Justification of the outcomes achieve in designing a rugby proforma

Rugby union is a contact sport played mainly by men in many regions around the world. According to the rugby football union website, there are about 1200 clubs in England alone, with about 24 fully professional clubs in the top two levels and two national divisions of about 30 teams below that. League 1 and 2 team websites indicated that most teams below the professional level train twice a week in the evening in preparation for Saturday matches. The first team squad will normally consist of 40 players who make up the first and second teams. These players will be classed as semi-professional. Due to the number of players involved and the limited time available, it is important that the player profiling be relatively quick and simple to complete. Although some clubs possess the facilities and the personnel to complete intensive, complex and lengthy athlete proforma’s, this is not often the norm. Most clubs at this level lack the resources for complex, time consuming profiling. The majority of the players and personnel in rugby below the highest standard would only have limited time and patience for this undertaking (Sheryn, 2004). For these reasons, the form and the associated tests need to be easy to understand and administer. Similarly, the information has to be simple to evaluate and have a high inter-tester and intra-tester reliability. 

Many sports have a participation risk, which will include extrinsic and intrinsic factors. In contact sports especially, injuries are an expected risk (Arnason, Sigurdsson, Gudmundsson, Holme, Engebretsen, and Bahr, 2004). The purpose in designing an athlete profiling proforma is to obtain relevant information to identify possible injury risk factors.  With this information, further examination can be undertaken, more detailed movement patterns observed and individual injury prevention strategies can be implemented with the aim to decrease the risk of injuries to a particular individual or within a particular group (Casson-Barkley and Axe, 2007).

When designing an athlete profiling proforma certain issues need to be considered. The proposed tests need to be valid and reliable (Dennis, Finch and McIntosh, 2008b). The tests, wherever possible, should have good inter-tester and intra-tester reliability. They should also have a high validity and should not be included for completion sake or because anecdotally, they identify certain risk characteristics without any associated research. Dennis, Finch, Elliott and Farhart, (2008a) say the tests should also be simple and inexpensive. This will allow the tests to be used in different locations and will increase the compliance of the professionals required to complete the tests. This will also increase the participation numbers which will improve the relevance of the results of risk factors within a particular group.

This particular proforma has a bias toward lower limb testing. Bathgate, Best and Craig (2002), showed that 51% for all injuries to Australian national rugby union players, involved the lower limb compared to 15% of the injuries involving the upper limb. Although 25% of the associated injuries affect the head, the vast majority of these are minor trauma and lacerations.  These statistics are similar throughout the literature (Best, McIntosh and Savage, 2003, Brooks, Fuller and Kemp, 2005a, and Brooks, Fuller and Kemp, 2005b).

The initial part of the proforma consists of a questionnaire. Although the questionnaire is subjective, it provides information which is relevant to injury risk.  Gabbe, Bennell, Finch, Wajswelner, and Orchard, (2005) have suggested that the high risk factors for hamstring injuries include age and previous injury, especially within the last 12 months (Gabbe, Finch and Bennell, 2005). Interestingly, although athletes were relatively good at recalling experiencing an injury within 12 months, they were poor when describing the details (Gabbe, Finch and Bennell, 2003). For this reason the questionnaire can be used as a screening tool but further questioning should be pursued by a trained therapist. If a player reports issues with a particular injury in the past then, further investigation or examination can be obtained.

Ankle and knee injuries are relatively common in rugby union (Brooks et al., 2005b). Often these injuries have been managed prophylactically be means of taping or strapping. Although ankle taping has been shown to reduce the risk of inversion sprains (Refshauge, Raymond, Kilbreath, Pengel, L. and Heijnen, 2009) this is a fairly short term solution, as the tape loses its effectiveness due to sweating and tissue movement. Similarly, knee taping has also been shown to reduce knee injuries but like ankle taping, this may be due to improved proprioception surrounding the joint (Callaghan, Selfe, McHenry and Oldham, 2008). Compression garments are often used during and after matches and training as a form of training aid. There is limited literature to suggest that they improve performance but some studies have shown reduced muscle soreness after training (Duffield, Cannon, and King, 2010). Interestingly, the effect of head gear as a prophylactic measure seems to be in question. (McIntosh, McCrory, Finch, Best, Chalmers, and Wolfe (2009), showed no difference in the injuries sustained between participants wearing head gear and those who did not. Shoulder pads however, did dramatically reduce the impact force sustained during tackling thereby reducing the severity of the injuries (Pain, Tsui, and Cove, 2008).

Although postural assessment is a very subjective technique, there is indication of a correlation between certain postural positions and injury risks. Brooks, Fuller and Kemp, (2005a, and 2005b) have shown that hamstring injuries are a large portion of lower limb injuries. Test-retest reliabilities for the measurements employed indicate acceptable method error coefficients of variation (Hennessey and Watson, 1993). Hennessey and Watson (1993) found a correlation between an increase lumbar lordosis and hamstring injuries. They suggest an increase lumbar lordosis can be managed effectively with corrective exercises. This is reiterated by Coole and Gieck, (1987), who suggest that poor posture, especially at the lumbar spine is a risk factor for hamstring injuries and Tovin and Reiss, (2007) discuss shoulder posture as a risk factor for shoulder impingement problems.

 

Many of the regular flexibility tests provide evidence to support their use as injury risk indicators (Dennis et al., 2008b). There are many studies which discuss the high reliability of these tests (Dennis et al., 2008a and Gabbe, Bennell, Wajswelner and Finch, 2004) but the available literature is often quite sports specific. Many studies have shown a correlation to certain injuries (Gabbe, Bennell, Finch, Wajswelner, and Orchard, 2005). Gabbe et al., (2004) found that of the five lower limb tests and two spinal tests, hip internal rotation and ankle dorsiflexion had a correlation to injuries in cricketers. Similarly in soccer players (Witvrouw, E., Danneels, L., Asselman, P., D’Have, T. and Cambier, D. 2003), sprinters (Jonhagen, Nemeth, and Eriksson, 1994) and basketball players (Harvey, 1998), correlations were found between certain tests as an injury indicator. There is a shortage of literature pertaining to rugby players and flexibility tests; however because of the similar nature of the above mentioned sports the current results could be applied to rugby. Interesting the spinal flexibility tests have limited nominal data but these tests are considered significant in a clinical setting if under taken by a trained clinician (Press, 2008) to observe thoracolumbar movement and deviations.

Shoulder injuries are the most common upper limb injuries in rugby (Brooks et al., 2005b). Similar to the lower limb tests, the selected upper limb tests also have excellent reliability (Myers, Oyama, Wassinger, Ricci, Abt, Conley and Lephart, 2007). Most of the literature compares overhead athletes’ dominant and non-dominate arms or to non overhead athletes. This is relevant to rugby players where certain players are involved with overhead activities. Many injuries associated with overhead activities can be related to shoulder imbalances often attributed to tightness in the posterior capsule (Tyler, Nicholas, Roy and Gleim, 2000), which has been shown in baseball pitches and tennis players (Myers et al., 2007). This imbalance has been shown to relate highly to shoulder impingement (Tyler et al., 2000).

Turl and George, (1998) have suggested that adverse neural tension is an indicator for risk of hamstring injury. Previous injury has a high correlation for future injury in the hamstring. 14 previously injured rugby players participated in a slump trial where 57% experienced adverse neural tension compared to 0% in the control group. Although there is limited data for adverse neural tension with the upper limb tension test and shoulder injuries; the test has clinical significance as a nociceptive response in patients with arm pain (Toppenberg, Wright and Darrell, 2005). This could be related to previous brachial plexus or disruptive shoulder trauma. The median nerve test is often used as a general test for upper limb neural tension (Coppieters and Alshami, 2007).

The strength and stability tests were selected based firstly on their simplicity and secondly on their reliability. Muscle strength and stability especially with regard to the core has consistently been proven to be closely related to injuries in sport (Brukner and Khan, 2008). Although there are countless strength and stability tests to choose from, the selected tests give a good indication of the player’s current abilities (Dennis et al., 2008b). In addition, these tests are simple to administer and have excellent retest reliability (Dennis et al., 2008a). With these tests especially, retesting will be a more useful indication of player improvement or regression. The tests are defined with clear parameters. If the player shows any signs of fatigue, pain or an inability to continue, the test is ended (Dennis et al., 2008b). 

Neck injuries are present in rugby simply due to the nature of the game. Although not common, concern is warranted (Bathgate et al., 2002). Deep neck flexors have been shown to play an important role in stabilising and protecting the neck (Jull, 2000). The test has excellent inter-tester reliability and good intra-tester reliability in patients without neck pain (Harris, Heer, Roy, Santos, Whitman and Wainner, 2005). Patients without neck pain were able to hold the position significantly longer than patients who had neck pain (Harris et al., 2005). Whether a result or the cause of previous injury, decrease muscle function has been observed in patients under load with neck pain. This links well to rugby players, were certain players are consistently under high loading during scrumming and regular play.

The multiple hop test is used to assess the proprioceptive level of players (Eechaute, Vaes and Dupuet, 2008). It has been shown to be a reliable and valid test to assess the functional performance of patients with chronic ankle problems. Behind thigh injuries in matches and training, ankle injuries have the highest prevalence in rugby union (Brooks et al., 2005b). Ankle instability, chronic pain and re-injury are risk factors following ankle injuries (Blaise-Williams III and Taunton, 2007). It has also been shown that, with intensive rehabilitation these issue can be prevented (Karlsson, 2008). This test provides information with regard to a player’s ankle status with nominal data suggesting a high test time as an indication of poor proprioception.

The function movement screening component has been included as variation to the functional movement screening developed by Gary Cook and Lee Burton. The full functional movement screening attempts to predict the risk of injury through movement analysis of 7 selected tests. Each participant is awarded points based on the movement control to a maximum of 21. Cook and Burton suggest that a score of 14 or less is a predictor for high injury risk in sport. Although the validity of this injury prediction has been questioned in other literature (Sorenson, 2009), there is clearly some valuable obtained from observing certain movements. The overhead squat, the step over and the lunge all have excellent inter-tester reliability, and with a similar scoring system, useful information can be obtained from each test relating to the player movement, stability and control (Sorenson, 2009).

This proforma was not designed to assess for injuries but to screen for potential risk factors. The self reporting component relies on the player to report  past and current injury status as well as perceived weaknesses or performance issues. This information can be used later to examine or investigate the area in question more thoroughly. The tests used in the examination were selected for the high validity and reliability to screen for potential injury risk. Specific area tests were not included, as the proforma was designed to be simple and quick to administer. Where specific injuries or areas for concern are revealed, a more specific proforma would be applied.    

Many different athlete proforma’s exist for many different sporting codes. When designing a proforma it is important to have a clear vision of what you intend to achieve and who will be involved. This proforma was designed to be simple and inexpensive, utilising valid and reliable tests with the aim to gain useful data which could decrease the risk of injuries among individuals and the group.

 

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