Injury and concussion in rugby
Submitting InstitutionSt Mary's University, Twickenham
Unit of AssessmentSport and Exercise Sciences, Leisure and Tourism
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
The outcomes of this research have directly influenced practices and
policies for injury prevention and player health in both rugby league and
rugby union. Besides giving a detailed analysis of injury profiles in
rugby league, the research has served to raise the profile and awareness
of two major issues, heat stress and concussion.
Presentations of research findings to members of the Rugby League Medical
Association (RLMA) have enhanced CPD workshops, and resulted in bylaw
changes in Rugby Football League medical standards. More recent work has
highlighted the seriousness of concussion in both rugby league and union.
Injury is often an unwanted consequence of sport participation, and Tator
(2012) considered sport-related concussion to be a public health problem.
An extensive body of work by Gissane and his co-authors has sought to
examine and further the understanding of the potential for injury in
several sports (Rugby League, Rugby Union, Rowing, and Gaelic Games). This
research has been accomplished through a number of international
collaborations (notably with colleagues in Ireland and New Zealand).
A series of 14 articles have been produced which examine the incidence of
injury in Rugby League. As part of this series it was possible to examine
the effect on injury when the playing calendar was moved from winter to
summer1 2 and the effect of the advent of fulltime
professionalism. A medical and performance issue that concerned Rugby
League medical staff was player hydration/dehydration as a result of
having to play in higher temperatures. Initially, the Rugby Football
League produced leaflets on the subject, and referees allowed support
staff to enter the field provided they didn't interfere with play. Within
three seasons, the controller of referees suggested that too many support
staff were on the field, and that they were doing more than supplying
water. The Rugby Football League then sought to limit the occasions on
which support staff could go onto the field. This move concerned the Rugby
League Medical Association. Their concern was that players would have a
much reduced access to water, and less opportunity to drink. The issue was
discussed at the RLMA AGM in 2000 and Dr Chris Wragg (Chairman) went back
to the RFL to describe the medical position and requested that the RFL
reconsider its position. He provided evidence in support of this request
in the form of the Jennings et al (1999) research3 which
described the risk involved.
Sport related-concussion is seen as a major problem in team contact
sports by sports medicine practitioners. Furthermore, the longer term
consequences can be especially problematic with research suggesting a link
between concussion and early onset dementia. Research has suggested that
concussion is under reported, because the diagnosis and management is
misunderstood. More recently, research by Gissane in collaboration with
others has sought to describe the problem in both rugby codes4 5
and its costs6 more fully. It has also sought to make use of
new tools (e.g. the King-Devick Test) that can be used to identify
concussion.4 5 Attitudes towards concussion have changed.
Personnel involved in sport, particularly medical staff, are now keen to
identify concussion rates, so that problems can be prevented in either the
immediate, medium or longer term, in order to improve the safety of
References to the research
1. Gissane C, Jennings D, Kerr K, White JA. Impact of the change
in playing season on injury in rugby league football. American Journal
of Sports Medicine, 2003;31(6):954-8.
2. Gissane C, Jennings DC, White JA, Cumine A. Injury in summer
rugby league football: the experiences of one club. British Journal of
Sports Medicine, 2003;32:149-52.
3. Jennings S, Robertson S, Jennings D, White J, and Gissane C.
Body mass loss and dehydration in rugby league. Coaching and Sports
Science Journal, 1998;3(3):31-3.
4. King D, Brughelli M, Hume P, Gissane C. Concussions in amateur
rugby union identified with the use of a rapid visual screening tool. J
Neurol Sci., 2013;326(1-2):59-63.
5. King DA, Clark T, Gissane C. Use of a rapid visual screening
tool for the assessment of concussion in amateur rugby league players.
J Neurol Sci., 2012; 320:16-21.
6. King D, Gissane C, Brughelli M, Hume PA, Harawira J.
Sport-related concussions in New Zealand: a review of 10 years of Accident
Compensation Corporation moderate to severe claims and costs. Journal
of Science and Medicine in Sport, 2013; http://dx.doi.org/10.1016/j.jsams.2013.05.007
All references listed here are published in established peer reviewed
journals. Regarding reference 3, this journal is no longer in print. All
journal articles are available on request from the institution.
Details of the impact
This research has assisted in mitigating harm to players. It has further
influenced professional standards and game legislation. Two specific
examples of impact are presented here to illuminate this case study,
demonstrating how impact has arisen from the body of research outlined
Firstly, a change in Rugby League bylaws, which occurred after a case was
made by the Chairman of The RLMA to The Rugby Football League which
occurred as a direct result of research undertaken by Gissane and
colleagues and, secondly, raising the debate around concussion in sport
globally, through research into the rapid assessment of concussion using
the King-Devick test. The RLMA was successful in getting a bylaw regarding
entering the field of play. Today, that bylaw is still part of RFL Medical
E.9 Hot Weather Code
When both clubs medical staff agree that the heat and/or humidity is
such that players require additional water they should approach the
Match Commissioner (or Referee if there is no Match Commissioner) to
request one or both of the special measures below. (Where there is only
one Doctor present he/she is entitled to make the request on his/her
own). The Match Commissioner shall grant this request and shall ensure
that the Referee, home Club secretary and broadcast partner are aware of
- The positioning of water containers around the ground (ensuring
that there is no danger to players or spectators) to enable players to
- A two minute break at an appropriate natural pause in the game
approximately half way through the first and second halves to allow
players to take on extra water.
From: RFL Medical Standards 2012 Section E page 59.
When the research1,2,3 was originally conducted, it was not
only the Super League and the professional ranks that needed to be
considered. For the first time, many amateur players played in the summer.
The evidence and the consequent bylaw were important to those players
also. Gissane was awarded the Esso prize for research by the Occupational
Medicine Society in 2004, in recognition of research and its impact.
Concussion as a topic is currently being debated in public. As part of
that debate, the research has been discussed extensively in online forums,
and has featured in the mainstream press, e.g. the `New York Times'. The
research that has been conducted by Gissane and his fellow researchers has
featured prominently in this discussion4,5,6. The discussion in
the media has included radio shows, television news shows and also
newspaper reports, raising awareness and stimulating debate amongst a wide
audience around this important issue.
The underpinning research focuses on the fact that anyone who
participates in sport risks being concussed. At the grassroots levels of
any sport resources and funding are often not available for some of the
more sophisticated equipment available to professional sports persons. The
importance of this issue was presented in an article in the journal Neurosurgery
(Duenas et al. 2013), where Gissane's work was directly cited and
highlighted. Yet, the risk is still present and coaching and support staff
must be educated in recognising and assessing the injury. This has led to
the interest in the research in the media. A simple test is employed,
which can be used at several sporting levels for minimal costs. It has
been able to identify un-witnessed concussion which has led to greater
understanding of the incidence of concussion in sport.
Sources to corroborate the impact
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