By Dr Tim McEwen

As an enthusiastic rugby player and a newly qualified Doctor, I am often asked by teammates what is the safest position on the rugby pitch. Is the assumption that playing on the wing is for wimps who don’t want to get hurt?

Rugby Union is growing in popularity, yet there is often a preconception that it can be dangerous and serious injuries are likely to occur, especially in certain positions. Interestingly, research indicates that the amateur game has a similar incidence and severity of injury to football and a much lower game injury ratio than other high intensity collision sports such as American football.

Within the game of rugby, analysis in the amateur game has found that flankers (men) and centres (women) were the most frequently injured during games, with the highest percentages of major injuries (causing more than 7 days training or matches to be missed) reported to be for the No 8 position (men and women). Fly halves and fullbacks were the least often injured in the men’s game whilst the scrum half got off lightest in the women’s game. In terms of injuries in training, it is bad news for any amateur men with presentations to do at work the following day as the head/face is the source of most complaints, whilst women suffer more knee injuries[i].

There has been far more research and analysis into the injury profiles of different positions within the professional game. Studies have shown that for every match 33 days of absence are incurred for forwards, and 28 days for backs. Forwards tend to suffer from shoulder, knee and ankle/heel problems whilst the lighter but fleeter of foot backs suffered most frequently from shoulder, hamstring and knee problems[ii].

Following concerns about injuries in the forwards and wasted game time due to the resetting of scrums, the International Rugby Board recently set up an expert Scrum Steering Group to give advice on law changes and referee instructions[iii]. Experimental law changes were brought in for the scrum at the start of the 2012/13 season. For this season, the instructions from the referee have been ‘crouch, touch, set’. Front rows crouch then touch and using their outside arm touch the point of the opposing prop’s outside shoulder. The props then withdraw their arms and the referee calls ‘set’ when the front rows are ready. The front rows will then set the scrum.

The RFU, in conjunction with the University of Bath, is currently undertaking a second study to see how the scrum can be further improved by looking at other engagement techniques, from this crouch, touch and set approach to a modified technique so that props maintain the touch before a deemphasised engagement technique.

Results are due this year with a focus on player welfare and trying to improve player, coach and referee education around scrummaging technique. At a time when there has been significant controversy regarding the understanding and refereeing of the scrum from within the professional game[iv][v], results are eagerly expected.

The UK trainee perspective (The BJSM blog features the trainee perspective every two weeks)*

Guest blog by Dr Dee Clark

Over the time I have worked with Rugby Union teams, I have come across a number of methods for players dealing with their own skin “wounds”.  These have ranged from use of safety pins, sewing needles (“sterilised” in a flame or just “off the shelf”) through to complicated use of homemade vacuum devices to draw out pus.  Whilst this has been an educational experience (!), in my role as a team medic, and particularly as an ex nurse, it fills my heart with dread when presented with the aftermath of the self-treated or ignored wound.  What often starts off as a relatively innocuous complaint, can lead to loss of training time, game time and even hospital admission.

Rugby is played on dirty surfaces.  Training facilities can hide potential for infection disaster. The sharing of washing and drying areas and materials as well as the constant comings and goings of those being treated in physio and medical rooms have the potential to wipe out a team.  Despite this, basic hygiene and common sense are often not employed in a strategy aimed at keeping players fit and healthy to play.

In one season we carried out an audit after noticing recurrent skin infections.  It was shown that in the first half of the season 11 players from the squad needed formal treatment (antibiotics/ minor surgical procedures), with 6 losing training days and 3 losing game time.  Further investigation led us to link the rise with a change in training facility where cleanliness had been an issue. After changing this facility, our infection rate decreased dramatically.

What we did to change things!

We reviewed facility cleaning arrangements, talked to the players about general hygiene including towel sharing, reporting of wounds, covering abrasions etc, installed more hand gel dispensers and instigated more stringent cleaning processes for physio and medical rooms.

Staff and players were encouraged to use hand gel and to wash their hands with greater frequency. Players were encouraged to report skin breaks at an early stage and were discouraged from self-treatment.

Sometimes, being swept up in the search for that extra 1% to make us bigger, better, stronger and faster than the others, can cause us to forget the basics.  After all, an ounce of prevention is worth a pound of cure.

 Articles of interest

Hayton MJ, Stevenson HI and Jones CD et al.  (2004) The management of facial injuries in rugby union, Br J Sports Med;38:314-317 

Stacey A and Atkins B (2000) Infectious diseases in rugby players: incidence, treatment and prevention, Sports Med Mar; 29 (3) 211-220

Horgan M and Bergin C,  IRB Policy on Hygiene, Infection control and Prevention of infection

 Goodman R et al (1994), Infectious diseases in competitive sport, JAMA Mar; 271 (11) 862-867

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Dr Dee Clark is a Sport and Exercise Medicine Registrar and GP in the North West.

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK Trainee Perspective” which runs every two weeks.

Concussion is certainly hot this week! Lots of news stories of variable quality. Today we review the International Consensus statement itself.

This practical resource was established, using a consensus-based approach, at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. It updates the recommendations of the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. Click here to read the full document.

Key areas include:

• Management of acute simple concussion,
• complex concussion and long-term issues,
• Return to play,
• Paediatric concussion.

BJSMs podcasts also include 3 interviews with concussion guru Professor Paul McCrory, one of the leads on the Consensus statement.  See also this systematic review on helmets.

What do You Think? How has the Consensus Statement on Concussion in Sport shaped how you view and treat concussion?

Keep an eye on our homepage as an opinion poll will be posted shortly.

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 sport^5-7. 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.