A comparison of public views about sports concussion recovery with current guidelines: where are the gaps and overlaps?

Introduction

Mild traumatic brain injury (TBI) or concussion is a significant health problem globally (Maas et al. 2022; Yue et al. 2023). Over 90% of people presenting to hospital for TBI will meet diagnostic criteria for mild TBI. The causes of mild TBI include common incidents, such as non-fatal road traffic crashes, falls, sport, and physical assaults. The incidence of mild TBI depends on the geographical region, with estimates ranging from 476 to 1153 cases per 100,000 individuals annually (Maas et al. 2022). Mild TBI can lead to adverse effects including symptoms such as headache. These effects can slow the return to work or usual activities, and at least one estimate suggests that as many as 50% of adults seen at hospital for mild TBI were not back to usual by 6 months (Maas et al. 2022). Improving TBI outcomes is a topic demanding global attention and the implementation of strategies for effective injury management is key to this endpoint (Maas et al. 2022).

Concussion management advice is fast evolving (Schneider et al. 2022), including guidance on the nature and duration of postinjury rest (Kroshus et al. 2021). Early advice for concussion management emphasised sustained rest from all activities, known as cocoon therapy, encompassing physical and cognitive domains (Leddy et al. 2018). However, several studies have not supported this approach. For example, a recent study showed that limiting children’s screen time as a postconcussion cognitive rest strategy improved their recovery; however, it was only effective if applied short-term, specifically within the first 48 h postinjury (Macnow et al. 2021). Further, a large systematic meta-analysis of more than 4000 patients found that while prescribed rest did not slow recovery, it did worsen symptoms (Kontos et al. 2023). Based on such findings, the field has moved away from the advice that prolonged rest is the best medicine for concussion (Silverberg and Iverson 2013).

Current guidelines for sports concussion (SC) management such as those promoted by American Congress of Rehabilitation Medicine (ACRM) Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force (Silverberg et al. 2020), the Concussion in Sport Interest Group (CISG) (Patricios et al. 2023), and the Australian Institute of Sport (AIS) (Australian Institute of Sport 2023) do recommend a short rest period, but this is not ‘strict’ or ‘bed’ rest (i.e. as in cocoon therapy). Instead, after a period of short rest, some of the current guidelines recommend ‘relative rest and exercise’ for SC (Patricios et al. 2023, p. 71) or ‘active recovery’ (Australian Institute of Sport 2023, p. 35). This form of recovery for SC is now known to benefit patients (Neidecker et al. 2021). The idea of relative rest supports an ongoing break from high-risk activities and exercise (such as contact sports) while other activities and exercises are gradually resumed. Specifically, it typically involves a brief period of postinjury rest (24–48 h), then a gradual return to usual activities, except contact sport or other activities with high brain injury risk. This approach allows for low intensity activity or exercise, with gradual increases in intensity as tolerated, over a period of approximately 10 days. The level of activity is ideally individually tailored and may be physiologically titrated (e.g. based on heart rate thresholds; Patricios et al. 2023). If postconcussion symptoms worsen or new symptoms emerge (Silverberg et al. 2020), the progression may be stopped or slowed. A medical evaluation is recommended for the final clearance for return to high-risk activity, such as contact sport.

Despite the new consensus around active recovery for SC, clinical practice may be lagging (Stuart et al. 2022). For example, a recent paper claimed that ‘the current standard of care remains to be strict rest’ (Haider et al. 2021, p. 154). To support the shift in clinical practice towards embracing active recovery for SC, formal strategies (such as ‘de-implementation’ through practitioner education) have been designed and are being researched. A recent intervention study with 21 family physicians evaluated a program aimed at supporting the de-implementation of the prior rest advice, in favour of active recovery. Despite its promising findings, including improving physicians’ concussion knowledge and use of the active recovery guidelines, the study could not be completed for feasibility reasons (Silverberg et al. 2021). A strategy for similarly preparing the public to receive the new active recovery advice has not yet been implemented.

Multiple additional factors appear to influence whether a concussed person will receive and can enact active recovery advice. These factors include: (1) the concussion point-of-care (e.g. primary or tertiary care; Stoller et al. 2014; Arbogast et al. 2016); (2) the specialisation/qualification of the care provider (e.g. medical or non-medical provider/s; Ellis et al. 2017); (3) the provider’s guideline knowledge and ‘confidence’ providing care (Salmon et al. 2022; Stuart et al. 2022); and (4) the provider’s capacity to ‘oversee’ care delivery, according to the guidelines (D’Lauro et al. 2018; Salmon et al. 2022). Patient-related factors also impact the chance of effectively enacting active recovery advice for SC. This includes whether patients adhere to the advice (Moor et al. 2015) and have the capacity to do so (Mohammed et al. 2023), and whether people understand, expect, and are supported to enact the advice. When a healthcare provider’s advice conflicts with patient’s expectations about what they might be told about their recovery, it can adversely affect communications (Hardavella et al. 2017) and potentially compliance.

Prior studies indicate that community members have some understanding of active recovery for SC (i.e. that a period of rest should be followed by gradual return to activity), and thus they may have some expectation that they could receive such advice (e.g. Sullivan and Cox 2019). However, these findings are from studies about activity plans postconcussion. By comparison, unless community volunteers are probed specifically about activity plans, they do not commonly propose active recovery for SC (Singaravelu 2022). For example, when 224 community members were asked for concussion recovery recommendations, rest was mentioned by 70% of the sample, medical referral by a third of the sample, and active recovery by less than 10% of the sample (Singaravelu 2022). Even in the studies framed around postconcussion activity plans, some gaps in community understanding of active recovery are evident (Sullivan and Finnis 2020) and rest duration is overestimated by the public compared to current advice (Sullivan and Billing 2019; Sullivan and Cox 2019). It remains unclear from this past research if members of the community would offer different concussion advice if given different timeframes to consider (e.g. immediate versus subacute). The current SC guidelines are time-sensitive, but it is unclear if the public has an awareness of this aspect of concussion care.

A study of community views about SC recovery could inform decisions about how to implement the new advice with patients. If the public is not sufficiently aware of the new advice, it could contradict or challenge their expectations about such advice, including if they had previously been told to take prolonged or strict rest for SC. Additional patient education could be needed to explain why prolonged (>48 h) strict rest is no longer best for SC. Despite the many challenges of patient adherence, a key requirement is that people need to know and understand what they need to do for their recovery (Martin et al. 2005), and this advice is most effectively communicated when it fits with patient expectations (Hardavella et al. 2017). The current study used a mixed methods approach to explore existing community views about SC recovery, and to extend the past research by determining whether these views are time-sensitive.

Materials and methods

Results

The sample characteristics are shown in Table 1. The average age of participants was 28.23 years (s.d. = 14.23; range = 18–69 years). More females than males participated (75:25), most were born in Australia (71%), and approximately half (52%) had some university education. People with (n = 44) and without (n = 113) a self-reported concussion history participated. While most participants resided in Queensland (~80%), all Australian states and territories were represented, except the Northern Territory. A subset of these participants (n = 90) provided the subacute advice.

Subacute advice

Most participants (n = 61/90, 69%) offered three pieces of subacute advice as requested, with a small number offering no (or no new advice, n = 5), one (n = 4), two (n = 15), or four (n = 4) suggestions. The most mentioned subacute recommendation was seek expert medical guidance and safety/prevention (46 mentions each), and rest (42 mentions; each accounting for approximately one-fifth of the subacute advice). The gradual return to activity was featured in 11% of the subacute advice (24 mentions), representing a significant increase in the proportion of these mentions compared to the immediate advice, χ²(1) = 14.359, P < 0.05. The proportion of comments about rest also reduced as a proportion of the subacute advice, compared to as a proportion of the immediate advice, χ²(1) = 7.211, P < 0.05. These data are graphed in Fig. 1.

Fig 1.

Thematic code volume (percentage) by timepoint (immediate versus subacute SC advice), excluding undecipherable data (<5% volume per timeframe).

Discussion

This study aimed to determine community understanding of what people should do for concussion recovery. In a previous study (Singaravelu 2022), rest for SC was most commonly recommended by community members, seeking medical advice was identified by less than half of the sample, and active recovery was infrequently mentioned. While the present study replicates these findings to a large extent, it also shows that community advice for SC is time-sensitive (immediate and subacute advice differed) and that, compared to immediate advice, mention of active recovery was proportionally higher as subacute advice, and rest was proportionally lower. Despite this, some of the SC advice that the community offered, and could expect if injured, was not explicitly recommended in the guidelines, and some strategies from the guidelines may need further public promotion (e.g. expert assessment for SC, active recovery).

This study shows, for the first time, that community members do offer different SC advice when asked to make recommendations for different timepoints (i.e. immediate versus subacute). Although rest still featured highly in the subacute period (and it could be indicated for some individuals in this period), very few respondents failed to adjust their advice for the different timepoints. This may indicate that community members are aware that SC management should change over time, and that immediate and subacute advice will likely emphasise different strategies (Patricios et al. 2023). Notably, compared to the immediate advice, ‘rest’ was a smaller component of the subacute advice and the gradual return to usual activities was mentioned more often, consistent with official directions (Silverberg et al. 2020; Australian Institute of Sport 2023; Patricios et al. 2023).

In most cases, the major themes identified in the present study were consistent with current SC advice, including in recently updated or synthesised guidelines (Silverberg et al. 2020; Australian Institute of Sport 2023; Patricios et al. 2023). An exception to this finding is that the theme of general health advice is not specifically articulated or endorsed in these guidelines (e.g. Australian Institute of Sport 2023; Patricios et al. 2023). The current SC guidelines refer to alcohol or drug use, or other factors identified in this theme such as sleep, but often in relation to diagnostic relevance (e.g. as a factor that is ‘concomitant’ (Patricios et al. 2023) or ‘confounding’ (Silverberg et al. 2020)) as opposed to recovery. It seems that the community responses indicate general injury (non-concussion) advice, which may be appropriate or expected from a non-specialist audience, but it could also signal an opportunity to direct public concussion education campaigns in ways that can improve this advice and support stronger alignment with injury-specific advice (e.g. expert clinical assessment is needed).

In another possible departure from current formal SC advice, this study identified a social/psychological support theme, as a component of the public’s advice for SC. Such advice is not a clear, or top-level, recommendation in all current SC guidelines (Silverberg et al. 2020; Australian Institute of Sport 2023; Patricios et al. 2023), although there are some relevant statements about it. For example, the CISG recommends consideration of mental health screening and prior psychological health (Patricios et al. 2023), primarily to support diagnosis. However, the ACRM recommendation to provide education/advice for the patient/family (including setting ‘favorable expectations for recovery’ (Silverberg et al. 2020, p. 389), and the AIS statement that ‘education of both athlete and their support network is crucial as part of this rehabilitation and graduated return to sport process’ (Australian Institute of Sport 2023, p. 27), do connect with this theme. Some community members identified a psychological or social dimension for SC care and may expect consideration of this should they require such care. It seems likely that not all providers will address this functional aspect, as it may depend on the guidelines they follow. The beneficial role of psychosocial factors (e.g. social support) in the SC recovery process due to the emotional challenges of recovery has been observed in some studies (McGuckin et al. 2016; Wayment and Huffman 2020). It might be worthwhile for providers to draw from such evidence when providing SC management advice.

A key study finding is that the SC advice offered by the community was time-sensitive (Silverberg et al. 2020; Australian Institute of Sport 2023; Patricios et al. 2023). However, rest for SC was still a prominent theme in the subacute period in this sample. According to current guidelines, rest should be reduced in the subacute period, typically giving way to active recovery. Further, the concept of ‘bed rest’ for SC recovery was proposed by some participants, but this is not endorsed in current guidelines. These findings suggest that the concept of ‘relative rest’ as promoted in recent guidelines (Silverberg et al. 2020; Australian Institute of Sport 2023; Patricios et al. 2023) would benefit from further public promotion to grow community awareness of it as core component of SC care. This would ensure that members of the public who need SC advice will be primed to expect active recovery advice.

This study has several limitations. First, some themes were challenging to distinguish from others, especially the idea of rest (reducing activity), presumably for recovery, versus the idea of avoiding or stopping activities, which could be for safety or re-injury prevention reasons (such as stopping contact sports). There could be some unreliability in these specific coded responses and thus identification of themes. These were identified by one author, and future studies could use additional coder/s for cross-checking. However, the coding difficulty likely reflects some conceptual overlap in these concepts and the known challenge of defining ‘rest’ for SC (Sullivan et al. 2012), including whether rest is achieved by increasing restorative activities or reducing energy-depleting activities or both (Bernhofer 2016; Rydstedt and Johnsen 2019). Second, three published guidelines were used to provide an indication of gold standard SC advice, but they should not be regarded as fully independent. For example, there is overlap in the authorship of some guidelines, and the AIS guidelines reference CISG statements (McCrory et al. 2017; Australian Institute of Sport 2023). Third, this study had a relatively small sample, obtained through convenience sampling, and the survey was not tested for readability. This study recruited members of the community, but it does not reflect the views of the wider community. The sample had a relatively narrow demographic range (e.g. overrepresentation of women and people with university education), and the views expressed by these participants may not be replicated in a larger or more representative sample. Fourth, this paper is a cross-sectional survey, so comments about change in understanding of SC advice, and awareness of active recovery specifically, must be understood as relative to the timepoints in this study. A longitudinal study is needed to empirically address the question of change in public understanding of SC management. Finally, this paper has discussed typical SC management advice including timeframes, but this advice will not suit all concussed individuals and is not appropriate for all circumstances.

In conclusion, this study found that members of the public have an understanding that SC advice is time-sensitive, and they offered different recommendations about SC care depending on the timepoint (immediate or subacute advice). Most of the SC recovery advice suggested by the participants in this study fell into themes that aligned with the formal advice, but the rest period was overestimated. Some specific exceptions were that general health advice and psychological and social supports were suggested by community members as important for SC recovery, whereas these factors are not featured as top-level advice in all current SC guidelines. Similarly, expert clinical assessment is identified as key in the guidelines, but it was not proposed by all respondents. Public education fact sheets and clinical services could specifically target these ‘gaps’; for example, explaining why bed rest is no longer recommended for SC, clarifying the meaning and timing of relative rest/active recovery, encouraging specialist injury assessment, and providing guidance for psychological and social support. Future studies could examine if such changes support more people to engage in correct SC recovery. Additionally, future research could investigate if the findings from this study are replicated in different sub-populations, including those with heightened injury exposure (e.g. contact sport players). Importantly, there appears to be a growing community awareness that an injured person may need to rest first, then engage in active recovery for SC, but there is still a strong need to grow community awareness that one of the first steps should be expert clinical injury evaluation.