Crying wolf: When media reports distort research evidence

As a researcher who has spent a considerable period investigating the risks of injury 1 2 in rugby, and setting up and evaluating injury prevention programmes designed to mitigate the risks 3, I read the BBC media report of July 4, 2010 (http://www.bbc.co.uk/news/10501327) quoting Professor Allyson Pollock that ‘high tackles and scrums should be banned in schools’ with some interest. This was especially so given that Professor Pollock was referring to recently published research she has been involved with that describes injuries sustained by Scottish schoolboy rugby players over the second half of the 2008-2009 season.

After accessing the research paper 4, I found myself puzzling to reconcile the claims made in Professor Pollock’s media statements with the evidence presented in the study. The paper describes a pilot study of methods used to collect rugby injury data prospectively from schools.  Data were collected on a total of 37 injuries. Twenty-six of the injuries occurred during matches, of which two were from the scrum. The site and severity of the scrum injuries is unable to be determined from reading the text. Most of the injuries resulted from tackles, a finding that has been consistently observed in full-scale investigations of injuries at various levels of the sport5-7. No confidence intervals were reported for the injury incidence statistics presented, but because of the small-scale nature of the study and the low number of injuries reported they would have been very wide, meaning that the study provides very limited evidence for drawing conclusions from the observed rates. In fact, the inferences drawn from the data that are reported in the published paper appear to be appropriately circumspect. Notably, there is no mention in the research report of banning scrums or high tackles – presumably because there is insufficient evidence presented for such claims to have withstood peer review.

A few days after reading the research article I happened upon a letter written by the lead author of the paper, Dr Andrew Nicol, which appeared in the Glasgow Herald (July 8, 2010). In the letter, Dr Nicol expresses disappointment that ‘the results have been inaccurately used as a springboard to launch an unwarranted attack on rugby’. Dr Nicol confirms that the study provides no evidence to form a credible basis for banning scrums in school rugby. It seems Dr Nicol was placed in the unenviable position of having to take public issue with a colleague, and I applaud him for acting swiftly to clarify his position. It was therefore notable that in a follow-up article Professor Pollock claimed:

There is no disagreement. I and Dr Nicol are in agreement over the findings of the paper. We must not lose sight of the key finding that it is relatively easy to collect good data on injuries among children playing rugby across Scotland. This needs to be implemented, without further delay.

Unless she made other comments that went unreported, it appears that Professor Pollock has not resiled from the statements she made in which she misrepresented the facts of the study.

So, on what basis was her call to ban scrums and high tackles made? Professor Pollock has extensive experience in communicating her views via the media, thus it would seem unlikely that her statements were made on the basis of naiveté.

It would also appear improbable  that the claims were made in ignorance of the existing state of risk management in rugby 8 9 were it not for the fact that (as noted by Dr Nicol) the call to ban high tackles is otiose, since they are already illegal within the sport 10 (presuming that ‘high tackles’ refers to tackles above the shoulder line, or those that start below the level of the shoulder but subsequently involve contact with the head of the ball carrier). If by ‘high tackles’ Professor Pollock meant tackles to the upper torso but below the level of the shoulders, then it might be of interest to her that a study of 140,000 individual tackles over 434 matches revealed that on a per tackle basis the risk of injury is higher for low tackles than it is for high tackles – especially for tacklers 10. Given this fact, a law change to enforce low tackles may well lead to an overall increase in rugby injury rates.

Likewise, awareness of the effectiveness of programmes to manage the risks involved in scrums and tackles without banning them from the sport 3 11 seem to have passed Professor Pollock by. In the New Zealand situation, for example, there was one scrum-related spinal injury resulting in permanent disability over the period 2001 to 2005, down from nine in the previous five year period. The incidence of less severe injuries (concussions, neck/spine, shoulder and knee) also decreased 12 13. These decreases coincided with the introduction of a compulsory nationwide injury prevention programme entitled RugbySmart, which included substantial training for coaches in safe scrummaging and tackle techniques. There have been no permanently disabling spinal injuries to players in New Zealand aged less than 14 in the past 33 years as a result of their participation in rugby 3. For children in New Zealand, the contact elements of rugby (scrums and tackles) are progressively introduced over a period of several years. I note that as of 2009 the Scottish Rugby Union has implemented a similar programme, as well as regulations about minimum standards for coaching, pitch-side medical care and the minimum age of players permitted to play in Under 18 and senior rugby.

Are there risks involved in playing rugby? Certainly. Are the effects of permanently disabling injuries catastrophic for those involved – players, families, and their communities? Absolutely. Is the risk of serious injury while playing the sport too high?  Fuller, 8 who has conducted an extensive review of the issue, concluded that the risk of sustaining a permanently disabling injury while playing rugby was:

generally lower than or comparable with the levels reported for a wide range of other collision sports, such as ice hockey, rugby league and American Football. In addition, the risk of catastrophic injury in rugby union was comparable with that experienced by most people in work-based situations and lower than that experienced by motorcyclists, pedestrians and car occupants. 8

Many researchers have had the experience of the media misconstruing or misreporting their statements; in some instances this is because ‘sensational’ claims are more newsworthy, on other occasions the meaning of complex or technical research findings may be lost in translation when reported. What is particularly concerning about the media reports quoting Professor Pollock, however, is the likelihood that she acted in full awareness of the fact that her comments were not made on the basis of evidence from the study she was involved in, but were deliberately designed to shape public opinion on an emotive issue by applying a veneer of scientific credibility to what are, essentially, her own opinions. On the face of it, it appears that Professor Pollock has done a disservice to the Journal of Public Health by leading the media to believe that research published within the journal provided a basis for her comments about the risks of rugby injury and the steps that should be taken to manage them when it did not.

I am glad that Dr Nicol, Professor Pollock and colleagues have set up a surveillance system in Scotland to monitor the risks of injury in rugby. I hope that the system continues, collects good quality data, and yields useful information to inform risk management decisions in rugby. There remain many areas in which the effect of participation in sport on long-term health outcomes is uncertain (for example, the effect of concussions on long-term cognitive function) – in time such relationships should be clarified as new evidence comes to hand. The surveillance system being developed in Scotland, and similar ones in other centres, will help provide such evidence. It is to be hoped that the comments of Professor Pollock do not have the unintended consequence of alienating those involved in rugby whose goodwill is required to enable such data collection to proceed.

Debate about the level of risk that is acceptable in sports, as in other activities, is to be encouraged, and I recognise that people have differing views on the appropriate methods and actions needed to achieve reductions in risk in activities that are perceived to be ‘high risk’. Of course, Professor Pollock is as entitled as anyone else to hold opinions on the risks involved in rugby, and the best ways to deal with those risks. It was beholden on Professor Pollock, however, to make it clear to the journalists with whom she dealt that her comments reflected her personal opinions, rather than research evidence from the study to which she referred.  Scientists occupy a privileged position in society with respect to the public discourse of facts derived from research. Because of this, they have an ethical obligation not to permit – or even suffer – claims regarding their research that are not supported by the facts to enter the public domain. Statements that are not supported by the research evidence not only diminish the credibility of the researcher(s) who make them, but over time undermine the trust the public places in scientists as a professional group.

Ken Quarrie, PhD

Rugby Injury Researcher

Wellington, New Zealand

Disclaimer

Ken Quarrie is employed by the New Zealand Rugby Union in the role of Senior Scientist, Injury Prevention & Performance. The views expressed herein are his own and should in no way be interpreted as reflecting the position of the New Zealand Rugby Union on any of the issues addressed.

References

1. Quarrie KL, Alsop JC, Waller AE, Bird YN, Marshall SW, Chalmers DJ. The New Zealand rugby injury and performance project. VI. A prospective cohort study of risk factors for injury in rugby union football. Br J Sports Med 2001;35(3):157-66.

2. Quarrie KL, Cantu RC, Chalmers DJ. Rugby union injuries to the cervical spine and spinal cord. Sports Med 2002;32(10):633-53.

3. Quarrie KL, Gianotti SM, Hopkins WG, Hume PA. Effect of nationwide injury prevention programme on serious spinal injuries in New Zealand rugby union: ecological study. BMJ 2007;334(7604):1150.

4. Nicol A, Pollock A, Kirkwood G, Parekh N, Robson J. Rugby union injuries in Scottish schools. J Public Health (Oxf) 2010.

5. Bird YN, Waller AE, Marshall SW, Alsop JC, Chalmers DJ, Gerrard DF. The New Zealand Rugby Injury and Performance Project: V. Epidemiology of a season of rugby injury. Br J Sports Med 1998;32(4):319-25.

6. Brooks JH, Fuller CW, Kemp SP, Reddin DB. Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med 2005;39(10):757-66.

7. Durie RM, Munroe A. A prospective survey of injuries in a New Zealand schoolboy rugby population. NZ J Sports Med 2000;28:84-90.

8. Fuller CW. Catastrophic injury in rugby union: is the level of risk acceptable? Sports Med 2008;38(12):975-86.

9. Fuller CW. Managing the risk of injury in sport. Clin J Sport Med 2007;17(3):182-7.

10. Quarrie KL, Hopkins WG. Tackle injuries in professional rugby union. Am J Sports Med 2008;36(9):1705-16.

11. Bohu Y, Julia M, Bagate C, Peyrin JC, Colonna JP, Thoreux P, et al. Declining incidence of catastrophic cervical spine injuries in French rugby: 1996-2006. Am J Sports Med 2009;37(2):319-23.

12. Gianotti S, Hume PA. Concussion sideline management intervention for rugby union leads to reduced concussion claims. NeuroRehabilitation 2007;22(3):181-9.

13. Gianotti SM, Quarrie KL, Hume PA. Evaluation of RugbySmart: a rugby union community injury prevention programme. J Sci Med Sport 2009;12(3):371-5.

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  • Professor Allyson Pollock

    Dear Sir

    Had Dr Quarrie approached me first, instead of selectively reading press reports, he would not have found himself “puzzling” nor would he have misled the reader by committing so many grave errors of fact.

    Turning first to errors of fact. Contrary to his assertion, Dr Nicol and I have not established a surveillance system in Scotland to monitor the risks of injury in rugby, though this is not for want of trying to persuade the Scottish Government. As the Scottish Government, the Chief Medical Officer, and the Scottish Rugby Union are aware, for several years I have been an advocate for improved surveillance of all injury, not just sport. The UK lags behind many European countries in this respect.1 2

    Rugby is significant because, as the SRU will tell you, in some schools it is a compulsory element of the curriculum. Teachers and schools have a duty of care to children and on that basis alone they should understand the risks and ensure preventive measures are in place.

    The SRU does require schools to return injury data. But the SRU data returns are meaningless because they are incomplete. This is irresponsible, negligent, and scandalous. The SRU is in receipt of public funds as well as funds from at least one health board to coach rugby to children living in areas of socioeconomic deprivation. These children are most at risk of all–cause injury; so it is imperative that injury monitoring be put in place.

    Dr Quarrie might be interested to learn the history of our study which he cites. 4 The CMO asked Dr Nicol, who was on secondment to his office, to work with me in the Centre for International Public Health Policy at the University of Edinburgh. Although Dr Nicol had not conducted any academic research, he was made an honorary research fellow in the Centre and the academic work was conducted under my direction; he was lead author in recognition of his major contribution to the study.

    When Dr Nicol and I independently tried to use the SRU data forms, we discovered that the forms were incomplete as they are only returned in case of death or overnight hospital stay. In the UK, few children with even serious injuries will be admitted overnight from Accident & Emergency and the majority of serious injuries including fractures, dislocations, ligament tears, and concussion will not be captured. The SRU and its medical team are well aware of this.

    Because of this, Dr Nicol, Graham Kirkwood and I, with support from Dr Robson at the SRU, decided to conduct a pilot study to look at the feasibility of improving the form with a view to implementing injury surveillance. The study was undertaken with no external grant funding apart from the release of Dr Nicol on secondment from the CMO office. Lack of proper funding meant that the study was restricted to the second half of the season and to five schools, and was based on small numbers. Nonetheless it showed a high risk of injury; the average player risk of injury in the second half of the season was 17 percent. This is the sort of information parents, coaches, and children need.

    This is the first such study in 11 years in the UK. This tells a story of both neglect and complacency on the part of government and rugby unions, not least because a meticulous and detailed follow-up to a Lancet study, published in the BJSM in 2000, by Prof Garraway and colleagues, reported a near doubling in the proportion of injuries after the game became professional, and particularly high rates in school age boys. Prof Garraway was not given further funding for his research from the SRU; there was concern about the negative impact of his findings on the game’s image.

    Third, a careful reading of the press reports and my quotes will show that I did not misrepresent the facts of the study. They are clearly set out and stated. All research is but a small contribution and stands on a body of research evidence. It would be unprofessional not to cite that larger body of evidence. As I made clear, the extensive literature shows that injuries are common, the probability and risk of injury are high, that tackle and scrum are vulnerable phases of play, and that injuries are more common early in the season. The academic literature shows that the scrum and tackles are the phase of play where injury occurs most commonly in children. The scrum occurs less frequently during the game but is associated with high injury rates. As Garraway et al write in the BJSM in 2000:

    “Many injuries occur in the tackle in both codes but changes in the laws of rugby union in recent years have been designed to encourage more open play. This has probably resulted in more tackles involving a higher degree of momentum or the use of greater force. Tackles coming in at high speed from behind the tackled player have recently been highlighted as an important factor in injuries occurring in rugby union.”

    Changes in the Laws of the Game which have come into force since the first survey was carried out during the 1993–1994 season may have played a part in the major increase in the rate of injuries which have occurred in both professional and amateur players.7

    High tackles may be illegal but it does not mean they are not occurring, and there is insufficient monitoring to ensure they are not occurring. Changes to the Laws may be ongoing, but Dr Quarrie, by his own admission and on his evidence, shows that not enough is being done and tackles are still too dangerous.

    Serious rugby experts and rugby commentators have also called in the pages of the BMJ and the international media for revisions to the Laws of the Game, including a ban on the scrum;8 9 but Dr Quarrie omits this coverage.

    Fourth, although SRU stresses it takes injuries and player welfare seriously this is not supported by evidence. Rather the SRU hides behind a veil of ignorance on the basis that “if we don’t collect data we don’t know the risk and if we don’t know the risks we don’t need to do more”.5 Lack of data on risk is a handy weapon with which to attack public health advocates. The SRU will not know whether its rugby prevention strategies are working for the simple reason that there is no independent monitoring to evaluate them. As of today, despite repeated enquiries to the SRU, the SRU refuses to provide details of the surveillance that is in place, and there are several reports of parents reporting that injury forms are not being completed or returned.

    Turning now to comparative studies. The Fuller study comparing risks across all sports is interesting but problematic as many researchers have shown. Different injury definitions, experience of observers, methods of recording events, and the use of various items of protective equipment by different sports make it difficult to compare frequency of injuries.

    Finally, the precautionary principle guides public health. Scotland has had an alarming number of catastrophic spinal injuries in boys in recent years; these are the tip of the iceberg of spinal and other injuries. Unlike New Zealand, there is not an Accident Compensation Corporation, and nor is there proper monitoring of all spinal injuries. Indeed the victims of such catastrophic spinal injuries, often do not have adequate insurance cover, and so must rely in large part on the NHS and social services; as well as charitable support for long term care, for example from the charity Hearts and Balls, which raises funds for lifelong victims of serious spinal injuries due to rugby.6

    At some point the evidence accumulates and becomes so obvious that it is irresponsible simply to continue with expensive studies and to repeat the call for more surveys research claiming that we don’t yet know enough about the risks. Prof Garraway, writing in the BJSM in 2000, noted

    The principal concerns of the IRB in adopting professionalism have been to establish the sport’s commercial viability and adapt organisational structures to manage it. More emphasis should now be placed on players’ health and welfare.

    Ten years on and we are all still waiting.

    In 1975, J W Kyle, a former international rugby union player and surgeon, said:

    Let us have no conspiracy of silence with regard to these serious injuries or to deaths on the rugby field. Our duty is to study the mechanisms of injury in all phases of the game. Then, and then only will we be able to take preventative action.

    Nearly forty years later the silence endures and the systems and research are largely absent in the UK.

    One explanation for the inertia on the part of government and the antagonism on the part of SRU to injury monitoring is the commercial stakes, which are high. Professionalisation has turned the game into a multimillion pound sport industry attracting extraordinary levels of sponsorship and incurring high debt for new stadia, etc. The game is increasingly driven by commercial rather than public health imperatives. Rugby is being rolled out to children, both school boys and girls, without proper thought of the risks to the young players, the majority of whom will never go on to play the game professionally but who may live a lifetime with the consequences of serious injury. With commercial pressures like these, conflicts of interest among researchers, and indeed universities where researchers and medical doctors have strong ties to the rugby industry, are always possible and we need to be aware of them. “Not to declare them will indeed undermine the trust the public places in scientists and doctors as a professional group”.

    It is time the rugby establishment got its house in order. Commercial interests and the survival of the game should not trump public health and the safety of children. What we need from government is proper community and hospital based injury surveillance. The cost of implementing a national all encompassing child injury surveillance system is paltry compared with the millions of pounds of sponsorship money spent defending the commercial interests behind the roll out of rugby and other sports.

    1. Kirkwood G, Parekh N, Pollock A. Preventing injury in children and adolescents. Trauma 2010 12:221-238.
    2. Kirkwood G, Pollock A. Preventing childhood injury. BMJ 2008;336:1388-1389.
    3. Nicol A, Pollock A, Kirkwood G, Parekh N, Robson J. Rugby union injuries in Scottish schools. Journal of Public Health 2010
    4. Pollock A. We have to tackle child injury on the sports field. The Herald 2009 09 March 2009.
    5. Donnelly B. Experts clash on scrum safety. The Herald 2010 08 July 2010.
    6. http://www.heartsandballs.org.uk/.
    7. Garraway W, Lee A, Hutton S, Russell E, Maclead D. Impact of professionalism on injuries in rugby union. British Journal of Sports Medicine 2000;34:348-351.
    8. Bourke JB. Rugby union should ban contested scrums. BMJ 2006;332:1281.
    9. Wynne-Jones J. Ban the scrum, says top rugby coach. The Independent 2006 12 February 2006.

  • Ken Quarrie

    Dear Sir

    First up, an apology. I apologise unreservedly to Professor Pollock, Dr Nicol and their colleagues for the ‘grave error of fact’ that I made in presuming that they had continued on from their pilot study and set up a surveillance system. Any inconvenience is regretted.

    As to the ‘many’ other grave errors of fact I am charged by Professor Pollock as having made, I am afraid that having read her rebuttal to my letter, I am still in the dark as to what these were.

    I do, however, wish to make a few points with respect to the issues Professor Pollock raises in her letter.

    First, my sentiments with respect to a surveillance system in Scottish rugby are unchanged. I hope that such a system is set up, and that it provides evidence that can assist in good risk management in rugby – regardless of who is involved. Evidence from robust systems and studies is the key here, and it is important that such evidence is distinguished from opinion and advocacy.

    As I already stated, I do not believe that the pilot study1 conducted by Professor Pollock, Dr Nicol and colleagues provides sufficient evidence upon which to base recommendations for making changes such as ‘banning high tackles and scrums’, which is, after all what Professor Pollock is quoted as having called for. I agree that each study is only a small part of the body of knowledge, but, having reread the media reports, it is not clear that Professor Pollock was referring to the ‘wider body of evidence’ or that she had switched from referring to the results of the pilot study to evidence from research in general.

    Both the paper and the media reports are matters of public record, and I invite those interested to read them and come to their own conclusions about whether Professor Pollock made unjustified comments about the implications of the research paper she co-authored. Based on the media reports, it certainly seems that at least one of her co-authors believes she did, regardless of Professor Pollock’s contention that a careful reading of the reports would reveal that she did not.

    I have, however, been provided with one letter written by Professor Pollock, apparently to the editor of a newspaper. I received this after my letter was published. Unfortunately I have been unable to locate the letter online, but it was entitled ‘Data proves that the risk of injury is high’. While I disagree with the title (especially the word ‘proves’), it is notable that the tone and content of letter are substantially different from the pieces previously reported, and I agree with the comments Professor Pollock makes therein. Rather than calling for bans to scrums and high tackles, it states that scrums and tackles are areas of the game where there are risks, and that these aspects of the game are modifiable. I have no argument with this. Scrums and tackles have been a focus of injury prevention efforts in rugby for some years, and modifying risks to activities in rugby extends beyond the laws and regulations of the sport, and includes education regarding skills and technique, proper physical preparation, as well as secondary and tertiary injury prevention efforts.

    Given the small scale of the study by Nicol, Pollock et al, the most useful finding was probably that collecting data from the method outlined was feasible. As to the actual injury data from the study, it is unclear what Professor Pollock is referring to when she states that the average player risk of injury was 17%. I did not notice this statistic in the published paper 1. Does this mean that in the second half of the season 17% of the cohort sustained an injury? Apparently not, because only 37 injuries were reported among 470 players – an incidence rate of around 8%. I would be interested to know how the 17% figure was derived.

    One figure that was reported in the study was a match injury rate of 10.8 per 1000 player hours (8.7 per 1000 player hours for injuries that kept players away from rugby participation from one week or more)1. Another way of expressing these figures is to convert them to the number of hours or matches a player would need to play on average before incurring an injury. From the reported rates, a school rugby player could expect to sustain an injury once every 93 hours of play, or once every 69 matches of 80 minutes duration (one injury every 86 matches that would keep the player away from rugby for a week or more). Parents, coaches and children probably should be provided with such information. I suspect there is room for considerable debate about whether such risks represent unacceptably high rates of injury.

    I have a couple of other points unrelated to the original issue of scientists misrepresenting the implications of their research, but relevant to Professor Pollock’s letter. First, I find it somewhat ironic that so much credence should be placed on the ‘meticulous and detailed’ study by Professor Garraway and colleagues 2. Malcolm et al. 3 conducted a critical appraisal of this work, and concluded that the analyses and interpretations derived therefrom were ‘patently flawed’. As a result, Garraway et al. made claims that were simply not supported by the data they collected. I agree with large parts of the evaluation of the work by Malcolm and his coauthors, and consider the comments made in the paper by Garraway et al. to have little more evidential value than opinions. This does not mean that the comments they made are necessarily wrong, merely that they should not be considered scientific facts. For example, with respect to the quoted comment that –

    “Changes in the Laws of the Game which have come into force since the first survey was carried out during the 1993–1994 season may have played a part in the major increase in the rate of injuries which have occurred in both professional and amateur players”

    – they may have, but there was no investigation by Garraway et al. 2 of how the activities in rugby had changed as a result of the law changes, simply a belief that they had, and that an increase in injury rate was the result. As a matter of fact, the apparent change in injury rate may well have been spurious, for reasons presented by Malcolm et al.3.

    Second, I am aware of the comments published by Dr Bourke in his personal opinion piece in the BMJ 4. My colleagues and I cited his work in the paper we published in the BMJ 5 in which we stated that decisions on injury prevention in rugby should be based on evidence rather than opinions and that educational initiatives were associated with a decrease in serious spinal injuries. I am also aware that Dr Bourke’s article generated considerable correspondence, and that members of the medical community expressed a wide range of views on the issue. Dr Bourke is entitled to hold the opinions he does, and I respect them. Where there have been no scientific studies, opinion may be the best level of evidence that exists. I submit that researchers investigating rugby injuries have been working very hard in many countries to move the level of debate beyond opinion to a point where there is factual data to support risk management decisions. Where research evidence is lacking, it is incumbent upon the sports medicine, injury prevention and the administrative bodies of sports to work to provide such evidence – and I am aware that large gaps in the evidence base still exist.

    Third, Professor Pollock makes the point that even though high tackles are illegal it does not mean they are not occurring. Although this is correct, Professor Pollock was quoted calling for a ‘ban’ on them. They are already ‘banned’, so such a call was redundant. If Professor Pollock believes that greater attention needs to be paid to the enforcement of the laws of the game in particular areas (such as high tackles) then she should have stated this.

    Third, Professor Pollock states that ‘At some point the evidence accumulates and becomes so obvious that it is irresponsible simply to continue with expensive studies and to repeat the call for more surveys research claiming that we don’t yet know enough about the risks’. I wonder why Professor Pollock makes this comment. Does she believe that this point has already been reached with respect to injury prevention in rugby? I suspect not, but if so it somewhat undermines the impassioned case for a ‘national all encompassing child injury surveillance system’ she makes in the final paragraph. Incidentally, I support her call for such a system.

    I certainly don’t believe that we have reached a point where the evidence has accumulated to an extent that further studies into the risks associated with rugby are unwarranted. In a widely recognized model of sports injury prevention, injury surveillance plays three roles 6. First, it helps quantify the size of the injury issue. Second, it facilitates the identification of risk factors. Third, it allows for evaluation of the effect of injury prevention interventions. Even if the risk factors for rugby were all well quantified and understood, continuing with further surveillance would be a responsible thing to do, so that the efficacy of any injury prevention initiatives could be appraised.

    Ken Quarrie, PhD
    Rugby Injury Researcher
    Wellington, New Zealand

    Disclaimer
    Ken Quarrie is employed by the New Zealand Rugby Union in the role of Senior Scientist, Injury Prevention & Performance. The views expressed herein are his own and should in no way be interpreted as reflecting the position of the New Zealand Rugby Union on any of the issues addressed.

    References

    1. Nicol A, Pollock A, Kirkwood G, Parekh N, Robson J. Rugby union injuries in Scottish schools. J Public Health (Oxf) 2010.
    2. Garraway WM, Lee AJ, Hutton SJ, Russell EB, Macleod DA. Impact of professionalism on injuries in rugby union. Br J Sports Med 2000;34(5):348-51.
    3. Malcolm D, Sheard K, Smith S. Protected research: Sports medicine and rugby injuries. Sport in Society 2004;7(1):95-108.
    4. Bourke JB. Rugby union should ban contested scrums. BMJ 2006;332:1281.
    5. Quarrie KL. The effect of a nationwide injury prevention programme on serious spinal injuries in New Zealand rugby union. 2007.
    6. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992;14(2):82-99.