Original article Hollis SJ, Stevenson MR, McIntosh AS, et al . Br J Sports Med (2011). doi:10.1136/bjsm.2011.085332 1 of 6 Accepted 15 May 2011 ABSTRACT Background There is a risk of concussion when playing rugby union. Appropriate management of concussion includes compliance with the return-to-play regulations of the sports body for reducing the likelihood of prema- ture return-to-play by injured players. Purpose To describe the proportion of rugby union players who comply with the sports body’s regulations on returning to play postconcussion. Study design Prospective cohort study. Methods 1958 community rugby union players (aged 15–48 years) in Sydney (Australia) were recruited from schoolboy, grade and suburban competitions and fol- lowed over ≥1 playing seasons. Club doctors/physiother- apists/coaches or trained injury recorders who attended the game reported players who sustained a concussion. Concussed players were followed up over a 3-month period and the dates when they returned to play (includ- ing either a game or training session) were recorded, as well as any return-to-play advice they received. Results 187 players sustained ≥1 concussion through- out the follow-up. The median number of days before players returned to play (competition game play or training) following concussion was 3 (range 1–84). Most players (78%) did not receive return-to-play advice postconcussion, and of those who received correct advice, all failed to comply with the 3-week stand-down regulation. Conclusions The paucity of return-to-play advice received by community rugby union players postcon- cussion and the high level of non-compliance with return-to-play regulations highlight the need for better dissemination and implementation of the return-to-play regulations and improved understanding of the underly- ing causes of why players do not adhere to return-to- play practices. INTRODUCTION A high incidence of concussion in contact sports, such as rugby union, is reported, with Australian community rugby union players 1 experiencing almost eight concussions per 1000 player game hours. Given the sizeable incidence of concussion and the potential for prolonged adverse effects or delayed long-term consequences (ie, chronic trau- matic encephalopathy) associated with premature return-to-play, 2 3 greater focus on the management and prevention of concussion is needed. For the management of concussion, the Australian Rugby Union 4 recommends that com- munity players and coaches follow the regulations endorsed by the International Rugby Board (IRB), namely that all players who suffer concussion take a 3-week break from both training and games. This regulation is mandatory for players in age-graded competitions (ie, junior players younger than 19 years); however, other players may return to play within the 3-week period only if they are found to be symptom-free and declared fit to play by a rec- ognised neurological specialist after assessment. 4 5 The extent of compliance with these regulations is unknown, including the extent of its implementa- tion in Australian community rugby union. Finch 6 7 has highlighted the need for a much greater focus on translation and implementa- tion research. For example, there is a paucity of research pertaining to the compliance, knowledge and awareness of the regulations or guidelines for returning to play postconcussion. In a recent Canadian study, 8 33% of ice hockey players who were advised by a physician not to return to play postconcussion were non-compliant. Furthermore, 80% of the non-compliant players continued to suffer postconcussion symptoms 2 or more years later. 8 In another Canadian study, 9 almost 25% of ice hockey players did not know whether a player who was experiencing symptoms of concussion should continue playing. Similarly, an American study found that almost half of all high school ath- letes failed to comply with the American Academy of Neurology 10 return-to-play guidelines and 40% returned to play prematurely. 11 In New Zealand, high school rugby union players also had limited knowledge of the concussion guidelines 12 and of players who subsequently sustained a concussion, over half reported returning to play without medi- cal clearance, and 22% against physicians’ orders. In community sport, the responsibility for implementation and adoption of sports safety measures, including regulations and guidelines for concussion management, involves different levels of sports delivery. 7 Even though the goal is to improve player safety and injury outcomes, it is most commonly the role of clubs, coaches or other support staff (rather than the players them- selves) to ensure that injury prevention measures are in place. In a study of certified athletic trainers of American football, soccer, basketball and base- ball, only 3% were found to fully comply with the concussion management guidelines. 13 In New Zealand, 48% of rugby union club teams irregu- larly used standardised procedures regarding return-to-play after musculoskeletal injury, with 1 Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia 2 The George Institute for Global Health, Sydney, New South Wales, Australia 3 Accident Research Centre, Monash Injury Research Institute and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia 4 School of Risk and Safety Sciences, The University of New South Wales, Sydney, New South Wales, Australia 5 Department of Psychology, Macquarie University, Sydney, New South Wales, Australia 6 Australian Centre for Research into Injury in Sport and its Prevention, Monash Injury Research Institute, Monash University, Melbourne, Victoria, Australia Correspondence to Stephanie J Hollis, Sydney Medical School, The University of Sydney, 25 Nichols Parade, Mount Riverview, NSW 2774, Australia; shollis@georgeinstitute.org.au Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players Stephanie J Hollis, 1,2 Mark R Stevenson, 1,3 Andrew S McIntosh, 4 E Arthur Shores, 5 Caroline F Finch 6 BJSM Online First, published on June 24, 2011 as 10.1136/bjsm.2011.085332 Copyright Article author (or their employer) 2011. 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