Tackling the tackle 1: A descriptive analysis of 14,679 tackles and risk factors for high tackles in a community-level male amateur rugby union competition during a lowered tackle height law variation trial.

OBJECTIVES: In rugby union (rugby), the tackle is the most frequent cause of concussion and thus a target for intervention to reduce concussion incidence. The aim of this study is to describe tackle characteristics and factors associated with illegal high tackles in amateur community-level rugby during a lowered (armpit level) tackle height law variation trial. DESIGN: Prospective observational cohort study. METHODS: Video surveillance of a single season, four-league competition with coding of video data according to a predefined coding framework. Descriptive statistics of tackle detail and logistic regression was performed to analyse factors associated with high tackles. RESULTS: One hundred and eight matches with 14,679 tackles and a mean of 137 (±30) tackles per match were analysed. High tackles (above armpit level) had significantly greater odds of occurring in the lower (2nd-4th) leagues (OR: 1.95; 95 % CI: 1.6-2.4; p < 0.001), front-on tackles (OR: 1.61; 95 % CI: 1.3-2.0; p < 0.001), arm tackles (OR: 1.65; 95 % CI: 1.3-2.1; p < 0.001), bent-at-waist ball carrier (OR: 1.93; 95 % CI: 1.6-2.4; p < 0.001), falling/diving ball carrier (OR: 2.21; 95 % CI: 1.6-3.1; p < 0.001), and an upright tackler (OR: 3.38; 95 % CI: 2.7-4.2; p < 0.001). A falling/diving tackler had significantly lower odds of being associated with a high tackle (OR: 0.44; 95 % CI: 0.3-0.6; p < 0.001). CONCLUSIONS: Overall mean tackles per match were similar to those of senior amateur and elite rugby. League, tackle type, tackle aspect, and player body positions were associated with high tackles. These findings reiterate the need for ongoing efforts to identify and implement mitigating strategies to reduce tackle-related injury risk.

Tackling the tackle 2: Evaluation of referee and player behavioural change as measures of implementation of a law variation in community-level male amateur rugby union.

OBJECTIVES: To evaluate player and referee behaviour during a lower tackle height law variation trial in community rugby union ('rugby'). DESIGN: Prospective observational cohort study. METHODS: In a law variation trial in male amateur community rugby, coded match video surveillance data were analysed. Referee (sanctioning rate) and player (tackler body position) behaviour changes over one season (under the lowered, armpit-level maximum legal tackle height condition) were analysed in three approximately equal periods of the season. Secondarily, an independent professional referee reviewed illegal high tackle sanctioning data. RESULTS: Overall, 108 matches with 14,780 tackles were filmed and coded. Sanctioned illegal high tackle propensity was significantly higher in the mid-season (41 sanctioned high tackles/1000 tackle events; 95 % CI: 35-47), compared with first and last periods. Upright tacklers in tackles decreased significantly in the final vs. middle period of the season (rate ratio: 0.69; 95 % CI: 0.54-0.88; p < 0.01). Of all the coder-determined high tackles also assessed as high under the new law by the independent referee, 51 % were sanctioned by the on-field referee. CONCLUSIONS: Positive player and referee behavioural changes were observed during a lowered legal tackle height law variation in this community rugby setting. Increased mid-phase high tackle sanctioning by referees was followed by fewer tackles with upright tacklers in the subsequent (last) phase of the season. Encouraging positive behaviour changes of this nature, particularly if sustained (beyond trial study periods), may contribute to overall injury risk reduction, and hold considerable importance to inform future injury prevention strategies in rugby.

Tackling sport-related concussion: effectiveness of lowering the maximum legal height of the tackle in amateur male rugby - a cross-sectional analytical study.

OBJECTIVE: Rugby union ('rugby') is popular globally, with most of its participants being amateur. Concern regarding sport-related concussion (SRC) sustained during rugby is increasing. SRC occurs most frequently in the tackle, yet few interventions have aimed to mitigate this risk factor. This study investigated the influence of a lowered legal tackle height on SRC incidence in amateur rugby. DESIGN: Cross-sectional analytical study: 2018 (control-standard tackle height) and 2019 (intervention-lowered legal tackle height) seasons. SETTING: South African collegiate student rugby competition. PARTICIPANTS: Between 800 and 900 male amateur student players (age: 20±1.6 years) in each year. INTERVENTION: Maximum legal tackle height lowered from line of the shoulder on the ball carrier to the line of the armpit. OUTCOME MEASURES: Number of overall (medical attention) and time-loss (≥1 day lost) injuries, head injuries and SRCs in 2018 and 2019 (dependent variables); events associated with injury incidents (independent variables). RESULTS: There was no statistically significant difference in incidences of time-loss injuries (IRR: 0.79; 95% CI: 0.6 to 1.1; p=0.13), head injuries (IRR: 0.83; 95% CI: 0.5 to 1.3; p=0.42) and SRC (IRR: 0.69; 95% CI: 0.4 to 1.2; p=0.20). In 2018 and 2019, most time-loss head injuries (57%, n=43) and SRCs (55%, n=26) occurred during the tackle. CONCLUSIONS: Despite a trend towards reducing injuries, head injuries and SRC, lowering maximum legal tackle height to armpit level did not change SRC incidence in this amateur male rugby cohort. Most time-loss head injuries and SRCs occurred during the tackle. Further tackle-related interventions to reduce SRC incidence require investigation.

Promotion of Para athlete well-being in South Africa (the PROPEL studies): Profiles and prevalence of psychological distress.

OBJECTIVES: There is a paucity of research investigating mental health in Para athletes. The aim of this study was to describe mental health concerns of a representative sample of South African Para athletes. DESIGN: A descriptive, cross-sectional survey was conducted at the 2019 National Championships for athletes with impairments. METHODS: Mental health was measured with the Trait component of the State/Trait Anxiety Inventory (STAI-T), and the Kessler Psychological Distress Scale (K-10). Between-group differences were analysed using the Mann-Whitney U test or one-way ANOVA. RESULTS: A total of 125 athletes were included. The average score for the STAI-T was 39 (±9) units, whilst a quarter (25%) of all athletes scored ≥45. The mean K-10 questionnaire score was 20 (±6) units. K-10 scores indicated that 12 % of athletes may meet formal definitions for anxiety and/or depressive disorders (score of ≥28), while 76 % of athletes have a high level of subclinical symptoms (score of ≥16). On average, females (36 ±â€¯9) had better STAI-T scores than males (40 ±â€¯9; p = 0.02) and married athletes (33 ±â€¯9) had better scores than unmarried athletes (40 ±â€¯9; p = 0.002). K-10 scores were also significantly better in married than in unmarried athletes (p = 0.002), but there was no difference between sexes. Neither the K-10 nor STAI-T was associated with level of competition, sport code or impairment type. CONCLUSIONS: The study identified a high prevalence of psychological distress and anxiety among South African Para athletes, compared to the general population. There is a need to further understand factors contributing to mental health in this population.

Evaluating the Implementation of Injury Prevention Strategies in Rugby Union and League: A Systematic Review using the RE-AIM Framework.

Rugby (union and league) has come under intense scrutiny due to its injury risk. Various interventions have been introduced to protect players from injury, with many deemed efficacious and advocated for use across various worldwide contexts. However, their implementation is less clear. The objective of this systematic review was to determine whether injury prevention interventions in rugby have evaluated their 'reach', 'effectiveness', 'adoption', 'implementation' and 'maintenance' as per the RE-AIM Multi-Dimension Item Checklist. Six electronic databases were searched in November 2019. Inclusion criteria included: English language, peer-reviewed journal article, original research, field-based rugby code, prospective intervention. Of the 4253 studies identified, 74 met the full inclusion criteria. Protective equipment, predominately mouthguards, was the intervention of interest in 44 studies. Other interventions included multimodal national injury prevention programmes, law changes and neuromuscular training programmes. 'Effectiveness' was the highest scoring RE-AIM dimension (55%), followed by 'reach' (26%). All other RE-AIM dimensions scored below 20%. Research currently focuses on determining intervention 'effectiveness'. For injury prevention strategies to have their desired impact, there must be a shift to address all determinants associated with implementation. Consideration should be given to how this can be achieved by adopting specific reporting checklists, research frameworks and study designs.

BokSmart rugby safety education courses are associated with improvements in behavioural determinants in attending coaches and referees: presurvey-postsurvey study.

BACKGROUND/AIM: BokSmart is a nationwide injury prevention programme that aims to reduce players' injury risk mainly through education of coaches and referees in mandatory biennial education courses. These courses are held throughout each rugby season. The objective of this cross-sectional study was to assess whether these courses were associated with improvements in attendees' behavioural determinants. METHODS: Coaches and referees completed a questionnaire based on the theory of planned behaviour, immediately before and after their 2012 BokSmart courses. Twelve behavioural determinants were assessed on a five-point Likert scale and open-ended questions. A meaningful change was defined as an improvement of ≥1 unit score supported by null hypothesis testing. Odds of improving by ≥1 unit score (compared with not improving) were assessed in attendees using multivariate logistic regression. RESULTS: In total, 390 coaches and 74 referees completed both questionnaires. 'Before' scores were high for most outcomes, except for knowledge. Although there was a significant (p<0.001) improvement in all 'after' course scores, the only meaningful change (=1 unit) was in knowledge of scrum techniques/rules. CONCLUSION: Although the only meaningful improvement in 2012 BokSmart course attendees was in one outcome, it should be noted that before-course scores were already high, reducing the questionnaire's ability to assess change because of a ceiling effect. Nonetheless, the knowledge acquisition of these courses was low and not related to previous course attendance or more years of rugby experience. These results justify the biennial nature of this safety course but also indicate that knowledge acquisition is generally low.

Effect of a concussion on subsequent baseline SCAT performance in professional rugby players: a retrospective cohort study in global elite Rugby Union.

OBJECTIVES: This study assessed whether concussion affects subsequent baseline performance in professional rugby players. Annual baseline screening tests are used to guide return-to-play decisions and concussion diagnosis during subsequent screens. It is important that baseline performances are appropriate and valid for the duration of a season and unaffected by factors unrelated to the current head impact event. One such factor may be a concussion following baseline assessment. SETTING: The World Rugby concussion management database for global professional Rugby Union. PARTICIPANTS: 501 professional rugby players with two baseline Sports Concussion Assessment Tools (SCATs) and an intervening concussion (CONC) were compared with 1190 control players with successive annual SCAT5s and no diagnosed concussion (CONT). PRIMARY AND SECONDARY OUTCOME MEASURES: Symptom endorsement, cognitive and balance performance during annual SCAT baseline assessments. RESULTS: Players with a diagnosed concussion (CONC) endorsed fewer symptoms (change -0.42, 95% CI -0.75 to -0.09), and reported lower symptom severity scores during their second assessment (T2, p<0.001) than non-concussed players (CONT). Concussed players also improved Digits Backward and Final Concentration scores in T2 (p<0.001). Tandem gait time was improved during T2 in CONT. No other sub-mode differences were observed in either group. CONCLUSIONS: Reduced symptom endorsement and improved cognitive performance after concussion may be the result of differences in the motivation of previously concussed players to avoid exclusion from play, leading to under-reporting of symptoms and greater effort in cognitive tests. Improved cognitive performance may be the result of familiarity with the tests as a result of greater exposure to concussion screening. The changes are small and unlikely to have clinical significance in most cases, though clinicians should be mindful of possible reasons, possibly repeating sub-modes and investigating players whose baseline scores change significantly after concussion. The findings do not necessitate a change in the sport's concussion management policy.

High Concussion Rate in Student Community Rugby Union Players During the 2018 Season: Implications for Future Research Directions.

Collision sports, such as Rugby Union ("Rugby") have a particularly high risk of injury. Of all injuries common to collision sports, concussions have received the most attention due to the potentially negative cognitive effects in the short- and long-term. Despite non-professional Rugby players comprising the majority of the world's playing population, there is relatively little research in this population. Stellenbosch Rugby Football Club ("Maties"), the official rugby club of Stellenbosch University, represents one of the world's largest non-professional Rugby clubs, making this an ideal cohort for community-level injury surveillance. The aim of this study was to describe the incidence and events associated with concussion in this cohort. Baseline demographics were obtained on the 807 male student Rugby non-professional players who registered for the 10-week long 2018 season, which comprised 101 matches and 2,915 of exposure hours. All match-related injuries were captured by the medical staff of Stellenbosch Campus Health Service on an electronic form developed from the consensus statement for injury recording in Rugby. The mean age, height and weight of this cohort were 20 ± 2 years, 182 ± 7 cm and 88 ± 14 kg, respectively. Overall, there were 89 time-loss injuries, which equated to an injury rate of 30.6 per 1,000 match hours [95% confidence intervals (CIs): 24.2-36.9], or about one injury per match. The most common injury diagnosis was "concussion" (n = 27 out of 90 injuries, 30%), at a rate of 9.3 per 1,000 match hours (95% CIs: 5.8-12.8). The three most common mechanisms of concussion in the present study were performing a tackle (33%), accidental collision (30%) and being tackled (11%). Concussion was the most common injury in this population, at a rate that was six times higher than the most comparable study from the UK, which had far more exposure time over six seasons and wider range of player ability, from recreational to semi-professional. This might be explained by the training and vigilance of the club's first aiders observing all matches for concussion. Future studies should try to explain this high rate and subsequently reduce these concussions. The addition of video surveillance data would assist in identifying the etiology of these concussions injuries in order to develop specific targeted interventions.

'In a blink of an eye your life can change': experiences of players sustaining a rugby-related acute spinal cord injury.

BACKGROUND: Though rare, rugby union carries a risk for serious injuries such as acute spinal cord injuries (ASCI), which may result in permanent disability. Various studies have investigated injury mechanisms, prevention programmes and immediate medical management of these injuries. However, relatively scant attention has been placed on the player's experience of such an injury and the importance of context. AIM: The aim of this study was to explore the injury experience and its related context, as perceived by the catastrophically injured player. METHODS: A qualitative approach was followed to explore the immediate, postevent injury experience. Semi-structured interviews were conducted with 48 (n=48) players who had sustained a rugby-related ASCI. RESULTS: Four themes were derived from the data. Participants described the context around the injury incident, which may be valuable to help understand the mechanism of injury and potentially minimise risk. Participants also described certain contributing factors to their injury, which included descriptions of foul play and aggression, unaccustomed playing positions, pressure to perform and unpreparedness. The physical experience included signs and symptoms of ASCI that is important to recognise by first aiders, fellow teammates, coaches and referees. Lastly, participants described the emotional experience which has implications for all ASCI first responders. SIGNIFICANCE: All rugby stakeholders, including players, first responders, coaches and referees, may gain valuable information from the experiences of players who have sustained these injuries. This information is also relevant for rugby safety initiatives in shaping education and awareness interventions.

Quality of life among individuals with rugby-related spinal cord injuries in South Africa: a descriptive cross-sectional study.

OBJECTIVES: Rugby-related spinal cord injuries (SCIs) are rare but life altering and traumatic events. Little is known about the long-term consequences and outcomes of players who have sustained these injuries. This study investigated current quality of life (QoL) and factors associated with QoL, among individuals with rugby-related SCI in South Africa, by using the International Classification of Functioning, Disability and Health (ICF) framework. DESIGN: Descriptive cross-sectional study. SETTING: Rugby-related SCI population of South Africa, as captured in the BokSmart/Chris Burger Petro Jackson Players' Fund database. PARTICIPANTS: Ninety (n=90) of the 102 eligible players on the database agreed to participate in the study. MAIN OUTCOME MEASURE: The relationship between QoL, as measured with the WHO Quality of Life questionnaire (WHOQOL-BREF) and specific independent variables (demographic information, level of independence and participation in various activities and life roles) was investigated. Variables that were significantly associated with QoL in bivariate analyses were included in multiple linear regression analyses. RESULTS: The mean score and SD of the WHOQOL-BREF was 15.1±2.3 arbitrary units. Participation (an ICF framework construct) and income were significantly associated with overall QoL (p<0.001). Participation was the only variable significantly associated with all QoL subdomains (p<0.001). Additionally, number of health concerns, type of healthcare (public vs private) and level of education were significantly associated with various QoL domains (p<0.001). CONCLUSIONS: On average, these individuals with rugby-related SCI presented with higher QoL scores than other comparable SCI studies. However, lower levels of participation and income, certain levels of education, increased health concerns and use of public healthcare were associated with lower levels of QoL. Sporting bodies have a responsibility to optimise player welfare, by acting on the modifiable factors associated with QoL.

Forced Retirement from Professional Rugby Union is Associated with Symptoms of Distress.

Rugby has a higher injury burden than other popular sports, such as football. Athletes who are forced to retire as a result of injury are associated with poor mental health. With its high injury burden, professional rugby players might be at risk of mental health conditions associated with injury-related forced retirement. This study aimed to compare mental health between former professional rugby players who were and weren't forced to retire. A questionnaire including the 4DSQ (distress), GHQ-12 (anxiety/depression), PROMIS short-form (sleep disturbance) and AUDIT-C (alcohol misuse) was completed by retired professional players from Ireland, France and South Africa. The questionnaire asked players whether or not they were forced to retire, as well as the reason for retirement. Players forced to retire were more than twice as likely to report symptoms of distress in comparison to those that retired voluntarily (odds ratio: 2.1, 95% confidence interval: 1.2-3.6, p<0.001). None of the other mental health measures (anxiety/depression, sleep disturbance or alcohol misuse) were associated with forced retirement. In conclusion, rugby players that were forced to retire may require support structures and longitudinal monitoring. Future studies should begin monitoring players during their careers to accurately assess the effect of retirement on mental health.

Mechanisms and Factors Associated With Tackle-Related Injuries in South African Youth Rugby Union Players.

BACKGROUND: The majority of injuries in rugby union occur during tackle events. The mechanisms and causes of these injuries are well established in senior rugby union. PURPOSE: To use information from an injury database and assess video footage of tackle-related injuries in youth rugby union matches to identify environmental factors and mechanisms that are potentially confounding to these injuries. STUDY DESIGN: Descriptive epidemiological study. METHODS: Injury surveillance was conducted at the under-18 Craven Week rugby tournament. Tackle-related injury information was used to identify injury events in match video footage (role-matched noninjury tackle events were identified for the cohort of injured players). Events were coded using match situational variables (precontact, contact, and postcontact). Relative risk ratio (RRR; ratio of probability of an injury or noninjury outcome occurring when a characteristic was observed) was reported by use of logistic regression. RESULTS: In comparison with the first quarter, injury risk was greater in the third (RRR = 9.75 [95% CI, 1.71-55.64]; P = .010) and fourth quarters (RRR = 6.97 [95% CI, 1.09-44.57]; P = .040) for ball carriers and in the fourth quarter (RRR = 9.63 [95% CI, 1.94-47.79]; P = .006) for tacklers. Ball carriers were less likely to be injured when they were aware of impending contact (RRR = 0.14 [95% CI, 0.03-0.66]; P = .012) or when they executed a moderate fend (hand-off) (RRR = 0.22 [95% CI, 0.06-0.84]; P = .026). Tacklers were less likely to be injured when performing shoulder tackles (same side as leading leg) in comparison to an arm-only tackle (RRR = 0.02 [95% CI, 0.001-0.79]; P = .037). Ball carriers (RRR = 0.09 [95% CI, 0.01-0.89]; P = .040) and tacklers (RRR = 0.02 [95% CI, 0.001-0.32]; P =.006) were less likely to be injured when initial contact was made with the tackler's shoulder/arm instead of his head/neck. CONCLUSION: The relative risk of tackle-related injury was higher toward the end of matches. Incorrect technique may contribute to increased injury risk. Implementing recovery strategies between matches, training safe and effective techniques, and improving levels of conditioning may counter the negative effects of fatigue. These findings may assist stakeholders in youth rugby to formulate injury prevention strategies and may improve the preparation of field-side medical staff for managing tackle-related injuries at these or similar tournaments.

The incidence of rugby-related catastrophic injuries (including cardiac events) in South Africa from 2008 to 2011: a cohort study.

OBJECTIVES: To establish an accurate and comprehensive injury incidence registry of all rugby union-related catastrophic events in South Africa between 2008 and 2011. An additional aim was to investigate correlates associated with these injuries. DESIGN: Prospective. SETTING: The South African amateur and professional rugby-playing population. PARTICIPANTS: An estimated 529 483 Junior and 121 663 Senior rugby union ('rugby') players (population at risk). OUTCOME MEASURES: Annual average incidences of rugby-related catastrophic injuries by type (cardiac events, traumatic brain and acute spinal cord injuries (ASCIs)) and outcome (full recoveries-fatalities). Playing level (junior and senior levels), position and event (phase of play) were also assessed. RESULTS: The average annual incidence of ASCIs and Traumatic Brain Injuries combined was 2.00 per 100 000 players (95% CI 0.91 to 3.08) from 2008 to 2011. The incidence of ASCIs with permanent outcomes was significantly higher at the Senior level (4.52 per 100 000 players, 95% CI 0.74 to 8.30) than the Junior level (0.24 per 100 000 players, 95% CI 0 to 0.65) during this period. The hooker position was associated with 46% (n=12 of 26) of all permanent ASCI outcomes, the majority of which (83%) occurred during the scrum phase of play. CONCLUSIONS: The incidence of rugby-related catastrophic injuries in South Africa between 2008 and 2011 is comparable to that of other countries and to most other collision sports. The higher incidence rate of permanent ASCIs at the Senior level could be related to the different law variations or characteristics (eg, less regular training) compared with the Junior level. The hooker and scrum were associated with high proportions of permanent ASCIs. The BokSmart injury prevention programme should focus efforts on these areas (Senior level, hooker and scrum) and use this study as a reference point for the evaluation of the effectiveness of the programme.

Perceptual cues in the regulation of exercise performance - physical sensations of exercise and awareness of effort interact as separate cues.

It has been argued that the physical sensations induced by exercise, measured as the ratings of perceived exertion (RPE), are distinct from the sense of effort. This study aimed to determine whether a new measure of task effort - the Task Effort and Awareness (TEA) score - is able to measure sensations distinct from those included in the conventional RPE scale. Seven well-trained cyclists completed a maximal effort 100 km time trial (TT) and a submaximal trial at 70% of the power sustained during the TT (70% TT). Five maximal 1 km sprints were included in both trials. Both the RPE related solely to physical sensation (P-RPE) and the TEA score increased during the TT and were linearly related. During the 70% TT, both P-RPE and TEA scores increased, but TEA increased significantly less than P-RPE (p<0.001). TEA scores reached maximal values in all 1 km sprints in both the maximal TT and 70% TT, whereas the RPE increased progressively, reaching a maximal value only in the final 1 km sprints in both the TT and the 70% TT. These results indicate that the physical sensations of effort measured as the P-RPE act as the template regulating performance during exercise and that deviation from that template produces an increase in the sense of effort measured by the TEA score. Together, these controls ensure that the chosen exercise intensity does not threaten bodily homeostasis. Our findings also explain why submaximal exercise conducted within the constraints of the template P-RPE does not produce any conscious awareness of effort.