Safety in youth rugby: education is not the answer to the concussion crisis

By Adam White @AdJWhite, Dr. Tim Gamble, and John Batten @JBatz85 

Injury worries

Despite the potential health benefits from participating in the sport, rugby is under increasing scrutiny as a result of the high number of injuries experienced by youth participants. We know, for example, that injury rates in rugby union for participants under 21 years of age can be as high as 128.9 injuries per 1000 playing hours, with a mean injury incidence rate of 26.7 per 1000 playing hours. The tackle is often to blame, causing sixty-three per cent of all injuries in one study on school rugby.

rugby-young-women

Concussion has received particular attention due to the potential long-term impacts (e.g., chronic traumatic encephalopathy) it may have upon brain functioning. Indeed, a systematic review of concussion in youth sport, stated that rugby had the highest risk of concussion compared to sports such as Field Hockey and American Football. In fact, one recently published study in Sweden shows many of the damaging social outcomes of concussion. Concerned about the potential damage the tackle may be having on children, we and the Sport Collision Injury Collective recently wrote to the British government urging them to ban tackling in rugby in school sport.

The HEADCASE programme

The Rugby Football Union’s response to safety concerns in their sport is through the delivery of educational initiatives. Specifically, the online HEADCASE programme provides key stakeholders with information about recognising concussion and managing injured players (i.e., secondary prevention). Delivered through an online, interactive web platform, it is freely available for players, coaches, officials, parents, teachers, first-aiders and spectators to complete. This potentially represents an improvement to player-safety, with the rugby authorities (the Rugby Football Union, World Rugby etc.) leaders in the management of brain trauma in sport. However, the following sections highlight some concerns about the effectiveness and delivery of this health-focused educational programme.

Voluntary participation

Globally, some rugby authorities require their coaches and teachers take either annual or biannual training to coach the sport. The Rugby Football Union, however, has no mandate for coaches to have undertaken HEADCASE training – although any individuals seeking to undertake a new coaching or refereeing qualification (which is also not mandatory to coach or officiate) are required to complete the programme before attending a course. Yet, this neglects the vast population of coaches who have completed their qualifications before the introduction of the HEADCASE programme, or those coaches and officials who do not seek qualifications at all. Furthermore, coaches and officials in England who have completed the training will only have to do so once, with no immediate plans to make it a yearly requirement like rugby governing bodies in the southern hemisphere.

Lack of evaluation

There is poor evaluation of educational initiatives aimed at reducing injury in sport. Only two rugby programmes (BokSmart and RugbySmart) complete all four elements of Van Mechelen’s Model of Injury Prevention (i.e., establishing the extent of the injury problem, establishing the aetiology and mechanisms of sports injury, introducing a preventative measure, assessing its effectiveness by repeating the process) to establish intervention effectiveness. Subsequently, researchers have asserted: ‘There is a dearth of evidence to support the effectiveness of such programmes’. Additionally, a recent BJSM systematic review found the concussion prevention benefits of technique training and practice time restrictions may be limited to a specific sub-set (i.e., 11-15 year olds) of the at-risk athletic population.

Education and injury prevention

Unless sporting bodies evaluate the effectiveness of their training, the impact upon injury prevention is unknown. However, evidence from the health and safety literature suggests that when implementing controls to manage risk, educational interventions are somewhat limited in effectiveness. Specifically, the Hierarchy of Control asserts that elimination of a risk is the most effective way of management, with personal protective equipment being the least effective, and administrative controls (i.e. education) the second least effective. Thus, altering the structure of an activity (substitution) or eliminating the mechanism – in this case tackling –  are likely to be much more effective interventions for the prevention of injuries than educational initiatives. Exemplifying this, law amendments in youth Ice Hockey (i.e., removing the body check) resulted in a reduction of injuries and concussions.

The way forward

Injury prevention must be the priority when considering the current concussion crisis in sport.  However, if the Rugby Football Union is committed to education about tertiary care of brain trauma at this stage, programmes should specify mandatory annual participation for the rugby workforce, with comprehensive evaluations of their effectiveness simultaneously undertaken. Although unlikely to be as effective as altering the structure of the sport (e.g., moving from contact rugby to touch rugby in schools), such changes may help to reduce the risk of concussion in youth rugby, while maintaining the cardiovascular and psychosocial health benefits offered by participation.

Conflicts of interest: None to be declared.

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Adam White [Adam.White@winchester.ac.uk] @AdJWhite, is a doctoral researcher at the University of Winchester and founding member of the Sport Collision Injury Collective. He also sits on the committee of the England Rugby Football Schools Union.

Dr. Tim Gamble [Tim.Gamble@winchester.ac.uk] is a Senior Lecturer in Psychology at the University of Winchester. His main research interest is investigating risk and protective equipment, specifically the unintended consequences of safety equipment provision.

John Batten [John.Batten@winchester.ac.uk] @JBatz85 is a senior lecturer in the Department of Sport and Exercise at The University of Winchester where he is currently programme leader for the BSc/MSci (Hons) Sport and Exercise Science.

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  • Tania Stanwood

    If the kids are learning the proper ways to tackle then they can reduce the injury factor. That seems very much like education. For instance in my sons football league they have started making the parents, coaches and all staff read resources that will help in the safer techniques. Bobby Vernon’s book Tackling Dummies is the one they used this year, and we have seen a huge difference in they ways these kids are being taught to tackle, and the injuries are way lower than they have been before. Rugby tackling is far safer than football, so I see that idea in coaches teaching tackling that way.

  • John Batten

    Although additional research on this topic is needed, a study by McIntosh et al (2010) concluded that no specific tackle technique was associated with a significantly increased risk of injury. Here, a total of 6,618 tackle events were analysed, of which 81 resulted in injury, with no statistical evidence of any difference in the odds of receiving an injury during an active shoulder tackle compared with passive shoulder tackles, jersey tackles, ankle taps, or smother tackles observed. The only association with technique was an increased risk of injury when a player was tackled by two players simultaneously, as opposed to being tackled by a single player. While McIntosh et al (2010) found that younger (U15) players were more likely to use a passive shoulder tackle and older players more likely to use an active shoulder tackle, a significantly lower risk of tackle game injury in younger players compared to elite players was reported. When taken collectively, these findings suggest that improving tackle technique and proficiency may have little impact on
    injury rates.

    However, this blog is not intended to stifle such investigation. Rather, it proposes that more needs to be done to prevent injury (e.g., concussion) in rugby. For instance, the efficacy of interventions that limit tackle exposure during training and competition, changing the definition of a legal tackle, weight-matched/size-matched groupings (bio-banding) all require further examination. Yet, the primary response to concerns around concussion by the RFU – as well as a number of other sporting organisations – has been education initiatives (e.g., HEADCASE) aimed at improving the management of injured players. While managing the recovery of injured players alongside a graduated return to play protocol is clearly important, such an approach will likely only prevent players from becoming injured again and/or reduce injury severity, as opposed to preventing them from becoming injured in the first place. Therefore, the primary focus of sporting organisations should shift from management (secondary prevention) to (primary) prevention, due to the increased likelihood of reducing overall injury risk. In the meantime, there are improvements that can be made to the HEADCASE programme, some of which are highlighted in the blog above.

  • BoyBath

    Conflicts of interest: None to be declared.

    Sport Collision Injury Collective had until recently the aim to remove all contact in youth sport.