The Incidence, Cost, and Burden of Concussion in Women's Rugby League and Rugby Union: A Systematic Review and Pooled Analysis

Analysis of Player Performance and Financial Costs Associated With Implementation of an Updated National Hockey League Concussion Protocol: A Retrospective Comparative Study

Background

An updated National Hockey League (NHL) concussion protocol (NHLCP) was established in the 2016-2017 season to mitigate the negative outcomes of sport-related concussions. However, few studies on the effects of implementing the NHLCP have been performed.

Purpose

To define concussion incidence and investigate differences in NHL player performance after a concussion during periods before and after NHLCP implementation and assess the financial impact on NHL teams associated with NHLCP implementation.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective review of NHL players who sustained a concussion before (2000-2001 to 2015-2016 seasons) and after (2016-2017 to 2020-2021 seasons) implementing the NHLCP (pre-NHLCP and post-NHLCP groups). For each group, multiple performance metrics-including 30 days, 1 season, and 3 seasons before and after concussion-were compared for both groups. Return to play, total concussion cost, and association of return to play with cost were investigated using regression analysis.

Results

A total of 452 players (423 skaters, 29 goalies) sustained concussions during the study period, including 331 players (315 skaters, 16 goalies) in the pre-NHLCP group and 121 players (108 skaters, 13 goalies) in the post-NHLCP group. For both groups, no significant differences in standard performance were observed during the 30-day and 1-season periods before and after concussion. The mean return to play was significantly higher in the pre-NHLCP group than in the post-NHLCP group (20.1 vs 15.7 days; P = .022). The mean adjusted player salary was not different between groups; nonetheless, the mean adjusted replacement player salary was significantly higher in the post-NHLCP group ($744,505 vs $896,942; P = .032). The mean cost of time missed did not differ between groups. The mean return to play time significantly decreased over the entire study period (R2 = 0.33; P = .005), and the mean return to play time was positively associated with cost R2 = 0.215; P = .030).

Conclusion

Concussion incidence did not change after implementation of the updated NHLCP; nonetheless, players had significantly less missed time from injury after protocol implementation. Changes in player performance 30 days and 1 year before and after concussion injury were not different before and after NHLCP implementation. No differences were found in the financial cost of concussions between the pre- and post-NHLCP groups, and missed time was significantly correlated with mean cost from missed time.

Return to Play, Performance, and Earnings Analysis After Lumbar Disc Herniation in National Hockey League Players

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Professional hockey players have a high incidence of lumbar disc herniations (LDH). The purpose of this study was to determine the impact of LDH on the performance and financial earnings of National Hockey League (NHL) players.

METHODS

NHL players who sustained a LDH were retrospectively reviewed utilizing an online database and a 2:1 matched control cohort. Player performance and game usage was compared at one- and three-season(s) pre- and post-injury season within the cohorts. Injured and matched players were divided into 3 groups based on the player's adjusted index season salary.

RESULTS

A total of 181 players were included, with 62 LDH players matched to 119 healthy controls. Return to play after LDH was 79%. The LDH cohort had fewer seasons played throughout their career compared to the matched group (12.5 ± 4.3 vs 14.2 ± 3.8; P = .031). At 1 season post-index, the LDH cohort had significantly fewer goals per 60 and points per 60 when compared to pre-index. At 3 seasons post-index, the LDH cohort exhibited a significant decline in time-on-ice per game played, goals per 60, and points per 60 compared to pre-index.

CONCLUSION

The majority of NHL players who sustained a LDH returned to play (79%) but had shorter careers overall and decreased performance outcomes when compared to matched cohorts at both 1 and 3 seasons post-injury.

The 50 Most Cited Papers on Rugby since 2000 Reveal a Focus Primarily on Strength and Conditioning in Elite Male Players

We sought to conduct a bibliometric analysis and review of the most cited publications relating to rugby since 2000 in order to identify topics of interest and those that warrant further investigations. Clarivate Web of Science database was used to perform a literature search using the search term "rugby." The top 200 papers by citation count were extracted and reviewed for the inclusion criteria: all subjects were rugby players. The top 50 manuscripts were included for analysis of author, publication year, country of lead authors, institution, journal name and impact factor, topic, participant sex, and level of rugby. The total number of citations was 9,071 (average of 181.4 citations/article), with an average journal impact factor of 7.21; the top article was cited 407 times at the time of analysis. The most frequent publication was the Journal of Strength and Conditioning Research (26%), followed by the British Journal of Sports Medicine (20%) and the Journal of Sports Sciences (18%). Forty-eight (96%) of the manuscripts contained only male subjects, with 1 manuscript including females only and 1 manuscript containing mixed sexes. Thirty-three (66%) of the manuscripts focused on professional rugby players, with the next highest player group being mixed levels (10%). Twenty-eight (56%) concentrated on topics regarding strength and conditioning, 11 (22%) on injury, and 4 (8%) on physiology. Despite rugby being one of the most injurious sports and community players representing the largest component of the player pool, most of the top-cited rugby articles are cohort studies of professional male athletes focused on performance and strength and conditioning, noting the bias in research towards socially relevant topics that may not impact the majority of stakeholders and long-term health of rugby athletes. These findings highlight the need for further research among women and community athletes and on topics in injury prevention.

Incidence, characteristics and cost of head, neck and dental injuries in non-professional football (soccer) using 3 years of sports injury insurance data

AIM

This descriptive epidemiological study aimed to quantify the incidence, characteristics and costs of head, neck and dental injuries in non-professional football players.

METHODS

Injury data were coded (using Orchard Sports Injury and Illness Classification System) from a de-identified insurance database containing three seasons (2018-2020) of data. Cost data included direct and indirect costs presented by type of injury, age group and sex using means ± SD, range of costs ($AU) and total costs ± SE. Chi-squared tests were used to analyse the data (significance level p < .05) with injury incidence rates (IR) calculated per 1000 match hours and per 1000 injury insurance claims.

RESULTS

A total of 388 injuries affecting 240 players were sustained. Of these, 43% (n = 102) of players also sustained one or more secondary injuries, mainly to the head or neck area. Dental injuries (n = 143, 39%, IR = 0.008) accounted for the highest number of primary and secondary injuries and the highest mean direct cost per injury ($AU1152), while head and facial injuries accounted for the highest proportion of total costs ($AU434,101). Players who sustained one or more secondary injuries had the highest direct and indirect mean cost per injury.

CONCLUSIONS

Given the frequency and cost of dental injuries in non-professional football players, injury prevention initiatives warrant further investigation.

Existence ≠ adherence. Exploring barriers to best practice in sports-related concussion return to play (SRC-RTP) in Irish amateur female sport

OBJECTIVES

Sports-Related Concussion (SRCs) are of relevant risk and burden for female athletes. The following study aimed to explore potential barriers to return to play (RTP) best practice in coaches of amateur female athletes, and medical professionals who may treat and manage SRCs in amateur female athletes.

DESIGN

Qualitative, semi-structured, virtual interviews following a critical analysis framework.

METHODS

Twenty-five coaches, allied healthcare professionals (AHPs), and general practitioners (GPs) were recruited and interviewed using a convenience snowball sample. Data were transcribed verbatim and thematically analysed.

RESULTS

Three themes were identified following reflexive thematic analysis; biopsychosocial norms, stakeholder inaction, and practitioner effectiveness. The findings identify numerous factors which limit the uptake of best practice guidelines as endorsed by Irish national governing bodies (NGBs). Education, training, and implementation of these guidelines are lacking, with sub-standard or non-existent medical support and poor general injury and/or SRC attitudes providing further resistance to these measures.

CONCLUSION

Existence of SRC-RTP protocols does not equal adherence to such. Greater efforts are required to translate knowledge provided by the 6th Concussion Consensus statement. NGBs, league and club administrators, and educators need to better support coaches, practitioners and athletes in the implementation of these protocols in amateur female sport.

A case-control study of tackle based head impact event (HIE) risk factors from the first three seasons of the National Rugby League Women's competition

Objective

The tackle is the most injurious event in rugby league and carries the greatest risk of concussion. This study aims to replicate previous research conducted in professional men's rugby league by examining the association between selected tackle characteristics and head impact events (HIEs) in women's professional rugby league.

Methods

We reviewed and coded 83 tackles resulting in an HIE and every tackle (6,318 tackles) that did not result in an HIE for three seasons (2018-2020) of the National Rugby League Women's (NRLW) competition. Tackle height, body position of the tackler and ball carrier, as well as the location of head contact with the other player's body were evaluated. Propensity of each situation that caused an HIE was calculated as HIEs per 1,000 tackles.

Results

The propensity for tacklers to sustain an HIE was 6.60 per 1,000 tackles (95% CI: 4.87-8.92), similar to that of the ball carrier (6.13 per 1,000 tackles, 95% CI: 4.48-8.38). The greatest risk of an HIE to either the tackler or ball carrier occurred when head proximity was above the sternum (21.66 per 1,000 tackles, 95% CI: 16.55-28.35). HIEs were most common following impacts between two heads (287.23 HIEs per 1,000 tackles, 95% CI: 196.98-418.84). The lowest propensity for both tackler (2.65 per 1,000 tackles, 95% CI: 0.85-8.20) and ball carrier HIEs (1.77 per 1,000 tackles, 95% CI: 0.44-7.06) occurred when the head was in proximity to the opponent's shoulder and arm. No body position (upright, bent or unbalanced/off feet) was associated with an increased propensity of HIE to either tackler or ball carrier.

Conclusions

In the NRLW competition, tacklers and ball carriers have a similar risk of sustaining an HIE during a tackle, differing from men's NRL players, where tacklers have a higher risk of HIEs. Further studies involving larger samples need to validate these findings. However, our results indicate that injury prevention initiatives in women's rugby league should focus on how the ball carrier engages in contact during the tackle as well as how the tackler executes the tackle.

A Global Women's Rugby Union Web-Based Survey

Rugby Union (rugby) is a full-contact team sport characterised by frequent collision events. Over one third (2.7 million) of global rugby participants are women and girls. Yet, most rugby research, laws, and regulations are derived from the men's game with limited transferability to the women's game. This includes research focused on injury and concussion management. Greater insights are urgently required to enable appropriate adaptations and support for all rugby participants. Therefore, this paper presents the protocol for a project that sought to gather insights into the understanding, experiences, and attitudes of players and coaches in women's rugby regarding key issues of concussion, injury, and training for injury prevention, as well as the implications of the menstrual cycle for training and performance. From August 2020 to November 2020, online, open, cross-sectional surveys for players and coaches were distributed globally through rugby governing bodies and women's rugby social media platforms using snowball sampling. Survey responses were recorded anonymously via a GDPR-compliant online survey platform, JISC (jisc.ac.uk, Bristol, England). Participant eligibility included being ≥18 years and either actively playing or coaching women's rugby 15s and/or sevens, or having done so in the past decade, at any level, in any country. To enhance the number and accuracy of responses, the survey was professionally translated into eight additional languages. A total of 1596 participants from 62 countries (27 ± 6 years; 7.5 ± 5.1 years of playing experience) and 296 participants from 37 countries (mean age = 36.64, SD = 9.09, mean experience = 6.53 years, SD = 3.31) completed the players' and coaches' surveys, respectively. Understanding women's participation in and experiences of rugby is important to enable lifelong engagement and enjoyment of the sport and health during and following participation.

The propensity of non-concussive and concussive head contacts during elite-level women's rugby league matches: a prospective analysis of over 14,000 tackle events

OBJECTIVES

Identify the frequency, propensity, and factors related to tackle events which result in contact with the head in elite-level women's rugby league.

DESIGN

Prospective video analysis study.

METHODS

Video footage from 59 Women's Super League matches were analysed (n = 14,378 tackle events). All tackle events were coded as no head contact or head contact. Other independent variables included: area contacting head, impacted player, concussion outcome, penalty outcome, round of competition, time in match and team standard.

RESULTS

There were 83.0 ± 20.0 (propensity 304.0/1000 tackle events) head contacts per match. The propensity of head contact was significantly greater for the tackler than ball-carrier (178.5 vs. 125.7/1000 tackle events; incident rate ratio 1.42, 95 % confidence interval 1.34 to 1.50). Head contacts occurring from an arm, shoulder, and head occurred significantly more than any other contact type. The propensity of concussions was 2.7/1000 head contacts. There was no significant influence of team standard or time in match on the propensity of head contacts.

CONCLUSIONS

The observed head contacts can inform interventions, primarily focusing on the tackler not contacting the ball-carrier's head. The tackler's head should also be appropriately positioned to avoid contact with the ball-carrier's knee (highest propensity for concussion). The findings are consistent with other research in men's rugby. Law modifications and/or enforcement (reducing the number of un-penalised head contacts), concurrent with coaching interventions (optimising head placement or reducing the head being contacted) may help minimise head contact risk factors for women's rugby league.

Nutritional interventions to support acute mTBI recovery

When mild traumatic brain injury (mTBI) occurs following an impact on the head or body, the brain is disrupted leading to a series of metabolic events that may alter the brain's ability to function and repair itself. These changes may place increased nutritional demands on the body. Little is known on whether nutritional interventions are safe for patients to implement post mTBI and whether they may improve recovery outcomes. To address this knowledge gap, we conducted a systematic review to determine what nutritional interventions have been prescribed to humans diagnosed with mTBI during its acute period (<14 days) to support, facilitate, and result in measured recovery outcomes.