The higher-order and corresponding lower-order themes are shown in table 3. In hierarchical order of significance, the five higher-order themes that emerged were (1) Clinical Judgement and the Interaction with Assessment Tools (CJ1), (2) Trust in Diagnostic Tools and Protocols (TD2), (3) The Evolution of Practice in Concussion Management (EP3), (4) Relationships and Athlete Specific Insight (RI4) and (5) Rugby Union Culture (RC5). All higher-order themes were interrelated through the overarching theme of familiarity. It is pertinent to acknowledge the lead author’s epistemological position of pragmatism in the formation of themes and areas of interest during the reflexive process.
CJ1: Clinical judgement and interaction with assessment tools
CJ1 explores the origins of clinical judgement among clinicians, how knowledge, experience and contextual understanding are synthesised to guide decisions regarding head injuries, and how head injury assessment tools, such as SCAT, are used. The roles held by the interviewed participants all required a degree in either medicine or physiotherapy, with most participants pursuing further postgraduate qualifications, for example, ‘From the Royal College of Emergency Medicine, I’ve got a diploma in Sports and Exercise Medicine’ (M3). All participants were currently working in England or Wales, but many had experience in European and Oceanic countries. Clinical judgement is multifarious, and HCPs place great value on their clinical judgement, for example, ‘You give me a test that’s sensitive and specific, then you can take away all my clinical judgement. But until you give me that, then I want to be able to use my clinical judgement’ (M3).
Formalised education
Participants highlighted the prerequisite qualifications, for example, ‘we have to have recognised trauma qualifications to be able to be pitch-side’ (M7). HCPs remarked that education is ever-evolving and seeks to reflect the most up-to-date guidelines and approaches, for example, ‘…making sure that the correct process is understood and implemented with regard to video review’ (M1). HCPs acknowledged the importance of education, especially concerning technology.
Matchday processes
All HCPs highlighted the matchday processes that they followed, for example, ‘who’s doing the HIA, if it’s either the doctor or the match day doctor…, there’s a lot of work that goes on before you actually reach the stadium’ (M1). In the event of a head injury, there was a consensus among the HCPs that observing the mechanism of the head impact event was critical, as described:
‘I mean, for me, like you get a feel for what is an awkward contact just from watching a lot of rugby. So, just like watching the game and seeing the collision, how they’ve fallen. How they’ve been hit’ (M8).
This extract also highlights the experiential and tacit knowledge that HCPs acquire. All of the interviewees commented on the importance of video review as part of the process. One medic outlined the specific protocol for the video analysis, stating:
‘So that is what you look for the mechanism, first of all, you look for the immediate response, OK, you look for the delayed response, the return to feet and then the return to play. So, I have to go to all of those steps in my head very, very quickly to establish what I think is wrong with this person’ (M1).
Head injury management
As the analysis of injury mechanism is performed, clinicians treat the player: ‘First and foremost, I’m going to check the player. So, there’ll be an on-field clinical assessment’ (M3). Six of the eight HCPs highlighted neck injuries as a primary concern during their initial assessment; ‘I have to clear their neck. First of all, to make sure … that we don’t suspect any neck injury, and we can only do that if they’re completely alert as well’ (M1). Several factors that would lead to the immediate and permanent removal from play were outlined by one HCP: ‘There are a number of signs and symptoms such as loss of consciousness… All of those things are obvious things that HIA is not applicable’ (M1). Conversely, several HCPs highlighted the signs and symptoms that would warrant further investigation through an HIA1, for example, ‘they kind of look like past, you sort of thing. So, it’s looking for that. I think they call it a glassy sort of eye’ (M8). HCPs also highlighted the accessibility of current testing protocols:
‘Yeah, can be done in just a room. Like you can have 80 000 yelling and screaming, and you just kind of need a quiet room with a piece of tape on the floor where you can kind of go through a SCAT’ (M8).
TD2: Trust in diagnostic tools and protocols
This theme explores the tension between reliance on standardised tools and the understanding that no tool is infallible, as shown in this quote: ‘At the moment, I think they’re good because what better tests are there out there?’ (M8). Through examining the confidence placed in concussion management tools, this theme questions how much trust practitioners can or should place in the current methods.
Scrutiny of current processes
Validity and reliability were common discussion points related to current HIA tools and protocols. The reliability of the SCAT was perceived positively among participants: ‘By and large, pretty robust in terms of its reproducibility. So, as in you do a SCAT, I do a SCAT. We should be getting pretty much the same result’ (M3). However, participants often remarked on the accuracy of the SCAT, for example, ‘Because they know that they can be concussed and still pass it’ (M2). Participants were accepting of the mandated protocols but also demonstrated a vision towards the future: ‘So the narrative around this in my head is, it’s the best thing we’ve got at the moment, but I don’t know how accurate it is’ (M3).
Perception of HIA
The imperfect and iterative nature of testing protocols associated with the complexities of head injury is captured when a participant (M1) stated: ‘I think that everyone, you know, knows the crack and knows it’s not perfect, but knows that you know it’s a positive step for player welfare’ (M1). It is critical for the ongoing improvement of player health and welfare systems that medical staff view the HIA as a valuable addition to their diagnostic and prognostic process.
Gold standard
Participants acknowledged the constraints of current assessment tools and often drew comparisons with diagnostic and prognostic tools used in their practice:
‘It’s not a gold standard test. As in, if we’re saying looking at a broken leg and I’ll say let’s look at an ultrasound scan, how useful is that? I’ll compare it to an X-ray, which is the gold standard. There’s no gold standard test for concussion’ (M3).
This extract highlighted both challenges and opportunities in the field of sport-related concussion. However, other participants took an alternative view: ‘When you actually break it down, it’s pretty robust, the sensitivity, specificity, it’s pretty good’ (M1). Demonstrating a more positive perception held by some HCPs.
EP3: The evolution of practice in head injury management
EP3 looks to demonstrate the unique demands of rugby union and poses thoughtful consideration of what constitutes progress in this field: ‘We wouldn’t give a shit about it [diagnosing concussion] if concussion didn’t have any long-term consequences’ (M3). This extract summarises the key motivations behind the ever-evolving field of head injury management and invites reflection on whether these changes are driven by advances in science or by shifts in ethical thinking.
Contemporary developments
Although well established, the use of video was highly regarded in terms of the evolution of HIA processes, for example, ‘I think they’re evolving, and they’re heading in the right direction. I think the massive thing in that evolution has been the addition of video’ (M2). This frequent observation highlights the importance of assessing the injury mechanism in their HIA process.
Participants also commented on the introduction of a computerised, app-based HIA management system. The ‘SCRM app’ was generally perceived positively, with participants in favour of the user-friendly interface: ‘It’s quite a nice interface to be fair. So, anyone who’s got a little like an orange circle around it and a little thing means that they’ve had a concussion’ (M4). However, this participant also highlighted logistical challenges associated with such a platform: ‘We had one where the app would not open, and we’ve got ten minutes in a game to get through that, and that is really stressful. I literally want to throw my phone’ (M4).
Systematic challenges
Many challenges emerged when reflecting on the situational and systemic barriers to the further evolution of acute concussion management. The challenge of differentiating between head impacts and concussion injuries was repeatedly reported, for example, ‘Like if someone’s been kicked in the head and they’ve just reported they have a sore head. Of course, he’s going to, he got kicked in the head’ (M4).
As well as the nuances of a collision-based sport, administering the HIA in an international setting poses unique challenges: ‘So having someone that knows the player and can do the HIA in the language and tongue that the players are used to would probably improve things further’ (M2). Additional challenges are related to the resistance from key stakeholders who have previously had a poor experience, for example, ‘Some people have seen it not work. You know, some people have unfortunately had false positives as well. In big games’ (M1). This highlights the human-tool interface as a challenging factor that could be addressed in future iterations of HIA guidelines.
Desirable future directions
There was agreement that a computerised system was a favoured means of administering an HIA tool. Participants repeatedly identified areas of interest: biomarkers, impact measurement and digital assessments of neurocognitive and motor function. Biomarkers were frequently discussed, but participants also acknowledged that this was currently beyond the scope of current testing modalities: ‘If a swab was completely objective… sensitive and specific… to swab like a rapid flow test, like a, you know, like a lateral flow test. Brilliant. Love that. You know, that’s the Nirvana’ (M1).
Comments associated with impact measurement were attributed to in-game metrics and neurocognitive and motor function assessments with pitch-side testing. HCPs highlighted the value in recording chronic impact exposure via instrumented mouthguards: ‘not necessarily to diagnose concussion, but actually that will help us with regards to understanding contact load through someone’s career’ (M1). In terms of pitch-side testing, HCPs were in favour of motor control-related testing, for example, ‘you know certainly encompassing the balance, the neurocognitive function’ (M7). HCPs also indicated value in assessing both fine and gross motor control: ‘don’t know how you would do it, but reaction time, joint position, sense or like body proprioception and noting the changes in that post concussion’ (M8). One HCP summarised their desired future directions succinctly: ‘Quick. Reproducible. Easy to apply, and easy to interpret’ (M3).
RI4: Relationships and athlete-specific insight
This theme looks to shed light on the relationship dynamics within the high-performance team, focusing primarily on the nuance and value of player-HCP relationships, for example, ‘That’s an extra little string to the bow compared to when an independent match day doctor does it. Who doesn’t know the player at all’ (M2). Familiarity with players can foster trust and deeper insights into their health, yet it also raises ethical questions about maintaining objectivity in high-pressure situations.
Knowing the player
HCPs place great value on familiarity with players, with all participants referencing the importance of knowing the player:
‘Experienced clinicians, they’ll probably tell you that the most valuable bit is going to be walking from the field of play to the medical room where you’re engaging with that player and when you’re working with a squad that you know. Then you know how players behave, and it’s how they are, compared with how they are normally. That’s where the real value is’ (M2).
Communicating with athletes
Participants repeatedly articulated that understanding the nuances of athletes’ characters is advantageous when communicating during the HIA process: ‘Just have a chat with him. Give him a squirt of water. Look him in the eyes. Have a chat with them, and I can generally tell whether they’re right’ (M8). Demonstrating communication as a critical feature of the HIA process.
Stakeholder conflict
Participants conveyed varying experiences with stakeholders within the performance team, for example, ‘very, very, very dependent on your coach’ (M2). Five participants explicitly commented on their experiences with coaching staff, offering both positive and negative feedback. While some HCPs articulated conflict with coaches: ‘from a coaching perspective and from a medical perspective with a lot of upset because it’s like, well, how can they do XY and Z and be back in seven, but we’re out for three weeks’ (M7). HCPs also stated that stakeholders generated a positive working environment, for example, ‘You know, that team environment does create people looking out for you both as a, you know, within the team, but also within sort of management and stuff. So I think it’s quite a nice environment’ (M2).
Rc5: Rugby union culture
The theme of Rugby Union Culture explores the complex and diverse interplay of key stakeholders within the performance environment. The physicality of collision-based sport inherently gives rise to unique social structures and linguistic nuances that shape this theme.
Hardiness
HCPs conveyed the camaraderie that is at the heart of rugby union:
‘There’s a massive team environment, which is really good. I think that boys don’t like to show weakness, so there’s that sort of culture of, you know, bravado and being tough. But there’s also a massive sort of feeling of looking out for each other’ (M2).
The participants expressed a clear sense of being embedded within the team. This extract also confronts the ‘bravado’ associated with Rugby Union environments, with one participant stating: ‘there’s definitely a kind of hard culture’ (M5).
Language of concussion
Rugby culture also contributes to the language used when referring to head impact events that could potentially trivialise the injury process, with participants recalling athletes having ‘taken a knock’ or that they have ‘picked up a bump’. These examples offer further insight into the cultural nuances of collision-based sports.
