Background: Concussions can lead to cognitive and behavioural changes, affecting school performance. We co-designed and implemented a FRAmework for maNaging Concussions in New Zealand Schools (FRANCS) to support return-to-learn and -activity.
Purpose: To describe attributes of students reporting their concussion across 12 schools, and to determine implementation outcomes, reported by school stakeholders.
Methods: The schools’ concussion officer referred students with a concussion to the research fellows (RFs). The RFs met weekly with the students, assessing the mechanism of injury and concussion-related symptoms with the Symptom Score (SS) of the Child Sport Concussion Assessment Tool (SCAT5). At the end of each year, an implementation outcomes questionnaire with Likert-style (1=best rating; 5=worst rating) and open-ended questions was administered to school staff.
Results: 81 students (71% Pākehā, 9% Māori, 5% Pasifika) participated. 87% of the concussions were sports-related. 56% of the students met with the RFs once, and the remainder upto 5 times. The Sympton Scale median (range) at the first and last meetings were 37.5 (0, 74) and 28.0 (0, 77, n=35) respectively. 24 school stakeholders completed the implementation questionnaire: 21 found that FRANCS was ‘mostly’ or ‘completely’ successfully implemented, and 22 would use FRANCS beyond project completion. Student and parent compliance had the least favourable scores (medians > 2). Support provided by the RFs, and the process of FRANCS were highly valued. Challenges included lack of time and inconsistent buy-in from some students, whānau, staff and coaches.
Conclusion: Although the implementation process was mostly regarded as successful, strategies to manage administrative burden, and education to highlight the seriousness of concussion with all stakeholders, are needed to improve buy-in.
Implications: FRANCS can be for schools to provide concussion support, adapted to individual schools’ contexts. Buy-in and good communication processes are needed from all members of the school community to sustain the processes.

Background: Football is the only sport where players intentionally use their head to shoot, redirect or pass the ball. This has sparked debate in the literature regarding the safety and potential long-term effects on brain health from cumulative ball heading. Yet there is limited understanding of the players’ perspectives on health and heading.
Purpose: To explore female football players’ perceptions of heading the ball and their knowledge and attitudes towards concussion.
Methods: This qualitative study used semi-structured focus groups and individual interviews. Reflexive thematic analysis was used for analysis and theme development.
Results: Seventeen players (aged 18-40 years, minimum 5 years playing experience) participated in six focus groups and one individual interview. Thirteen of these had incurred at least one concussion. Three themes were developed: (1) The battle of “risk vs. reward”: views around the importance of heading for the game but also the perceived injury risks; (2) “Spare the brain” vs. “train the skill”: players often avoided heading the ball in training rather than practising the skill; (3) Changes in perspectives following concussion: players reported being more apprehensive to head the ball post-concussion, preferring to use other body parts (e.g. the chest) and coaches/family influenced attitudes towards heading and concussion.
Conclusion: In contrast to other injury prevention strategies and skills, the task of heading is often avoided in training rather than practised as a skill, limiting the number of head impacts to ‘reduce injury risk’. Various factors influence perspectives of heading, particularly following concussion, with some players constantly having to choose whether to avoid heading at the cost of decreased performance.
Implications: The outcome of this study highlights many players’ apprehension to head the ball in training/repetitively and how concussion changes their views on heading. These player perspectives may help to inform return to play protocols and heading guidelines.

Background
Assessment of recovery from mild traumatic brain injury (mTBI, also known as concussion) is complex, and challenging. People returning to participate in sports after a mTBI have double the risk of a subsequent injury. This may suggest that they may have ongoing unidentified impairments. Exertional testing, where individuals are tested for mTBI impairments following physical exercise, has shown promise in the research setting through the identification of deficits that cannot be provoked under standard testing conditions performed at rest.

Purpose
To conduct a systematic literature review to determine if the effect of exertion on objective outcome measures differs in people with mTBI compared to healthy individuals.

Methods
A systematic search was carried out according to a pre-defined protocol (PROSPERO Registration CRD42023411681). Studies were eligible for inclusion if they: i) compared people aged 12-65 with a recent history of mTBI with healthy controls, ii) investigated the effects of a single session of physical exertion, iii) collected pre- and post-intervention measures of physiological or sensorimotor function.

Results
Descriptive analysis of 24 papers was completed. Meta-analysis was precluded due to the methodological variations and diverse outcome measures across the included papers. The literature demonstrated significant differences in the immediate effect of physical exertion on mTBI versus control participants in sensorimotor measures, including the King-Devick test, and physiological measures, including heart rate variability, autoregulation and haemodynamics, respiration, and perceived exertion.

Conclusions
The majority of the studies confirmed that post-exertion objective assessments can differ in mTBI compared with healthy, and these differences were less apparent at rest.

Implications
Exertional testing could therefore play a role in the assessment of recovery following mTBI. Physiotherapists have the skills and expertise to be an integral part of this process. The review findings will be used to inform the development of a return-to-play protocol that incorporates exertion.