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HEAD IMPACT PREVENTION & MANAGEMENT PLAN ANNOUNCED FOR PROFESSIONAL GAME

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The Rugby Football Union (RFU), Premiership Rugby (PRL) and the Rugby Players’ Association (RPA) have announced an action plan aimed at reducing the exposure to head impacts and concussion risk within men’s and women’s elite rugby matches and training in England.

The action plan sets out how science and technology is being used to evolve thinking to optimise player welfare and brain health for prospective, current and past players.

The expanded focus on head impact exposure sits alongside ongoing work to enhance the standard of head impact and concussion management within the professional game and the introduction of a new brain health assessment service for retired elite male and female players.

The decision to broaden out the approach to target head impacts generally in addition to concussion risk demonstrates the RFU, PRL and RPA’s ongoing commitment to look at all possible ways of continually improving player welfare.

HEAD IMPACT EXPOSURE ASSESSMENT 

To evaluate the level of head impact exposure in men’s and women’s elite rugby in England, a discovery research project was successfully conducted with Sports & Wellbeing Analytics (SWA) and Harlequins men’s and Bristol Bears women’s squads earlier this year.

Players from both squads wore PROTECHT instrumented mouth guards with embedded accelerometers and gyroscopes, able to measure linear and rotational accelerations of the head, in matches and training. Taking place over a month, output from the PROTECHT instrumented mouth guards was matched with video footage to provide the first detailed description of head impact exposure during elite adult rugby training and matches. 

Outcomes from the initial project indicate that:

  • Male players experienced a higher volume of contacts in both training and competition than their female counterparts. The same was true of forwards who were exposed to greater volumes of contact than backs.
  • The ruck provided the biggest risk of head impact exposure in both training and competition and this is an area that will be the subject of further investigation.
  • Tackle height affected the intensity of the impact, with lower body tackles resulting in lower intensity impacts. 

This discovery study demonstrated the feasibility and value of instrumented mouth guards in describing the head impacts in matches and training and for the first time provided objective insights into the number and magnitude of head impacts associated with both match events and training activities in the elite English game.

However, to further develop our understanding and quantify any variation in head impact exposure and contact demands of matches and training across a whole league, we will be offering all Premiership clubs the opportunity to be part of a league wide instrumented mouth guard (iMG) project to take place during the 2021/22 and 2022/23 seasons and are currently in consultation with all 13 Premiership clubs on this.

Premiership Clubs and England coaches, conditioners, medical staff, the RPA and players have collaborated with researchers from the University of Bath in the development of a new standardised framework to accurately categorise contact and non-contact rugby training activities. Data from the league wide iMG project will be integrated with this standardised categorisation with the aim of reducing head impact exposure in both training and matches.

Recognising the added value of integrating data streams within the framework provided by the World Rugby Head Injury Assessment Protocol and following the publication of the 2018-2019 SCRUM study, we will again be collaborating with the University of Birmingham and Marker diagnostics and collecting salivary miRNA samples in the Premiership next season as part of the 3 stage HIA process.

A key ambition for the next phase of this ground-breaking study in the men’s elite game is reduce the number of miRNAs required to accurately identify a concussion with the aim of accelerating the development of a commercially available test that could be used across sports in both the professional and community game, as well as in the military and healthcare settings.      

HEAD IMPACT & CONCUSSION MANAGEMENT 

The enhanced approach to concussion management centres around the implementation of the World Rugby enhanced Graduated Return to Play Protocol and specifically the introduction of an Independent Concussion Consultant review where the return to play is anticipated to be ten days or less and for players with a significant history of previous concussions in the Premiership, Championship and Allianz Premier 15s (AP15s) competitions.

Recognising the value of the Head Injury Assessment Protocol in managing head impacts where the diagnosis is not immediately apparent, the RFU will also be introducing the Head Injury Assessment (HIA) supported by real-time video review provided by Hawkeye in the AP15s for the 2021/22 season. The AP15s will be the first domestic women’s league to introduce the HIA.  

Alongside the introduction of the HIA in the AP15s next season, in collaboration with the University of Birmingham and Marker diagnostics the RFU will be collecting salivary miRNA samples in the elite women’s domestic game. This will be the first time that miRNA biomarkers will have been collected in the elite women’s game and will provide novel insights into any differences in the biomarker signal found after head injury in men and women.

POST-CAREER BRAIN HEALTH ASSESSMENT & CARE FOR PLAYERS 

The Advanced BRAIN Health Clinic, due to start operations later in the year, will see the RFU and PRL partnering with independent clinical and academic experts Professor David Sharp and Dr Richard Sylvester. The specialist clinical service, which we aim to run at the Institute of Sport, Exercise and Health (ISEH), will provide the assessment and management of retired elite male and female rugby players between the ages of 30-55 who have concerns over their individual brain health.

This London- based unique specialist neurological assessment service, supported by advanced imaging, neurocognitive assessment and biomarker measurements, will provide retired elite players with a comprehensive assessment of medical and psychological factors relevant to their brain health, led by a team of multi-disciplinary experts. An integrated research programme will conduct research in relation to the risk, causes, assessment and management of brain problems occurring following participation in elite rugby.

Further information regarding the clinical service will be available here in due course.

This service for retired elite players will complement existing specialist clinics in London (ISEH) and Birmingham (RECOS) that are providing specialist concussion assessments for current players. A further study in collaboration with the Drake Foundation on the brain health of retired players is due for publication later this year.

WIDER ACTIVITY

Other initiatives will focus on the consistent application of the Head Contact Process by match officials, as well as the exploration of possible technical coaching interventions with the aim of seeing a change in player and coach behaviours.

A key outcome currently evident in the 2020/21 Gallagher Premiership Rugby season is that the focus by referees to issue red and yellow cards more accurately is contributing to what seems to be behavioural change by players. After an understandable lag, the data now suggests that dangerous tackle events are reducing.

In addition, English rugby will continue its engagement with World Rugby on other possible control measures for head impact and concussion reduction such as laws reviews, trials, and amendments. Engagement with World Rugby will also aim to address control measures to reduce the severity of match injury risk generally in men’s professional club rugby.

The RFU, PRL and RPA also intend to: 

  • Agree a standardised categorisation of training activities with all clubs and the England senior men’s and women’s national and age grade teams and...
  • Ensure key data is shared and there is regular consultation with Premiership clubs, England teams and players. 

Simon Kemp, RFU Medical Services Director said: “The RFU is fully committed to advancing our understanding of the short, medium and long term consequences of head impacts and concussions so that we can ensure we can make continued improvements in player welfare.

“For many years we have been using science and technology to evolve our thinking to optimise player welfare for prospective, current and past players as demonstrated with the action plan we are setting out today. By refining our existing knowledge, for example around the head injury assessment and creating new knowledge, such as that from the saliva microRNA and BRAIN studies, we continue to enhance our understanding.

“We welcome any research that helps to advance our knowledge which is why we actively collaborated with the academic institutions on the Drake Foundation Rugby Biomarker Study from its inception, particularly to promote the recruitment of players. While it is unclear from that research what the individual long-term implications are regarding the brain changes seen in these advanced imaging techniques, it is clearly a priority to investigate this further.

“To further develop our understanding the RFU, in partnership with Premiership Rugby and independent experts, will be providing a specialist clinical service for the assessment and management of retired elite male and female rugby players between the ages of 30-55 to individually assess their brain health. An integrated research programme will review the risk, causes, assessment and management of brain problems for those who have participated in elite rugby.” 

Phil Winstanley, Rugby Director at Premiership Rugby, said “Premiership Rugby and all our clubs are united in our commitment to reduce exposure to head impacts and the risks of concussion. This is a game-wide issue and progress will be made through continued collaboration with stakeholders across rugby, both in England and the international game.

“Over the last decade, we have developed several initiatives to improve player welfare including having Hawkeye, head injury video reviewers in the stands and independent match day doctors at every game. Technology and understanding are at the centre of our initiatives and it’s important we continue to develop our understanding further allowing us to make player centred decisions, particularly linked to long term health. Next season using new technology we plan to involve hundreds of players in the instrumented mouth guard project in order to provide valuable data to increase understanding of all head impacts and the links to concussion and help to shape continued action to protect players across the professional game.

“In addition, as well as promoting the welfare of current players, we want to make sure there is access to expert clinical support for their long-term health for those who have retired from the game and will be investing in a Brain Health clinic which will provide clinical assessment and on-going expert support for former professional players.”

Damian Hopley RPA Group CEO said: “Player welfare is at the heart of the work of the RPA and we welcome this research as it is imperative that our sport continues to make progress to address the long term brain health of the players. The goal must be to reduce player exposure to head impact by removing unnecessary impacts. We acknowledge the need to work through all the available information and welcome the significant work that the RFU medical experts have devoted within this area.

“We look forward to clearer guidance and developments around head impact prevention and management going forward, especially within controlled training sessions. The specialist clinical service to assess brain health funded by the RFU and PRL is an important step in providing enhanced data and subsequent care for the players and the game.”

World Rugby Chief Executive Alan Gilpin said: “Rugby is united in its unwavering commitment to advance player welfare. At the centre of that mission is a multi-faceted focus on reducing head impact exposure and concussion risk at all levels of the game.

“The action plan launched by the RFU, Premiership Rugby and the RPA today is a strong example of that commitment, demonstrating a clear desire to explore rapidly-evolving technology and science. The instrumented mouthguard study across the men’s and women’s premierships will dovetail with the University of Otago community rugby head injury study to build a complete picture of head impacts across the sport and importantly how to reduce them.”

PRISP & WRISP

The 2019/20 Professional Rugby Injury Surveillance Project (PRISP) and Women’s Rugby Injury Surveillance Project (WRISP) reports have also been released today here.

PRISP is the most comprehensive and longest-running injury surveillance study in professional rugby union. Running since 2002 it monitors the injury risk of Premiership Rugby players in Gallagher Premiership, European and national competition as well as training sessions.

WRISP now in its third season outlines findings from the Allianz Premier 15s. WRISP will be pivotal in providing the baseline data needed to assess trends in injury risk and in guiding further investigation into injuries that are common, severe, or increasing in incidence.

The 2019-20 season was unlike any previous season, and it is important to consider its’ unique structure when reading through the reports. Firstly, for PRISP, 2019 was a World Cup year, meaning that the season began with 80 Premiership players representing their nations in Japan.

Secondly, the outbreak of the Coronavirus pandemic resulted in the Gallagher Premiership Rugby season being suspended three-quarters of the way through for a duration of 22 weeks. For the first 12 weeks of this period a nationally enforced lockdown meant that all normal training activity was suspended. Players then returned to a 10-week team training period (around half of which was non-contact) before competition resumed.

To facilitate a timely completion of the 2019-20 season, when competition restarted a schedule that included mid-week matches was agreed by the Professional Game Board. Despite the potential for disruption to the season to result in players being unable to maintain the physical qualities necessary to protect against injury, our early analysis tells a positive story about how players were managed during these extraordinary times.

Given the short turnaround between the 2019-20 and the 2020-21 Gallagher Premiership Rugby seasons, further analysis will be needed to determine any medium-term impact of the disruption, and this will be presented in next year’s report.

The 2019-20 AP15s competition was halted in March 2020 due to the pandemic and was subsequently declared null and void. Given that this is only the third season of data collection in the women’s professional setting and that the current season was cut short, there is currently insufficient data to comment on trends in injury risk or the significance of changes between seasons.

Overall, it is the view of the WRISP steering group that despite being one of the most comprehensive injury surveillance projects in the women’s game to date, the injury risk profile presented in the current report does not yet fully reflect the injury risk in this setting. A number of improvements to the data monitoring and quality-checking processes have already been made to ensure the WRISP data is of the highest quality for monitoring and reducing the risk of injury in the women’s professional game moving forwards.

Key findings from the 2019/20 season PRISP report include:

Overall 

  • In 2019-20, the match injury incidence was 88 injuries per 1000 hours. This is almost identical to the 2002-19 period mean of 87 injuries per 1000 hours and equates to nearly 2 injuries per match.
  • On average, each match injury lasted 38 days. This is the highest recorded average severity in the surveillance period and reflects the higher rate of injuries lasting >84days and lower rate of injuries lasting 2-7days than the 2002-19 period mean.
  • The injury rate in the post-suspension period of the 2019-20 season was significantly lower than both the equivalent period of the 2016-19 seasons and the 2019-20 pre-suspension period.
  • There was no difference in the incidence, severity or burden of injuries sustained in fixtures with a shorter than normal turnaround time played during the post-suspension period. 

Concussion 

  • For the ninth season the most commonly reported match injury was concussion, contributing 22% of all match injuries and with an incidence of 19.8 concussions per 1000 hours.
  • This is close to, but below the upper limit of expected season-to-season variation.
  • On average, each match concussion resulted in 16 days missed, which is above the 2002-19 period mean, but a substantial decrease on recent years. 

Other

  • As in 2019-20, 52% of all match injuries associated with the tackle.
  • 44% of all injuries were sustained during training, which is higher than the 2002-19 period mean of 32% and is likely a result of the increased total time spent in training activity due to the unique nature of the 2019-20 season. The incidence of training injuries was stable.
  • During 2019-20, as with the season prior, neither the incidence, severity nor burden of match injuries was different between artificial turf and grass.
  • When aggregating seven seasons of match data, the incidence is not different, but the mean severity of injuries on artificial turf is 6 days greater than natural grass. 
  • As well as presenting findings from the previous season, the PRISP report compares these with the previous seasons in professional rugby. This provides the baseline data needed to assess trends in injuries.

 Key findings from the 2019/20 season WRISP report include:

Overall 

  • The overall incidence of match injury in the AP15s was 39 / 1000hs (10 injuries per team, or 1.6 injuries per match), which was similar to 2018-19 (35 per 1000 hours). This incidence rate is relatively low and might reflect under-reporting of minor (2-7 day) injuries. As such, it might be expected that the reported incidence will rise in future seasons as reporting continues to improve.
  • The average time missed per match injury was 46 days. This figure is higher than in Gallagher Premiership Rugby (38 days), and further reflects under-reporting of minor (2-7 day) injuries in this setting. The reported mean days missed per injury may be expected to fall in the future as reporting of minor injuries improves. 

Concussion 

  • Concussion was again the most commonly reported match injury (5.3 per 1000 hours), making up 14% of all match injuries. Concussion prevention is a priority for the women’s game, alongside developing strategies to optimally detect and manage such injuries.

Other 

  • The incidence rate for training injuries was low (1 / 1000 h), while the average number of days missed per training injury was high (51 days). This equates to one time-loss training injury every 11 team-training sessions (assuming 2 h sessions involving 45 players). This data may reflect the challenges associated with detecting and reporting injuries in this setting. For instance, medics do not see players as regularly as in Gallagher Premiership Rugby, and so minor injuries are more likely to be missed in the women’s game. Developing medical resources and practitioner reporting will impact upon this.
  • Despite their low incidence rate, training injuries still accounted for the majority (55%) of all injuries reported in this setting. Given the more controllable nature of the training environment, these injuries should be a priority for future preventative efforts. 

The Community Rugby Injury Surveillance Project (CRISP) – an entirely separate report – outlines findings from the grassroots adult game. One-week time-loss injury rates in men’s senior community rugby are approximately half of those reported in Gallagher Premiership Rugby.

The original article can be found here.

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