Introduction
Concussion as a public health issue
Media attention regarding the catastrophic complications of sport-related concussion (SRC), such as the injury suffered by Zackery Lystedt in 2006,1 and recurrent concussion in high-profile athletes contributed to the identification of SRC as a public health issue. A recent analysis of ambulatory consultations between 2003 and 2013 documented a fourfold increase of reported diagnosis of concussion.2 Increased awareness and competencies within the healthcare professions are among the factors that might explain this increase in reporting. Yet, this epidemiological data most likely still represent an underestimation of the true incidence of concussion. Accordingly, further efforts are warranted to develop awareness around concussion for healthcare professionals, in sport and school environments, and in the general population.
One of the major initiatives to address the issue of SRC is the ongoing process of integrating knowledge into consensus statements and recommendations such as the Berlin Consensus on Concussion in Sport.3 The implementation of such recommendations has been beneficial at the highly resourced and structured elite levels of sport participation. However, their implementation across levels of participation, from grassroots to elite, with proper consideration for the broad spectrum of sport and leisure activities, environments (eg, school-based, non–school-based), available resources and access to qualified health professionals likely remains a challenge. This situation is illustrated by the fact that, following the Berlin consensus, the Canadian national strategy on concussion has focused most of its dissemination efforts at the elite level of national sport organisations.4 This allowed the development of sport-specific concussion management strategies that will hopefully facilitate further efforts at other levels of participation.
One remaining challenge is to achieve the implementation of best practices at every level of sport and leisure participation. This will likely rely on multifaceted strategies. Part of the solution might include legislation, such as the Lystedt laws adopted in the 51 US jurisdictions.5 Data on the implementation of these laws indicate that, although they contributed to increase awareness, measures of enforcement remain largely non-existent.1 6 In line with these findings, amendments have already been adopted in several States.7 In Ontario (Canada), a policy that outlined formal requirements about concussion in high schools was implemented in 2015.8 However, very limited information regarding the impact of this policy is available.9 More recently, the first legislative requirement related to SRC in Canada was adopted by the Ontario legislature.10
Challenge of global implementation
A key characteristic of additional implementation strategies should be to support a reflective process that prompts consideration of the challenges of knowledge transfer in a broad range of environments.11 Reflective learning, or the acquisition of knowledge with reflection about its context of application, is acknowledged as an important component of education on health-related issues.12 Relevant considerations for knowledge implementation related to SRC include the characteristics of the environment and sport, identification of barriers and tailoring of the implementation strategy.13
One key consideration was captured in a recent joint statement from the national family medicine and sport medicine organisations in Canada: “… key aspects of concussion prevention, detection and management occur prior to as well as after the initial medical intervention. … Physicians with expertise in sport and exercise medicine can contribute to these strategies by working in conjunction with families, schools, sports organisations, employers and governments to educate, support and empower the implementation of proper concussion prevention, detection and management protocols”.14 “Empower” is a key word in this statement because the availability of qualified healthcare professionals to directly manage the day-to-day aspects of concussion management in the sport environment, at home and through the return-to-school process will always be limited to all but the most resource-rich organisations. Outside of such environments, many aspects of concussion prevention, detection and management will depend on stakeholders in the sport, family and school environments. Multidisciplinary collaborations between healthcare professionals that are defined by the terms of medically supervised protocols have been proposed as a potential solution.15 For example, if timely access to medical experts on concussion is limited, a protocol could define how a school personnel, nurse or team therapist can play a role in the management of concussion, including timely referral for medical evaluations.
A potential strategy to improve access to concussion education for every possible stakeholder is the use of a massive open online course (MOOC). The term MOOC was used for the first time in 2008 and, over the last decade, with the availability of the World Wide Web, MOOCs have become a knowledge dissemination strategy used by many major universities.16 MOOCs are defined by several key characteristics: (1) a topic of broad public interest; (2) free and open registration; (3) online, self-paced delivery; (4) interactive educational support; (5) formal assessment.16 This strategy has been used in the field of sport and exercise medicine to promote the benefits of physically active lifestyles17 but, to our knowledge, had not been used to address the issue of concussion. By providing free access to education outside of formal educational programmes, MOOCs have the potential to increase the health literacy of the public and provide an innovative teaching model for learning focused on patient-centred and family-centred care.18 19
Accordingly, the assumption driving the development of a MOOC on concussion by Laval University (Quebec, Canada) was that it would successfully create a learning environment that brings together participants from every stakeholder group concerned with concussion regardless of the context of sport and leisure participation. The initial four iterations of the MOOC on concussion have been presented between April 2016 and October 2018. The current study had two main objectives: (1) to document the volume of successful participation and (2) estimate the impact of the course on protocol implementation. The analysis also provided insights regarding how to optimise the integration of an evaluation strategy in future adaptations of the MOOC.