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PURPOSE: To perform a Delphi consensus for return to sports (RTS) following sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Individualized graduated RTS protocols should be used. A normal clinical, ocular and balance examination with no more headaches, and asymptomatic exertional test allows RTS. Earlier RTS can be considered if athletes are symptom free. The Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening are recognized as useful tools to assist in decision-making. Ultimately RTS is a clinical decision. Baseline assessments should be performed at both collegiate and professional level and a combination of neurocognitive and clinical tests should be used. A specific number of recurrent concussions for season-or career-ending decisions could not be determined but will affect decision making for RTS. CONCLUSIONS: Consensus was achieved for 10 of the 25 RTS criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending. LEVEL OF EVIDENCE: Level V, expert Opinion.

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OBJECTIVES: To evaluate player and referee behaviour during a lower tackle height law variation trial in community rugby union ('rugby'). DESIGN: Prospective observational cohort study. METHODS: In a law variation trial in male amateur community rugby, coded match video surveillance data were analysed. Referee (sanctioning rate) and player (tackler body position) behaviour changes over one season (under the lowered, armpit-level maximum legal tackle height condition) were analysed in three approximately equal periods of the season. Secondarily, an independent professional referee reviewed illegal high tackle sanctioning data. RESULTS: Overall, 108 matches with 14,780 tackles were filmed and coded. Sanctioned illegal high tackle propensity was significantly higher in the mid-season (41 sanctioned high tackles/1000 tackle events; 95 % CI: 35-47), compared with first and last periods. Upright tacklers in tackles decreased significantly in the final vs. middle period of the season (rate ratio: 0.69; 95 % CI: 0.54-0.88; p < 0.01). Of all the coder-determined high tackles also assessed as high under the new law by the independent referee, 51 % were sanctioned by the on-field referee. CONCLUSIONS: Positive player and referee behavioural changes were observed during a lowered legal tackle height law variation in this community rugby setting. Increased mid-phase high tackle sanctioning by referees was followed by fewer tackles with upright tacklers in the subsequent (last) phase of the season. Encouraging positive behaviour changes of this nature, particularly if sustained (beyond trial study periods), may contribute to overall injury risk reduction, and hold considerable importance to inform future injury prevention strategies in rugby.

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OBJECTIVES: In rugby union (rugby), the tackle is the most frequent cause of concussion and thus a target for intervention to reduce concussion incidence. The aim of this study is to describe tackle characteristics and factors associated with illegal high tackles in amateur community-level rugby during a lowered (armpit level) tackle height law variation trial. DESIGN: Prospective observational cohort study. METHODS: Video surveillance of a single season, four-league competition with coding of video data according to a predefined coding framework. Descriptive statistics of tackle detail and logistic regression was performed to analyse factors associated with high tackles. RESULTS: One hundred and eight matches with 14,679 tackles and a mean of 137 (±30) tackles per match were analysed. High tackles (above armpit level) had significantly greater odds of occurring in the lower (2nd-4th) leagues (OR: 1.95; 95 % CI: 1.6-2.4; p < 0.001), front-on tackles (OR: 1.61; 95 % CI: 1.3-2.0; p < 0.001), arm tackles (OR: 1.65; 95 % CI: 1.3-2.1; p < 0.001), bent-at-waist ball carrier (OR: 1.93; 95 % CI: 1.6-2.4; p < 0.001), falling/diving ball carrier (OR: 2.21; 95 % CI: 1.6-3.1; p < 0.001), and an upright tackler (OR: 3.38; 95 % CI: 2.7-4.2; p < 0.001). A falling/diving tackler had significantly lower odds of being associated with a high tackle (OR: 0.44; 95 % CI: 0.3-0.6; p < 0.001). CONCLUSIONS: Overall mean tackles per match were similar to those of senior amateur and elite rugby. League, tackle type, tackle aspect, and player body positions were associated with high tackles. These findings reiterate the need for ongoing efforts to identify and implement mitigating strategies to reduce tackle-related injury risk.

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PURPOSE: To perform a Delphi consensus for on-field and pitch-side assessment of sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus, or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Loss of consciousness (LOC) or suspected LOC, motor incoordination/ataxia, balance disturbance, confusion/disorientation, memory disturbance/amnesia, blurred vision/light sensitivity, irritability, slurred speech, slow reaction time, lying motionless, dizziness, headaches/pressure in the head, falling to the ground with no protective action, slow to get up after a hit, dazed look, and posturing/seizures were clinical signs of SRC and indicate removal from play. Video assessment is helpful but should not replace clinical judgment. LOC/unresponsiveness, signs of cervical spine injury, suspicion of other fractures (skull/maxillo-facial), seizures, Glasgow Coma Scale score <14 and abnormal neurologic examination findings are indications for hospitalization. Return to play should only be considered when no clinical signs of SRC are present. Every suspected concussion should be referred to an experienced physician. CONCLUSIONS: Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals. LEVEL OF EVIDENCE: Level V, expert opinion.

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OBJECTIVE: Rugby union ('rugby') is popular globally, with most of its participants being amateur. Concern regarding sport-related concussion (SRC) sustained during rugby is increasing. SRC occurs most frequently in the tackle, yet few interventions have aimed to mitigate this risk factor. This study investigated the influence of a lowered legal tackle height on SRC incidence in amateur rugby. DESIGN: Cross-sectional analytical study: 2018 (control-standard tackle height) and 2019 (intervention-lowered legal tackle height) seasons. SETTING: South African collegiate student rugby competition. PARTICIPANTS: Between 800 and 900 male amateur student players (age: 20±1.6 years) in each year. INTERVENTION: Maximum legal tackle height lowered from line of the shoulder on the ball carrier to the line of the armpit. OUTCOME MEASURES: Number of overall (medical attention) and time-loss (≥1 day lost) injuries, head injuries and SRCs in 2018 and 2019 (dependent variables); events associated with injury incidents (independent variables). RESULTS: There was no statistically significant difference in incidences of time-loss injuries (IRR: 0.79; 95% CI: 0.6 to 1.1; p=0.13), head injuries (IRR: 0.83; 95% CI: 0.5 to 1.3; p=0.42) and SRC (IRR: 0.69; 95% CI: 0.4 to 1.2; p=0.20). In 2018 and 2019, most time-loss head injuries (57%, n=43) and SRCs (55%, n=26) occurred during the tackle. CONCLUSIONS: Despite a trend towards reducing injuries, head injuries and SRC, lowering maximum legal tackle height to armpit level did not change SRC incidence in this amateur male rugby cohort. Most time-loss head injuries and SRCs occurred during the tackle. Further tackle-related interventions to reduce SRC incidence require investigation.

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Collision sports, such as Rugby Union ("Rugby") have a particularly high risk of injury. Of all injuries common to collision sports, concussions have received the most attention due to the potentially negative cognitive effects in the short- and long-term. Despite non-professional Rugby players comprising the majority of the world's playing population, there is relatively little research in this population. Stellenbosch Rugby Football Club ("Maties"), the official rugby club of Stellenbosch University, represents one of the world's largest non-professional Rugby clubs, making this an ideal cohort for community-level injury surveillance. The aim of this study was to describe the incidence and events associated with concussion in this cohort. Baseline demographics were obtained on the 807 male student Rugby non-professional players who registered for the 10-week long 2018 season, which comprised 101 matches and 2,915 of exposure hours. All match-related injuries were captured by the medical staff of Stellenbosch Campus Health Service on an electronic form developed from the consensus statement for injury recording in Rugby. The mean age, height and weight of this cohort were 20 ± 2 years, 182 ± 7 cm and 88 ± 14 kg, respectively. Overall, there were 89 time-loss injuries, which equated to an injury rate of 30.6 per 1,000 match hours [95% confidence intervals (CIs): 24.2-36.9], or about one injury per match. The most common injury diagnosis was "concussion" (n = 27 out of 90 injuries, 30%), at a rate of 9.3 per 1,000 match hours (95% CIs: 5.8-12.8). The three most common mechanisms of concussion in the present study were performing a tackle (33%), accidental collision (30%) and being tackled (11%). Concussion was the most common injury in this population, at a rate that was six times higher than the most comparable study from the UK, which had far more exposure time over six seasons and wider range of player ability, from recreational to semi-professional. This might be explained by the training and vigilance of the club's first aiders observing all matches for concussion. Future studies should try to explain this high rate and subsequently reduce these concussions. The addition of video surveillance data would assist in identifying the etiology of these concussions injuries in order to develop specific targeted interventions.

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CONTEXT: Rugby union is the most widely played team collision sport globally. As with other contact sports, there is substantial risk of injury. To date, the majority of studies on injury epidemiology have focused on elite male cohorts, which inherently prevents extrapolation of research findings to other groups within the player continuum. This review aims to describe emerging injury trends across the spectrum of various rugby union subpopulations and to highlight gaps that may influence future injury prevention tactics. EVIDENCE ACQUISITION: Relevant articles published from 2007 to 2017 were obtained by searching MEDLINE, PubMed, and SPORT Discus. Studies on 15-a-side rugby union, implemented according to the 2007 consensus statement on injury definitions and data collection procedures for injuries in rugby union, were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Match injuries occur more frequently than training injuries. Injury rates increase consistently according to age and level of play. Severity of injury often is greater among lower levels of the game, and sex-specific differences relating to injury patterns and incidence rates exist. CONCLUSION: To date, a paucity of injury surveillance data exists for women and players of both sexes at all levels of community rugby union. Furthermore, the incidence of injuries and illnesses are poorly reported in epidemiological studies. Despite methodological differences, injury trends remain consistent throughout all levels of play.

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BACKGROUND: Identification of the nature of cardiac murmurs during the periodic health evaluation (PHE) of athletes is challenging due to the difficulty in distinguishing between murmurs of physiological or structural origin. Previously, computer-assisted auscultation (CAA) has shown promise to support appropriate referrals in the nonathlete pediatric population. HYPOTHESIS: CAA has the ability to accurately detect cardiac murmurs of structural origin during a PHE in collegiate athletes. STUDY DESIGN: Cross-sectional, descriptive study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 131 collegiate athletes (104 men, 28 women; mean age, 20 ± 2 years) completed a sports physician (SP)-driven PHE consisting of a cardiac history questionnaire and a physical examination. An independent CAA assessment was performed by a technician who was blinded to the SP findings. Athletes with suspected structural murmurs or other clinical reasons for concern were referred to a cardiologist for confirmatory echocardiography (EC). RESULTS: Twenty-five athletes were referred for further investigation (17 murmurs, 6 abnormal electrocardiographs, 1 displaced apex, and 1 possible case of Marfan syndrome). EC confirmed 3 structural and 22 physiological murmurs. The SP flagged 5 individuals with possible underlying structural pathology; 2 of these murmurs were confirmed as structural in nature. Fourteen murmurs were referred by CAA; 3 of these were confirmed as structural in origin by EC. One such murmur was not detected by the SP, however, and detected by CAA. The sensitivity of CAA was 100% compared with 66.7% shown by the SP, while specificity was 50% and 66.7%, respectively. CONCLUSION: CAA shows potential to be a feasible adjunct for improving the identification of structural murmurs in the athlete population. Over-referral by CAA for EC requires further investigation and possible refinements to the current algorithm. Further studies are needed to determine the true sensitivity, specificity, and cost efficacy of the device among the athletic population. CLINICAL RELEVANCE: CAA may be a useful cardiac screening adjunct during the PHE of athletes, particularly as it may guide appropriate referral of suspected structural murmurs for further investigation.

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