Accepted Manuscript

Regular Article

Title:
Effects of a Rugby-Specific Concussion Awareness Program on Collegiate Rugby Union
Players

Running Title: Effects of a Rugby-Specific Concussion Awareness Program

Keita Suzuki1*

suzuki.k@ngu.ac.jp

Satoshi Nagai2

s-nagai@tius.ac.jp

Masahiro Takemura3

1

takemura.masahiro.gw@u.tsukuba.ac.jp

Faculty of Health and Sports, Nagoya Gakuin University, 1350 Kamishinano, Seto,

Aichi, Japan
2

Faculty of Health Sciences, Tsukuba International University, 6-8-33 Manabe,

Tsuchiura, Ibaraki, Japan
3

Institute of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba,

Ibaraki, Japan

Number of tables: 2
Number of figures: 1

Page. 1

Abstract
This study assessed the effects of a rugby-specific concussion awareness program on
improving the recognition of relevant symptoms and knowledge of concussion in malecollegiate rugby union players. Thirty-one collegiate rugby union players from Japan
were offered a concussion awareness program; they responded to a questionnaire
assessing symptom recognition and knowledge of concussion three times (before,
immediately after, and four weeks after the implementation of the program). Immediately
after the program, the recognition score of suspected concussion symptoms was higher
compared with before and four weeks later, when it was still higher than before but notstatistically significant. In addition, more players selected the correct answers about
rugby-specific concussion topics after the program. Our findings suggest that while
concussion awareness is expected to improve immediately, this effect was not maintained
after four weeks. Therefore, concussion awareness opportunities should be scheduled
regularly, such as at the start of each season, before the beginning of the competitionseason, and when new players join the team.

Keywords: rugby union, sport-related concussion, concussion awareness

Page. 2

ラグビー選手に向けた脳振盪啓発プログラム実施効果の検証

鈴木啓太 1*， 永井智 2，竹村雅裕 3

1

名古屋学院大学スポーツ健康学部，愛知県瀬戸市上品野町 13502

つくば国際大学医療保健学部，茨城県土浦市真鍋 6-8-33

3

筑波大学体育系，茨城県つくば市天王台 1-1-1

抄録
本研究は、ラグビー特有の脳振盪啓発プログラムを実施することによって、選手の脳振盪が疑われる症状の認識や脳振盪に関する知識が向上するかを明らかにすることを目的とした。大学ラグビー選手 31 名を対象とし、ラグビー特有の脳振盪啓発プログラムを 1 回実施し，実施前、実施直後、また実施 4 週間後に脳振盪の症状認識、知識に関するアンケートを実施した。選手の症状認識スコア（SRS）、知識の理解度を比較した。啓発プログラム導入で、SRS は実施直後が実施前、実施 4 週間後に比べて有意に高かった。一方で、実施 4 週間後の SRS
は実施前と比べて高値を示したが、統計的に有意な差ではなかった。また、ラグ
ビーで脳振盪が多く発生するプレーや技術要素の関わりについて、正しく回答
Page. 3

した選手の割合が有意に増加した。本研究の結果は、脳振盪の啓発は脳振盪の認識を改善する即時効果が期待される一方で、継続的な啓発が必要であることが示唆している。そのため、各シーズンの開始や、試合期に入る前、新入生・新加
入選手が合流するタイミングなど、脳振盪啓発の機会を継続的に設けることが重要である。

Page. 4

1

Introduction

2

Previous studies have reported that rugby union (RU) has a higher incidence of

3

concussion than other contact/collision sports.1,2) Reporting a concussion by the players

4themselves or detecting the symptoms by those around them is necessary for the medical

5

staff to check the players and adapt a gradual return-to-play protocol to their needs.

6

Therefore, previous research has focused on whether RU players experienced or reported

7

concussions. In RU, 25.0-69.0% of players experienced concussions,3-5) of which 46.6-

8

52.5% did not report suspected symptoms.4,5) In a study of collegiate RU players in

9Japan,6) 94.2% of participants experienced at least one suspected concussion symptom,

10

and 29.9% of them did not report to others. These results indicate that most Japanese

11collegiate RU athletes report suspected concussion symptoms to others, but there are still

12

some cases of unreported symptoms.

13

Suspected concussion symptoms can be divided into two categories: (1) those that14

others can detect and (2) those that the individual needs to recognize. If players do not

15know the concussion symptoms, they cannot recognize them. Therefore, concussion

16

education is important not only for teachers and coaching staff but also for the RU players

17themselves. Previous studies have investigated and shown that concussion education

18

immediately improves concussion knowledge in various players.7,8) However, the effects

19

do not always persist in the long term,7) and increasing players' knowledge does not20necessarily improve their reporting behavior too.9) The addition of sports-specific21

information, such as situations in which concussions are likely or unlikely to happen, to22

educational interventions will increase the likelihood that players themselves and those23

around them will recognize that a concussion has happened. Therefore, this study aimed

24

to determine the effects of a rugby-specific concussion awareness program on improving

Page. 525

the recognition of suspected symptoms and knowledge of concussion in male collegiate

26

RU players.

27
28

Materials and Methods

29

Participants30

A total of 31 male collegiate RU players from one university in Japan participated31

in the study. This team belonged to the regional league Division 1 when conducting the32

study. The Research Ethics Committee at the Nagoya Gakuin University approved the33

study (reference number 2022-01). All subjects provided written informed consent before

34

participating.

35
36

Study protocol

37

Questionnaires were administered before, immediately after the concussion

38

awareness program and four weeks later to determine the effects. A priori power analysis

39

indicated that in order to achieve a power (1-β) of 0.80 with a confidence level of 95% (α40= .05) and an effect size of 0.25 in a repeated measures analysis of variance, an estimated41

total sample size of 28 subjects would be required.

42
43

Contents of the concussion awareness program

44

The intervention program was composed of the following information based on the45latest consensus statement on concussion in sport at the time when this study was

46

conducted 10) and the previous studies about rugby-related concussions:11-17) (1) what is a47

concussion (definition, knowledge and symptoms thereof); (2) what to do after48

concussions occur; (3) rugby-related concussions (incidence rate, mechanism, andPage. 6

49

situations in which concussions are likely or unlikely to happen); and (4) procedures for50

returning to play after a concussion. This program took around 15 minutes to complete.

51
52

Assessing the effectiveness of the concussion awareness program

53

Online questionnaires were administered to participants using Google Forms before,

54

immediately after the concussion awareness program and four weeks later to determine55

its effectiveness. These consisted of three sections: (1) player profile (name, age,56

academic year, and years of RU experience—asked only before the program), (2)57

recognition of suspected concussion symptoms, and (3) knowledge of concussion. The

58

pre-implementation questionnaire had an additional section on the experience of59

suspected concussion symptoms.

60

In the symptom recognition section, we included 33 symptoms; 22 were correct

61

symptoms from Sports Concussion Assessment Tool 5 (SCAT 5),18) and 11 were incorrect

62

distracters.19) The symptoms recognized scores (SRS) were calculated as the number of63

correct symptoms a player recognized out of 33. A higher SRS indicated a better64knowledge of suspected concussion symptoms.

65

The section on concussion knowledge consisted of four sports-related concussion

66

questions and three on rugby-specific concussion.3,11,12,20) In addition, the players were67

asked whether they had received concussion education only before the intervention.

68

Experience of suspected concussion symptoms was defined as “had experienced at69

least one of the 22 suspected concussion symptoms from SCAT 518) after a blow to the70

head, face, neck, or other parts of the body with an impulsive force transmitted to the71

head.” Players with such experience were asked for additional details: (1) “How many72

times have you experienced the suspected concussion symptoms?”; (2) “Have you

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73

experienced any of the suspected concussion symptoms within the last three months?”74

and (3) “Have you had symptoms more than three months ago that are still present, or

75

have you been treated in a hospital for those symptoms?”

76
77

Statistical analysis

78

Continuous variables were reported as means and 95% confidence intervals (95%79

CI); categorical variables were reported as frequencies. SRS, that is, numerical data, were80

checked for normality using the Shapiro-Wilk normality test. Due to the non‑normality

81of SRS, the Friedman test was used to compare the SRS at three time points: before,

82

immediately after the program implementation, and four weeks later. As multiple

83

comparisons were performed, a Bonferroni adjustment was applied to reduce the risk of

84

Type Ⅰ errors (p < 0.0167).

85

The chi-square test was used to compare the differences in the recognition rates of86suspected symptoms and knowledge of concussion at the same three-time points.

87

Following this line of analysis, the adjusted standardized residuals (ASR) from the88

contingency tables were analyzed to determine the differences between the three groups.

89

The categories with ASR > 1.96 indicated that there were more cases than expected,

90

whereas those with ASR < –1.96 that there were fewer cases than expected.21) All91

statistical analyses were performed using the SPSS version 28.0 package (IBM Japan Inc.,

92

Tokyo, Japan) with the significance level set at p < 0.05.

93
94

Results

95

One participant, absent when the questionnaire was administered four weeks after96

the program, was excluded from the analysis; therefore, 30 participants were included inPage. 8

97

the study. Their mean age was 19.5 years (95% CI, 19.2–19.8), and the mean number of98

years players had been playing RU was 7.7 years (95% CI, 6.5–9.0). Of the 30 players,99

29 (96.7%) had experienced suspected concussion symptoms at least once. The mean

100

number of times this had happened was 2.5 (95% CI, 1.8–3.2). Moreover, of these 29

101

players, 4 (13.8%) had experienced suspected symptoms within the last three months.

102

None of the players had symptoms that had been present for more than three months or103

had been treated in a hospital for those symptoms.

104
105

Effectiveness of concussion awareness program

106

When comparing SRS at the three-time points (Fig. 1), SRS immediately after

107(28.3; 95% CI, 27.1–29.6) was significantly higher than before (24.0; 95% CI, 22.8–22.5;

108

p < 0.001) and four weeks later (26.1; 95% CI, 24.8–27.5; p = 0.002). On the other hand,109

the SRS after four weeks was higher than before; however, the difference was not

110

statistically significant (p = 0.019; Fig. 1).

111

Insert Fig. 1 near here.

112
113

The program changed the recognition of suspected concussion symptoms (Table 1).

114

Immediately after its implementation, the following nine symptoms were significantly

115

more often recognized as correct: fatigue or low energy (100.0%), drowsiness (100.0%),

116

neck pain (96.7%), being more emotional (96.7%), nervous or anxious (96.7%),

117

sensitivity to light (93.3%), irritability (93.3%), sadness (93.3%), and trouble falling118

asleep (93.3%). In addition, four weeks later, the following five symptoms were119

significantly more often recognized: sensitivity to light (96.7%), sensitivity to noise120(90.0%), trouble falling asleep (90.0%), irritability (86.7%), and being more emotional

Page. 9121

(80.0%).

122

Insert Table 1 near here.

123
124

The program did not statistically significantly change the responses to the three125

sports-related

126

implementation, significantly more players correctly responded that the "doctor" would

127

decide on their return to play after concussions (27, 90.0%; p < 0.001; Table 2).

128

concussion

questions(Table2).

However,

immediately

after

Insert Table 2 near here.

129
130

Regarding the mechanism of concussions in rugby, "when a player is tackled" (14,131

46.7%) was selected by significantly more respondents before the program, while "when132

a player tackles" (30, 100.0%) was so immediately after its implementation (p < 0.001;

133

Table 2).

134

Regarding the tackle phase, which participants thought is important in concussion

135

prevention, "the moment of tackle" (14, 46.7%) was selected by significantly more

136

players before the program, while "the approach phase" (23, 76.7%) was so immediately

137

after its completion (p = 0.001; Table 2).

138

Before the program, more players thought that a tackler's technique was not

139

involved in concussions than expected frequency (9, 30.0%; p = 0.001; Table 2), while140

immediately after, 100% of them reckoned that it was (p = 0.001; Table 2).

141
142

Discussion

143

This study investigated whether implementing a rugby-specific concussion

144

awareness program improved the recognition of suspected symptoms and knowledge ofPage. 10

145

concussion in male collegiate RU players. The results demonstrated that the SRS

146

immediately after implementation was significantly higher than before and four weeks

147

later; additionally, four weeks later, it was higher than before, but the difference was not148

statistically significant. These results suggest that the effect of a one-time concussion

149

awareness program decreases over approximately four weeks. Therefore, continuous

150

education would provide opportunities to improve the players' understanding of151

concussions and the team's concussion literacy.

152
153

Effectiveness of the concussion awareness program

154

The SRS results were in line with previous research.7) In addition, the recognition

155

rate for some symptoms shown in Table 1 was still significantly higher after four weeks,

156

whereas the overall trend was similar to the change in the SRS. The findings suggest that157

continuous concussion education is needed. However, setting up learning opportunities

158

every four weeks is not practical for many teams. Therefore, such opportunities should159

be scheduled regularly, such as at the start of each season, before the beginning of the160

competition season, and when new players join the team.

161

In this study, the program was in a lecture format, and absorbing concussion

162

knowledge might be limited. Kneavel et al. evaluated the effectiveness of a peer163

concussion-education program for college student-athletes in the United States.22) The

164

results showed that the effects were maintained even four weeks after implementation. In

165

the future, it is important to promote concussion awareness in Japan, including peer

166

education programs.

167

Immediately after implementing the program, significantly more players agreed

168

that the doctor make the final decision to return to play after suffering concussions. Before

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169

the program, significantly more of them had reported that trainers would decide whether

170

to return and significantly fewer that doctors would make the decision. A previous study

171

by Salomon et al.3) reported that players felt that the injured player, not a health172

professional/team medical staff, should decide when to return to play after concussions.

173

Moreover, 25.4% of RU players returned to play after concussions without receiving

174

medical advice.23) These findings suggest that rugby players are likely to feel that they

175

should decide to return to play by themselves after such an incident. The results of this176

study indicated that awareness education can change a player's recognition about the177

appropriateness of returning to play after a concussion. Such recognition shared also by

178

the other players in the team can help to facilitate a correct return process. Therefore, it is179

important that a team is regularly provided with concussion awareness educational

180

opportunities for the safety of its players.

181

Before the program, significantly more players answered that concussions were182

more likely to occur when they were tackled, that is, when being the ball-carrier (Table

1832). However, previous studies have indicated that concussions occurring in RU are more184

frequent while tackling, regardless of the level of competition.17,24-26) This suggests that185

rugby players recognize being the ball carrier as a situation that is likely to lead to

186

concussions based on their own experiences. Additionally, the implementation of the187

awareness program significantly increased the number of players who answered that188

concussions occurring in rugby were more frequent during tackling and, after four weeks,

189

an increase from before persisted but was not statistically significant (Table 2).

190

Educational opportunities about the mechanisms of concussions are important for players’

191

safety based on a correct understanding of the relevant risks.

192

Before the program, significantly more players thought that the tackler's techniquePage. 12

193

was not involved in concussions, whereas after its implementation, 100% of them194

reckoned that it was (Table 2). Previous research by Hendricks et al.27) has shown that195

rugby players perceive the acquisition of good tackling skills as more important for

196

performance improvement than injury risk reduction. In addition, their attitude toward197

safety decreases during matches.27) Hence, the recognition of a player’s technical factors

198

involved in concussions during tackling is important to promote behavioral changes. At

199

the same time, the technical improvement of the players depends strongly on the coaching200

staff's instruction. Mandatory annual educational programs for coaching staff have201

reduced concussion/brain injury-related personal injury claims and associated costs in

202

RU.28) The coaching staff should also take part in the concussion awareness program

203

proposed by this study to promote prevention among RU players.

204

Before the program, more players thought that a concussion was only caused by a205

direct hit to the head (56.7%), whereas after its implementation, fewer players thought206

the same (26.7%); however, the difference was not statistically significant (p = 0.061;

207

Table 2). Because rugby is a collision sport, before the program, many players may have208

thought that concussions are only caused by a direct impact on the head.

209
210

Study limitations

211

In Japan, concussion awareness interventions have only been conducted with

212

teachers and coaches;29) this study was the first one to be conducted with athletes.

213

However, a limitation should be addressed. Since just one team of college RU players

214

was used, a generalization of our results should be applied with caution, even at the same215

level of competition. Further research should be required to accumulate data from rugby

216

teams, which have a variety of backgrounds.

Page. 13

217
218

Conclusions

219

This study aimed to determine the effects of a rugby-specific concussion awareness220

program on improving the recognition of suspected concussion symptoms and knowledge

221

of concussion in male collegiate RU players. As a result, immediately after the program,

222

SRS showed a statistically significant increase compared to before; however, this increase223

was not maintained after four weeks. In addition, regarding returning to play following

224

concussion and the mechanisms of its occurrence in rugby, the program immediately

225

increased the number of correct responses; however, this effect was not maintained after

226

four weeks. Our results suggest that education is expected to improve concussion

227

awareness immediately; however, it should be done regularly. As setting up educational

228

opportunities every four weeks is not practical for many teams, these should be scheduled229

at key time points, such as at the start of each season, before the beginning of the230

competition season, and when new players join a team.

231
232

Acknowledgements

233

This work was supported by JSPS KAKENHI (Grant Number 19K20009).

234
235

Contributions

236

Study conception and design: KS, SN, and MT. Intervention and questionnaire

237

implementation: KS. Analysis and interpretation of the data: KS. Paper composition: KS.

238

Writing advice: NS and MT. All authors approved the final version of the manuscript.

239
240

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Conflicts of Interest

242

The authors declare that there are no conflicts of interest.

243
244

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Figure legend362

Fig. 1 Change in symptom recognition scores (SRS) by implementing the concussion

363

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Bonferroni adjustment was applied to reduce the risk of Type Ⅰ errors as multiple

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comparisons were performed.)366

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Table 1 Change in the Recognition of Suspected Concussion Symptoms

BeforeAfter

4 weeks later

Suspected Concussion Symptomsa

n (%)

n (%)

n (%)

p

Headache (true)

28 (93.3)

30 (100.0)

29 (96.7)

0.355

Pressure in head (true)

27 (90.0)29 (96.7)

29 (96.7)

0.429

Neck pain (true)

21 (70.0)b29 (96.7)c

24 (80.0)

0.024

Neck muscle weakness (true)

14 (46.7)

8 (26.7)

7 (23.3)

0.112

Joint stiffness (false)

22 (73.3)

19 (63.3)

15 (50.0)

0.174

Numbness in arms (false)

20 (66.7)

19 (63.3)

15 (50.0)

0.378

Nausea or vomiting (true)

29 (96.7)30 (100.0)

30 (100.0)

0.364

Dizziness (true)

29 (96.7)30 (100.0)

30 (100.0)

0.364

Blurred vision (true)

30 (100.0)

27 (90.0)29 (96.7)

0.160

Black eye (false)

21 (70.0)

22 (73.3)

14 (46.7)

0.065

Bleeding from the ears (false)

24 (80.0)26 (86.7)

20 (66.7)

0.165

Bleeding from the mouth (false)

27 (90.0)27 (90.0)

24 (80.0)

0.237

Nosebleed (false)

20 (66.7)

23 (76.7)

17 (56.7)

0.259

Balance problems (true)

30 (100.0)

30 (100.0)

29 (96.7)

0.364

Sensitivity of light (true)

20 (66.7)b

28 (93.3)

29 (96.7)c

0.001

Sensitivity of noise (true)

15 (50.0)b28 (93.3)c

27 (90.0)c< 0.001

Abnormal sense of smell (false)

23 (76.7)

19 (63.3)

16 (53.3)

0.166

Abnormal sense of taste (false)

25 (83.3)

19 (63.3)

18 (60.0)

0.108

Feeling slowed down (true)

26 (86.7)30 (100.0)

29 (96.7)

0.064

Feeling like “in a fog” (true)

22 (73.3)

24 (80.0)25 (83.3)

0.627“Don’t feel right” (true)

29 (96.7)

29 (96.7)

28 (93.3)

0.770

Difficulty concentrating (true)

27 (90.0)28 (93.3)

30 (100.0)

0.227

Difficulty remembering (true)

25 (83.3)

29 (96.7)

26 (86.7)

0.232

Fatigue or low energy (true)

24 (80.0)b30 (100.0)c

28 (93.3)

0.021

Fever (false)

15 (50.0)

15 (50.0)

12 (40.0)

0.669

Skin rash (false)

29 (96.7)

24 (80.0)

24 (80.0)

0.106

Confusion (true)

24 (80.0)26 (86.7)

27 (90.0)

0.533

Drowsiness (true)

21 (70.0)b30 (100.0)c

29 (96.7)< 0.001

More emotional (true)

6 (20.0)b29 (96.7)c

24 (80.0)c< 0.001

Irritability (true)

9 (30.0)b28 (93.3)c

26 (86.7)c< 0.001

Sadness (true)

9 (30.0)b28 (93.3)c

22 (73.3)< 0.001

Nervous or anxious (true)

19 (63.3)b29 (96.7)c

26 (86.7)

0.002

Trouble falling asleep (true)

12 (40.0)b28 (93.3)c

27 (90.0)c< 0.001

a The correct response for each item is indicated in parentheses.
b The adjusted standardized residuals < -1.96.
c The adjusted standardized residuals > 1.96.

Table 2 Change in Knowledge of Concussion
Questiona

BeforeAfter

4 weeks later

n (%)

n (%)

n (%)

A concussion can only occur if there is a direct hit to the

p
0.061

head.
Yes

17 (56.7)c

12 (40.0)

8 (26.7)bNo

13 (43.3)b

18 (60.0)

22 (73.3)c

After a concussion occurs, brain imaging (e.g., CT scan,
MRI, X-Ray) typically shows visible physical damage

0.955

to the brain.
Yes

12 (40.0)

12 (40.0)

13 (43.3)

No

18 (60.0)

18 (60.0)

17 (56.7)

Players must not be left alone for about 24 hours after a

0.600

concussion.
Yes

29 (96.7)30 (100.0)

29 (96.7)No

1 (3.3)0 (0.0)1 (3.3)

Who makes the final decision to return to play from a

0.003

concussion?
Players

6 (20.0)

1 (3.3)3 (10.0)

Club advisor/coach4 (13.3)

2 (6.7)

1 (3.3)Trainer

7 (23.3)c

0 (0.0)b2 (6.7)

Doctor13 (43.3)b27 (90.0)c

24 (80.0)

Most frequent plays leading to concussion in rugby< 0.001

union.

Tackling

14 (46.7)b

30 (100.0)c

27 (90.0)

Be tackled

14 (46.7)c

0 (0.0)b2 (6.7)

Aerial collision

2 (6.7)0 (0.0)1 (3.3)

Tackler's technique is involved in concussions
during tackling.

< 0.001Yes

21 (70.0)b30 (100.0)c

29 (96.7)No

9 (30.0)c

0 (0.0)b1 (3.3)The most important phase in preventing concussions in

0.001

tacklers.
Approach phase

7 (23.3)b23 (76.7)c

17 (56.7)

The moment of contact

14 (46.7)c

4 (13.3)b

10 (33.3)

Post contact phase

9 (30.0)c

3 (10.0)

3 (10.0)

a Bold and underline set as a correct answer.
b The adjusted standardized residuals < -1.96.
c The adjusted standardized residuals > 1.96.