The definition of concussion adopted for the RPQ reflects a widely recognised description focusing on a disturbance of neural functioning (see Appendix B). It requires the injury to result in 'at least dizziness, disturbed vision, confusion and! or a loss of consciousness' (Newcombe, 1995), incorporating symptoms endorsed by the American Academy of Neurology, Quality' Standards Subcommittee (1997) as indicative of
concussion. As discussed in Chapter 2, Section 2.1.4 the term 'head injury' was utilised in the construction of these questionnaires in a bid to avoid the value laden connotations associated with the terms 'concussion' and 'MmI'.
a-IAPTER 7 ME1HOD -PART !
To establish the rate of MTBI respondents were asked to record the number
oflmd
injuries
they had received playing rugby during the target season (current) and prior to the target season (history). Responses were recorded on Liken-type scales, ranging from'None' to '4 or more' to establish current MTBI, and 'None' to '15 or more' to obtain the respondents MTBI history. As the latter scale required consideration of injuries sustained much earlier in time, respondents were required only to provide an approximation of the number incurred.
To identify the existence of a relationship between the rate of MTBI and the
frequency of non-MTBI related injury, respondents were asked to indicate the number of injuries sustained to eleven other regions of the body during the target season. In the 2000 RPQ, the use of an accepted definition of 'injury' was incorporated (an additional question) . to establish the disparity between the injuries reponed in response to the question above and those injuries requiring medical attention and/or requiring them to miss competition for at least one week.
Sewity of
Brain Injury
Many of the questions adopted to determine the severity of MTBI replicated those used by Gerberich et al. (1983). As in this earlier study, players were asked whether they had suffered a LOC ("Did you lose consciousness following a blow to the head?") and to indicate their experience of eight concussive symptoms associat,;d with MTBI ("Did you have any of the following symptoms/problems after a blow to the head, even though you may not have been unconscious?"). Respondents were also given the option of including symptoms that were not listed.
The 1998 and 1999 versions incorporated a question to establish symptom duration, which asked whether any of the symptoms respondents had indicated were being
experienced at present. While this question was initially incorporated to help establish MTBI severity, it was eliminated from the 2000 version on the basis that an accurate
rnAPTER 7 METIIOD -PART !
estimate of duration could not be established as the date of injury was not recorded. Responses could not therefore be considered a reliable indicator of severity and were not incorporated in any subsequent analysis. As an additional indicator of severity,
respondents were asked to identify how many of the
hftld injuries
sustained throughout the season had been diagnosed by a medical professional as concussion.P/ayer-
and Game-ReIat«i Varidhles Associataiwith Brain Injury
To obtain information pertinent to injury patterns and risk factors associated with
MfBI, questions adopted by other sports research were incorporated in the RPQ. These questions included identification of the players' age and grade (Lingard et al., 1976
)
,position (Roux et al., 1987; Dalley et al., 1982; Albright et al., 1985; Seward & Patrick,
1992
)
, whether the injury occurred during a match or training session (Roux et al., 1987)
,during the first or second half (Lingard et al., 1976; Wekesa et al., 1996
)
, the phase of play during which the injury was sustained (Dalley et al., 1982; Norton & Wilson, 1995; Bird et al., 1998)
, and the way in which the injury was received (i.e., regulation manoeuvres or foul play) (Norton & Wilson, 1995)
. Respondents were provided with a variety of possible answers in relation to each of these questions of which they were required to select one optlon.V se
of
ProtfX."til£Gear
Previous research has examined the relationship between TBI and mouthguard (Dalley et al., 1982; Dalley et al., 1992; Norton & Wilson, 1995
)
and headgear use (Norton& Wilson, 1995
)
. Due to the retrospective nature of the RPQ, the accuracy of players' recall regarding their use of protective gear at the time injury was questionable. Hence, respondents were asked to indicate their frequency of mouthguard use ('always','sometimes', or 'never') during the target season in matches and training sessions. This line of questioning was also adopted to examine the use of headgear, but pertained only to match situations.
G-IAPTER 7 MElHOD -PART I
Lewis ofR� AssessmmtandM�
Respondents completing the 1998 and 1999 RPQ were asked to identify the person (if any) who attended to their injwy(s) (coach, referee, St. Johns personnel, or a member of team management) and indicate where this attention was first received. Response options included: (1) whether the
head
injury was first attended during the game/training session; or (2) on completion of the game/training session at either: (a) the rugby grounds; or (b) a doctors surgery or hospital.Three questions were introduced into the 2000 questionnaire to determine why players sustaining a MmI may not receive attention. The first newly introduced question required respondents to record the number of 'current season'
he::Td injuries
that had received some form of attention. If respondents had not received attention they were directed to the second question where the selection of one of three reasons for the injury not being reported was required. These reasons (in multi-choice format) included: (1) the injury being considered too minor to report; (2) the player choosing not to report despite persisting symptoms; and (3) the absence of persons to attend the injury despite the player's willingness to report it. The opportunity to record other reasons for attention not being received was also given. If respondents indicated the second of these three reasons, they were directed to the third new question that was designed to investigate their reason for not reporting. Responses associated with this question included: (1) not wanting to be removed from the game; (2) not wanting to risk missing future games (Lovell & Collins,1998); (3) not wanting to appear 'soft'; and (4) thinking the injury was not severe enough to report. Again respondents were given the opportunity to record any other reasons not listed.
As knowledge of a player's MTBI history is essential to consider regarding retum-to
play decisions, respondents were asked to indicate whether their coach was aware of previous
head
injuries they had sustained.GIAPTER 7 ME1HOD -PART I
AcIherrtue
to Reg;datimsand
R�Players were asked whether the 3-week mandatory stand-down period was observed for any of the head injuries sustained during the target season. The 1999 version also asked whether this period of abstinence had been enforced for
he:Jd
injuries sustained to the target season, although this question was abandoned for the 2000 RPQ as the information obtained was not considered reliable.Respondents were also queried as to whether they had ever been advised not to play rugby by a medical practitioner or neurologist due to
hmd
injury. Although the question intended to identify those having been advised of a permanent exclusion from rugby, the question was interpreted by some as referring to a temporary exclusion. Themisinterpretation of this question resulted in its rephrasing for the 2000 version, to read "Have you ever been advised not to play rugby ever again by a medical practitioner or neurologist as a result of head injury?" .
7.2.2 The Headgear and Mouthguard Use Questionnaire (HMQ)
The HMQ (refer Appendix C) was designed to obtain information pertinent to players' attitudes regarding the use of headgear and mouthguards. The questionnaire consisted of 15 questions, the majority requiring a ry es', 'No', 'Always', 'Sometimes', 'Never', 'Maybe', or 'Don't know' response by way of a tick box.
Respondents were asked: (1) whether they had ever sustained a
hmd
injury whilst playing club grade rugby; (2 - 5) how often they used headgear and mouthguards (Always, Sometimes or Never) during both competition and training; (6 -7) whether they believed mouthguards could: (a) help prevent dental injuries; and (b) aid in the prevention of concussion; (8) whether they believed headgear could aid in the prevention of concussion; (9 - 12) if they would bereluctant
to play and/or rrfose to play without either piece of protective gear; (13) the type of mouthguard worn from one of three options: (a) Boil andCRAPTER 7 ME1HOD -PART I
Bite;
(b)
Custom-made; or (c) Other (allowing for details to be supplied); (14) the make or brand of headgear used; and (15) the reason they opted to wear headgear.7.2.3 The Assessing and Managing Head Injury Questionnaire (AMQ)
The AMQ (refer Appendix D) was developed to gather information from coaches, members of team management, and referees, to establish their ability to attend and manage MTBI. The formulation of this questionnaire involved consideration of some of the issues raised by the RPQ, with many of the questions incorporated in the questionnaire based on a policy statement formulated by Sports Medicine New Zealand (1999). In an effort to generate more consistent practices, recommendations pertaining to the recognition, assessment, and management of a brain-injured player were established by Sport Medicine New Zealand after consultation with the NZRFU Medical Advisory Panel and expert reviewers from both New Zealand and Australia.
The AMQ consisted of 24 questions of which the majority featured tick boxes to indicate the respondent's choice. The remaining questions were open-ended, requiring a brief written response.
Respondents were asked to indicate their age, gender, current role {e.g., coach, referee, team management, etc.), grade(s) involved with, and the person viewed as most frequently providing attention to a 'head-injured/ concussed' player during competition.