enforcing the use of protective gear, better conditioning of the neck, and improved on-field
medical care (reviewed in Chapter 4) are some of the factors that have been attributed to
this reduction.
Incontrast to the musculoskeletal system, the brain is unable to be
conditioned to accept trauma. Rather, trauma to this region may leave the brain more
vulnerable to future injury (Gerberich et al., 1983). This section reviews four of the five
main areas that Cantu (1992) suggests should be introduced to prevent the occurrence or
reoccurrence of
TBIin sport (the fifth area relates to on-field management, addressed in
the previous chapter).
o-IAPTER 5 PREVENTION
5.2.1 Rule Changes
Rule changes may need to be introduced in order to reduce the potential for brain injury, particularly if there is clear-cut evidence of a mechanism being solely responsible for such an occurrence (McCrory et al., 1992). For example, in 1976 a ruling was enacted that made illegal "any initial impact of the helmeted head when tackling or blocking" (darke,
1998; p. 7) in both school and college level American football. This ruling led to a noticeable reduction in head-related fatalities, corresponding to the diminished use of the head as a battering ram and spear tackling.
The Australian Rugby Football Union (and the NZRFU) have taken measures to decrease "forces at scrum engagement, interrupting play once a player is on the ground, encouraging participants to play 'the ball' not 'the man' and preventing dangerous tackling" (Hughes & Fricker, 1994; p. 249). Dangerous tackling is penalised at the referee's
discretion, with high tackling prohibited and late tackling more strictly enforced (T ornasin et al., 1989).
5.2.2 Coaching Techniques
Injury prevention should incorporate educating players on ways to protect the head.
One method of reducing injuries among players is to ensure that skills such as tackling and scrumrnaging are taught correctly (Collinson, 1984; Tomasin et al., 1989; Powell, 1999) . It is considered the responsibility of coaches to ensure that these skills are correctly taught and that the positions players are selected for are appropriate for their build (e.g., hookers and front row players should have a short strong neck) and level of skill (Collinson, 1984).
Coaches also play an important role in reducing foul play and should be seen not to condone the illegal actions of their players on the field. To this effect, Roy (1974) claims that "the coach's influence in forming the attitude of his [sic] players is of paramount importance" (p. 2325).
o-IAPTER 5 PREVENTION
5.2.3 Protective Gear
Clear support for the use of mouthguards in sports such as rugby has been indicated in the scientific literature. Investigations have provided evidence that mouthguards are effective in protecting against orofacial injuries (Chapman, 1985) and more importantly, offer protection against concussion and injuries to the cervical spine (Chalmers, 1998).
Rates of mouthguard use in rugby and other collision sports are varied, although the general trend reflected an increasing number of players electing to use mouth guards even before mandatory laws were enforced. Dalley et al. (1992) reported that on average 66.4% of their 1989 rugby sample wore mouthguards during competitive games, although the rate of use declined in response to age group. Lower rates of mouthguard wearing were evident in those over 30 years of age (54.6%), while those in the 21 - 25 year age group exhibited the highest rate of use (67%). Gerrard et al. (1994) revealed a much higher rate of
mouthguard use (85%) in their investigation involving club and school grade rugby players.
A more recent investigation involving AFL players of varying levels of perfonnance
identified mouthguard wearing rates in competition of 89% for elite players, 71% for those in organised competition (equivalent to club level), and 64% for those under 1 8 years (Banky & McCrory, 1999) . During training, rates of use for each of these groups were
40%, 21 %, and 1 %, respectively.
A number of studies (e.g., Jennings, 1990; Bird et al., 1998) have shown that the majority of players of collision sports who have sustained concussion have not been wearing a mouthguard at the time of injury. In a survey of club grade rugby players in
England, 48% reported having been concussed at some stage during their career and 7 1 % indicated not wearing a mouthguard at this time (Jennings, 1990). Bird et al. (1998)
revealed that 72% of players who had sustained a concussive injury were wearing neither a mouthguard nor headgear. Hughes and Fricker (1994) found that only 31.2% of players sustaining an injury to the head region had not been wearing mouthguards.
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Many studies have revealed a high degree of acceptance regarding the efficacy of mouthguards with the majority of players surveyed indicating regular use (Stokes & Chapman,
1991;
Chapman & Nasser,1993).
Investigations of international players' attitudes to mouthguards in rugby have shown that many players at this level would be reluctant to play without a mouthguard. Stokes and Chapman(1991)
surveyed the All Black test squad and found that all members of the squad believed mouthguards protected against injury, with47.6%
of squad members indicating that they would not play without a mouthguard and38.1 %
stating they would be reluctant to do so. Chapman and Nasser(1993)
identified that of the84%
of players in their investigation who regularly wore a mouthguard, the percentage of players who would not play without a mouthguard ranged from27.3%
to54.6%,
far outweighing those who would be willing to play without it(4.6%
- 15.8%).
The quality of the mouthguard is important in preventing against concussive injuries.
Maximum protection and safety is afforded by mouthguards custom-made by dentists (Chapman,
1985;
Kerr,1986;
Chalmers,1998).
Non-custom mouthguards (i.e., stock and mouth formed) are plagued by problems associated with being poorly fit, such as being easily dislodged, causing gagging and interfering with speech, swallowing, and breathing (Banky & McCrory,1999).
The most common reasons for the use of headgear are preventing scalp and facial lacerations and minimising the risk of concussion by reducing the magnitude of the force of impact (Wilson,
1998).
According to Gerrard et al.(1994),
New Zealand rugby players attributed their use of protective gear to the prevention of injury(57%),
previous injury(53%),
and on the basis of medical advice(21 %).
Rates of headgear use and controlled studies of headgear effectiveness have not been well documented (Mclntosh & Me£rory,2000). Gerrard et al.
(1994)
reported that20%
of players in their investigation used headgear, while according to McIntosh and Mc£rory(2000),
the rate of adoption ofCHAPTER 5 PREVENTION
headgear in players under 15 years of age is around 60%. Whilst improved protective headgear, properly fitted and maintained, has been claimed to reduce the incidence of
heal
injury
(Cantu, 1992), as yet no sport-specific helmets have been shown to be beneficial in sports such as ARF and rugby union (.McCrory et al., 1992). A more recent studyconcluded that the current commercially available models are unlikely to reduce concussion or more severe head
injury
as impact energy attenuation performance is poor in comparison to other helmet types (.McIntosh & McCrory� 2000).5.2.4 Improved Conditioning of Athlete
Another area pertinent to primary prevention emphasizes the need for improved conditioning of an athlete's body, especially of the neck (Cantu, 1992). As stated earlier, most injuries occur early in the season or in the later stages of a match when fatigue
becomes an issue (Tomasin et al., 1989). Strengthening exercises to develop both neck and shoulder muscles are recommended from school age (Collinson,1984; Tomasin et al., 1989; Cantu, 1992) as strong neck muscles in good tone may help reduce the effect of a blow to the head (Wrightson & Gronwall, 1983). While Estell et al. (1995) report that weight training may assist a player in minimising the number of minor injuries to the body by being able to absorb a greater impact, they caution that the player's perception of a 'tougher' body may increase the likelihood of a more severe injury.
5.3 CHAPTER SUMMARY
Primary prevention in sports requires the knowledge of factors that may increase athletes' risk of injury. In rugby, these factors include being young (i.e., 16 - 20 years), competing at a senior level, and occupying a forward position. Injuries also appear to
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occur most frequently in the early season games, the second half of a match, tackles and as a consequence of foul play. Of contention is whether these factors are valid indicators of risk as a consequence of the somewhat equivocal nature of the data gathered in this area. Despite this concern, the general trends that have been established in relation to these particular areas are worth calling attention to.
In order to avoid a MTBI in the first instance, primary prevention strategies should address: (1) rule changes;
(2)
the responsibility of coaches; (3) the importance of using protective gear (particularlymouthguards); and(4)
improving a player's overallconditioning. In instances where a MTBI has been not been prevented, it is advised that the circumstances resulting in the concussion be analysed. Where repetitive brain injuries are evident, Lovell and Collins (1998) recommend assessing whether the reoccurrence of such injuries are a consequence of poor playing technique, ill-fitting or poorly maintained equipment, or poor neck strength.