Daniel Tadmor

Individuals who sustain a concussion can experience a range of symptoms which can significantly impact their quality of life and functional outcome. This study aims to understand the nature and recovery trajectories of post-concussion symptomatology by applying an unsupervised machine learning approach to data captured from a digital health intervention (HeadOn). As part of the 35-day program, patients complete a daily symptom diary which rates 8 post-concussion symptoms. Symptom data were analysed using K-means clustering to categorize patients based on their symptom profiles. During the study period, a total of 758 symptom diaries were completed by 84 patients, equating to 6064 individual symptom ratings. Fatigue, sleep disturbance and difficulty concentrating were the most prevalent symptoms reported. A decline in symptom burden was observed over the 35-day period, with physical and emotional symptoms showing early rates of recovery. In a correlation matrix, there were strong positive correlations between low mood and irritability (r = 0.84), and poor memory and difficulty concentrating (r = 0.83). K-means cluster analysis identified three distinct patient clusters based on symptom severity. Cluster 0 (n = 24) had a low symptom burden profile across all the post-concussion symptoms. Cluster 1 (n = 35) had moderate symptom burden but with pronounced fatigue. Cluster 2 (n = 25) had a high symptom burden profile across all the post-concussion symptoms. Reflecting the severity of the clusters, there was a significant relationship between the symptom clusters for both the Rivermead (p = 0.05) and PHQ-9 (p = 0.003) questionnaires at 6-weeks follow-up. By leveraging digital ecological momentary assessments, a rich dataset of daily symptom ratings was captured allowing for the identification of symptom severity clusters. These findings underscore the potential of digital technology and machine learning to enhance our understanding of post-concussion symptomatology and offer a scalable solution to support patients with their recovery.

The health-service redesign that came with the preparation for the surge of COVID-19 had a potential of disrupting the Family Medicine internship programme like it did to many other health and academic programmes. A team of Cape-Town based Community Health Centre (CHC) doctors mitigated this challenge by designing an innovative tool that facilitated ongoing supervision of the interns in order to achieve the outcomes of the Health Professions Council of South Africa (HPCSA).

Objectives: This study investigated the disclosure and reasons for non-disclosure of possible concussions and their symptoms in National Rugby League Women's (NRLW) Premiership players in Australia. Design: Cross sectional survey. Methods: During the 2022 NRLW season, NRLW players were invited to participate in a voluntary, anonymous, online survey exploring (i) player demographics, (ii) rugby playing history, (iii) concussion disclosure, and (iv) instances of, and reasons for, non-disclosure of possible concussions to medical staff during the past two seasons. Logistic regression analyses were used to identify reasons for non-disclosure of possible concussions in NRLW players. Results: Of the 132 eligible participants, 86 players responded to the survey and 63 % (n = 54/86) reported that they always disclosed a possible concussion during the past two seasons. A substantial number of NRLW players surveyed (n = 32/86, 37 %) did not disclose a possible concussion to their team or medical staff on one or more occasions. Sixty-three players (73 %) always reported symptoms during a medical assessment. Twenty-three players (27 %) did not disclose their symptoms during a medical assessment, primarily during or after a game or training session (n = 12/23, 52 %). Of the players who did not disclose their possible concussion symptoms, the two main reasons for non-disclosure were ‘not wanting to be ruled out of the game or training session’ (n = 8/23,35 %) and not being ‘sure if the symptoms were related to concussion’ (n = 8/23, 35 %). Most surveyed players (n = 74/86, 86 %) reported attending mandatory concussion education sessions at their respective clubs. Conclusion: We found high rates of non-disclosure amongst NRLW players, which is inconsistent with previous research suggesting that women are more aware of their symptoms than men and more likely to disclose their concussions. Not wanting to be ruled out of the game or training session and being unsure if the symptoms were related to concussion were the two most common reasons for nondisclosure. Concussion education initiatives could promote a supportive culture fostering disclosure amongst all stakeholders to ensure optimal player welfare.

Objective To establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome. Design This consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%. Setting Specialist outpatient services. Participants Members of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England. Primary outcome measure A consensus statement on the structure and process of specialist outpatient care for patients with concussion in England. Results 55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics. Conclusions This work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.

Objectives: Quantify concussion under-reporting and factors associated with concussion reporting in rugby league players. Design: Cross-sectional online anonymised survey. Setting: Rugby league in Europe. Participants: 422 elite men’s and women’s players registered with the governing body. Interventions: Independent variables: age, playing history, international experience and playing position. Outcome Measures: Dependent variables: concussion history, prevalence and reasons of under-reporting concussion, concussion knowledge and long-term implications of concussion. Results: 19.5% did not report concussion-related symptoms to medical staff during the 2020 and 2021 seasons. The most common reasons for under-reporting concussion were ‘didn’t want to be ruled out of a match’ (34.5%) and ‘didn’t want to let down team’ (24.3%). Symptoms of concussion were correctly identified on 73.5 ± 0.2% of occasions. At the start of their senior rugby league career versus now, 65.2% and 88.6% of players had an appropriate level of knowledge about concussion and the potential long-term implications. 56.7% of players were concerned about the potential long-term implications from concussion, and 11.3% of players would encourage their/family members children to not play rugby league. Conclusion: More players in this study tried to hide concussion symptoms than previously reported in a similar cohort. The main reasons for not reporting concussion appear linked to the players perceptions of what is beneficial for the team, suggesting both performance and medical staff should encourage the reporting of concussion symptoms. This is an individual modifiable risk-factor and should be a priority for rugby league players and all stakeholders for supporting long-term concussion management.

Concussions in contact sports are challenging for athletes, health professionals and sporting bodies to prevent, detect and manage. Design of interventions for primary prevention, early recognition of concussion and continuing to improve postconcussion management are essential for protecting athletes and promoting brain health. Over the last decade, there have been advancements in video technology for analysing head impact events and improvements in the clinical management of concussions. This study protocol describes how researchers, clinicians and staff from the Australasian National Rugby League (NRL) have brought these advancements together and developed a database of videos with head impact events and clinical outcomes. The intended outputs from this work will enhance the understanding of head impact events in NRL, from biomechanical and gameplay factors to concussion and return to play outcomes. Publishing this protocol increases the transparency of this large-scale effort to better identify head impacts and their relationship to concussions and player movement behaviour to contextualise these variables to generate new knowledge and support the reproducibility of these emerging findings. Between 2017 and 2023, over 5250 head contact cases were recorded in the database, from which >1700 head injury assessments were performed, and >600 concussions were diagnosed. Future studies using these data are planned to inform both primary and secondary injury prevention initiatives, such as risk analysis and prediction of game scenarios that result in concussion, as well as investigation of features and factors that help to inform the duration of recovery and return to play.

Objectives Quantify and identify factors associated with concussion underreporting in Super League rugby league players. Design Cross sectional survey. Methods During the 2022 season preseason, 422 Men's and Women's Super League players completed an online survey quantifying player demographics, rugby playing history, concussion history, prevalence of, and reasons for underreporting concussion, concussion knowledge and long-term implications and perceptions of concussion. Results Overall, 20% of respondents stated they did not report concussion-related symptoms to medical staff during the 2020 and 2021 seasons. The two most common reasons for underreporting concussion were ‘didn't want to be ruled out of a match’ (35%) and ‘didn't want to let down team’ (24%). 65% of players reported an appropriate level of knowledge about concussion and potential long-term implications at the start of their senior rugby career, versus 89% now. In relation to concussion knowledge, symptoms were correctly identified on 74% of occasions. 57% of players surveyed were concerned about the potential long-term implications from concussion, and 11% of players would encourage their/family members' children to not play rugby league. Conclusions The proportion of Super League players who did not report concussion symptoms was similar to rugby league players in Australia. The main reasons for not reporting concussion appeared to be due to perceptions of what is beneficial for the team, suggesting both performance and medical staff should collectively encourage players to report concussion. A player's attitude towards concussion is potentially an individual modifiable risk factor and should be considered within the concussion management of players.

Recognising and removing players with suspected sport-related concussions is crucial for community sports. Objectives Quantify rates and factors associated with non-reporting of concussion symptoms in community rugby league. Methods Overall, 484 community rugby league players aged ≥18 years and 965 parents of rugby league players aged <18 years completed an online survey, regarding concussion history, knowledge, prevalence and reasons for non-reporting of concussion, long-term implications and perceptions of concussion. Results Thirty-five percent of players aged ≥18 years and 22% of parents of players aged <18 years reported at least one concussion in the last two seasons. Forty-three percent of players aged ≥18 years and 5% of parents of players aged<18 years surveyed stated they did not report concussion-related symptoms sustained during 2020 and 2021 seasons. The two most common reasons for non-reporting of concussion symptoms were‘didn’t want to be ruled out of a match’and‘didn’t want to let down the team’. Players aged ≥18 years who received external coaching pressures around concussion were more likely to not report concussion symptoms. Over 40% of parents and players were concerned about the potential long-term implications. Ten percent of players aged ≥18 years and 7% of parents of players aged <18 years would encourage their family members/children to not play rugby league. Conclusions Non-reporting rates of suspected concussion symptoms in adult community players were twice as high as in professional rugby league, with similar reasons (wanting to play and not letting the team down). Engaging coaches to prioritise brain health and providing broader and appropriate education on concussion should be focused on, given the concerns reported by community players and parents.

Objectives: To quantify the incidence of concussion and compare between playing level in male rugby league. Design: Retrospective cohort Methods: Between 2016 and 2022, medically diagnosed concussions in Super League, Championship, and Academy competitions were reported to the Rugby Football League via club medical staff. Anonymised data were analysed using generalized linear mixed-effects models by season, month, and between competitions. Results: Overall, 1,403 concussions were identified from 104,209 player-match hours. Concussion incidence for Super League, Championship, and Academy was 15.5, 10.5, and 14.3 per 1,000 player-match hours, respectively. Championship concussion incidence was significantly lower than the Super League (p<0.001) and Academy (p<0.001). No significant differences were identified between year for Super League (range: 13.3 to 18.8 per 1,000 player-match hours) and Championship (range: 8.4 to 12.1 per 1,000 player-match hours). In Academy (range: 9.6 to 20.5 per 1,000 player-match hours), concussion incidence was significantly greater in 2021 compared to earlier years (2016, p=0.01 and 2017, p=0.03). No significant differences were identified between months for any competition. Conclusions: The incidence of concussion is greater in Super League and Academy compared to the Championship. Academy concussion incidence has increased over time. Different factors between and within competitions, such as changes to medical standards and knowledge, could have influenced the identification and diagnosis of concussion.