Return to Play Following a Sports-Related Concussion – What is the Experience of General Practitioners and Physiotherapists Managing This in Primary Care? A Qualitative Study in New Zealand

Abstract

Background: A concussion is a mild form of traumatic brain injury (TBI), with sports-related concussion (SRC) making up around a quarter (21-30%) of all concussions. Current guideline recommendations for SRC include advice to facilitate a gradual return to recreational and sporting activity, termed return-to-play (RTP). RTP following SRC too soon can increase the risk of other injuries or prolong recovery. The consideration of a safe RTP is a unique characteristic of SRC management that a healthcare professional (HCP) needs to integrate into their care. In New Zealand, the Accident Compensation Corporation (ACC) recommends that the GP clear a person as having recovered sufficiently before they can RTP. Given that around 90% of SRC injuries are managed in primary care, healthcare providers such as General Practitioners (GPs) and physiotherapists, have the role of managing RTP following a SRC. However, there is limited understanding of the experiences and perceptions of GPs and physiotherapists in managing RTP or their attitudes about supporting each other to deliver RTP. This thesis aimed to explore the experience and perceptions of GPs and physiotherapists delivering RTP for SRC in New Zealand.

Methods: A cross-sectional qualitative study was conducted using open-ended interviews among four GPs and five physiotherapists to explore participants' perspectives on RTP. Convenience sampling was used to recruit participants with at least 2 years of primary care SRC experience in New Zealand. Interview transcripts were thematically analysed using a data-driven approach to generate a framework representing participants’ experiences and perceptions of delivering RTP for a SRC.

Results: Three themes were identified: (1) “What RTP means to me”, describes how participants assess recovery, how they build a therapeutic relationship that is contextual to the person, and ensure early education to minimise loss to follow-up during the RTP; (2) “What influences how well I can help someone with RTP”, describes the factors influencing RTP which are related to professional practice, the patient, and the health system; (3) “How the context and my connections influence how I provide RTP support”, describes participants perceptions of the need for local clinician-led community education, and the need for interdisciplinary communication to be better supported. Participants described the management of SRC RTP as challenging to perform well. A key barrier to supporting RTP was current resourcing within general practice, with limitations of clinical time to safely discern recovery or develop therapeutic relationships with the person and supporting stakeholders, alongside health workforce challenges, particularly rurally. Both GPs and physiotherapists were positive about working with each other, sharing responsibility on aspects of SRC such as diagnosis, referral to multi-disciplinary teams (MDT), and ensuring safe RTP decision-making.

Conclusion: Management of RTP is influenced by the context in which it is delivered and to whom. Support for an increase in knowledge about how to discern recovery for RTP is required. Sharing roles in the management of RTP was acceptable to GPs and physiotherapists but support is also needed to facilitate better interdisciplinary communication. Addressing these needs could improve outcomes for people undergoing RTP.