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Objective: To compare physical contacts (PCs), including head contacts (HCs), suspected concussion, and nonconcussion injury incidence rates between youth ringette and female ice hockey., Design: Cross-sectional., Setting: Alberta ice arenas., Participants: Players participating in 8 U16AA (ages 14-15 years) ringette and 8 U15AA (ages 13-14 years) female ice hockey games during the 2021 to 2022 season., Assessment of Risk Factors: Dartfish video-analysis software was used to analyze video recordings., Main Outcome Measures: Univariate Poisson regression analyses (adjusted for cluster by team-game, offset by game minutes) were used to estimate PCs (including HCs) and suspected injury (concussion and nonconcussion) and concussion-specific IRs and incidence rate ratios (IRRs) to compare sports. Proportions of all PCs that were body checks (level 4-5 trunk PC) and direct HCs (HC 1 ) penalized were reported., Results: Ringette had a 2.6-fold higher rate of body checking compared with hockey (IRR = 2.63, 95% CI: 1.59-4.37). Ringette also had a 2-fold higher rate of HC 1 compared with hockey (IRR = 2.08, 95% CI: 1.37-3.16). A 3.4-fold higher rate of suspected injury was found in ringette (IRR = 3.37, 95% CI: 1.40-8.15). There was no significant difference in suspected concussion IRs in ringette compared with hockey (IRR = 1.93, 95% CI: 0.43-8.74). Despite being prohibited in both sports, only a small proportion of body checks (Ringette = 18%; Hockey = 17%) and HC 1 (Ringette = 6%; Hockey = 6%) were penalized., Conclusions: Higher rates of body checking, HC 1 , and suspected injuries were found in ringette compared with female ice hockey. Body checking and HC 1 were rarely penalized, despite rules disallowing them in both sports. Future research should consider other youth age groups., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare head contact (HC) and suspected concussion incidence rates (IRs) in male and female university basketball players and describe associated game event and court location., Design: Cross-sectional., Setting: Canadian basketball courts., Participants: Players from 5 male and 5 female 2019 to 2020 regular season basketball games., Assessment of Risk Factors: Prerecorded game footage was analyzed using Dartfish video analysis software to compare sexes., Main Outcome Measures: Poisson regression analysis was used to estimate IRs and incidence rate ratios (IRRs) for HCs and suspected concussions. Head contacts were classified as HC1 (direct, player-to-player) or HC2 (indirect, player-to-environment). Game event, court location, and penalization of HCs were reported., Results: Two hundred thirty HCs (88.7% HC1s, 11.3% HC2s) were observed. The HC1 IR was higher in male than female players (IRR, 1.55; 95% CI, 1.16-2.06). Most HCs occurred within the key. Shooting was the primary offensive game event for male and female players for receiving HC1s (24.6% and 20.0%, respectively). Defensively, HC1s occurred most frequently while guarding an attacker for male players (40.6%) and rebounding for female players (31.0%). The suspected concussion IR was not significantly different between male and female players (IRR, 2.00; 95% CI, 0.20-19.8). In total, 11.2% of HC1s to defenders and 25.7% of HC1s to offensive players were assessed as a foul., Conclusion: Head contact rates were higher for male varsity basketball players compared with female players; however, suspected concussion rates did not differ. Game event and court locations differed by sex. A priority target for injury prevention is penalization of HCs because most HCs in competition went unpenalized., Competing Interests: The authors report no conflicts of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Rugby Union has a relatively high risk of injury. Early evidence suggests a benefit of lowering tackle height to reduce head and neck injuries, although concerns persist among stakeholders regarding implementation challenges. This study aimed to understand whether referees can reach the same conclusion regarding tackle height in a controlled environment (ie, video) and whether priming influenced these decisions., Methods: Forty-eight active referees completed a questionnaire based on high-tackle decision-making guidelines after watching tackles. Participants were randomly assigned one of two instructional videos containing a high or legal tackle to investigate the impact of priming on law interpretation., Results: The percent agreement regarding tackle height was 78.1% between participants, 62.7% between participants and an experienced analyst, and 74.0% between participants and a gold-standard referee. Mean intra-rater reliability when determining whether a tackle was high was substantial (percent agreement: 91.2%). For high tackles, 83% of participants agreed on the danger level, 57% on the contact location and 71% on the presence of mitigating factors. No significant effects of priming were observed. Inter-rater agreement among participants and the gold-standard referee was moderate for all items except danger and height, which showed strong agreement., Conclusion: These results suggest a need for improved referee training to support changes to the legal tackle height., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Objectives: To determine the rates, severity and burden of knee injuries in professional male rugby union from the English Premiership., Methods: Injury and exposure data were captured over 20 seasons using a prospective cohort design. Knee injury incidence, days' absence and burden were recorded for each injury type and by pitch surface type for match and training., Results: The rate of knee injury in matches was 9.8/1000 hours (95% CIs 9.3-10.3). Mean days lost were 50 (95% CI 46 to 53) in matches and 51 (95% CI 44 to 57) in training. In matches, medial collateral ligament injuries were the most common, while anterior cruciate ligament (ACL) injuries had the highest mean severity and burden. There was no significant change in the count of knee injuries over time; however, average severity increased significantly (annual change: 2.18 days (95% CI 1.60 to 2.77); p<0.001). The incidence of match knee injury was 44% higher on artificial pitches than grass pitches (incidence rate ratio: 1.44 (95% CI 1.21 to 1.69); p<0.01), with no significant difference in severity between surfaces. In matches, the tackle was the event most commonly associated with knee injuries for all diagnoses, except ACL injuries (running). In training, running was a more common injury event than the tackle., Conclusion: Knee injuries in matches are common and severe in English professional men's rugby union. Despite an increased focus on player conditioning and injury prevention throughout the study period, rates of knee injury remained stable, and resulting days' absence increased. New strategies for the prevention of knee injuries should be considered a priority., Competing Interests: Competing interests: SWW holds grant funding from the World Rugby; SH PhD funding from the Rugby Football Union (RFU). MC is employed by the Premier Rugby Limited. SPTK is employed by the RFU. KAS is employed by the RFU. AMW is a shareholder in the Innovate Orthopaedics and DocComs start-ups. AMW receives lecturing fees, research support and part funding of a clinical fellow from Smith and Nephew. AMW is an editorial board member of the AJSM and is a member of the board of directors of ISAKOS. SW has received funding from the World Rugby and the RFU/Premiership Rugby., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This review and meta-analysis aimed to describe the current rugby-7s injury epidemiological literature by examining injury data from both sexes, all levels of play, and their associated risk factors. Studies published up until March 2024 were included. These studies were retrieved from six databases using search terms related to rugby-7s or sevens, tackle, collision, collision sport, injury, athlete, incidence rate, mechanism, and risk factor. Only peer-reviewed original studies using prospective or retrospective cohort designs with a clearly defined rugby-7s sample were considered. Included studies needed to report one injury outcome variable. Non-English and qualitative studies; reviews, conference papers, and abstracts were excluded. Twenty studies were included. The meta-analysis used the DerSimonian-Laird continuous random-effects method to calculate the pooled estimated means and 95% confidence interval. The estimated mean injury incidence rate for men was 108.5/1000 player-hours (95% CI: 85.9-131.0) and 76.1/1000 player-hours (95% CI: 48.7-103.5) for women. The estimated mean severity for men was 33.9 days (95% CI: 20.7-47.0) and 44.2 days (95% CI: 32.1-56.3) for women. Significantly more match injuries occurred in the second half of matches, were acute, located at the lower limb, diagnosed as joint/ligament, and resulted from being tackled. Fatigue, player fitness, and previous injuries were associated with an increased risk of injury. There were no statistically significant differences between women's and men's injury profiles. However, the inherent cultural and gendered factors which divide the two sports should not be ignored. The findings from this review will help pave the way forward beyond the foundational stages of injury prevention research in rugby-7s., (© 2024 The Author(s). European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Objectives: The aim of this study was to compare the incidence, severity, and burden of injury in starting and replacement players from professional men's teams of five rugby unions., Methods: Match injuries of greater than 24 h time-loss (including data on the severity, match quarter, event, body region) and player minutes of match exposure data were collated for all starting and replacement players in the men's English Premiership, Welsh Pro14 (both 2016/17-2018/19 seasons), and Australian, New Zealand, and South African Super Rugby (all 2016-2018 seasons) teams. Injury incidences and mean injury burden (incidence × days missed) were calculated, and rate ratios (RRs) (95% confidence intervals [CIs]) were used to compare injury incidence and burden between starting (reference group) and replacement players., Results: Overall injury incidence was not different between starters and replacements for all injuries (RR = 0.98, 95% CI 0.88-1.10), nor for concussions (RR = 0.85; 95% CI 0.66-1.11). Mean injury burden was higher for replacement players (RR = 1.31, 95% CI 1.17-1.46). Replacement injury incidence was lower than the starters in the third (RR = 0.68, 95% CI 0.51-0.92) and fourth (RR = 0.78, 95% CI 0.67-0.92) match quarters. Injury incidence was not different between starters and replacements for any match event or body region, but compared with starters, replacements' injury burden was higher in lower limbs (RR = 1.24, 95% CI 1.05-1.46) and in the tackled player (RR = 1.30, 95% CI 1.01-1.66)., Conclusion: This study demonstrated a lower injury incidence in replacement players compared with starters in the second half of matches, with a higher injury burden for replacement players due to higher mean injury severity., (© 2024. The Author(s).)

Objective: To compare game events, head contact (HC) rates, and suspected concussion incidence rates (IRs) in boys' and girls' youth basketball., Design: Cross-sectional., Setting: Canadian club basketball teams (U16-U18)., Participants: Players from 24 boys' and 24 girls' Canadian club basketball teams during the 2022 season., Assessment of Risk Factors: Recorded games were analyzed using Dartfish video analysis software to compare sexes., Main Outcome Measures: Poisson regression analyses were used to estimate HCs [direct (HC1) and indirect (HC2)], suspected concussion IRs, and IR ratios (IRRs). Game event, court location, and HC1 fouls were reported., Results: Division 1 HC rates did not differ between boys (n = 238; IR = 0.50/10 player-minutes; 95% confidence interval [CI], 0.43-0.56) and girls (n = 220; IR = 0.46/10 player-minutes; 95% CI, 0.40-0.52). Division 2 boys experienced 252 HCs (IR = 0.53/10 player-minutes; 95% CI, 0.46-0.59); girls experienced 192 HCs (IR = 0.40/10 player-minutes; 95% CI, 0.35-0.46). Division 2 boys sustained higher HC1 IRs compared with Division 2 girls (IRR = 1.42; 95% CI, 1.15-1.74). Head contacts, rates did not differ between boys and girls in either Division. Suspected concussion IRs were not significantly different for boys and girls in each Division. Head contacts occurred mostly in the key for boys and girls in each Division. Despite illegality, HC1 penalization ranged from 3.9% to 19.7%. Head contact mechanisms varied across Divisions and sexes., Conclusions: Despite current safety measures, both HCs and suspected concussions occur in boys' and girls' basketball. Despite the illegality and potential danger associated with HC, only a small proportion of direct HCs were penalized and therefore targeting greater enforcement of these contacts may be a promising prevention target., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The tackle contest is the most common and most injurious match contact event in rugby and is an indicator of performance. Tackle Ready is World Rugby's tackle technique education program. Limited research has characterized the tackle contest in women's rugby. The purpose of this study is to: (1) identify the match situational characteristics, ball-carrier and tackler technical actions demonstrated in elite women's Rugby Union and (2) to determine the extent to which Tackle Ready recommended tackle techniques were exhibited. Technical characteristics for 1500 tackle events in the 2022-2023 Women's Six Nations Championship were visually assessed according to a predefined coding framework and the Tackle Ready program. Tackles lacked full completion (0.2%) of the 22 coded Tackle Ready techniques with 47% of the recommended techniques demonstrated in each tackle on average (range 15%-98%). A high proportion of tackles involved two defenders (48%), approaching ball-carriers from the side (38%) or oblique angles (39%), in an upright position (30%), and with initial contact made with the arm (51%). Incorrect pre-contact head positioning and head placement upon contact accounted for 50% and 15% of tackles, respectively, and there was a mean of 14 (95% CI 11-18) head and neck contacts to a tackler and 18 (95% CI 14-22) head and neck contacts to a ball-carrier per game. Targeted interventions to encourage adoption of recommended techniques are needed to reduce tackle-related injury risk in women's rugby. This study provides valuable context for future discussion across law enforcement, coach education and gender-specific tackle coaching in the women's game., (© 2024 The Authors. European Journal of Sport Science published by Wiley‐VCH GmbH on behalf of European College of Sport Science.)

Objective: To describe shoulder-related injury rates (IRs), types, severity, mechanisms, and risk factors in youth ice hockey players during games and practices., Design: Secondary analysis of data from a 5-year prospective cohort study, Safe-to-Play (2013-2018)., Setting: Canadian youth ice hockey., Participants: Overall, 6584 player-seasons (representing 4417 individual players) participated. During this period, 118 shoulder-related games and 12 practice injuries were reported., Assessment of Risk Factors: An exploratory multivariable mixed-effects Poisson regression model examined the risk factors of body checking policy, weight, biological sex, history of injury in the past 12 months, and level of play., Main Outcome Measures: Injury surveillance data were collected from 2013 to 2018. Injury rates with 95% confidence interval (CI) were estimated using Poisson regression., Results: The shoulder IR was 0.35 injuries/1000 game-hours (95% CI, 0.24-0.49). Two-thirds of game injuries (n = 80, 70%) resulted in >8 days of time-loss, and more than one-third (n = 44, 39%) resulted in >28 days of time-loss. An 83% lower rate of shoulder injury was associated with policy prohibiting body checking compared with leagues allowing body checking (incidence rate ratio [IRR], 0.17; 95% CI, 0.09-0.33). A higher shoulder IR was observed for those who reported any injury in the last 12-months compared with those with no history (IRR, 2.00; 95% CI, 1.33-3.01)., Conclusions: Most shoulder injuries resulted in more than 1 week of time-loss. Risk factors for shoulder injury included participation in a body-checking league and recent history of injury. Further study of prevention strategies specific to the shoulder may merit further consideration in ice hockey., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine differences in match and training musculoskeletal injury and concussion rates and describe mechanisms of concussion while considering previous playing experience in female and male Canadian high school Rugby Union ('rugby') players., Methods: A 2-year prospective cohort study was completed in a high school league (n=361 females, 421 player-seasons; n=429 males, 481 player-seasons) in Calgary, Canada over the 2018 and 2019 rugby playing seasons. Baseline testing was completed at the start of each season and injury surveillance and individual player participation through session attendance was documented to quantify individual-level player exposure hours. Injury incidence rates (IRs) and incidence rate ratios (IRRs) were calculated using Poisson regression, offset by player exposure hours and clustered by team., Results: Overall match IR for females was 62% higher than males (overall IRR=1.62, 95% CI: 1.20 to 2.18) and the overall training IR was twice as high for females (overall IRR=2.15, 95% CI: 1.40 to 3.32). The female match concussion IR was 70% higher than the males (concussion IRR=1.70, 95% CI: 1.08 to 2.69). Females had a 75% greater tackle-related IR compared with males (IRR=1.75, 95% CI: 1.20 to 2.56). Additionally, female tacklers had a twofold greater rate of injury compared with male tacklers (IRR = 2.17, 95% CI: 1.14 to 4.14). Previous playing experience was not associated with tackle-related injury or concussion IRs., Conclusion: The rate of injury and concussion was significantly higher in females within this Canadian high school cohort. These results emphasise the need for development, implementation and evaluation of female-specific injury and concussion prevention strategies to reduce injury and concussion in female youth rugby., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Video analysis is a useful tool for injury surveillance in rugby union. There are few video analysis studies in the professional female game, with most studies published in the male elite/professional settings. Moreover, there is a sparsity of literature in youth rugby settings. The following narrative review outlines the strengths and limitations of the current video analysis literature for injury surveillance in youth rugby union, highlights the importance of video analysis for youth rugby player safety and welfare, and discusses recommendations for using video analysis to inform player safety in youth rugby., Competing Interests: Competing interests: Funding and disclosures: JB’s salary is partially funded by World Rugby, the international governing body of rugby union. In addition, JB has previously received research grants from World Rugby. KAS is employed by the Rugby Football Union, the national governing body for rugby union in England. SH is a BMJ Open Sport and Exercise Medicine Editorial Board Member. IJS would like to acknowledge the support of CIHR-Vanier Canada Graduate Scholarships (NSERC/SSHRC/CIHR Vanier CGS) program., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Rugby Union is a collision team sport played globally. Despite this, significant concerns have been raised regarding the sport's safety, particularly in youth players. Given this, a review of injury rates, risk factors and prevention strategies is required across different youth age groups as well as in males and females., Objective: The objective of this systematic review (SR) and meta-analysis was to investigate injury and concussion rates, risk factors and primary prevention strategies in youth rugby., Methods: To be included, studies were required to report either rates, risk factors or prevention strategies in youth rugby and to have a randomised controlled trial, quasi-experimental, cohort, case control, or ecological study design. Exclusion criteria included non-peer-reviewed grey literature, conference abstracts, case studies, previous systematic reviews and studies not written in English. Nine databases were searched. The full search strategy and list of sources are available and pre-registered on PROSPERO (Ref: CRD42020208343). Each study was assessed for risk of bias using the Downs and Black quality assessment tool. Meta-analyses were conducted using a DerSimonian Laird random effect model for each age group and sex., Results: Sixty-nine studies were included in this SR. The match injury rates (using a 24-h time-loss definition) were 40.2/1000 match hours (95% CI 13.9-66.5) in males and 69.0/1000 match hours (95% CI 46.8-91.2) in females. Concussion rates were 6.2/1000 player-hours (95% CI 5.0-7.4) for males and 33.9/1000 player-hours (95% CI: 24.1-43.7) for females. The most common injury site was lower extremity (males) and the head/neck (females). The most common injury type was ligament sprain (males) and concussion (females). The tackle was the most common event associated with injury in matches (55% male, 71% females). Median time loss was 21 days for males and 17 days for females. Twenty-three risk factors were reported. The risk factors with the strongest evidence were higher levels of play and increasing age. Primary injury prevention strategies were the focus of only eight studies and included law changes (n = 2), equipment (n = 4), education (n = 1) and training (n = 1). The prevention strategy with the most promising evidence was neuromuscular training. The primary limitations included a broad range of injury definitions (n = 9) and rate denominators (n = 11) used, as well as a limited number of studies which could be included in the meta-analysis for females (n = 2)., Conclusion: A focus on high-quality risk factor and primary prevention evaluation should be considered in future studies. Targeting primary prevention and stakeholder education remain key strategies in the prevention, recognition and management of injuries and concussions in youth rugby., (© 2023. The Author(s).)

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., Competing Interests: MS is part-funded by Leeds Rhinos rugby league club. RT is a consultant to World Rugby Pty. World Rugby is the governing body for the sport of Rugby Union and responsible for law changes in the sport. BJ is employed by Leeds Rhinos, Rugby Football League and Premiership Rugby in a consultancy capacity. GLI serves as a scientific advisor for NanoDX® Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes). He has received research funding as a principal investigator from the National Football League, and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Mooney-Reed Charitable Foundation, Boston Bolts, the National Rugby League, and the Schoen Adams Research Institute at Spaulding Rehabilitation. None of the above entities were involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication. AJG serves as a scientific advisor for HitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has current philanthropic support from the Nick Tooth Foundation. He acknowledges unrestricted philanthropic support from the National Rugby League (NRL). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 McLeod, Tucker, Edwards, Jones, Page, Spiegelhalter, West, Iverson and Gardner.)

Objectives: To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk., Design: This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Data Sources: Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review., Eligibility Criteria: Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English., Results: In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies., Conclusions: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC., Prospero Registration Number: CRD42019152982., Competing Interests: Competing interests: PE: Data consultant to the National Hockey League. Received an honorarium for the administrative aspects of the concussion consensus review. JMG: No conflicts of interest. ATK: Research funding for PhD received from Canadian Institutes of Health Research and University of Calgary Eyes High Doctoral Recruitment Scholarship. Youth Council Member for the Canadian Institutes of Health Research Institute of Human Development, Child, and Youth Health’s. MPP: No conflicts of interest. SWW: Research funding received from World Rugby. SBailey: PhD Research was funded by Scottish Rugby, the national governing body for rugby union in Scotland. LM: No conflicts of interest. AMB: Peer-reviewed research funding from the Social Sciences and Humanities Research Council, Sport Information Resource Center board member, Canadian Athletic Therapists Association committee member. Received an honorarium for the administrative aspects of the concussion consensus reviews. SBroglio: Research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense-USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex and EA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation, and received speaker honorarium and travel reimbursements for talks given. He is coauthor of 'Biomechanics of Injury (3rd edition)' and has a patent pending on 'Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source' (US Application No. 17/164490). He is on the and is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), British Journal of Sports Medicine (2008 to 2019). GAD: Member of the Scientific Committee of the 6th International Consensus Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF and FIFA; however, has not received any payment, research funding, or other monies from these groups other than for travel costs. BEH: No conflicts of interest. JDS: No conflicts of interest. KAS: Employed (part-time) by the Rugby Football Union, the national governing body for rugby union in England. Research funding received from World Rugby, Rugby Football Union, Premiership Rugby, Football Association Premier League, England and Wales Cricket Board, and British Racing Foundation. MT: No conflicts of interest. RT: Employed as a consultant by World Rugby, the body that regulates the sport of Rugby Union globally. The role includes research into prevention of concussion through various interventions. NW: International Paralympic Committee Medical Committee. RZ: Current or past competitively funded research grants from Canadian Institutes of Health Research (CIHR), National Institutes of Health (NIH), Health Canada, Ontario Neurotrauma Foundation (ONF), Ontario Ministry of Health, Physician Services Incorporated (PSI) Foundation, CHEO Foundation, University of Ottawa Brain and Mind Research Institute, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), and the National Football League (NFL) Scientific Advisory Board. I hold Clinical Research Chair in Pediatric Concussion from University of Ottawa, and I am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity). I am the cofounder, Scientific Director, and a minority shareholder in 360 Concussion Care (an interdisciplinary concussion clinic). AH: No conflicts of interest. KAS: Kathryn Schneider has received grant funding from the Canadian Institutes of Health Research, National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary) with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid positions). CE: Carolyn Emery has received external peer-reviewed research funding from Canadian Institutes of Health Research, Canada Foundation for Innovation, International Olympic Committee Medical and Scientific Committee, National Football League Play Smart Play Safe Program, and World Rugby. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member for HitIQ., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Ringette and female ice hockey are high participation sports in Canada. Despite policies disallowing body checking, both sports have high injury and concussion rates. This study aimed to compare physical contact (PC), head contact (HC), and suspected injury and concussion incidence rates (IRs) in female varsity ringette and ice hockey., Design: Cross-sectional., Setting: Canadian ice arenas., Participants: Eighteen Canadian female university ringette and ice hockey tournament/playoff games in the 2018-2019/2019-2020 seasons., Assessment of Risk Factors: Game video-recordings were analyzed using Dartfish video-analysis software to compare both sports., Main Outcome Measures: Univariate Poisson regression analyses (adjusted for cluster by team, offset by game-minutes) were used to estimate PC, HC, and suspected injury IRs and incidence rate ratios (IRRs) to compare rates across sports. Proportions of body checks (level 4-5 trunk PC) and direct HC (HC 1 ) penalized were reported., Results: Analyses of 36 team-games (n = 18 ringette, n = 18 hockey) revealed a 19% lower rate of PCs in ringette than ice hockey {IRR = 0.81 [95% confidence interval (CI), 0.73-0.90]}, but a 98% higher rate of body checking [IRR = 1.98 (95% CI, 1.27-3.09)] compared to ice hockey. Ringette had a 40% higher rate of all HC 1 s [IRR = 1.40 (95% CI, 1.00-1.96)] and a 3-fold higher rate of suspected injury [IRR = 3.11 (95% CI, 1.13-8.60)] than ice hockey. The proportion of penalized body checks and HC 1 s were low across sports., Conclusions: Body checking and HC 1 rates were significantly higher in ringette compared to ice hockey, despite rules disallowing both, and very few were penalized. These findings will inform future injury prevention research in ringette and female ice hockey., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine injury and concussion rates, mechanisms, locations, and types of injury in Canadian high school male rugby., Design: Prospective cohort study., Setting: High school male rugby., Participants: A total of 429 high school players (2018: n = 225, 2019: n = 256) were recruited from 12 teams in 7 schools in Calgary, Canada., Interventions: None., Main Outcome Measures: Injury surveillance included baseline questionnaires, weekly exposure, and injury reports. Injuries included those requiring medical attention, resulted in time loss and/or inability to complete a session. Concussion was defined as per the fifth Consensus on Concussion in Sport, and all players with a suspected concussion were referred to a study sport medicine physician., Results: A total of 134 injuries were captured, leading to an injury incidence rate (IR) of 57.9/1000 hours [95% confidence intervals (CIs): 45.4-73.8]. Median time loss was 6 days (range: 0-90). Injuries to the head were the most common (40%), followed by shoulder (12%) and ankle (10%). The concussion IR was 22.0/1000 hours (95% CIs: 15.9-30.4), which was the most common injury type (38%), followed by sprain (20%) and strain (15%). Sixty-five percent of injuries occurred in the tackle (ball carrier 35%, tackler 30%) and 76% of concussions (ball carrier 41%, tackler 35%)., Conclusions: The rate of injury and concussion in Canadian youth high school male rugby is high, with tackle-related injuries and concussions the most common. Given this, there is a critical need for implementation of prevention strategies, in particular targeting concussion and the tackle event (eg, neuromuscular, tackle training, and law changes)., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To investigate the influence of previous season match exposure on injury incidence and burden in elite men's rugby union., Design: A three-season (2016-17 to 2018-19) retrospective cohort design was used to collect and analyse injury and exposure data across English Premiership rugby union teams., Methods: Generalised linear mixed-effects models were used to model the influence of match exposure (all match involvements, match involvements of ≥20 mins, and full-game equivalents) upon match and training injury incidence and burden in the following season., Results: Involvement in ≥31 matches within a season was associated with substantially increased match and training injury burden in the following season. Match exposure was not clearly associated with injury incidence in the following season. The increased match injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Forwards, whilst the increased training injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Backs., Conclusions: The present study demonstrates that all match involvements, regardless of duration, should be considered when exploring associations between match exposure and injury risk. High match involvements (≥ 31 matches) are associated with elevated injury burden, in both matches and training, in the following season. The physical and psychological load of players with high previous-season match exposure should be carefully managed., Competing Interests: Declaration of Interest Statement Richard Bryan and Mark Lambert are employed by the Rugby Players Association. Matthew Cross is employed by Premier Rugby Limited. Simon Kemp and Keith A. Stokes are employed by the Rugby Football Union, the governing body for rugby union in England. Sean Williams has received research funding from the Rugby Football Union and Rugby Players Association., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Women's participation in field collision sports is growing worldwide. Scoping reviews provide an overview of scientific literature in a developing area to support practitioners, policy, and research priorities. Our aim is to explore published research and synthesise information on the physical and technical demands and preparation strategies of female field collision sports. We searched four databases and identified relevant published studies. Data were extracted to form (1) a numerical analysis and (2) thematic summary. Of 2318 records identified, 43 studies met the inclusion criteria. Physical demands were the most highly investigated (n+=+24), followed by technical demands (n+= 18), tactical considerations (n+=+8) and preparatory strategies (n=1). The key themes embody a holistic model contributing to both performance and injury prevention outcomes in the context of female field collision sports. Findings suggest a gender data gap across all themes and a low evidence base to inform those preparing female athletes for match demands. Given the physical and technical differences in match-demands the review findings do not support the generalisation of male-derived training data to female athletes. To support key stakeholders working within female field collision sports there is a need to increase the visibility of female athletes in the literature., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

The use of artificial playing surfaces in professional rugby union is growing, but their effect on the injury risk profile remains unclear. The aim of this study was to examine the effect of playing surface on match injury risk in men's professional rugby in England. Six seasons of injury data (2013/14-2018/19) were collected from 15 professional English, men's rugby teams participating in domestic and European competition. The incidence, severity, and burden of match injuries were compared across playing surfaces. The dataset included 3351 injuries from a combined European and domestic data set (separated in to 2 categories; artificial and natural/hybrid surfaces) and 2675 injuries from a domestic only dataset (separated into 3 categories; artificial, hybrid, and natural surfaces). There were no differences in incidence rates between surface types on combined European and domestic match data, but injury burden was significantly greater on artificial (3082 days/1000 h, 95% CI 2847-3337) in comparison with natural/hybrid surfaces (2364 days/1000 h, 95% CI 2277-2454, p < 0.001). These differences were primarily driven by a significantly greater mean severity of hip/groin, and foot/toe injuries on artificial surfaces. This is the largest study to date to examine the relationship between surface type and injury risk in rugby union. The average severity and burden of injuries sustained on artificial surfaces was significantly greater compared with those sustained on hybrid/natural grass surfaces. This study can inform those involved in selection of surface for elite sport, weighing up the positive and negative elements of the varying surface types., (© 2022 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

The importance of contributors that can result in negative player outcomes in sport and the feasibility and barriers to modifying these to optimise player health and well-being have yet to be established. Within rugby codes (rugby league, rugby union and rugby sevens), within male and female cohorts across playing levels (full-time senior, part-time senior, age grade), this project aims to develop a consensus on contributors to negative biopsychosocial outcomes in rugby players (known as the CoNBO study) and establish stakeholder perceived importance of the identified contributors and barriers to their management. This project will consist of three parts; part 1: a systematic review, part 2: a three-round expert Delphi study and part 3: stakeholder rating of feasibility and barriers to management. Within part 1, systematic searches of electronic databases (PubMed, Scopus, MEDLINE, SPORTDiscus, CINAHL) will be performed. The systematic review protocol is registered with PROSPERO. Studies will be searched to identify physical, psychological and/or social factors resulting in negative player outcomes in rugby. Part 2 will consist of a three-round expert Delphi consensus study to establish additional physical, psychological and/or social factors that result in negative player outcomes in rugby and their importance. In part 3, stakeholders (eg, coaches, chief executive officers and players) will provide perceptions of the feasibility and barriers to modifying the identified factors within their setting. On completion, several manuscripts will be submitted for publication in peer-reviewed journals. The findings of this project have worldwide relevance for stakeholders in the rugby codes. PROSPERO registration number CRD42022346751., Competing Interests: Competing interests: SMcC, SS research fellowships are part-funded by the Rugby Football League. KT and BJ are employed by Leeds Rhinos Rugby League club in a consultancy capacity. JW PhD is part-funded by Leeds Rhinos Rugby League club. KS and MB are employed by Rugby Football Union. MC is employed by Premiership Rugby. JB research fellowship is funded by World Rugby. PD and EF are employed by World Rugby. SF and JS are employed by the National Rugby League. JP PhD is part-funded by the Rugby Football League. BJ and GP are employed by the Rugby Football League in a consultancy capacity. CR research fellowship is part-funded by Scottish Rugby Union. AG concussion consultant to RugbyAU., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objective of this study was to identify and report the incidence and mechanisms of suspected injury and concussion in women's rugby union., Design: A cross-sectional video analysis study., Methods: Using video analysis of non-professional, single-angle footage, cases of suspected injury and concussion were identified and reported, based on content validation and consensus by eight rugby-specific researchers, therapists, and sport medicine physicians., Results: There were 225 suspected injuries recorded in 48 games [Suspected injury rate (IR) = 117.5/1000 h (95 % CI;102.6-133.9) or 4.7 suspected injuries per match]. The on-field medical attention IR was 95.0/1000 h (95 % CI;81.7-109.9: 3.8 per game). Suspected concussions accounted for 26 % of injuries (30.8/1000 h: 95 % CI;23.5-39.7: 1.2 per game). The attacking team sustained 64 % of suspected injuries. Permanent removal from play was observed for 29 % of suspected injuries. The most common suspected injury locations were head/neck (28.4 %) and lower extremity (27.6 %). The tackle accounted for 67.1 % of all suspected injuries, with a propensity of 11.2/1000 tackle events (95 % CI;9.5-13.2) or 3.1 tackle-related injuries/game. Of tackle-related injuries, 63.6 % were to the ball carrier while 52.2 % of tackle-related concussions were to the ball carrier., Conclusion: This study adds to the growing body of literature examining women's rugby. The rate of suspected injury is high compared with other studies. It is acknowledged that these are suspected injuries not supported by prospective injury surveillance. The high proportion of suspected injuries that are tackle-related warrants specific attention to identify tackle characteristics associated with injury and concussion., (Copyright © 2022 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe injury and concussion rates and mechanisms in female high school rugby players., Design: Two-year prospective cohort study., Setting: High school rugby., Participants: Participants included 214 female High school rugby players (year 1) and 207 female High school players (year 2) from the Calgary Senior High School Athletics Association 2018 and 2019 rugby competition., Intervention: None., Main Outcome Measures: Match and training injury and concussion. Injury definition included any injury resulting in time loss, inability to complete a session, and/or requiring medical attention. Details of reported injuries were collected on injury report forms and validated by a certified athletic therapist on a validated online injury surveillance platform. Exposure hours for players were tracked using paper or virtual weekly exposure forms by team designates., Results: A match incidence rate (IR) = 93.7 injuries/1000 match hours (95% confidence intervals (CI): 78.6-11.7) and training IR = 5.3 injuries/1000 training hours (95% CI: 4.0-6.9) were estimated. The tackle accounted for 109 (70%) match and 37 (44%) training injuries. Tackling was the most frequent mechanism of injury (IR = 37.5 injuries/1000 match hours, 95% CI: 27.5-51.8 and 1.2 injuries/1000 training hours, 95% CI: 0.7-2.4). Sixty-two match concussions (IR = 37.5 concussions/1000 match hours, 95% CI: 26.8-52.3) and 16 training concussions (IR = 1.0 concussions/1000 training hours, 95% CI: 0.7-1.4) occurred. Of 78 reported concussions, 78% for match and 56% for training were physician diagnosed. Tackling was the most frequent mechanism of concussion in matches (IR = 18.1 concussions/1000 match hours, 95% CI:11.4-28.6)., Conclusions: Injury and concussion rates in female high school rugby are high. The tackle accounted for the highest proportion of injuries. Prevention strategies (eg, tackle policy change, tackle-training programs, and neuromuscular training) should be explored to increase sport safety., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Cost-effectiveness data on chimeric antigen receptor (CAR) T cell therapies for relapsed/refractory large B cell lymphoma (R/R LBCL), accounting for inpatient/outpatient site of care (site), are sparse., Methods: This payer model compares lifetime costs/benefits for CAR T cell-treated (axicabtagene ciloleucel [axi-cel], lisocabtagene maraleucel [liso-cel], tisagenlecleucel [tisa-cel]) patients with R/R LBCL in the USA. Three-month post-infusion costs were derived from unit costs and real-world all-payer (RW) site-specific utilization data for 1175 patients with diffuse R/R LBCL (CAR T cell therapy October 2017-September 2020). Therapy- and site-specific grade 3+ cytokine release syndrome (CRS) and neurologic event (NE) incidences were imputed from published trials. Lifetime quality-adjusted life-years (QALYs) and long-term costs were calculated from therapy-specific overall and progression-free survival data, adjusted for differences in trial populations. The base case used 17% outpatient site (RW) for all therapies. ZUMA-1 trial cohorts 1/2 informed other axi-cel base case inputs; ZUMA-1 cohorts 4/6 data (updated safety management) supported scenario analyses., Results: Base case total costs for axi-cel exceeded liso-cel ($637 K versus $621 K) and tisa-cel ($631 K versus $577 K) costs. Three-month post-infusion costs were $57 K to $59 K across all therapies. Total QALYs for axi-cel also exceeded those for liso-cel (7.7 versus 5.9) and tisa-cel (7.2 versus 5.0) with incremental costs per QALY gained of $9 K versus liso-cel and $25 K versus tisa-cel. Base case incremental net monetary benefit was $255 K (95% confidence interval (CI) $181-326 K) for axi-cel versus liso-cel, and $280 K (95% CI $200-353 K) versus tisa-cel. Longer survival with axi-cel conferred higher lifetime costs. In all scenarios (e.g., varied outpatient proportions, CRS/NE incidence), axi-cel was cost-effective versus both comparators at a maximum willingness-to-pay of under $26 K/QALY as a result of axi-cel's higher incremental survival gains and quality-of-life., Conclusions: Axi-cel is a cost-effective CAR T cell therapy for patients with R/R LBCL compared to tisa-cel and liso-cel. Site of care does not impact the cost-effectiveness of CAR T cell therapy., (© 2022. The Author(s).)

Concussion is the most common match injury in rugby union. Some players wear padded headgear, but whether this protects against concussion is unclear. In professional male rugby union players, we examined: (i) the association between the use of headgear and match concussion injury incidence, and (ii) whether wearing headgear influenced time to return to play following concussion. Using a nested case-control within a cohort study, four seasons (2013-2017) of injury data from 1117 players at the highest level of rugby union in England were included. Cases were physician-diagnosed concussion injuries. Controls were other contact injuries (excluding all head injuries). We determined headgear use by viewing video footage. Sixteen percent of cases and controls wore headgear. Headgear use had no significant effect on concussion injury incidence (adjusted odds ratio=1.05, 95% CI: 0.71-1.56). Median number of days absent for concussion whilst wearing headgear was 8 days, compared with 7 days without headgear. Having sustained a concussion in the current or previous season increased the odds of concussion more than four-fold (odds ratio=4.55, 95% CI: 3.77-5.49). Wearing headgear was not associated with lower odds of concussions or a reduced number of days' absence following a concussion., Competing Interests: KAS and STPK are employees of the Rugby Football Union, which is the governing body for rugby union in England. MJC is employed by Premiership Rugby, the body responsible for the highest-level rugby union competition in England., (Thieme. All rights reserved.)

Aim: To describe trends in the incidence of match concussions and time to return-to-play in professional rugby union., Methods: Match concussion incidence (injuries per 1000 player-match-hours) and time to return-to-play (mean and median days absence) were recorded in 3006 male professional rugby union players over 16 seasons (2002/03 - 2018/19)., Results: From 2002/03 to 2009/10, incidence of concussions was stable at 4.3/1000 player-match-hours. From 2009/10 to 2018/19, there was an increase in concussion incidence, with the highest incidence in 2016/17 at 20.9/1000 player-match-hours (95% CI: 17.9-24.3). Annual prevalence of concussion also increased, suggesting more players were concussed rather than the same players sustaining more concussions. Before the introduction of standardized graduated return-to-play (GRTP) guidelines in 2011, 27% of players returned to play in <6 days. After the introduction of the GRTP, this decreased to 7%, with no players returning in <6 days after 2014/15. Between 2002/03 and 2018/19, incidence of all other injuries remained stable., Conclusions: From 2009/10 onwards, the incidence of diagnosed concussions increased. Since the introduction of the GRTP, there has been a dramatic reduction in the number of players returning in <6 days.

Objectives: The Professional Rugby Injury Surveillance Project is the largest and longest running rugby union injury surveillance project globally and focuses on the highest level of rugby in England., Methods: We examined match injuries in professional men's rugby over the period 2002/2003 to 2018/2019 and described trends in injuries over this time., Results: Over the period 2002/2003-2018/2019, 10 851 injuries occurred in 1 24 952 hours of match play, equating to a mean of 57 injuries per club per season and one injury per team per match. The mean incidence, severity (days absence) and burden (days absence/1000 hours) of injury were 87/1000 hours (95% CI 82 to 92), 25 days (95% CI 22 to 28) and 2178 days/1000 hours (95% CI 1872 to 2484), respectively. The tackle accounted for 43% injuries with running the second most common activity during injury (12%). The most common injury location was the head/face with an incidence of 11.3/1000 hours, while the location with the highest overall burden was the knee (11.1 days/1000 hours). Long-term trends demonstrated stable injury incidence and proportion of injured players, but an increase in the mean and median severity of injuries. Concussion incidence, severity and burden increased from the 2009/2010 season onwards and from 2011 to 2019 concussion was the most common injury., Conclusion: The rise in overall injury severity and concussion incidence are the most significant findings from this work and demonstrate the need for continued efforts to reduce concussion risk as well as a greater understanding of changes in injury severity over time., Competing Interests: Competing interests: SK and KAS are employed by the Rugby Football Union. MC is employed by Premier Rugby., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Training load monitoring has grown in recent years with the acute:chronic workload ratio (ACWR) widely used to aggregate data to inform decision-making on injury risk. Several methods have been described to calculate the ACWR and numerous methodological issues have been raised. Therefore, this study examined the relationship between the ACWR and injury in a sample of 696 players from 13 professional rugby clubs over two seasons for 1718 injuries of all types and a further analysis of 383 soft tissue injuries specifically. Of the 192 comparisons undertaken for both injury groups, 40% (all injury) and 31% (soft tissue injury) were significant. Furthermore, there appeared to be no calculation method that consistently demonstrated a relationship with injury. Some calculation methods supported previous work for a "sweet spot" in injury risk, while a substantial number of methods displayed no such relationship. This study is the largest to date to have investigated the relationship between the ACWR and injury risk and demonstrates that there appears to be no consistent association between the two. This suggests that alternative methods of training load aggregation may provide more useful information, but these should be considered in the wider context of other established risk factors., Competing Interests: SK and KS are employed by the Rugby Football Union, the national governing body for rugby union in England. MC is employed by Premiership Rugby, the body responsible for the highest league of rugby union in England. The research was funded by the Rugby Football Union and Premiership Rugby., (Thieme. All rights reserved.)

Background: Canadian rugby coach injury prevention beliefs and attitudes have not been studied, yet are key to informing injury prevention strategy implementation. Despite neuromuscular training (NMT) warm-up success in reducing injury, adoption of these programs is variable. Therefore, objectives of this study included (1) describing Canadian youth rugby coach injury prevention beliefs and attitudes and current warm-up practices and (2) evaluating intention to use a rugby-specific NMT warm-up. Methods: High school rugby coaches completed a questionnaire before and after a rugby-specific NMT warm-up workshop. The pre-workshop questionnaire captured demographics, current warm-up practice, and NMT warm-up knowledge and use. Both questionnaires captured injury prevention beliefs, attitudes and behavioral intention. Results: Forty-eight coaches participated in the workshops. Pre-workshop, 27% of coaches were aware of NMT warm-ups. Coaches primarily included aerobic and stretching components, while balance components were not common in their warm-ups over the past year. Additionally, 92% of coaches agreed to some extent they would "complete a rugby-specific warm-up program prior to every game and training session this season." Post-workshop, 86% of coaches agreed to some extent that they would use the program in every rugby session. No differences were observed between pre- and post-workshop intention to implement the warm-up ( p = 0.10). Interpretation: This is the first study to examine current Canadian youth rugby coach warm-up practices and intention to use NMT warm-ups. Canadian rugby coach intention to use a rugby-specific NMT warm-up is high, providing ample opportunity to investigate the efficacy of a NMT warm-up in youth rugby., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Shill, Räisänen, Black, Barden, van den Berg, McKay, West, Pasanen, Hagel and Emery.)

Background: Rugby union demands a multifaceted approach to training, given the multiple physical and technical attributes required to play the sport., Objectives: The aim of this study is to describe the distribution of training throughout the week and investigate how this may be influenced by match-related factors., Methods: Training load data (session Rating of Perceived Exertion [sRPE], total distance and high-speed running [HSR]) were collected from six professional English rugby teams during the 2017/18 season. Five contextual factors were also recorded including: standard of opposition, competition type, result of previous fixture, surface type, and match venue., Results: The day prior to matches demonstrated the lowest training load (101 AU (95% CIs: 0-216 AU), 1 047 m (95% CIs:1 128-1 686 m) and 59 m (95% CIs: 0-343 m), respectively), while four days prior to the match demonstrated the highest training load (464 AU (95% CIs: 350-578), 2 983 m (95% CIs: 2 704-3 262m) and 234m (95% CIs: 0-477m), respectively). Of the five contextual factors, competition type was the only variable that demonstrated greater than trivial findings, with training before European fixtures the lowest stimulus across the four different competition types. Standard of opposition, previous result, surface type and venue had only trivial effects on training load (effect sizes = -0.13 to 0.15)., Conclusion: Future studies should outline the distribution of other training metrics, including contact and collision training. This study provides a multi-club evaluation that demonstrates the variety of loading strategies prior to competitive match play and highlights competition type as the most influential contextual factor impacting the average training load., Competing Interests: Conflict of interest and source of funding: The authors declare no conflict of interest and no source of funding., (Copyright © 2021 South African Journal of Sports Medicine.)

The COVID-19 pandemic in 2020 has resulted in widespread training disruption in many sports. Some athletes have access to facilities and equipment, while others have limited or no access, severely limiting their training practices. A primary concern is that the maintenance of key physical qualities (e. g. strength, power, high-speed running ability, acceleration, deceleration and change of direction), game-specific contact skills (e. g. tackling) and decision-making ability, are challenged, impacting performance and injury risk on resumption of training and competition. In extended periods of reduced training, without targeted intervention, changes in body composition and function can be profound. However, there are strategies that can dramatically mitigate potential losses, including resistance training to failure with lighter loads, plyometric training, exposure to high-speed running to ensure appropriate hamstring conditioning, and nutritional intervention. Athletes may require psychological support given the challenges associated with isolation and a change in regular training routine. While training restrictions may result in a decrease in some physical and psychological qualities, athletes can return in a positive state following an enforced period of rest and recovery. On return to training, the focus should be on progression of all aspects of training, taking into account the status of individual athletes., Competing Interests: No funding was received for the preparation of this review. KAS, GLC, AMK, SPTK and BS are employed by the Rugby Football Union. BJ is employed by the Rugby Football League. MB is employed by the Rugby Union of Russia. NG is employed by New Zealand Rugby Union. MC is employed by Premiership Rugby. The review was prepared based on the ethical standards of the International Journal of Sports Medicine 168, (Thieme. All rights reserved.)

Context: Individual and team injury burden and performance are 2 key considerations facing practitioners in the daily prescription of an athlete's training load. Whereas a considerable number of researchers have examined univariate relationships between training load and performance, training load and injury, or injury and performance, few investigators have examined all 3 concurrently., Objective: To assess the association among training load, injury burden, and performance in professional rugby union., Design: Descriptive epidemiology study., Setting: The English Premiership competition., Patients or Other Participants: Individual injury and training load data, as well as team performance data, were captured during the 2015-2016 (n = 433 players) and 2016-2017 (n = 569 players) seasons., Main Outcome Measure(s): Data were aggregated into team average scores for each week, including weekly (acute) load, smoothed chronic load, changes in load, injury burden, and weekly performance. Linear mixed modelling techniques were used to assess the association among measures., Results: Injury burden was negatively associated with performance, with a high weekly burden associated with a likely harmful (P = .01) decrease in performance. Training load measures displayed only trivial associations with performance. Only the acute:chronic workload ratio measure was clearly associated with injury burden, with a possibly harmful effect (P = .02). Both squad size and player availability were associated with only trivial changes in performance., Conclusions: Whereas no association between average training load and performance existed, associations between training load and injury burden and between injury burden and performance were clear. Further investigation using more sensitive and individualized measures of load, performance, and injury may elicit a clearer relationship and should be considered for future work., (© by the National Athletic Trainers' Association, Inc.)

Rugby union is a popular team sport that demands high levels of physical fitness and skill. The study aim was to examine trends in training volume and its impact on injury incidence, severity and burden over an 11-season period in English professional rugby. Data were recorded from 2007/08 through 2017/18, capturing 1,501,606 h of training exposure and 3,782 training injuries. Players completed, on average, 6 h 48 minutes of weekly training (95% CI: 6 h 30 mins to 7 h 6 mins): this value remained stable over the 11 seasons. The mean incidence of training-related injuries was 2.6/1000 player-hours (95% CI: 2.4 to 2.8) with a mean severity rising from 17 days in 2007/08 to 37 days in 2017/18 (Change/season = 1.773, P < 0.01). Rate of change in severity was dependent on training type, with conditioning (non-gym-based) responsible for the greatest increase (2.4 days/injury/season). As a result of increasing severity, injury burden rose from 51 days absence/1000 player-hours in 2007/08 to 106 days' absence/1000 player-hours in 2017/18. Despite the low incidence of injury in training compared to match-play, training accounted for 34% of all injuries. Future assessments of training intensity may lead to a greater understanding of the rise in injury severity.

In an effort to combat growing demands on players, athlete monitoring has become a central component of professional sport. Despite the introduction of new technologies for athlete monitoring, little is understood about the practices employed in professional rugby clubs. A questionnaire was circulated amongst conditioning staff across the 12 Premiership rugby clubs to capture the methods used, relative importance, perceived effectiveness and barriers to the use of multiple different athlete monitoring measurements. Previous injury, Global Positioning System (GPS) metrics, collision counts and age were deemed the most important risk factors for managing future injury risk. A wide range of GPS metrics are collected across clubs with high-speed running (12/12 clubs), distance in speed zones (12/12 clubs) and total distance (11/12 clubs) the most commonly used. Of the metrics collected, high-speed running was deemed the most important for managing future injury risk (5/12 clubs); however, there was considerable variation between clubs as to the exact definition of high-speed running, with both absolute and relative measures utilised. While the use of such monitoring tools is undertaken to improve athlete welfare by minimising injury risk, this study demonstrates the significant heterogeneity of systems and methods used by clubs for GPS capture. This study therefore questions whether more needs to be done to align practices within the sport to improve athlete welfare.

Health disparities that cannot be fully explained by socio-behavioral factors persist in the Central Appalachian region of the United States. A review of available studies of environmental impacts on Appalachian health and analysis of recent public data indicates that while disparities exist, most studies of local environmental quality focus on the preservation of nonhuman biodiversity rather than on effects on human health. The limited public health studies available focus primarily on the impacts of coal mining and do not measure personal exposure, constraining the ability to identify causal relationships between environmental conditions and public health. Future efforts must engage community members in examining all potential sources of environmental health disparities to identify effective potential interventions.

A 2-year U.S. Department of State-funded project* was conducted with the purpose of engaging health professionals from Malawi and Zambia who are actively involved in health care and health education for marginalized populations to develop, implement, and evaluate health education and public health interventions/programs. Twenty-six health professionals from Malawi and Zambia, referred to as Global Health Fellows, participated in the 2-year program, of which the main training component was conducted in the United States. Fellows were exposed to health education and public health best practices and developed an action plan to address a health problem of concern in their respective communities/countries. After completion of the program, Fellows received $300 to implement their action plans. Teams of Americans involved in the training program participated in follow-up visits to Malawi and Zambia to observe real-time progress on Fellows' respective action plans. The project was successful in creating an educational experience focused on health education best practices as well as implementation of action plans to address selected health problems in Malawi and Zambia.

Over 1.7 million Virginians rely on private water sources to provide household water. The heaviest reliance on these systems occurs in rural areas, which are often underserved with respect to available financial resources and access to environmental health education. This study aimed to identify potential associations between concentrations of fecal indicator bacteria (FIB) (coliforms, Escherichia coli) in over 800 samples collected at the point-of-use from homes with private water supply systems and homeowner-provided demographic data (household income and education). Of the 828 samples tested, 349 (42%) of samples tested positive for total coliform and 55 (6.6%) tested positive for E. coli. Source tracking efforts targeting optical brightener concentrations via fluorometry and the presence of a human-specific Bacteroides marker via quantitative real-time polymerase chain reaction (qPCR) suggest possible contamination from human septage in over 20 samples. Statistical methods implied that household income has an association with the proportion of samples positive for total coliform, though the relationship between education level and FIB is less clear. Further exploration of links between demographic data and private water quality will be helpful in building effective strategies to improve rural drinking water quality.

Historically, the importance of public health has often been recognized during or as a result of major tragedy. The attacks that occurred in the United States in 2001 are no exception. These events have raised awareness of our vulnerability and the need for emergency preparedness, the need for a flexible and sustainable public health infrastructure, and the importance of linkages between environmental exposures and health outcomes. The authors encourage the public health community, along with policymakers, to develop a national environmental health tracking system that can improve our overall public health capacity and prepare us to investigate the critical issues of the day, whether they be emerging infectious diseases, terrorist attacks, or chronic illnesses.

Cutaneous surgeons cannot predict blood-thinner status by intraoperative visual inspection. Many surgeons believe they can discern whether a patient is taking an anticoagulant or a platelet inhibitor (blood thinner) by visual inspection of intraoperative oozing. However, there is little objective evidence to support this strongly held belief. The authors' objective was to determine whether visual inspection of intraoperative oozing during cutaneous surgery is accurate in identifying use of blood thinners. Blinded physician evaluators observed intraoperative oozing in 110 patients having cutaneous excisional surgery, rated the amount of oozing, and judged the likelihood that the patient was taking a blood-thinning agent. On the basis of the impressions of the most senior evaluator, 43 patients having used aspirin in the past 14 days or warfarin or vitamin E in the past 2 days, seven were judged as definitely or probably taking blood-thinning agents (sensitivity, 16.3 percent; 95 percent confidence interval, 6.8 to 30.7 percent). Of 67 patients who did not report recent use of a blood-thinning agent, just 11 were judged as definitely or probably taking blood-thinning agents (false-positive rate, 16.4 percent; 95 percent confidence interval, 8.5 to 27.5 percent). The level of training of the physicians doing the judging did not affect diagnostic sensitivity. Only 10 of the 110 patients (9.1 percent) were assessed as exhibiting excessive oozing, and of those, only four (40 percent) were actually taking a blood thinner. Results were similar when only patients who were taking aspirin or warfarin were analyzed. Thus, contrary to a commonly and strongly held belief, visual inspection of intraoperative oozing during cutaneous excisional surgery correlates poorly with blood-thinner use by patients. The data add further evidence that use of blood thinners does not have an objectively measurable adverse effect during cutaneous surgery.