methods used to assess and determine RTP after concussion, and concussion knowledge using patient–clinician scenarios and signs and symptoms recognition.^8,15,16 Patient-clinician scenarios consisted of items such as, “If a player reported postconcussion symptoms but appeared normal on standardized methods of concussion (eg, Standardized Assessment of Concussion [SAC], Balance Error Scoring System [BESS], neurocognitive testing), would the athlete be allowed to return to play at your institution?” The signs and symptoms recognition section was drawn from a reliable, valid, and earlier published survey consisting of 20 items (8 true, 12 false) asking athletic therapists to indicate whether the listed sign or symptom was associated with a concussion.^15,17 Survey items are presented in Tables 1–4.

Table 1 Athletic Therapists' Training and Practice Backgrounds^a

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Table 2 Reported Concussion Characteristics Among Irish and Canadian Athletic Therapists

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Table 3 Survey Items and Responses for Signs and Symptoms Recognition

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Table 4 Patient–Clinician Scenario Results

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Data Analyses

We examined Irish and Canadian survey responses separately. Some individuals (<0.01% in both cohorts) created a range or fraction of the number of concussions occurring in each sport. In these cases, the range midpoint was determined and used. Frequencies and proportions were calculated for all survey responses. Survey items had various participant response rates, which did not sum to the total sample size because participants were allowed to skip individual survey items or discontinue the survey at any time. Descriptive statistics were calculated for responses to athletic therapists' training and practice backgrounds, patient–clinician scenarios, and signs and symptoms recognition items. Responses to signs and symptoms recognition items were transformed into composite scores by summing the number of correct items and dividing by the total number of items on the measure (n = 20), resulting in a percentage correct score.^15,18,19

Univariable, binary logistic regression models were fit to calculate the odds ratios (ORs) with 95% CIs of using a 2-domain (≥2 of symptom checklist, balance assessment, or neurocognitive assessments) and 3-domain assessment (all 3 assessments) for injury assessment and RTP decision making separately between education (bachelor's versus master's degree) and years of clinical experience (4 total models).⁸ Primary work setting was not examined because Canadian and Irish athletic therapists often work in >1 setting by default (eg, working 50% in a clinic setting and 50% in a secondary sport).⁸ All ORs with 95% CIs not including 1.0 were considered different. We completed all analyses using The R Project for Statistical Programming (version 3.4.3; The R Foundation)²⁰ with the α level set a priori at .05.

Concussion Knowledge

Irish athletic therapists (n = 48) had a mean signs and symptoms recognition score of 72.8% ± 17.0% (median = 70.0%; range = 40.0%–100%; Table 3). They were most familiar with sport-specific RTP guidelines, with 97.9% (47/48) familiar with the Irish Rugby Football Union guidelines,²¹ followed by 68.8% (33/48) with the 2016 Berlin “Consensus Statement on Concussion in Sport”¹ and 54.2% (26/48) with the 2012 Zurich “Consensus Statement on Concussion in Sport.”²²

Canadian athletic therapists (n = 156) had a mean signs and symptoms recognition score of 76.6% ± 17.0% (median = 80.0%; range = 35.0%–100%; Table 3). Approximately 80.9% (123/152) of them were most familiar with the 2017 “Canadian Guideline on Concussion in Sport,”²³ followed by 75.7% (115/152) with the 2016 Berlin “Consensus Statement on Concussion in Sport,”¹ and 75.0% (114/152) with the 2012 Zurich “Consensus Statement on Concussion in Sport.”²² The patient–clinician scenario results for both Irish and Canadian athletic therapists are shown in Table 4.

Initial Concussion Assessment

Individual instrument proportions within each concussion assessment domain among Irish and Canadian athletic therapists are depicted in Figure 1. A 3-domain minimum concussion assessment was indicated by 3.5% (2/57) of Irish athletic therapists, and a 2-domain minimum assessment was indicated by 38.6% (22/57; Figure 2). A 3-domain minimum concussion assessment was selected by 19.7% (35/178) of Canadian athletic therapists, and a 2-domain minimum assessment was selected by 73.6% (131/178).

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Concussion Management and RTP

Methods for determining RTP are presented in Figure 1E. A 3-domain concussion assessment was indicated by 1.9% (1/53) of Irish athletic therapists when determining RTP, and a 2-domain concussion assessment was specified by 34.0% (18/53). The athletic therapist was chosen by 73.1% (38/52) of Irish athletic therapists as being primarily responsible for RTP decision making, followed by 15.4% (8/52) who named the team physician. They indicated the player was primarily responsible for final RTP decisions in 5.8% of cases (3/52).

A 3-domain concussion assessment was selected by 9.6% (16/166) of Canadian athletic therapists when determining RTP, and a 2-domain concussion assessment was specified by 50.0% (83/166). The athletic therapist was cited by 37.2% (61/164) of Canadian athletic therapists as being primarily responsible for RTP decision making, followed by 32.9% (54/164) who named the team physician and 17.1% (28/164) who chose a general physician. The coach and player were never selected as being primarily responsible for final RTP decisions.

Multidimensional Assessment Use By Level of Education and Clinical Experience

Among Irish athletic therapists, the odds of using a 2-domain minimum concussion assessment at initial evaluation and RTP, respectively, were not different between those with master's and bachelor's degrees (OR = 1.59; 95% CI = 0.44, 6.16; P = .48 and OR = 1.08; 95% CI = 0.30, 4.22; P = .91) or by years of clinical experience (OR = 0.98; 95% CI = 0.90, 1.06; P = .65 and OR = 0.95; 95% CI = 0.85, 1.03; P = .24). We did not generate models for 3-domain concussion assessments because of the low reported frequencies (n ≤ 2).

Canadian athletic therapists with master's degrees had greater odds (OR = 1.80; 95% CI = 1.41, 1.95; P = .01) than those with bachelor's degrees of completing 2-domain minimum assessments at initial evaluation but not 3-domain assessments (OR = 1.47; 95% CI = 0.71, 2.22; P = .15). Their years of clinical experience were not associated with different odds of performing 2-domain (OR = 1.02; 95% CI = 0.97, 1.06; P = .50) or 3-domain (OR = 1.03; 95% CI = 0.99, 1.08; P = .14) concussion assessments at initial evaluation. In the RTP timeframe, no odds differences were observed for 2-domain (OR = 0.72; 95% CI = 0.33, 1.57; P = .41 and OR = 1.00; 95% CI = 0.97, 1.04; P = .84) or 3-domain (OR = 0.35; 95% CI = 0.11, 1.13; P = .07 and OR = 1.03; 95% CI = 0.97, 1.09; P = .28) concussion assessments for education or clinical experience, respectively, among Canadian athletic therapists.

Concussion Knowledge

We examined overall concussion knowledge among Irish and Canadian athletic therapists. Irish athletic therapists demonstrated 72.8% symptom recognition on average, whereas Canadian athletic therapists demonstrated 76.6% (Table 3). Previous researchers¹⁵ using this symptom recognition survey determined that American athletic trainers correctly identified 78% of concussion signs and symptoms. Therefore, Irish and Canadian athletic therapists displayed comparable symptom recognition as American athletic trainers using the same measure. Importantly, symptom recognition items such as bleeding from the ear or weakness in neck movements (Table 3) had low frequencies of correct responses that may be attributed to instructions being misconstrued and participants identifying more severe traumatic brain injury symptoms. Although it is only 1 assessment component, the symptom checklist is the most sensitive concussion diagnostic assessment,^4–6 and therefore, clinicians should maintain their knowledge of concussion signs and symptoms to ensure recognition.

Irish and Canadian athletic therapists responded to the patient-clinician scenarios (Table 4) in accordance with current consensus guidelines overall.^1,24–27 However, 1 concerning finding was the high proportion of yes responses to item 3 in Table 4, which implies that athletes would be able to RTP if their clinical examination (eg, Glasgow Coma Scale, Maddocks questions, neurologic assessment) did not show abnormalities but the player stated, “I'm fine, I just got my bell rung.” For this item, 58.3% and 39.5% of Irish and Canadian survey participants, respectively, responded yes. In comparison, approximately 46% of American athletic trainers earlier gave the same response.¹⁵ Allowing individuals to RTP in the suggested context may result in prolonged recovery^2,3; secondary injury; and rare yet catastrophic injury (ie, second impact syndrome).²⁸ Health care providers need to identify the colloquial “had my bell rung” as a descriptor for a transient moment of deficits in cognitive or motor function with or without the presence of symptoms and conduct a thorough multimodal assessment.²⁴

Most patient–clinician scenario responses also yielded higher percentages of yes responses for scenarios asking athletic therapists if athletes would be allowed to RTP at their institution compared with the identical scenario specifying if athletic therapists feel comfortable (Table 4). The high proportions of yes responses to item 3 and the be allowed items were previously noted among American athletic trainers.¹⁵ Athletic therapists may not thoroughly consider the importance of athletes reporting “having their bell rung” (Table 4, items 3 and 4) versus specific signs and symptoms, despite previous consensus statements explicitly indicating athletes should be removed from play in these circumstances.²⁴ Also, the additional stakeholders identified as being involved in RTP decision making or the specific RTP guidelines may negatively influence what would be allowed at an institution versus what the athletic therapist feels comfortable with. Clinicians should aim to implement medical models autonomous from athletic department or club administration stakeholders to ensure unbiased diagnoses,²⁹ and ARTI and CATA should consider monitoring and augmenting concussion education to improve concussion practices.³⁰

Concussion Characteristics

Irish athletic therapists reported a relatively low rate of observed concussions (2.5 concussions per athletic therapist annually) relative to Canadian athletic therapists (12.2 concussions) and American athletic trainers (16.0 concussions).⁸ The most frequent concussions noted annually for Irish (Gaelic football, rugby)^31–33 and Canadian (American football, rugby; Table 2)^34–36 sports in the present study were comparable with the sport concussion proportions in established epidemiologic studies. Irish athletic therapists described relatively high proportions of loss of consciousness (45.6%) and amnesia (58.8%), whereas Canadian athletic therapists recounted comparable proportions relative to the 2% to 6% and 10% to 12%, respectively, that have been reported (Table 2).^37,38 The observed proportions of concussions with symptom recovery and RTP taking >10 days were greater for Irish athletic therapists (68.4% and 98.7%, respectively) than for the Canadian cohort (26.9% and 44.6%, respectively) and US athletic trainers (28% and 59%, respectively).^37,38 These discrepancies may be related to sport-specific guidelines, such as the Irish Rugby Football Union's concussion RTP protocol requiring removal from sport for a 21-day minimum.²¹ Other variations may reflect the inherently different sports, cultures, and policies across countries or the possibility that Irish athletic therapists may not have diagnosed all experienced concussions among their patients, as evidenced by the self-reported low annual concussion rates and high prevalences of loss of consciousness and amnesia (Table 2). Regardless, these findings should not be interpreted as true epidemiologic outcomes, and future researchers should comprehensively examine concussion epidemiology in Irish and Canadian sports.

Concussion Assessment and Management

Our study provides early insights into the concussion assessment and management benefits supplied by Irish and Canadian athletic therapists and highlights areas for improvement. The current use of assessments among Irish and Canadian athletic therapists as well as those described by American athletic trainers are shown in Figure 2.⁸ Irish and Canadian athletic therapists conveyed high levels of use of clinical examinations, standardized sideline assessments, and postural stability measures for concussion diagnosis, and these levels were comparable with those of American athletic trainers (Figure 2).⁸ A low percentage of Irish athletic therapists used symptom checklists, and few Irish or Canadian athletic therapists used any neurocognitive testing method. Low frequencies of 2- and 3-domain assessment battery use were noted among Irish athletic therapists, and low 3-domain use was seen among Canadian athletic therapists. Use of 2- and 3-domain assessments was even less common for RTP decision making among both cohorts. Previous investigators¹⁵ of American athletic trainers demonstrated that 52.7% used 3-domain assessments in 2018 (Figure 2). Contrary to our hypotheses, higher levels of education and clinical experience generally were not associated with multidimensional domain assessment practices, except that Canadian athletic therapists with master's degrees had greater odds of using 2-domain but not 3-domain assessments. Our hypotheses were based on surveys of American athletic trainers in which those with fewer years of clinical experience and higher levels of education displayed greater odds for optimal clinical practices.^8,15 Why these factors affected American athletic trainers more than Irish or Canadian athletic therapists is unknown. Our findings did not allow us to determine why athletic therapists and athletic trainers implemented these practice patterns. However, this collective body of work surrounding concussion practices highlights the observation that clinical practice does not meet international consensus guidelines¹ and provides clinicians and academic stakeholders in all 3 countries with information that can enhance program and education development.

Since 1997,³⁹ global consensus^1,24–27 has called for symptom, balance, and neurocognitive assessments at minimum when diagnosing sport-related concussion. Symptom checklists and balance assessments are often cost-free evaluations for clinicians. Neurocognitive testing exists across many platforms (eg, paper and pencil, computerized) at various price points with equitable psychometric properties, which may facilitate accessibility for clinicians. Yet funding in Canada and Ireland for computerized neurocognitive testing may be a large barrier to implementation, especially in nonprofessional sport settings, and may partially explain suboptimal use of computerized neurocognitive testing. Athletic therapists should aim to implement a 3-domain assessment to ensure accurate concussion diagnosis and may need to request additional funding from stakeholders to allow computerized neurocognitive testing to be more readily implemented.

Irish and Canadian athletic therapists most frequently used specific RTP guidelines, a clinical examination, and standardized sideline assessments to determine RTP eligibility (Figure 1E). The RTP eligibility methods recorded were similar to those of American athletic trainers, who also most often used RTP guidelines (91%) and a clinical examination (88%). The second and third most used methods to determine RTP eligibility differed in that American athletic trainers relied on their directing physician's recommendation (68%) and computerized neurocognitive testing (61%),⁸ whereas computerized neurocognitive testing was rarely administered by Irish and Canadian athletic therapists. The RTP practices are generally promising among Irish and Canadian athletic therapists, but it is valuable for clinicians to reexamine patients using the 3-domain assessment, at minimum, to verify that function has returned to preinjury or normative levels after concussion. Current international consensus guidelines¹ indicated that computerized neurocognitive testing was not a requirement for concussion diagnosis but provides additional information beneficial for assessment and RTP decision making. Importantly, a lack of objective measures can lead to biased, subjective RTP decisions and may introduce postconcussion complications.^2,3 Clinicians should aim to fully implement international consensus RTP guidelines^1,24–27 in their concussion protocols to promote patient safety. Future authors should monitor Irish and Canadian athletic therapists' concussion management strategies to monitor whether clinical practice is keeping up with evidence-based guidelines.

Limitations

This study was completed during the COVID-19 pandemic. To account for nonpandemic-related practices, we explicitly instructed participants to respond as they would have before the pandemic and during normal work responsibilities. The survey study design inherently had the potential for response, recall, or social desirability bias, or all of these. However, participants were instructed to answer honestly and accurately throughout the survey and were allowed to leave items blank or skip items; furthermore, the research team's contact information was supplied for any questions. Our survey also had various response rates between cohorts (49.7% for Irish athletic therapists, 10.1% for Canadian athletic therapists), although both response rates were in line with those of similar surveys.^8,40 Lastly, whether the surveyed Irish and Canadian athletic therapists were representative of their respective ARTI and CATA organizations is unknown. At the time of the survey, demographics were not collected by or available from the organizations, and thus, we could not compare demographics between respondents and the organizations.