EPIDEMIOLOGY OF CATASTROPHIC RUGBY FOOTBALL INJURIES IN NEW SOUTH WALES Tai Rotem This dissertation is submitted in fulfilment of the requirements of the degree of Masters by research thesis. Faculty of Medicine, University of New South Wales, 2007 Publications and official reports generated from this research Published articles in refereed journals Rotem TR, Lawson JS, Wilson SF, Engel S, Rutkowski SB, Aisbett CW. 1998. Severe cervical spinal cord injuries related to rugby union and league football in New South Wales, 1984-1996. Medical Journal of Australia 168(8): 379-381. Rotem TR, Davidson R. 2001. Epidemiology of Schoolboy football injuries. International Sports Med Journal 2(2). [Online] Available at: www.esportmed.com/ismj Lawson J, Rotem T, Wilson S. 1995. Catastrophic injuries to the eyes and testicles in footballers. Medical Journal of Australia 163(5): 242-244. Published letters in refereed journals Wilson SF, Atkin PA, Rotem T, Lawson JS. 1996. Spinal cord injuries have fallen in rugby union in New South Wales. British Medical Journal 313(7071):1550. Published conference papers Geffen S, Wilson S, Rotem T, Lawson J. 1999. Severe injury and fatality in Rugby League football. Abstracts from the Football Australasia Conference. Journal of Science and Medicine in Sport 2 (1): 178. Official reports Rotem T, Wilson S, Lawson J. 2001. Rugby football injury mechanism study. Report to the New South Wales Sporting Injuries Committee Research and Injury Prevention Program. Lawson J, Wilson S, Rotem T. 1995. Head and neck injuries in sport: Report to the New South Wales Sporting Injuries Committee Research and Injury Prevention Program. Epidemiology of catastrophic rugby football injuries in New South Wales ABSTRACT Aims and objectives: To investigate the epidemiology, risk factors, and preventive strategies for serious head and spinal injuries related to rugby league and union football in New South Wales (NSW). Methods: The three main components of this study included. 1. A retrospective analysis of clinical and compensation case file records during the 16-year period, 1984-1999. 2. A review of game rules, weights and heights of players, over the past 100 years. 3. A review of film and video footage of rugby football games spanning most of the 20th century. A method was developed to allow valid comparisons in style of play over a 70-year period. Results: The estimated annual incidence rate of SCI for rugby league players was 1.9 (95%CI 1.3 - 2.8) per 100,000 estimated players per year, and 3.3 (95%CI 2.2 - 4.8) per 100,000 estimated rugby union players per year over the study period 1984 to 1999. There was no significant change in the incidence of rugby league related serious spinal cord injuries (1984-1999), fatalities (1984-1999) or serious head injuries (1984-1999). There was a small but significant decline in rugby union related serious spinal cord injuries (1984-1999, P<0.05). However, the relative risk of spinal cord injury was 1.34 times greater for rugby union compared to rugby league over the entire study period (95%CI 1.01 - 1.67, P<0.05). For rugby football, the evidence suggested that the force of impact between participants was a key causal risk factor for serious injury. Elite rugby league and union players from 1999-2000 teams were significantly heavier (P<0.05) and taller (P<0.05) than players pre 1950. Players in modern elite games post 1989 were more likely to be tackled by multiple opponents (P = 0.000), tackled head on (P<0.05), at chest level (P<0.05) and at greater speeds than their earlier counterparts pre 1958. However, modern players appear to be no more aggressive or perpetrate greater foul play than their predecessors. Conclusions: There was a continued annual occurrence of catastrophically serious injuries leading to permanent brain damage and quadriplegia associated with rugby league and union in NSW. The critical risk factors found to be associated with serious injury in rugby football suggest relatively novel approaches to the development of preventive strategies. ACKNOWLEDGMENTS I would like to acknowledge with much appreciation the support and guidance of Professor Anthony Zwi and Associate Professor Mary-Lou McLaws, my academic supervisors. Their guidance has been very helpful in completing the present dissertation report. I would also like to convey deep appreciation to Professor James Lawson, my original academic supervisor. I was privileged to work with Professor Lawson and Dr Stephen Wilson in the conduct of the original study in 1998 from which this dissertation evolved. The late Dr David Garlick (School of Physiology and Pharmacology, UNSW) provided valuable advice and support as my co supervisor. I am indebted to the NSW Sporting Injuries Committee for the funding support they have provided reflecting their strong commitment to injury prevention research. Special thanks to Mr John Anderson and all the staff at the NSW Sporting Injuries Committee who provided ongoing support and access to the benefits paid case data. Dr George Argyrous (School of Social Science and Policy, UNSW) offered most helpful advice on statistical analysis and research methods. Dr Sue Rutkowski and Dr Stella Engel provided access to spinal unit medical records. Mr Simon Drake and Ms Naomi Lamb at Screensound Film and Sound Archive Australia assisted in obtaining archival football video footage. Similarly, Mr Alex Byron at Sports Recording Services assisted in providing footage of more recent games. I acknowledge with appreciation the work completed by Mr Jordan Telfer. Using the designed recording tool, Mr Telfer was employed to review the archival film and video footage gathered for this study independently, with no knowledge of the study hypothesis. Finally, I am very grateful to my parents for the interest and support they have provided over the years. 1 TABLE OF CONTENTS LIST OF APPENDICES 7 LIST OF FIGURES 7 LIST OF TABLES 8 TABLE OF ABBREVIATIONS 9 CHAPTER ONE – INTRODUCTION 10 Background 10 Importance of sport and recreational activities 10 The risk of injury associated with sport and recreational activities 11 The burden of sporting injuries 12 The role of research and government policy in sporting injury prevention 13 Objective 15 Research objectives 15 Organization of thesis structure 17 CHAPTER TWO – LITERATURE REVIEW 19 SECTION ONE Public health approaches to preventing serious injuries in Australia 20 Establishment of injury prevention programs 21 Resources and coordination for injury prevention research 24 Road related injury and fatality prevention 26 Childhood pool drowning prevention 28 Sport and recreational injury and fatality prevention 30 SECTION TWO Developing and evaluating injury prevention strategies in sport and recreational activities 37 Study design in epidemiological studies of sport injuries 38 Constraints in data collection 40 SECTION THREE Background to serious injuries occurring in sport 42 Spinal Cord Injury 42 Clinical definition and management of spinal cord injury 42 Risk Factors for spinal cord injury 45 Epidemiology of spinal cord injuries in Australia 46 Head and Brain Injury 50 Clinical definition and management of head and brain injury 51 Risk factors for head injury 54 Epidemiology of head and brain Injuries in Australia 55 2 Fatalities 57 Risk factors for fatal injuries 57 Epidemiology of fatalities in Australia 58 Non-traumatic fatalities in sport and recreational activities 60 SECTION FOUR Serious rugby football injuries 62 Explanation of rugby football codes 62 Rugby league rules 62 Rugby union rules 64 SCI in rugby football 68 Brain injuries in rugby football 70 Prevention strategies for serious rugby football injuries - safety programs, rule change and enforcement 71 Rugby union 71 Rugby league 74 Effectiveness of prevention strategies in reducing serious injury 75 Legal consequences of rugby football injuries 77 SECTION FIVE Risk factors for serious injury in rugby football 79 Overview 79 Extrinsic risk factors 82 Types and style of play that increase the risk of serious injury 82 Spinal cord injury 82 Head injury 83 Mechanism of tackling injury 83 Force of impact 85 Direction of impact 88 Multiple tacklers 90 Level of impact 91 High tackles risk of injury to the ball carrier 91 Low tackles increased risk of injury to the tackler 92 Mechanism of ruck and maul injuries 93 Mechanism of scrum injuries 94 Acute management for suspected serious injuries 97 Spinal cord injury 97 Brain injury 98 Illegal/foul play 99 Number of players 103 Stage of season 104 Other external risk factors 105 Protective equipment for serious injury in football 106 Spinal cord injury 107 Head and brain injury 108 3 Intrinsic risk factors 110 Player characteristics that influence players’ serious injury risk 110 Anthropometric and physiological characteristics 110 Pre-existing conditions 114 Physical preparation 116 Skills, experience and technique 118 Level of competition, competitiveness and aggression 121 Age 127 Player position 128 Risk Exposure duration 130 SECTION SIX The historical and sociological development of rugby football and its effect on participant aggression and competitiveness 131 SECTION SEVEN Style of football played in modern times (post 1989) compared to that played in an earlier era (pre 1958) 139 Number of tacklers 140 Impact force 141 Dangerous scrums and tackling technique 141 Illegal/foul play 144 Number of players 145 Players strength, fitness and size 146 CHAPTER THREE – METHODOLOGY 152 SECTION ONE Injury definitions of data included in study population 152