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BokSmart — South African Rugby’s National Rugby Safety and Injury Prevention Program

2014; Lippincott Williams & Wilkins; Volume: 13; Issue: 3 Linguagem: Inglês

10.1249/jsr.0000000000000049

1537-8918

Jon Patricios,

Traumatic Brain Injury Research

Rugby — the Game Rugby Union (“Rugby”) is a collision sport played by men, women, boys, and girls in over 100 countries worldwide. In South Africa (SA), there are approximately 500,000 rugby players ranging from under 7 years old to senior professional players. Associated with Rugby as a collision sport are injuries some of which may be serious or even catastrophic. Historically, in SA, the incidence of catastrophic head, neck, and spine injuries in particular has been viewed as unacceptably high, albeit that more recent data have shown this to fall within an “acceptable” level of risk (2). BokSmart is an injury prevention program and an intervention strategy that is evidence driven and evidence based, and which implements policies to both reduce the number of injuries and manage them more effectively. BokSmart — the Program “Bok” refers to an antelope, the “Springbok,” that is South Africa’s national animal and emblem of the South African Rugby Team. “Smart” implies using a smarter and safer approach to playing rugby. BokSmart evolved from similar national safety programs, in particular, New Zealand’s RugbySmart (3), and is an initiative of the South African Rugby Union (SARU) in conjunction with the Chris Burger/Petro Jackson Players’ Fund. South Africa has several challenges that any intervention strategy has to overcome, including the existence of many geographically remote, underprivileged, and under-resourced communities. Historical data reveal that it is in these communities that catastrophic injury statistics are highest and their management most difficult (4). BokSmart specifically targets those closest to the player at the time of injury, namely, coaches and referees, to ensure a basic standard of prevention, knowledge, and care. The Format BokSmart’s program has four main components (10): Rugby Safety Workshops — these are attended biennially by all coaches and referees nationwide; no one may coach or officiate Rugby at any level without being BokSmart certified no matter how qualified they might be; these free workshops are facilitated by accredited trainers in each province and are augmented by DVDs and printed materials. Online material — this is freely accessible at boksmart.com and provides evidence-based research on a wide range of sports medicine topics accompanied by practical, illustrated interventions. The BokSmart Rugby Medic Program — an entry-level rugby-related first-aid short course with a specific focus on head, neck, and spine injuries, aimed at implementing appropriate immediate field side care particularly in underprivileged communities; this is augmented by the donation of essential equipment such as spine boards and cervical collars. The BokSmart Spineline — a toll-free hotline that provides advice on potentially serious rugby-related head, neck, and spine injuries and facilitates ambulance transport to the nearest appropriate medical facility, where applicable. The Process The BokSmart program is driven by a fulltime manager, employed by the SARU, who coordinates management and steering committees, and facilitates program content, development, and rollout nationally. The manager synchronizes input from medical and scientific experts on various aspects of sports, exercise, and rugby medicine. Each expert’s input begins with an updated literature review of his or her area, which then is translated into pragmatic protocols, to be implemented across all levels of the game. The most relevant and prioritized content is incorporated into the educational DVDs and is facilitated by the BokSmart trainers to all coaches and referees attending the Rugby Safety Workshops countrywide, reinforced by the printed material and internet support. This is one of the ways in which BokSmart aims to fulfill all four steps of Van Mechelen’s concept of injury prevention (9). Accomplishing the objectives of the BokSmart program includes the following: ➢ The education and training of all coaches and referees nationally on rugby safety matters. This is certification based rather than accreditation based to promote maximum participation; a national database of attendees is kept, and each participant receives a certification card with a unique code and an expiration date on the license. ➢ The development of medical protocols for rugby at all levels. These are available on the Web site and updated when appropriate and include standardized injury reporting methods to enable data collection. The protocols include the following: Eating and drinking right for rugby; Effective play and controlling the game; Fair play and BokSmart Code of Conduct; Management of rugby injuries; Physical preparation and recovery techniques; Preparticipation screening of players; Preseason testing and physical profiling of players; Protective equipment in rugby union; Safety in the playing environment; Serious injury protocol; Strength and conditioning for effective rugby; ➢ Research — both as evidence-based reviews for every aspect of BokSmart’s injury prevention and management protocols and as an ongoing means of facilitating injury surveillance through the program leading to publishable outcomes; to date, 15 peer-reviewed articles have been published both locally and internationally with two currently in review (5). ➢ Legislation — the development of specific regulations and the addition or altering of the laws of the game to reduce injury risk; examples of the influence of the BokSmart program include the prohibiting of underage players participating in senior rugby, school age banding, and the modification of scrum laws for amateur players. ➢ The communication and marketing of rugby as a safer game through Web sites, scientific and public presentations, and media interaction, e.g., Facebook (www.facebook.com/boksmart), Twitter (@BokSmart), and YouTube (www.youtube.com/boksmartsa) platforms, are available to reinforce and increase exposure of the safety messages to a wider audience. Specific interventions Neck injuries The scrum, a set piece whereby eight forwards from each team interlock, pack down, and push against each other to compete for the ball, has been identified as a significant contributor to permanent catastrophic neck injury (1,7,8). BokSmart’s interventions include a large educational focus on player preparation for scrumming, coaching correct body position and technique, referees controlling and marshaling the scrums effectively, and law and regulation changes to remove “impact on engagement” injuries, to prevent age and development mismatches, and to control and better manage the setting of the scrum and ensuing scrum contest. Concussion SARU has had several cases in the past of rugby players dying from fatal head injuries that were either not identified or managed appropriately. BokSmart and SARU’s philosophy on concussion is that no concussion should ever become a catastrophic event if appropriately recognized and managed from the time of the injury. Apart from forming a significant part of the coaches and referees’ training on the biennial Rugby Safety Workshops, pocket concussion guides are provided to each attendee as well as posters for schools and clubs. The BokSmart Web site and 24-h BokSmart Spineline also provides more and detailed information on correctly identifying, treating, and managing these injuries. The International Rugby Board’s guidelines, based on the latest International Concussion Consensus Statement (6), strictly are adhered to with a stringent policy of no return to play until a graduated (preferably medically supervised) protocol is followed, and that the player is medically cleared before returning to full contact training and match play. Monitoring Effectiveness The most well-intended and researched protocols may not lead to effective results if behaviors are not altered (2). South African Rugby, through the BokSmart program, aims to change the standard practices of players, coaches, referees, and support personnel. BokSmart uses a form of intervention mapping to reevaluate continually course content relevance and effectiveness. The stepwise process involves (i) defining the program objectives based on the extent of the problem, (ii) choosing the most appropriate intervention to effect an outcome, (iii) designing the intervention and selecting appropriate tools, (iv) developing the implementation plan, and (v) evaluating the intervention’s success. To this end, an expert research team of international and local sports and exercise scientists and epidemiologists currently is evaluating BokSmart’s effectiveness. A 5-year analysis of serious and catastrophic head, neck, and spine injuries (2008–2013) in SA shows a 14.6% decrease in the number of these injuries at an amateur club level and a 23.9% decrease at school level (under 18 years). This particularly is encouraging bearing in mind that data collection likely is to have improved, a confounding variable that tends to increase rather than decrease injury statistics. Moving Forward ... BokSmart is an example of an intervention model based on the identification of a significant problem of serious injury. The program has highlighted risk factors, implements a strategy to address the issues that acknowledge regional demographic challenges, and employs independent monitoring to assess effectiveness. It is a local product that wishes to be judged by international standards leading not only to a significant reduction in injury but also to greater participation in the game of Rugby Union as a form of sport and exercise. The author declares no conflicts of interest and does not have any financial disclosures.