Allyson Pollock and Graham Kirkwood: Tackle and scrum should be banned in school rugby

Evidence shows that collision sports, such as youth rugby, carry high rates of injury

Most injuries in youth rugby are due to the collision elements of the game, mainly the tackle. [1-8] In March 2016, scientists and doctors in the Sport Collision Injury Collective (SCIC) called for the tackle and other forms of harmful contact to be removed from school rugby. [9] The data in support of the call to remove the tackle and other forms of harmful contact in school rugby is compelling. We call on CMOs to act on the accumulating evidence and advise the UK government to put the interests of the child before the interests of corporate professional rugby unions and remove the tackle and other forms of harmful contact from the school game.

Rugby union and rugby league are the most commonly played collision sports in the physical education curriculum of schools in England. [10] Collision sports where “athletes purposely hit or collide with each other or with inanimate objects (including the ground) with great force” include rugby, ice-hockey and American football. [11]

The few studies which compare youth injury rates between sports show higher rates of injury for collision sports than for non-collision contact sports. [12,13] A meta-analysis by Pfister et al found rugby, ice-hockey, and American football had the highest concussion rates in children, 4.18, 1.20, and 0.53 concussions per 1000 athlete exposures respectively. [13]

A survey carried out by the Australian Sports Medicine Federation across all age groups taking participation into account found rugby league, rugby union, and Australian rules football had the highest rates of injury. [14] A New Zealand study also across all age groups combining injury insurance claims data with exposure data from a range of surveys found playing rugby (one game every three weeks) was 460 to 530 times more dangerous than cycling (a half hour trip three times a week). [15]

Furthermore a New Zealand study using instrumented ear patches to measure head impact acceleration found that under nine year olds playing rugby union with tackling experienced head impacts of a similar magnitude to American high school and collegiate football players despite the rugby players being younger, lighter and slower [16]. Other studies show, rugby related injury emergency department attendances in the US are on the rise in particular head and face injuries which make up more than a third of injuries [17]; girls take three or four times longer to recover from concussion than boys [18]; a history of concussion is associated with a lowering of a person’s life chances across a range of social and educational measures including receipt of disability pension, psychiatric inpatient admissions or outpatient visits, premature mortality, low educational achievement and receipt of state welfare payments (p<0.05 for all) [19]; concussion is associated with an increase in violent behaviour and violent injury in adolescents the year following their concussion, with children exhibiting violent behaviour in year nine 2.34 (95% confidence interval 1.07 to 5.16, p<0.05) times more likely to have had a concussion in year eight than non-violent children and children who had received a violent injury in year nine, 2.96 (95% CI 1.33 to 6.58, p<0.01) times more likely to have had a concussion in year eight than non-injured children 20; and head injury is associated with an increased risk of any dementia, relative risk (RR) = 1.63 (95% CI 1.34 to 1.99) and Alzheimer’s disease, RR = 1.51 (95% CI 1.26 to 1.80) adding to existing evidence that head injury may lead to neurodegenerative diseases [21].

Rule changes in collision sports can make a difference. [22, 23] Canada imposed a ban on body-checking in Pee Wee (under 13 years) ice-hockey, where a player deliberately makes contact with an opposing player to separate them from the ice-puck; a subsequent systematic review and meta-analysis found an unadjusted 67% reduction, incidence rate ratio 0.33 (95% CI 0.25, 0.45), in concussion risk. The evidence for other strategies to reduce concussion risk in sport including the wearing of protective equipment such as mouthguards is weak. [23] The introduction of player education programmes in New Zealand and South African rugby was associated with a reduction in catastrophic injuries although not in other injuries including concussion. [24] In the UK, teacher training in the skills of rugby are lacking as is concussion awareness training. [25, 26]

In July 2016, the four UK chief medical officers (CMOs) rejected the call for a ban on tackling in youth rugby citing a report [27] they had commissioned from the Physical Activity Expert Group (PAEG) chaired by Professor Charlie Foster of University of Oxford and a paper [28] authored by two World Rugby employees, which claimed rugby was no more injury prone than other sports. The PAEG report [27] (unlike World Rugby’s paper) stated that rugby has a higher incidence of injury than other sports but did not consider the Rights of the Child.

It is well recognised that children are vulnerable and require specific measures to control the unique risks associated with this group. [29] The call for a cautionary approach and the removal of collision from school rugby and to end compulsion in the school game is likely to reduce and mitigate the risk of injury in school children. Under the United Nations Convention on the Rights of the Child (Article 19) governments have a duty to protect children from risks of injury and to ensure the safety of children, which is why we are calling  on CMOs to act now. [30]

Allyson M Pollock is professor of public health and Director of Institute of Health and Society in the Medical Faculty of Newcastle University.  She is a public health doctor and has been researching injuries and rugby injuries for more than ten years.

Graham Kirkwood is a former NHS nurse and works as a senior research associate in the Institute of Health and Society at Newcastle University with interests in injuries and access to healthcare.

Competing interests: None declared.

Not commissioned, peer reviewed.

References:

  1. Freitag A, Kirkwood G, Scharer S, Ofori-Asenso R, Pollock AM. Systematic review of rugby injuries in children and adolescents under 21 years. Br J Sports Med 2015;49(8):511-9. doi: 10.1136/bjsports-2014-093684
  2. Kirkwood G, Parekh N, Ofori-Asenso R, Pollock AM. Concussion in youth rugby union and rugby league: a systematic review. Br J Sports Med 2015;49(8):506-10. doi: 10.1136/bjsports-2014-093774
  3. Bleakley C, Tully M, O’Connor S. Epidemiology of adolescent rugby injuries: a systematic review. J Athl Train 2011;46(5):555-65.
  4. Burger N, Lambert MI, Viljoen W, Brown JC, Readhead C, Hendricks S. Tackle technique and tackle-related injuries in high-level South African Rugby Union under-18 players: real-match video analysis. Br J Sports Med 2016;50(15):932-8. doi: 10.1136/bjsports-2015-095295
  5. Hendricks S, O’Connor S, Lambert M, et al. Contact technique and concussions in the South African under-18 Coca-Cola Craven Week Rugby tournament. Eur J Sport Sci European journal of sport science 2015;15(6):557-64. doi: 10.1080/17461391.2015.1046192
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  8. Leung FT, Franettovich Smith MM, Hides JA. Injuries in Australian school-level rugby union. J Sports Sci 2017;35(21):2088-92. doi: 10.1080/02640414.2016.1255771
  9. Sport Collision Injury Collective. Open Letter: Preventing injuries in children playing school rugby. 01 Mar 2016. www.sportcic.com/resources/Open%20Letter%20SportCIC%20March1st%202016.pdf.
  10. Department for Education. GCSE PE activity list. Jan 2015. www.gov.uk/government/uploads/system/uploads/attachment_data/file/447738/GCSE_activity_list_for_PE.pdf.
  11. Rice SG. Medical conditions affecting sports participation. Pediatrics 2008;121(4):841-8. doi: 10.1542/peds.2008-0080
  12. Spinks AB, McClure RJ. Quantifying the risk of sports injury: a systematic review of activity-specific rates for children under 16 years of age. Br J Sports Med 2007;41(9):548-57. doi: 10.1136/bjsm.2006.033605
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  14. Routley V, Ozanne-Smith J. Hazard (Edition No. 8). Sport related injuries – an overview. Oct 1991. www.monash.edu/__data/assets/pdf_file/0006/218445/haz08.pdf.
  15. Chieng M, Lai H, Woodward A. How dangerous is cycling in New Zealand? J Transp Health 2017. doi: 10.1016/j.jth.2017.02.008i
  16. King DA, Hume PA, Gissane C, Clark TN. Similar head impact acceleration measured using instrumented ear patches in a junior rugby union team during matches in comparison with other sports. J Neurosurg Pediatr 2016;18(1):65-72. doi: 10.3171/2015.12.PEDS15605
  17. Sabesan V, Steffes Z, Lombardo DJ, Petersen-Fitts GR, Jildeh TR. Epidemiology and location of rugby injuries treated in US emergency departments from 2004 to 2013. Open Access J Sports Med 2016;7:135–42. doi: 10.2147/OAJSM.S114019
  18. Miller JH, Gill C, Kuhn EN, Rocque BG, et al. Predictors of delayed recovery following pediatric sports-related concussion: a case-control study. J Neurosurg Pediatr 2016;17(4):491-6. doi: 10.3171/2015.8.PEDS14332
  19. Sariaslan A, Sharp DJ, D’Onofrio BM, Larsson H, Fazel S. Long-Term Outcomes Associated with Traumatic Brain Injury in Childhood and Adolescence: A Nationwide Swedish Cohort Study of a Wide Range of Medical and Social Outcomes. PLoS Med 2016;13(8):e1002103. doi: 10.1371/journal.pmed.1002103
  20. Buckley L, Chapman RL. Associations between self-reported concussion with later violence injury among Australian early adolescents. J Public Health (Oxf) 2017;39(1):52-7. doi: 10.1093/pubmed/fdw009
  21. Li Y, Li Y, Li X, et al. Head Injury as a Risk Factor for Dementia and Alzheimer’s Disease: A Systematic Review and Meta-Analysis of 32 Observational Studies. PloS one 2017;12(1):e0169650. doi: 10.1371/journal.pone.0169650
  22. Vriend I, Gouttebarge V, Finch CF, van Mechelen W, Verhagen EA. Intervention Strategies Used in Sport Injury Prevention Studies: A Systematic Review Identifying Studies Applying the Haddon Matrix. Sports Med 2017. doi: 10.1007/s40279-017-0718-y
  23. Emery CA, Black AM, Kolstad A, et al. What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review. Br J Sports Med 2017;51(12):978-984. doi: 10.1136/bjsports-2016-097452
  24. Freitag A, Kirkwood G, Pollock AM. Rugby injury surveillance and prevention programmes: are they effective? BMJ 2015;350:h1587. doi: 10.1136/bmj.h1587
  25. Oxfordshire Rugby Football Schools Union. Training Audit. Oct 2015.
  26. Shibli S, Moore R, Barrett D, Edmondson L, Christy L, Millar R. All Schools Monitoring Report – Autumn Term: Sheffield Hallam University. Sport Industry Research Centre. 16 Mar 2015.
  27. The four UK Chief Medical Officers. RE: Open Letter: Preventing injuries in children playing school rugby including UK Physical Activity Expert Group – Response to Sports Collision Injury Collective (SCIC) Letter for UK CMOs. 29 Jul 2016.
  28. Tucker R, Raftery M, Verhagen E. Injury risk and a tackle ban in youth Rugby Union: reviewing the evidence and searching for targeted, effective interventions. A critical review. Br J Sports Med 2016;50(15):921-5. doi: 10.1136/bjsports-2016-096322
  29. Fuller C, Drawer S. The application of risk management in sport. Sports Med 2004;34(6):349-56.
  30. UNICEF. United Nations Convention on the Rights of the Child, 02 Sep 1990. www.unicef.org.uk/crc.

 

  • Raymond Hogan

    It is disappointing to see yet another study/report/demand to “protect children from X,Y and Z” which forgets entirely the lasting effect it will have on the child’s development, social interaction, and life prospects. And the damaging effect it will have on society as a whole.
    Contrary to popular belief, life is not fair. Not every adult is a winner. To achieve success, you must work hard, and take risks. You will get hurt occasionally.
    Continuing down this path of wrapping children up in cotton wool (banning conkers, banning Sports Day etc.) only leads to a preponderance of Adults who think that life is a cake walk. We already see this in day-to-day life (outside of ivory towers that is) with children who have no respect for authority, young workers entering employment with an expectation that everything will be given to them no matter how hard working or lazy they are, and an explosion in the “compensation culture” where everyone is to blame except the person themselves.
    It is not the interests of Corporate Rugby (or any other entity) that needs competition and risk in a child’s development. It is society itself.
    So do not ban Rugby, Conkers, Sports Day’s etc. Find a way to encourage them in a SAFE way – such as ensuring schools provide adequate equipment (helmets, gum shields, shin pads etc.).
    The world our Grandchildren will inherit will thank you for it.

  • paul Armstrong

    The safest activity is sitting in front of the games console eating junk food and sugared drinks. No risk of injury just obesity, diabetes and early death.
    Health and safety gone mad again

  • Josh

    Ridiculous – so many other ways to ensure safety in schools contact sport. I played rugby from the age of 9 – 23 and recently at 30 played again. I have actually felt it more being older not playing as an U9. If it wasn’t for rugby and playing contact sport I would not be the man I am today. This is another attempt to mollycoddle children and the next generation to simply fall into line. We should be pushing more contact sports into society to toughen up the next generation not make them weaker both mentally and physically. So many added benefits come from playing contact sport from memories of bus journeys across the country, camaraderie and team spirit from being part of a team and discipline from ensuring I was revising hard for my school exams to ensure I had the time to play in the 1st team.

    Measures should be put in place to develop the game not hinder the game. Age / size matching / increased padding but taking contact out of rugby would be a backward step for evolution on this planet..where does this end? Why not ban long jump in athletics or hurdles. It annoys me when academics such as Pollock & Kirkwood come out with research like this to vindicate their career research choices but failing to realise the long term effect on how many people’s lives have changed for the better because of contact sport.

    I for one do not want to live in a society which is wrapped in cotton wool because we are afraid of the risks of contact sports.

  • obscurelines

    I played Rugby until I was 19, Judo and boxing into my late thirties. I appreciate toughness in people and have loved my involvement in these sports. But I wouldn’t dismiss this as ‘health and safety gone mad again’. That is a cop out. Respected doctors have produced a significant amount of data to indicate that children are getting concussed and that this is a risk. Please see wider debates on risks of concussion in contact sports for the way in which new data is demonstrating co-morbid links to depression, memory loss etc. There is a discussion to always be had between risk and reward and dismissing one or the other is asinine. Let’s have a fullsome debate about what we want for our kids. Let’s not descend into ‘it dint do me no ‘arm’ nonsense.

  • Chris Jones

    I’d played rugby at school and at club level from the age of 6 and never felt in danger…in fact I would actively encourage playing rugby rather than wrapping kids up and sheltering them.
    No wonder they are totally unprepared for the real world and shirk responsibility.

  • Dr Paul McDonald

    i am bemused how a professor of public health and a nurse cannot see the positive outcomes of playing rugby union – being fit, playing in a team, respect for others, friendship etc etc. Ban conkers as well – they can be lethal

  • Chris Jones

    Totally Agree

  • Catherine Warren

    Those benefits are not unique to rugby, though, whereas the high concussion rate is…

  • Catherine Warren

    False dichotomy. There are other options besides “wrapping kids up and sheltering them” if you don’t play rugby.

  • david.caulton

    It would be honest of Prof Pollock (and by association, BMJ) if she prefaced anything she wrote about rugby with the fact she is approaching the topic from the subjective position of a parent whose kid was injured not once, but twice on the rugby pitch. Most people reading this opinion, the original article in August, and the BBC promotional news item, would not be aware of this. That it is ‘out there’ in the public domain is not good enough.

    She has clearly set out since to ‘protect’ other parents’ kids. For reference, see her article written over two years ago in http://www.telegraph.co.uk/sport/othersports/schoolsports/11335526/Why-Im-glad-my-sons-rugby-playing-days-were-over-at-14.html.

    This is someone with a clear agenda and thus BMJ should declare this in the ‘Competing Interests’ field above where it says None Declared! Come on, BMJ, up your game – you are a serious academic publication, aren’t you?

    And then readers can make a better informed judgement of the merits or otherwise of her position.

  • Catherine Elizabeth Futers

    Hi, what i’d really like to know to make an informed decision as a mother of an U12 player is, you mentioned that the number of injuries in the US has gone up 7 fold but what has the increase in the number of players been in the same period and is this in rugby or american football? also in the cycling v rugby injuries what would the stats be like in somewhere like London/New York etc rather than New Zealand, where everyone seems to play rugby and a 30 min bike ride is probably a round trip to your nearest neighbor in some places. New Zealand only has 4.7 m population London has nearly double that at 8.6m (2015) so with nowhere near the number of cars on the roads as in Britain is this study really relevant to the British?

  • Catherine Elizabeth Futers

    The 1014.com have a really interesting 2 part interview with the chief Doctor at The Blues Super Rugby team in which he describes the protocols regarding head injuries in place in Rugby Union. My son’s club follow the three Rs Protocol of Recognise, Remove and Refer

  • Catherine Elizabeth Futers

    What about Skateboarding, BMX, Boxing, or Hockey? any contact sport has injuries associated with it.

  • deebles

    As one of those awkward, clumsy kids terrible at tracking projectiles and thus picked / ranked about last for football, tennis, cricket and most other ball sports, rugby made a nice change as there were niches in the pack for physical strength, endurance and foolhardy fearlessness alone and thus for someone who could run, tackle, push, hold up the scrum etc. If it wasn’t for that, judo, and hiking I’d probably have been a very unfit child and teenager indeed. But sadly, this research does make a lot of sense.

  • MissCostello

    Apart from hockey, when were the other three ‘sports’ taught in schools?

  • Olog Hai

    Those who don’t know how to tackle will be ruled over by those that do. Life is risk.

  • Graham Kirkwood

    Letter to Guardian 29 Sep 2017
    Research has repeatedly shown the serious and high risks of injuries during the tackle and collision phase in school age rugby in a range of studies. World Rugby confuses variation in incidence rates across studies with the consistent finding of high rates of injury in most studies. They are incorrect in their claim that we mixed age groups in our analysis.

    Our meta-analysis of these worldwide studies of school children shows that the risk of sustaining an injury in a season for children aged 13 years and under is 18.6% (95% confidence interval 12.8% to 26.6%) with a 9.0% (2.3% to 31.5%) risk of an injury requiring removal from play for at least a week (http://www.sportcic.com/resources/SCIC%20evidence%20to%20UK%20CMOs%20re%20rugby%20injury%2013July2017%20V2.pdf). Studies on children aged 14 years and over show that the risk of injury rises to one in four or 25.0% (21.6% to 28.9%) and the risk of an injury requiring more than seven days away from play is one in five or 19.5% (4.1% to 67.6%). Most of these injuries occur in the tackle.

    The Rugby Football Unions (RFUs) repeatedly conflate the benefits of physical activity and the wish to reduce obesity, with collision rugby where the harms are well established. The English RFU claim that “the values and quality of our sport far outweigh the risks attached to it through some studies” is unsupported by evidence. While the evidence of the benefits of physical activity are undisputed, there is no evidence that rugby confers additional benefits over and above other forms of physical activity i.e. non collision sports and other team games or that it reduces obesity.

    Professor Allyson Pollock
    Graham Kirkwood

    Newcastle University

  • Catherine Elizabeth Futers

    Those serous injurys a broken nose and leg could just of easily occured on a football pitch. I ended up with a skull fracture after playing badminton at school.

  • Catherine Elizabeth Futers

    My sons school has a number of aftet school clubs

  • Dr Paul McDonald

    Are you a mind guard Catherine?

  • Dr Paul McDonald

    I really admire public health experts! 30 years ago they told us we were all going to die of AIDS; a few years ago we were going to be wiped out by flu; and soon, very many of us will die because of resistance to antibiotics. The risks by three sons took when playing rugby seem well worth it!