Injury Risk Estimation Expertise Assessing the ACL Injury Risk Estimation Quiz

Background: Available methods for screening anterior cruciate ligament (ACL) injury risk are effective but limited in application as they generally rely on expensive and time-consuming biomechanical movement analysis. A potential efficient alternative to biomechanical screening is skilled movement analysis via visual inspection (ie, having experts estimate injury risk factors based on observations of athletes’ movements). Purpose: To develop a brief, valid psychometric assessment of ACL injury risk factor estimation skill: the ACL Injury Risk Estimation Quiz (ACL-IQ). Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 660 individuals participated in various stages of the study, including athletes, physicians, physical therapists, athletic trainers, exercise science researchers/students, and members of the general public in the United States. The ACL-IQ was fully computerized and made available online (www.ACL-IQ.org). Item sampling/reduction, reliability analysis, cross-validation, and convergent/discriminant validity analysis were conducted to optimize the efficiency and validity of the assessment. Results: Psychometric optimization techniques identified a short (mean time, 2 min 24 s), robust, 5-item assessment with high reliability (test-retest: r = 0.90) and consistent discriminability (average difference of exercise science professionals vs general population: Cohen d = 1.98). Exercise science professionals and general population individuals scored 74% and 53% correct, respectively. Convergent and discriminant validity was demonstrated. Scores on the ACL-IQ were most associated with ACL knowledge and various cue utilities and were least associated with domain-general spatial/decision-making ability, personality, or other demographic variables. Overall, 23% of the total sample (40% exercise science professionals; 6% general population) performed better than or equal to the ACL nomogram. Conclusion: This study presents the results of a systematic approach to assess individual differences in ACL injury risk factor estimation skill; the assessment approach is efficient (ie, it can be completed in\3 min) and psychometrically robust. The results provide evidence that some individuals have the ability to visually estimate ACL injury risk factors more accurately than other instrument-based ACL risk estimation methods (ie, ACL nomogram). The ACL-IQ provides the foundation for assessing the efficacy of observational ACL injury risk factor assessment (ie, does simple skilled visual inspection reduce ACL injuries?). It also provides a representative task environment that can be used to increase our understanding of the perceptual-cognitive mechanisms underlying observational movement analysis and to improve injury risk assessment performance

Managing concussion in the real world: Stakeholder perspectives of New Zealand Rugby's concussion management pathway

The potential adverse consequences associated with poor concussion management highlights the need to improve the translation of concussion guidelines into consistent use in real-world sport settings. To facilitate this process, New Zealand Rugby developed a community concussion management pathway to support concussion recognition, diagnosis, and management. This study adopted a pragmatic, descriptive qualitative approach to explore key stakeholders’ perceptions of the concussion management pathway, with the aim to inform policy and practice. Interviews were conducted with 123 participants, including players, parents, coaches, healthcare professionals, and school and provincial union representatives. The framework method was used to analyze data. Themes were organized according to the principles of realist process evaluation that considers contextual factors and mechanisms influencing a program's operation to produce specific outcomes. Contextual factors influencing the concussion management pathway's implementation included governing bodies’ support, existing local resources, general concussion attitudes, or concussion severity. The optimal functioning of the concussion management pathway (mechanism) was influenced by (i) pathway resources, (ii) roles and relationships, (iii) buy-in and support towards the concussion management pathway, and (iv) diligence and communication. Outcomes identified included (i) hitting the target (optimally managed and enhanced awareness) or (ii) missing the mark (dissatisfaction or management gaps). Overall, participants found the concussion management pathway valuable. However, the acceptability of certain policy-related aspects and the underlying attitudes associated with these perceptions, are some areas requiring further investigation and support. Tailoring programs according to end-users’ perceptions is crucial in developing context-sensitive interventions appropriate for a specific setting. These findings may act as a foundation for investigations of concussion management in other settings

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand’s community rugby system’s perceptions of their own and others’ concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players’ welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A ‘framework of responsibilities’ may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders

Knowledge and Attitudes (KA) Surveys on Concussion in Sports: Parents September 2017 Survey. Third Report to Accident Compensation Corporation (ACC)

OVERVIEW This report is the third in a series presenting baseline Knowledge and Attitudes (KA) around concussion in sport. The first report (Reid et al., 2017) focused on referees’ and the second report focused on secondary school students’ knowledge and attitudes about concussion (Reid et al., 2018). This third report focuses on the parents of secondary school students and is termed the “Parents Survey September 2017 Survey”. The ‘Sports Concussion in New Zealand ACC National Guideline’ was released in 2014. The KA studies aim to assess current knowledge and attitudes of secondary school students involved in sports and referees and parents towards concussion in sport following release of the guideline. The results from the Parents September 2017 Survey suggest that the parents of school children involved in coached sports (69/100 = 69% response rate) have some knowledge regarding concussion and show positive attitudes towards correct management of the injury. However, parents expressed a need to know more about how concussion happens, and its prevention and management. The participants in this study have large gaps in their ability to recognise key symptoms and the safe time frame to return to play. Parents reported receiving most information on concussion from medical professionals and their school. Only a small percentage (13%) recognised ACC as source of information and guidance for concussion. Recommendations: • Further education of parents is required to increase understanding of some of the symptoms of sports concussion including amnesia, nausea and insomnia. Changes to simpler terms may be needed. • Further education of parents is needed with regards to the fact that onset of symptoms of concussion may not be evident immediately following injury and can emerge up to several days following injury. • Further education of parents is needed regarding the time frames to return to sport. • Further education of parents is required regarding the potential impacts of multiple concussions. • Further education of parents is required regarding avoiding the use of devices that may affect cognitive function after concussion. • Continuing education programmes for parents are required to ensure the current overall moderate levels of knowledge in the parent group improve

Knowledge Attitudes and Behaviours (KAB) Surveys on Concussion in Sport: Secondary School Students September 2018 Survey. Report # 1 to Accident Compensation Corporation.

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Knowledge Attitudes and Behaviours (KAB) Surveys on Concussion in Sports: Rugby Referees March 2018 Survey. Report #4 to Accident Compensation Corporation (ACC)

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Knowledge, Attitudes and Behaviours (KAB) Surveys on Concussion in Sports: Parents 2018 Survey Report #2 to Accident Compensation Corporation (ACC)

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Knowledge and Attitudes (KA) Surveys on Concussion in Sports: Referee March 2017 Survey. Report to Accident Compensation Corporation

This report is the first in a series presenting baseline Knowledge and Attitudes (KA) around concussion in sport in Rugby Referees March 2017 Survey. The ‘Sports Concussion in New Zealand ACC National’ Guideline was released in 2014. The KA analysis provided an opportunity to assess current knowledge and attitudes of rugby referees towards concussion in sport. The results from the Referee March 2017 Survey suggest that the Auckland-based sample of 140 rugby union referees are knowledgeable regarding concussion, and show positive attitudes towards correct management of the injury. There was a general consensus of the referees that further education for players, coaches and referees is required to optimise management and improve the awareness of concussion. Almost 50% of the referees who participated in the survey reported experiencing a previous concussion, and this, in addition to the high level of current media coverage surrounding concussion, may have contributed to improved recognition of key concussion signs and symptoms. Recommendations • Further education is required to understand some of the symptoms of sports concussion such as amnesia and the use of devices that may affect cognitive function • Further education is needed over the time frames to return to sport • Continuing educations programmes are required to ensure the current overall high levels of knowledge in the referees group remain high. • It will be of interest to measure the impact of the ACC Concussion Guidelines and the Blue Card initiative with this group

Knowledge Attitudes and Behaviours (KAB) Surveys on Concussion in Sports: Coaches September 2018 Survey. Report #3 to Accident Compensation Corporation (ACC)

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