Does the way concussion is portrayed affect public

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BJSM Online First, published on May 3, 2011 as 10.1136/bjsm.2011.083618 Original article

Does the way concussion is portrayed affect public awareness of appropriate concussion management: the case of rugby league Tracey L McLellan,1 Audrey McKinlay1,2 1Department

of Psychology, University of Canterbury, Christchurch, New Zealand 2School of Psychology and Psychiatry, Monash University, Victoria, Australia Correspondence to Tracey McLellan, Department of Psychology, University of Canterbury, Private Bag 4800, Christchurch, New Zealand; tracey.mclellan@canterbury. ac.nz Accepted 28 March 2011

ABSTRACT It is important to identify factors that might adversely affect appropriate medical consultation and management of concussion. One factor that might present a barrier to timely intervention is media portrayal of concussion in sporting events, such as professional rugby league. Accordingly, the current study employed a surveillance method of publicly available broadcast information to establish the incidence rate of probable concussion in the National Rugby League’s Telstra Premiership 2010 season and examined how these injury events were shown to be managed with respect to return-to-play procedures. The incident rate for probable concussion was higher than previously reported: 11.10\1000 player hours (95% CI 5.78 to 16.40) and was likely underestimated. Importantly, most injured players were shown to continue playing or return to play despite being visibly concussed and described as such by the commentary team. Although ‘return-to-play decisions’ for professional players are guided by medical assessment, the authors discuss whether the way concussion is portrayed might affect public awareness of appropriate concussion management.

INTRODUCTION Mild traumatic brain injury, also known as concussion, is one of the most frequently occurring injury events1 and as such represents a significant health problem. Concussion is particularly common among children and young adults due to their participation in high-risk activities such as contact sports.1 2 Although the effects of concussive injuries are generally transient if managed correctly, research indicates that if these injuries are not appropriately managed they will result in prolonged or complicated recoveries. 3 4 It is important, therefore, to identify factors that might adversely affect appropriate medical consultation and management. One particular area that may present a barrier to timely intervention is media portrayal of concussion in sporting events. The majority of professionals agree that to minimise risks the most effective concussion management plan should include rest and withdrawal from high-risk activities for 1–4 weeks 5 6 and until all symptoms are resolved, 7 with more conservative management (1–3 months) of children and young people. 2 3 The portrayal of how concussion is managed via broadcast sport, however, is often strikingly different. Sports people are commonly shown to return to play within minutes of an injury occurring. This is particularly evident in professional rugby league. Rugby league is a full McLellan TL, McKinlay A. Br J Sports Med (or (2011). doi:10.1136/bjsm.2011.083618 Copyright Article author their employer) 2011.

contact/collision sport played by two teams of 13 players for 80 min over two halves. Tackling is a key component of rugby league which requires the offensive player’s progress to be halted generally by being put to ground. Previous research shows most injuries, including concussion injuries, occur in the tackle.8 9 Further, early return to play may result in multiple concussions which are more likely in the sporting context given the frequency that sporting players encounter repetitive high-risk mechanisms for injury. Multiple injuries, over a short period are of particular concern as they may have catastrophic consequences.10 11 Recent research has demonstrated that there are detrimental cognitive effects of multiple concussions to adult male rugby union players, particularly related to visual motor speed and processing speed.12 Concussion incident rates for rugby/rugby league are reported to range from approximately 7.9713 to 9.84.14 However, when examining observed rather than reported concussion rates in other full contact sports, such as ice hockey, the incident rate was much higher.15 Further, Echlin et al found approximately 29% of players concealed a concussion to keep playing and they did not actively declare any immediate symptoms in 30% of the physician-diagnosed occurrences of concussion. It is important to note that while professional rugby league players are assessed and monitored by qualified medical experts, the public including young amateur sports people do not always have access or seek medical treatment in the event they experience a concussive injury. Further, while sporting bodies and community education encourage individuals to recognise the symptoms of concussion, seek appropriate treatment and follow appropriate recovery guidelines, the way in which concussion symptoms are managed in broadcast sport may well influence how the public understand concussion and how they manage their own injury events. With this in mind the current study sought to establish the observable incidence rate of concussion in professional rugby league. The National Rugby League’s (NRL) Telstra Premiership is the top competition for professional clubs in Australasia. The full coverage multiple-camera technique used to broadcast the Telstra Premiership competition ensures that all on-play action and therefore likely mechanisms for injury are visible to the viewing audience. We depart from previous research by identifying probable concussion injuries from the

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Original article prospective of the television viewer. The incidents are deemed probable concussion because they will be identified only by immediate visible symptoms such as loss of consciousness (LOC), unsteadiness and/or the player appearing dazed and confused. They will not be identified by player report or by non-visible symptoms like headache, amnesia and/or nausea, and they have not been diagnosed as concussion by a physician. The aims of the current study are as follows. 1. Establish the incidence rate and injury features of probable concussion as televised during the Telstra Premiership Rugby League Competition in 2010. 2. Examine how these events are shown to be managed with respect to return-to-play procedures.

METHOD The current method was employed to establish the incidence rate, features and mechanisms of probable concussion injuries that the public is exposed to during the viewing of broadcast professional rugby league. We applied the following two steps. Step 1: Fifty-two games from the 2010 NRL Telstra Premiership were included in the current study. This represents 25% of games in the 2010 season. The fi nal 36 games of the 2010 season were available prospectively and 16 games from the fi rst six rounds were independently selected retrospectively from the draw so that each of the 16 teams was represented twice. The 52 games equated to 1802.67 player hours or 69.33 viewer hours. Each game, as broadcast on television (via archive footage on the NRL website for the earlier 16 games), was viewed by two independent observers. Both observers recorded each incident that involved an observable injury/impact to the head region of a player and that resulted in an observable disruption of play. For instance, (1) the player was left on the ground as play continued, (2) play was stopped because the player was injured on the ground, (3) the player was assisted in back play (off the ball play) by the team trainer while play continued without him and (4) the player was unable to correctly play the ball and the referee intervened. Step 2: Each recorded incident involving an injury/impact to the head was then reviewed by a research psychologist experienced in traumatic brain injury research. An initial determination that an injury event was indicative of probable concussion was made due to the presence of an observable mechanism (ie, blow to the head) and an immediate observable neurological sign (LOC, vomiting, player was unstable, player lacked coordination, player appeared dazed and/or confused). Blind to the determinations made by the research psychologist, a registered clinical neuropsychologist experienced in TBI research and clinical assessment of TBI injuries then viewed each incident and a fi nal determination that a probable concussion had occurred was made on the basis of 100% agreement between both observers. The public is also subject to concurrent information about the perceived status of a player from the comments made by game commentators and sideline injury updates when watching broadcast rugby league. Accordingly, the explicit reference to the probable concussion event by the commentary team was noted. Reference to a player being ‘knocked out/concussed’, or any colloquial terminology to this effect was coded as indicative of ‘industry-assumed concussion’ whereas other or no commentary reference was coded as ‘industry-assumed non-concussion’.

RESULTS Step 1: The fi rst observer identified 71 incidents during the 52 games that involved an observable injury/impact to the head 2 of 4

region of a player and that resulted in an observable disruption of play. The second observer identified 73 incidents and agreement between both observers was found for 70 incidents. Incidents (70) occurred in 37 of the 52 games (71.2%). Step 2: Of the 70 incidents reviewed and agreed upon in Step 1, 20 incidents were initially classified as probable concussions according to the televised presence of neurological signs established in the method. All 20 incidents were confi rmed as probable concussions by the clinical neuropsychologist. The 20 probable concussions experienced by 19 individual players occurred during 16 of the 52 games, that is, 30.8% of games showed a player visibly experience a probable concussion. Eleven of the 16 teams involved in the competition had a player/s concussed during play. The incident rate for probable concussion was 11.10\1000 player hours (95% CI 5.78 to 16.40) or 2.89\10 viewing hours (95% CI 1.63 to 4.15). The television audience will see a player concussed every 3.46 h spent watching, which is 1 concussion every 2.6 games or 0.39 concussions per game. Significantly more probable concussions occurred in the second half of the game (16.64\1000 player hours, 95% CI 8.22 to 25.06) compared to the fi rst half of the game (5.55\1000 player hours, 95% CI 0.69 to 10.41), χ2 (1,19) = 10.00, p < 0.01. Furthermore, 50% of probable concussions occurred within 5 min of starting or fi nishing a half which only accounted for 25% of game time. Significantly, more probable concussions were experienced by offensive (75%) compared to defensive players (25%), χ2 (1,19) = 10.00, p < 0.01. Of the 15 injuries to offensive players, 11 (73.3%) were due to play that resulted in the defensive player being placed on report for a high tackle/ high swinging forearm to the head. Only 3 out of the 11 players placed on report for an illegal tackle that resulted in a probable concussion to the opposition player received a match penalty. An examination of how return to play was managed shows that 13 of 20 players (65%) left the field as a result of a probable concussion. In 12 of these injury events, the player was shown to be supported by one or two training staff while leaving the field. Six players (30%) continued to play without leaving the field after receiving attention from the team trainer/medical staff, and the remaining player was injured in the fi nal 15 s of the game. Of the 13 players that left the field, 6 returned to play within the same game. This means that 12 of 20 players (60%) who were shown to experience a probable concussion were also shown to continue or return to play within the same game, including 3 players who appeared to experience a LOC. The seven players who left the field at the time of injury and did not return to play were stood down for 0 games (1), 1 game (3), at least 3 games (1) or were injured in their last game of the season (2). The following statements were made by the commentary team with regard to the six players who experienced a probable concussion and continued to play. 1. There’s an injury here for…and it’s a bad one, concussion. He’s gone well before he hit the ground…I can’t say he looks OK but he’s up…(during next couple of minutes of play) Here’s a towering kick for the man who’s had concussion… you’ve got to admire the courage, that’s quite a recovery… He’s not good though, he’s in about round 9 and still on his feet, he’s hoping to hear the bell in a moment. 2. He’s down on his back…concern for him…he’s got some flexibility in the jaw…looks to be totally OK to get up and go on. 3. We’ve got a player knocked out in back-play…he doesn’t know where he is at the moment…that looked nasty. McLellan TL, McKinlay A. Br J Sports Med (2011). doi:10.1136/bjsm.2011.083618


Original article 4. ...Ooh, He has been hit by…and the aggressive back rower for the…is still down. That’s collected him right in the face. 5. He’s lost the ball; I think he’s really hurt. 6. He is not sure where he’s at the moment. The following statements were made by the commentary team with regard to the six players who experienced a probable concussion and returned to play. 1. .…That’s not looking good…He’s groggy…not a well boy. 2. Arg…(he’s) been laid down fl at…he doesn’t look to be in a great way…He might not return for some time, well planet earth anyway, he’s seeing stars. 3. He went down like he’d been shot…that doesn’t look good…would have taken some impact to get him as groggy as he is. 4. (He’s) down …and not a lot of movement there as play continues…(He’s) in real strife here. 5. He’s hurt…certainly looks groggy doesn’t he…you can see how rubber legged he is. 6. (He’s) down…looks a little dazed, trying to make out something in the ground so he can tell the trainer so he’ll let him stay on… doesn’t look like the shot of a man who will be coming back in this game…they can not afford to lose that man tonight…He’s all over the shot at the moment…His head’s not clear…his legs not working…He’s all over the place, blowing hard, blinking hard, looks like he’s gone. According to the comments made by the commentary team, the public were provided information that suggested 8 out of the 12 players who continued or returned to play had experienced an industry-assumed concussion.

DISCUSSION The current study has shown that the incidence rate of concussion in professional rugby league is likely to be higher than previously reported.14 The television audience is regularly exposed to a concussion injury in the NRL Telstra Premiership and is regularly exposed to how that injury is managed. The current fi ndings demonstrate the audience will see the majority of injured players either continue to play or return to play having displayed symptoms the public are otherwise told require more caution and more stringent management than demonstrated in each of these incidents. Certainly, evidence from other contact sports suggests that concussion-related symptoms do not resolve for an average of 48.6 h,16 so it appears likely many professional rugby league players are playing on despite being symptomatic and the television audience is privy to this practice. Whether, and in what ways this information then affects public knowledge and behaviour relating to concussion management is beyond the scope of the current study but worthy of future research consideration. It is reasonable to suggest that young people or other individuals involved in high-risk activity might minimise their own symptom experience or have difficulty adhering to injury management advice as a result of watching similar injuries with disparate management on television. The most common mode of injury in the current study was a high tackle which was placed on report for being dangerous. However, the lack of any meaningful penalty to the transgressing player may well suggest that the practice of targeting the head, whether accidentally or with intention is an acceptable/ tolerated part of play. Research that investigated the effect of delayed (on-report) versus immediate (send-off) consequences McLellan TL, McKinlay A. Br J Sports Med (2011). doi:10.1136/bjsm.2011.083618

on public perception of injury severity would contribute valuable information towards understanding individual variance in concussion knowledge. It is noteworthy to reiterate, the incidence rate reported in the current study relied on visual information (concussion was not verified by physical examination; player report or close up examination) but nevertheless likely underestimated the actual risk given the most common self-disclosed symptoms experienced by athletes diagnosed with concussion are headache followed by other largely unobservable symptoms such as ‘don’t feel right’, low energy and sensitivity to light.15 It is likely in the current study that some of the 50 incidents that were not identified as probable concussion through visual confi rmation were later diagnosed as concussion or were undiagnosed examples of concussive injuries. In contrast to the underestimation by visual restrictions, the surveillance method employed here was independent of player report and therefore unrestricted from known tendencies to minimise and hide symptoms to ensure continued regular play.15 The restricted number of games viewed was a limitation of the current study. The sample was dominated by games from the latter stages of the season and more injuries may well have occurred towards the end of the season than during the beginning and middle stages.8 Although this may have elevated the injury incidence rate, it was nevertheless representative of audience viewing behaviour. Television ratings in Australia reported average audiences of approximately 330 000 during the regular season and 1 450 000 during the fi nals weeks (TV ratings are based on the available OzTAM, AGB Nielsen and ASTRA estimates for the Australian capital cities and regional Australian TV markets, as shown on talkingfooty.com). It was important therefore to include the information with greatest public exposure.

CONCLUSION The purpose of the current study was to establish the incidence rate and injury features of probable concussion as televised during the Telstra Premiership Rugby League Competition in 2010. The current rates were established only via visible symptoms and were higher than those previously

What is already known on this topic? ▶ ▶

Concussion is a significant health problem, especially for young people involved in high-risk activity. Appropriate management and timely intervention can reduce long-term complications.

What does this study add? ▶

▶ ▶

Rugby league players were shown to experience visual signs of concussion more frequently than previously reported. The majority of injured players were shown to continue playing following a probable concussion. The way probable concussion was managed was often contrary to common advice given to the public and may represent a barrier to appropriate management of viewer’s injuries. 3 of 4


Original article reported by more traditional injury registration methods. Most importantly with respect to how concussion is portrayed in broadcast sport the majority of injured players were seen continuing or returning to play with minimal time to recover. It is now important to examine how this information impacts on the viewing public’s knowledge and understanding of their personal real-world experiences of concussion management. Acknowledgements The authors would like to acknowledge the assistance of Taylor McLellan for supervising the observation procedures in the current study.

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8. 9.

Funding The current study was funded by the Department of Psychology, University of Canterbury, New Zealand.

10.

Competing interests None.

11.

Provenance and peer review Not commissioned; externally peer reviewed. 12.

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McLellan TL, McKinlay A. Br J Sports Med (2011). doi:10.1136/bjsm.2011.083618


Does the way concussion is portrayed affect public awareness of appropriate concussion management: the case of rugby league Tracey L McLellan and Audrey McKinlay Br J Sports Med published online May 3, 2011

doi: 10.1136/bjsm.2011.083618

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