Mike England

Epidemiology of time-loss injuries in English community-level rugby union

Objectives Using a prospective cohort study design, to establish the incidence and nature of time-loss injuries in English community rugby and to assess the differences between different playing levels. Setting English community rugby clubs. Participants Injury information for 4635 matches was collected during seasons 2009/2010 (46 clubs), 2010/2011(67 clubs) and 2011/2012 (76 clubs). Clubs were subdivided into groups A (semiprofessional), B (amateur) and C (recreational) for analysis. Primary and secondary outcome measures Any injury resulting in 8 days or greater absence from match play was reported by injury management staff at the clubs. The primary outcome measure was injury incidence (per 1000 player match-hours) and the secondary outcome measure was severity (ie, days absence). Results Overall match injury incidence was 16.9 injuries per 1000 player match-hours. Incidence was higher for group A (21.7; 95% CI 19.8 to 23.6) compared with group B (16.6; 95% CI 15.2 to 17.9) and C (14.2; 95% CI 13.0 to 15.5, both p<0.001). The mean time-loss was 7.6 weeks absence, with knee and shoulder injuries the most severe with mean absences of 11.6 and 9.3 weeks, respectively. Half of all injuries occurred to the lower limb, with knee and ankle joint/ligament injuries the most common diagnoses. Shoulder joint/ligament injuries were the most common and severe upper limb injuries. Contact events accounted for 80% of all injuries and tackles accounted for 50%. Running was the most common non-contact injury event, of which 56% were hamstring injuries. Conclusions More time-loss injuries occur at higher levels of community rugby. Injury prevention strategies should focus on good technique in the tackle and conditioning exercises for the knee, ankle, hamstrings and shoulder.

Collapsed scrums and collision tackles: what is the injury risk?

Aim To establish the propensity for specific contact events to cause injury in rugby union. Methods Medical staff at participating English community-level rugby clubs reported any injury resulting in the absence for one match or more from the day of the injury during the 2009/2010 (n=46), 2010/2011 (n=67) and 2011/2012 (n=76) seasons. Injury severity was defined as the number of matches missed. Thirty community rugby matches were filmed and the number of contact events (tackles, collision tackles, rucks, mauls, lineouts and scrums) recorded. Results Of 370 (95% CI 364 to 378) contact events per match, 141 (137 to 145) were tackles, 115 (111 to 119) were rucks and 32 (30 to 33) were scrums. Tackles resulted in the greatest propensity for injury (2.3 (2.2 to 2.4) injuries/1000 events) and the greatest severity (16 (15 to 17) weeks missed/1000 events). Collision tackles (illegal tackles involving a shoulder charge) had a propensity for injury of 15 (12.4 to 18.3) injuries/1000 events and severity was 92 (75 to 112) weeks missed/1000 events, both of which were higher than any other event. Additional scrum analysis showed that only 5% of all scrums collapsed, but the propensity for injury was four times higher (2.9 (1.5 to 5.4) injuries/1000 events) and the severity was six times greater (22 (12 to 42) weeks missed/1000 events) than for non-collapsed scrums. Conclusions Injury prevention in the tackle should focus on technique with strict enforcement of existing laws for illegal collision tackles. The scrum is a relatively controllable event and further attempts should be made to reduce the frequency of scrum collapse.

Incidence and Nature of Medical Attendance Injuries in English Community Rugby Union

Background: Previous research has identified injury patterns during community-level rugby union match play, but none have investigated the frequency and reasons for on-field injury management. Purpose: To establish the frequency, reasons, and patterns of on-field injury management in English community rugby, including differences between different levels of play. Study Design: Descriptive epidemiology study. Methods: Over 3 seasons, injury information was collected from 46 (2009-2010), 67 (2010-2011), and 76 (2011-2012) English community clubs (Rugby Football Union [RFU] levels 3-9). Club injury management staff reported information for all medical attendances during match play, including details on the injury site and type, playing position (seasons 2010-2011 and 2011-2012 only), and whether the player was removed from play. Clubs were subdivided into groups A (RFU levels 3 and 4 [mainly semiprofessional]; n = 39), B (RFU levels 5 and 6 [mainly amateur]; n = 71), and C (RFU levels 7-9 [social and recreational]; n = 79) to differentiate playing levels. Results: The overall medical attendance incidence was 229 per 1000 player-match hours (95% CI, 226-232), with 45 players removed per 1000 player-match hours (95% CI, 44-46). Attendance incidence for group A (294 per 1000 player-match hours; 95% CI, 287-301) was higher compared with group B (213; 95% CI, 208-218; P < .001) and C (204; 95% CI, 200-209; P < .001). There was a higher incidence of attendances to forwards (254; 95% CI, 249-259) compared with backs (191; 95% CI, 187-196; P < .001). The head was the most common specific site of injury (55 per 1000 player-match hours; 95% CI, 53-57) but the lower limb region overall accounted for most attendances (87; 95% CI, 85-89) and the greatest chance of removal from the pitch (22; 95% CI, 21-23). Conclusion: With the likelihood of 1 injury for each team per match severe enough for the player to leave the pitch and with at least 1 attendance for a head injury per match, there is clear evidence that pitch side staff should be trained to recognize potentially serious injuries.

Efficacy of a movement control injury prevention programme in adult men’s community rugby union: a cluster randomised controlled trial

Background Exercise programmes aimed at reducing injury have been shown to be efficacious for some non-collision sports, but evidence in adult men’s collision sports such as rugby union is lacking. Objective To evaluate the efficacy of a movement control injury prevention exercise programme for reducing match injuries in adult men’s community rugby union players. Methods 856 clubs were invited to participate in this prospective cluster randomised (single-blind) controlled trial where clubs were the unit of randomisation. 81 volunteered and were randomly assigned (intervention/control). A 42-week exercise programme was followed throughout the season. The control programme reflected ‘normal practice’ exercises, whereas the intervention focused on proprioception, balance, cutting, landing and resistance exercises. Outcome measures were match injury incidence and burden for: (1) all ≥8 days time-loss injuries and (2) targeted (lower limb, shoulder, head and neck, excluding fractures and lacerations) ≥8 days time-loss injuries. Results Poisson regression identified no clear effects on overall injury outcomes. A likely beneficial difference in targeted injury incidence (rate ratio (RR), 90% CI=0.6, 0.4 to 1.0) was identified, with a 40% reduction in lower-limb incidence (RR, 90% CI=0.6, 0.4 to 1.0) and a 60% reduction in concussion incidence (RR, 90% CI=0.4, 0.2 to 0.7) in the intervention group. Comparison between arms for clubs with highest compliance (≥median compliance) demonstrated very likely beneficial 60% reductions in targeted injury incidence (RR, 90% CI=0.4, 0.2 to 0.8) and targeted injury burden (RR, 90% CI=0.4, 0.2 to 0.7). Conclusions The movement control injury prevention programme resulted in likely beneficial reductions in lower-limb injuries and concussion. Higher intervention compliance was associated with reduced targeted injury incidence and burden.

THE EFFICACY OF A MOVEMENT CONTROL EXERCISE PROGRAMME TO PREVENT INJURIES IN YOUTH RUGBY: A CLUSTER-RANDOMISED CONTROLLED TRIAL

Background Structured pre-activity exercise programmes have demonstrated injury prevention in a variety of settings, but their efficacy is largely unknown in contact-orientated sports. Objective To assess the efficacy of a pre-activity movement control exercise programme to reduce injury risk in youth rugby when compared with a standardised exercise programme. Design Single-blind cluster-randomised controlled trial. Setting Independent schools within England during the 2015/16 playing season. Participants Schools with onsite medical provision were eligible to participate in this trial. 31 schools (intervention, 17 schools, 1,325 players; control, 14 schools, 1,127 players) completed the trial. Interventions Both programmes were completed for 15–20 minutes prior to main sessions, with team coaches acting as delivery agents. The intervention programme combined progressive proprioceptive, resistance, and plyometric activities. The standardised programme combined dynamic stretching, wrestling-based and speed-based activities. Main Outcome Measures Trial-arm comparisons were made across summary measures of time-loss (>24 hours) injuries, with effects analysed through magnitude-based inference against thresholds for the smallest worthwhile effects (RR=0.90 & 1.11). Results 441 time-loss injuries (intervention, 233; control, 208) were reported across 15,953 match exposure-hours (intervention, 9,083 hours; control, 6,870 hours). Intention-to-treat analyses revealed a 15% reduction in overall match injury incidence favouring the intervention (relative risk=0.85, 90% CI 0.61–1.17, unclear effect), whilst reductions were also identified in match concussion incidence (RR=0.71, 0.48–1.05, likely beneficial effect). Per-protocol analyses revealed that completing the intervention programme compared with the control programme an average of 2x/week was associated with a further reduction in overall match injury incidence (RR=0.73, 0.45–1.20, unclear effect), whilst an average use of 3x/week halved overall match injury incidence (RR=0.50, 0.22–1.13, likely beneficial effect). Conclusions This study presents encouraging evidence that using a preventive exercise programme 2–3x/week prior to training and matches can reduce injury risk in youth rugby when compared with a standardised programme.

55 the recognition of paediatric sports related concussion (5–16 year olds), initial management and advice among london based emergency medicine trainees

Objective This study aimed to investigate knowledge of paediatric concussion amongst emergency medicine trainees, testing the hypothesis that emergency medicine trainees lack sufficient knowledge to competently assess, diagnose and manage sports-related paediatric concussion. Design cross-sectional questionnaire survey. Setting Secondary care emergency medicine departments. Participants All emergency medicine trainees in one geographical training region in the UK were invited to participate. Outcome measures occupational grade, years of experience, history of specific concussion training, awareness of head injury guidelines, perceived knowledge and confidence in concussion diagnosis and management. Main results Sixty questionnaires were returned. Across all training grades, the mean correct response score on questions of diagnosis, assessment and management of concussion was 73.4%. Nearly 70% of trainees were not aware of any concussion guidelines, and only 10% had attended a course or received training regarding concussion. There was a negative correlation between awareness of guidelines and perceived confidence (r=−0.50 p<0.001), and knowledge in diagnosis and management of concussion (r=−0.51, p<0.001). The majority (91.7%) of the participants would like further education on concussion management, with an online learning module being the preferred format (71.7%). Conclusions The study revealed insufficient level of knowledge and confidence in the assessment, diagnosis and management of paediatric concussion among emergency medicine trainees. None of the variables studied statistically predicted knowledge score. Additional concussion-specific education would be beneficial to optimise trainees’ knowledge of paediatric concussion. Competing interests None.

AN EPIDEMIOLOGICAL STUDY OF MATCH INJURIES IN YOUTH RUGBY UNION

Background Injury risk in youth rugby is perceived as high when compared with other youth sports, and has become a notable public health topic. Objective To investigate the incidence and nature of match-related injuries sustained in youth rugby union. Design Two-season prospective cohort study. Setting Independent schools within England during 2013/14 and 2015/16 playing seasons. Participants Eligible schools had onsite medical personnel for injury treatment and data capture. All male players within the under-15 to under-18 age groups of included schools were eligible to participate. In total, 3,179 rugby players (aged 14–18 years) from 40 schools participated. Main Outcome Measures Time-loss (>24 hours) match injury incidence (per 1000 match hours) and burden (days lost per 1000 match hours), classifications made on injury location, severity, and inciting event. Results 598 time-loss injuries were reported from 21,865 match exposure-hours, giving an overall match injury incidence of 27 injuries/1000 match-hours (90% CI 26 to 29) and burden of 731 days lost/1000 match-hours (90% CI 721 to 740). The head was the most frequently injured location (31% of injuries), followed by the shoulder (14%), wrist/hand (12%), and knee (8%). Moderate time-loss injuries (8–28 days) were the most commonly reported (38%), followed by minor injuries (2–7 days, 33%), whilst over a quarter of injuries were severe (>28 days, 27%). Most injuries were associated with contact events (88%), particularly the tackle (58%) and ruck (14%), with 8% associated with running. Concussion incidence was 6/1000 match-hours (90% CI 5 to 7). Conclusions Match injury incidence was similar to figures reported in recent studies, whilst injury burden and the proportion of severe injuries were lower than previously reported. Implications of this studys findings would include focusing further on identifying risk factors and preventive strategies for tackle-related injuries as well as for head injuries, particularly concussion, in youth rugby.

EFFICACY OF A MOVEMENT CONTROL INJURY-PREVENTION PROGRAMME IN AN ADULT COMMUNITY RUGBY UNION POPULATION; A CLUSTER RANDOMISED CONTROLLED TRIAL

Background Exercise programmes aimed at reducing injury have been shown to be efficacious for some non-collision sports, but evidence in collision sports such as rugby union is lacking. Objective To evaluate the efficacy of an evidence-informed injury prevention exercise programme in reducing match injuries in adult community rugby union players. Design Prospective cluster randomised (single-blind) controlled trial. Clubs were the unit of randomisation. Setting English adult community clubs (2015–2016 season) with a formally qualified medical professional to diagnose and report match-injuries. Participants 860 clubs were invited to participate of which 81 volunteered and were randomly assigned. Data was received from 41 clubs (control, 19; intervention, 22). Interventions A 42-week exercise programme comprising 6-week graduated exercise blocks was introduced during pre-season. The control programme reflected ‘normal practice’ exercises, whereas the intervention focused on proprioception, balance, cutting, landing, and resistance exercises. Main Outcome Measurements Match-injury incidence and burden for: all ≥8 days time-loss injuries and targeted (lower-limb, shoulder, head and neck, excluding fractures and lacerations) ≥8 days time-loss injuries. Results Poisson regression identified unclear differences between groups for overall injury incidence (rate ratio (RR), 90% confidence interval (CI)=0.9, 0.6–1.3) and injury burden (RR, 90% CI=0.8, 0.5–1.4). A likely beneficial difference in targeted injury incidence (RR, 90% CI=0.6, 0.4–1.0) was identified, with ∼40% lower lower-limb incidence (RR, 90% CI=0.6, 0.4–1.0) and ∼60% lower concussion incidence (RR, 90%CI=0.36, 0.18–0.70) in the intervention group. Completing the intervention at least once per week was associated with a likely beneficial difference between groups (intervention n=15, control n=13; RR, 90% CI=0.7, 0.4–1.0). Conclusions This movement-control injury-prevention programme appeared efficacious, with likely beneficial differences for lower-limb injuries and concussion for the treatment clubs. Targeted injury incidence was ∼30% lower when 1 or more intervention sessions were completed each week.

Does concussion education have an impact in behaviours amongst school-age rugby players?

Background Concussion is a common injury in school-boy rugby, if managed incorrectly it can have serious consequences such as further injury, prolonged symptoms, and second impact syndrome. Adolescent players show poor knowledge levels and symptoms-reporting behaviour. Objective Investigate the effects of an educational presentation on the knowledge and behaviour of school age rugby players regarding concussion. Design Questionnaire based study. Setting 120 male rugby players, aged 16–18. Participants Three large rugby union playing schools in England. Interventions Independent Variable – Educational presentation aimed at school-age rugby players to improve their education and behaviours related to the condition. Players completed a questionnaire testing for likely behavioural responses from a selection of common concussion scenarios. Additional questions assessed knowledge of concussion symptoms, diagnosis and management. The questionnaires were completed pre-season and repeated 2–3 months after the presentation. Outcome Dependent variable: Questionnaire scores. Results The students had significantly improved their responses giving 53.9% appropriate responses after the presentation (Md=55, n=34) compared to 46.1% before (Md=33.5, n=34) (U=400, Z=-2.18, p=0.029) with a moderate effect size (r?=?0.37). The knowledge of students increased from 37.85% correct responses before (Md=28, n=35) and 44.07% on follow up?(Md=28, n=35) but with no significant difference (U?=?575.5, Z?=?-?0.88, p=0.378 with a small effect size (r?=?0.15)). Completed surveys showed increased awareness of guidelines from 19.4% to 73.2% (p=0.00 McNemars Test). Conclusions The students had showed improved concussion behaviour in response to concussion scenarios at 2–3 month follow up in contrast to previous studies on educational interventions. There was no increase in players knowledge of concussion. The literature shows increases in short-term knowledge with other forms of concussion education but this effect is often lost at long term follow up. There was increased awareness of guidelines. Future concussion education should be modeled on the educational presentation to improve behavioural outcomes.

Shoulder Injuries in English Community Rugby Union.

The aim of this study was to describe the incidence, severity and type of shoulder injuries resulting from match play in adult community rugby union between 2009-2013. A total of 254 time-loss shoulder injuries were reported, an overall incidence of 2.2 per 1 000 h (95% CI: 1.9 to 2.4), and a mean injury severity of 9.5 weeks missed (95% CI: 8.2 to 10.8). The semi-professional group had an incidence of 2.8 injuries per 1 000 h (95% CI: 2.2 to 3.5), which was higher than the recreational group at 1.8 injuries per 1 000 h (95% CI: 1.4 to 2.2, p=0.004). The incidence of acromioclavicular joint injury for semi-professional players was 1.2 per 1 000 h (95% CI: 0.8 to 1.6); which was significantly higher than the incidence of this injury type in recreational players (0.5 per 1 000 h 95% CI: 0.3 to 0.7, p=0.002). Overall, back row players sustained the highest incidence of all shoulder injuries for a given playing position, 2.9 injuries per 1 000 h (95% CI: 2.2 to 3.6). The tackle was the main event associated with injury. Injury prevention programs and coaching strategies that consider tackle technique and physical conditioning of the shoulder region are therefore considered important.