Table 4

Subthemes, codes and exemplary quotes on the theme ‘Concussion prevention and improving concussion management?’

Subtheme	Code	Exemplary quotes
Prevention ideas	Education	“Athlete education: I think it’s making players aware that they are not doing themselves or the team a disservice by admitting it…admitting that they have a head injury, and they are struggling cognitively.” “Coach education: Coaches of any level really…really understanding how to help players to protect themselves and coach them away from potential dangers, that is, the guy behind the goal not letting a player run smack into a goal post or, you know, help basically to create safe environments for those players.” “Coach education: With the coaching issue, I think we can just get over that just by having maybe better modules in blind coaching courses around safety, head protection, head injury, concussion.” “Athlete, coach and medical staff education: I think it’s just reaffirming those things across players, coaches, and medical staff that if you have a problem, you do have to say, you do have to put your hand up. You know, you would if you had a broken leg, so why not with a concussion.” “Referee education: It could even just be where the referee has some type of training or medical or something just to come over to see you, check whether you’re alright quickly at any head injury or facial injury.”
	Spotters	“One option could be even just having a sighted person on the touchline that are open because you’ve got people on the sides, so even someone talking, it could just be a volunteer, and just someone stood there.”
	Equipment	“You don’t want to pad up the goalposts because, for one, it makes it less like a goal and, two, it just gives it padding, and it could be the difference between a goal and not because obviously, it could take the pace out of the ball or anything.”
	Rule changes	“I definitely remember, even just in training sometimes or something, where you’re in a match or something, and someone gets a knock, and you sit up, and you’re like, okay, I’m alright, and the referee says, are you alright, and you just go, yeah, and you just get up, and that’s it. It could even just be in blind football or in any football. If the medical team come on, then you have to go off.”
	Importance of voy rule	“Regarding perceptions on Voy rule: I think it’s fairly consistent. Any referees can make a mistake. If you’re involved in football, how many challenges…how many challenges do people get away with in any…in any form of football. So I think there are probably mistakes now and again with the voy and that, but no, I think it’s fairly consistent. It’s a big rule in blind football.” “Voy is obviously part of the game to make your game flow and make it attractive, but yeah, also primarily, I guess, is a safety measure.”
	Referee standards and consistency	“I would say actually the standard of refereeing because generally what happens is the referees aren’t always under control with fouls and things like that, and using the voy rule… that’s when the risk of getting seriously injured increases.” “I think they vary it. I don’t know why or anything. I played a couple of weeks ago, and I had hold of the ball, and I was basically through on goal, and there was someone literally just stood there, and I ran straight into them, and they never said voy, but the referee never gave it. But then you’ve got things like battling on the ball, but yet they’ll give no voy on things, and you’re right next to each other. So I think they should definitely be a lot more harsh on the fact if there’s no contact, then you don’t know where that person is. They should definitely have a look at every challenge of no voys and see how serious it is because if there’s no voy there and you don’t know where they are, then it’s going to be a lot more fatal than if you’re on the boards and you know where they are than battling but yet they’re still not saying voy, at least there’s more control over it.” “I think that’s where there’s some responsibility on the referees to referee out properly because I think too often it’s…putting it the other way is its late voys and late voys can…it’s frustrating because they…they found a, from a footballing point of view it can result in a kind of unfair turnover of possession but also probably, more importantly, that is where you quite often have a large number of head collisions is the if the voy you felt is way too late because you just don’t have time to react and kind of take evasive action.”
	Referee experience dependent	“I remember particularly one season where we basically had new referees coming in practically every league fixture, and I felt at times it got quite dangerous because they were just so new to the game. It’s different internationally because the sport has moved on a lot and the referees internationally are highly experienced now, so they know what to look for, they know the nuances of the game, and that makes a big difference.” “Referees, again, at the international level and below, being really, really strict on the voy rule for whoever it is, you’ve got a tendency with referees maybe to give some leeway to people who are novices or intermediates are not saying voy or not saying voy early enough, and it’s always been a bugbear of mine that because yes you may be penalising them in the short term but in the long term you’re making them safe and everybody else around them safer.” “I think it’s very important for it to be refereed more stringently, and I know when I play in the league sometimes, and we sometimes have new referees to the sport if they are not refereeing that rule correctly…I often come back from the league I kind of have more bumps and bruises than I would have done in an international even though the pace of the game isn’t as fast, and it’s just because of how much of that is let go.”
	Voy rule is player experience dependent	“I think when you get to that top level, then everyone and each of us can sustain levels, so you don’t really get surprised by, you know, a loose ball or a player dribbling particularly fast at you or a quick change of direction, so the voy rule is consistently managed and done well amongst the players. I think the troubles you come into with the voy rule is again when you come down to the national, regional level when you’ve got international players playing against intermediate, intermediates playing against novices that people can get surprised and they don’t voy early enough, or they don’t voy at all.” “I think when you’re new to the game. Obviously, you’re told about the voy rule, but when you’re new to the game, it’s kind of hard to get it in time.”
	Player responsibility	“Players can easily have a role to play, wearing headguards and saying the voy, bringing that rule in and making sure it’s nice and loud and clear.” “I think definitely you have to be a lot more harsh on the voy rule of the person who is saying voy coming into that person, because if you’re running with the ball and someone is stood still, and you run into them, then I think you have maybe more control of that.”
	Voy rule enforcement	“I think if you’ve got someone who has literally said voy as they’re running into you, obviously it’s been given as a freekick, but it definitely has to be something where you have personal fouls, and you have so many to get to until you get a red card. But it has to be given as the fact that if you have, for example, two late voys on someone, then you get a yellow card or something in that sense because, like I say, if someone is running at you, they don’t have as much control over the situation…” “I think if referees were stricter on voys then that could…that would help the number of collisions, and I feel that’s grown in importance over time as the game has got a lot quicker.” “I think referees need to be more aware of is what we call the second man Voy, which sometimes can kind of go under the radar. So, for instance, the first man of the defence says Voy, you go past that player. However, because he said Voy, he’s actually screamed at the person who is defending behind him or her, who then doesn’t say it, and the referees sometimes don’t pick up on it because it’s so quick and because of the person in front… you know, there’s quite a lot of noise going on, and sometimes they don’t necessarily pick up on the second one.”
Temporary concussion substitutes	Sufficient time to assess	“If you don’t, after ten minutes, know whether someone’s concussed or not, then you shouldn’t probably be bringing them back on the pitch.” “I think sometimes you can have a head collision, and it’s uncertain whether it’s a concussion or not…I think possibly from a blind point of view, you would never know unless you took time, so it would show whether it was more long-term, lasting effects or if it was just adrenaline from the situation.” “I was well aware of an incident that happened in a game only a few years ago where one of our players actually got a really bad concussion wearing a head guard, and there were all kinds of bother between the physio and the head coach whether he should be treated on the pitch or not and again with this…with the protocol that sort of stuff wouldn’t happen, it shouldn’t have happened anyway, but it wouldn’t happen now.” “I think definitely that’s a good thing because it gives them time to actually fully assess whether you’ve got a concussion or not.”
	Resource dependent	“So I think ten minutes is a good period of time, and the question then moves to how many teams have the ability to diagnose, so how many, you know, if you look at the sort of national scale, for example, or even at a local team level, how many, is the skill going to be there, you know, to be able to diagnose, that’s the question and what resources are available to enable people to do that.” “There’s a more practical reason in blind football why a third party may be more appropriate, which is that not every nation has…brings a doctor with them. Having a third party available to adjudicate on this could actually be quite useful in terms of providing that resource to nations that can’t afford it.” I’m not sure that in some cultures, a team…a team doctor is the right person to be making that call necessarily.”
	Responsibility removed from the athlete	“Within our game, you might need those extra few minutes to assess that player because obviously, when you’re in the thick of the game and you’re just being quickly tested, your thing is to get back in the game as quickly as possible, you might not want to come off.” “I have seen one player that I believe had a concussion at the time, just kept saying I’m fine, I’m fine and carried on playing, and I believe now he still has a bit of like a lapse of what had happened during that game, but I think with these temporary concussion subs you just take that away from the player, that’s what needs to happen because the player isn’t going to want to come off with anything really.” “I think this is great because I don’t think you know yourself.”
	Better than alternative permanent substitution	“The only other alternative is for it to be a permanent substitution and for that player to go off regardless if they’ve had a head collision, but, you know, I think we all know that that’s…that’s not necessarily the right thing to do because, you know, not every head…not every head injury is a concussion, so I think it’s a good thing.” “I think if they can bring that (TCS) on, I think that would be fantastic. It would definitely help the team. I think as well because you’re not necessarily forced to use one of your actual substitutions.” “This is a great thing because it means…because they’re still limited to having the amount of subs you can have in each half, aren’t they now? So at least coaches, even if they were disinclined to use up one of those subs, they wouldn’t be now because that’s there.” “I think you’re allowed to make six subs per half anyway so you already have plenty of scope to make substitutions so it will be rare, very rare, I think, that anybody could bend the system to their advantage.”
Equipment	Padded headguards and blindfolds	“We have these headguards that we wear now to protect us a bit, like a rubbery foamy headguard thing that we wear, and I’ve noticed more teams around Europe and stuff have started to introduce them, so they are helping, so it’s not full skull on skull contact, there is a bit of padding.” “Technology has changed considerably since I’ve been playing, and there is more padding around the eye socket area, and initially, I think that was because there was so much cutting going on, and so when people crashed heads before those padded blindfolds got more padded, there was a lot of cuts around the eyebrow, cheekbone, that sort of area. I couldn’t say if I think it limits concussions or not because that whole area, like around the face, you know, I’m not too sure how many concussions happen around there.” “I think the padding that we use now has become the norm. In my view, it’s definitely made a difference. For example, on a few occasions where I’ve had someone actually break the back of me and not only is it safer for them because they’re not smashing their teeth or their faces right into the back of my head, they’re hitting the headguard which is softer. But also, I’ve had somebody’s tooth actually go into my head before now.” “It gives me a bit more confidence when playing. I do take a hit on the head, it’s going to absorb some of the impacts, and if you do take a particularly bad knock to the head, you would hope that it would reduce the risk of actually becoming concussed. When I was concussed, it was a full-on kind of knee to the temple, and, you know, we will never know, but maybe if I’d been wearing something like that day, it would have reduced the force that actually went through my head.”
	May have issues	“The head protection, I think it leads people into trying to win balls they wouldn’t necessarily win or maybe not protecting their body with their arm as they could or should do.” “Some of that head protection is really kind of bulky and a bit unwieldy. It’s not necessarily the most attractive to play in.” “Internationally people are more kitted up with headgear and suchlike because it’s been provided for them.”