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BJSM Online First, published on October 21, 2017 as 10.1136/bjsports-2017-098005
Original article

Efficacy of a movement control injury prevention
programme in adult men’s community rugby union: acluster randomised controlled trial
Matthew J Attwood,1,2 Simon P Roberts,1 Grant Trewartha,1 Mike E England,3
Keith A Stokes1►► Additional material ispublished online only. To viewplease visit the journal online(http://d​ x.​doi.o​ rg/​10.​1136/​
bjsports-​2017-​098005).
1

Department for Health,
University of Bath, Bath, UK
School of Sport and Health
Sciences, Cardiff Metropolitan
University, Cardiff, UK
3
Rugby Football Union,
Twickenham, London, UK
2

Correspondence to
Dr Keith A Stokes, Department
for Health, University of Bath,Claverton Down, Bath BA2 7AY,
UK; k​ .​stokes@b​ ath.​ac.​uk
Accepted 12 September 2017

Abstract
Background Exercise programmes aimed at reducing
injury have been shown to be efficacious for some
non-collision sports, but evidence in adult men’s collision
sports such as rugby union is lacking.
Objective To evaluate the efficacy of a movement
control injury prevention exercise programme for
reducing match injuries in adult men’s community rugby
union players.
Methods 856 clubs were invited to participate in thisprospective cluster randomised (single-blind) controlled
trial where clubs were the unit of randomisation. 81
volunteered and were randomly assigned (intervention/
control). A 42-week exercise programme was followed
throughout the season. The control programme reflected’normal practice’ exercises, whereas the intervention
focused on proprioception, balance, cutting, landing andresistance exercises. Outcome measures were matchinjury incidence and burden for: (1) all ≥8 days time-loss
injuries and (2) targeted (lower limb, shoulder, head andneck, excluding fractures and lacerations) ≥8 days timeloss injuries.
Results Poisson regression identified no clear effects on
overall injury outcomes. A likely beneficial difference intargeted injury incidence (rate ratio (RR), 90% CI=0.6, 0.4
to 1.0) was identified, with a 40% reduction in lowerlimb incidence (RR, 90% CI=0.6, 0.4 to 1.0) and a 60%
reduction in concussion incidence (RR, 90% CI=0.4, 0.2 to0.7) in the intervention group. Comparison between arms
for clubs with highest compliance (≥median compliance)
demonstrated very likely beneficial 60% reductions intargeted injury incidence (RR, 90% CI=0.4, 0.2 to 0.8) andtargeted injury burden (RR, 90% CI=0.4, 0.2 to 0.7).
Conclusions The movement control injury prevention
programme resulted in likely beneficial reductions inlower-limb injuries and concussion. Higher intervention
compliance was associated with reduced targeted injury
incidence and burden.

Introduction

To cite: Attwood MJ,
Roberts SP, Trewartha G, et al.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-098005

Sports injuries negatively influence teamsuccess1 2 and may lead to withdrawal from sports
participation.3 4 Injuries are also associated withsecondary degenerative disease including osteoarthritis,5 6 which can impact on long-term quality oflife.7 There has not been a large-scale movement
control-informed injury prevention randomised
controlled trial in adult men’s community rugby
union, despite a need to minimise injury rates tomaximise sports participation and maintain players’
long-term health.

Exercise-based injury prevention interventions
including FIFA 11+8 focus on reducing lower-limb
injuries by means of exercises targeting balance,
coordination, strength and power. In soccer, FIFA
11+ has been reported to reduce injury incidence
rates by between 32%9 and 72%.10 However, in addition to the injury mechanisms common in soccer,
rugby union (rugby) has additional contact/collision
events. In community rugby, 80% of match injuries are associated with contact events11 comparedwith 44% in community soccer.12 The high-impact
collision nature of the rugby tackle13 can result inblunt force trauma injuries. For example, fracturesand lacerations account for 27% of all head injuries.14 Similarly, acromioclavicular joint dislocationis the most common rugby shoulder injury,15 where
the injury mechanism is commonly a direct impactof the player’s shoulder with the ground during atackle.16 Such injuries are likely to be difficult toprevent through movement control programmes.
Knee and ankle ligament injuries combined withhamstring injuries account for 33% of injuries
overall and are the most common non-contact rugby
injury diagnoses.11 Importantly, injury prevention
programmes have reduced knee (70% reduction)
and ankle sprains (62% reduction)17 as well as
hamstring strains (70% reduction).18 Although FIFA
11+ was designed to reduce lower-limb injuries insoccer, implementing the programme in basketball
reduced lower-limb injury by 32%.19 This indicatesthat the type of exercises included in FIFA 11+ may
be appropriate across sports where lower-limb injuries predominate. Lower-limb injuries are common
in rugby, but upper-limb and head and neck injuries
account for 41% of all injuries11 compared with 6%
in soccer.20 The profile of injuries in community
rugby therefore warrants a new movement control
exercise programme.
The aim of this study was to investigate theefficacy of a rugby-specific movement control
programme to reduce injury risk in adult men’scommunity rugby union players.

Methods
Trial design and randomisation

This prospective cluster randomised control trial
was designed in accordance with the CONSORT
framework for cluster randomised trials.21 The
playing population from which the study sample
was recruited has been described previously as
semi-professional (Rugby Football Union (RFU)
levels 3–4; highest level of English community

Attwood MJ, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-098005   1

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Original article

Figure 1 Flow chart of clubs through study period. RFU, Rugby Football Union.
rugby), amateur (RFU levels 5–6) and recreational (RFU levels
7–9).11 Injury incidence varies across these playing categories,11and therefore, recruited clubs were stratified by playing level
before being randomly allocated to the intervention or control
group.

Ethical approval

The study was approved by the Research Ethics ApprovalCommittee for Health, University of Bath, UK (Reference:
EP14/15142).

Sample size

The required sample size was estimated22 at club level, indicating
54 clubs (27 clubs per trial arm, intervention/control) for a minimally important (α=0.05) injury burden rate ratio (RR) of 0.70
or less based on expected injury burden of 899 days/1000 player
match-hours23 in the control group and anticipated exposure of
480 player match-hours per club (cluster). This allowed for an
anticipated 50% drop-out rate and was adjusted for cluster coefficient (k=0.26).23

exercise programme reflecting the injury profile of community
rugby players was developed following discussion with an expert‘Technical Group’ of sports medicine researchers, physiotherapists and strength and conditioning specialists that specialised inhuman movement, injury prevention, epidemiology and rehabilitation and a rugby coach. The intervention programme included
proprioceptive, mobility and strengthening exercises within aprogressive structure targeting the lower limb, shoulder, head andneck. The control programme included dynamic stretching andnon-targeted resistance exercises presented in a similar progressive format to the intervention. A pilot trial was conductedduring the 2014–2015 season in 16 clubs. Delivery agents (typically coaches) from pilot study clubs were interviewed at the endof this season to determine factors that affected implementation, following which the exercise programmes were modified.
Revised programmes were examined by a second expert ‘Technical Group’ including strength and conditioning coaches, sports
physiotherapists and sports medicine researchers.

Exercise programmes

Before the 2014/2015 preseason, a review of successful
injury prevention exercises from different sports settings was
conducted alongside a review of adult men’s community rugby
injury epidemiology. An evidence-informed injury prevention

The final exercise programmes included seven 6-week progressive phases spanning the 2015/2016 rugby preseason andinseason period to be used at training sessions (twice weekly) andprematch (once weekly). Programmes recommended 5–10 minof small-sided games after which the main content lasted 15 min.
The control programme followed a raise, activate, mobilise
and potentiate format24 incorporating whole-body dynamic
stretching and resistance exercises, such as partner grappling,
front planks, press-ups and sprint drills, before finishing withhigh-intensity running exercises. The intervention warm-up
incorporated balance/proprioceptive exercises, resistance andperturbation exercises and sport-related landing, cutting andplyometric exercises. Proprioception and balance exercises
progressed through alterations including the use of upper-limb
movement, performing the exercises with eyes closed and thus

2

Attwood MJ, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-098005

Study setting and recruitment

Between March and June 2015, before the 2015/2016 preseason,
856 adult men’s community rugby clubs competing in RFU
league levels 3–9 in England were invited to participate in thisstudy (figure 1). Inclusion criteria were that clubs must haveaccess to a registered healthcare practitioner for injury diagnoses(sports therapists, osteopaths, chiropractors, physiotherapists orphysicians).

Programme design

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Original article
removing the visual component to balance and by perturbations in frontal and sagittal planes. Dynamic stability exercises
targeting upper and lower limbs progressed in load by altering
the number of sets and reps, intensity and by variations in the
directions of movement. Resistance exercises progressed in duration or intensity as well as by altering the type of muscle contraction to include isometric, concentric and eccentric muscle
activity. Landing, cutting and plyometric exercises varied phaseto phase but reflected sport-specific skills such as jumping tocatch a high ball and progressed in difficulty. Variations included
progressing from a single cutting manoeuvre to a cut, spin andaccelerate movement pattern. Plyometric exercises progressed
through each of the phases beginning with lower-load doublelegged tasks to high-load single-legged tasks. Throughout theintervention warm-up, there was a consistent theme of qualityof movement control and body alignment for delivery agentsto feedback to the players (see online supplementary file for an
example of one intervention phase). The intervention finishedwith the same high-intensity shuttle running exercises as thecontrol programme.

Blinding of clubs

Club members were blind to which programme they received.
Clubs were informed that they were involved in a study evaluating the efficacy of different combinations of exercises forinjury risk reduction and that clubs throughout the country wereusing different exercise combinations. This was deemed a pragmatic approach to limit contamination due to clubs who, due tobeing randomly assigned, could be situated in close geographicalproximity to other participating clubs.

Programme delivery

Each club was visited by a ‘programme trainer’ from theresearch group to train each club’s nominated ‘delivery agent’(commonly the strength and conditioning coach) in how todeliver the programme to their players. Seventy-four per cent ofclubs (n=60) received training before the start of preseason and
26% (n=21) received training before the start of the competitive
season. Two clubs received training less than 5 weeks before thestart of the season.

Data collection

Data were collected during the 2015–2016 English rugby
union season from July 2015 to May 2016. Clubs nominateda programme coordinator to report first team match exposure,exercise programme compliance and match injuries on a weekly
basis using standardised forms. Data collection forms were available in paper and electronic formats.

Injury definitions

All first-team match injuries that resulted in absence from matchplay for ≥8 days were defined as a ‘time-loss’ injury, including
both acute and overuse injuries. Injuries were recorded using
the Orchard Sports Injury Classification System (V.8)25 detailinginjury type and location. The date a player was fit to play wasrecorded as the return to play date. Overall injury incidence
refers to injuries with a ≥8 days time-loss. Severe injuries were
defined as injuries with >28 days time-loss.26 Injury burden
was defined as the total number of days lost from training or
match play. Targeted injuries were defined as injuries to thelower limb (buttock, hip, upper leg, knee, lower leg, ankle andfoot), head and neck, or shoulder (glenohumoral joint), withdiagnoses limited to muscle strains, ligamentous sprains, joint
Attwood MJ, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-098005

and neurological injury that resulted in ≥8 days time-loss.
Diagnoses including haematoma, laceration/contusion, fracture
and undiagnosed pain at any body site were excluded from thetargeted injury analysis.

Outcomes

Injury burden was the primary outcome between trial arms for
all injuries. Secondary outcomes included overall injury incidence, targeted injury incidence and targeted injury burden.

Statistical methods

Data analysis, computed using SPSS (V.22 for Windows, IBM)was performed on an intention-to-treat (last observation carriedforward) basis with the control clubs as the reference group.
Injury burden (number of days absence per 1000 player
match-hours) and 90% CIs were estimated vis-à-vis for primaryand secondary outcome measures of this study. Injury incidence was estimated as the number of injuries per 1000 player
match-hours. The General Estimating Equation was used to
conduct Poisson regression analysis and explore the effects of
the intervention on injury outcomes. Club (cluster) and playing
level (semiprofessional; amateur; recreational) were included as
random effects, and analysis was offset for club match exposure.
Overdispersion was controlled for using a Pearson χ2 scaling
parameter.27 Club programme compliance was defined by two
measures: overall club compliance (proportion of all possible
sessions where the programme was delivered) and the numberof club programme sessions/week. Overall compliance, adjusted
for varying lengths of clubs’ participation in the study and the
proportion of compliant sessions, was measured as the numberof compliant sessions/total potential compliant sessions. Results
are presented as RR with 90% CI and interpreted using Clinical-Magnitude Based Inferences.28 Ten per cent was considered
the minimum effect, and threshold values for unlikely/harmful(25) and most/very unlikely (0.5)28 were used to derive the OR
for making clinical inference.

Results
Overview

Eighty-one clubs were randomised to the intervention (n=41)
or control (n=40) arm, of which forty clubs (intervention=19,
control=21) dropped out or otherwise returned incomplete
data. Forty-one clubs (intervention=22, control=19) returned
complete data detailing 255 injuries averaging 5.5±5.7 injuries
per intervention club and 7.0±5.1 injuries per control club. Total
player match exposure was 19 560 hours (intervention=9900,
control=9660 player match-hours), averaging 477±121 player
match-hours per club. Across the 41 clubs, 222 different players
sustained ≥1 injury. All injuries were reported as acute injuries, and the majority were associated with contact mechanisms(contact=199 (78%), non-contact=56 (22%)). Player demographic information is displayed in table 1.
Table 1 Player demographics (mean, SD and number) for
participants in the intervention and control arms
Level

Age (years)

Mass (kg)Height (cm)All players

25.5 (5.6)(n=673)94.4 (13.9)(n=1346)181.6 (7.3)(n=1355)

Intervention

26.1 (5.7)(n=273)93.6 (13.3)(n=675)181.8 (7.5)(n=682)Control

25.0 (5.5)(n=400)95.2 (14.5)(n=671)

181.4 (7.1)(n=673)3

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Table 2 Incidence rate ratios by injury stratification (all injury, targeted injury) based on Poisson regression analysis adjusted for cluster andplaying level
Arm

Clubs (n)Player match- Injuries/days
hours
lost countRate per 1000 player
match-hours (90% CI)

RR (90% CI)

Magnitude-based inference(beneficial/trivial/harmful) (%)

Control

19

9660

133

13.8 (11.9 to 15.9)

0.9 (0.6 to 1.3)

Unclear (51/31/18)

Intervention

22

9900

122

12.3 (10.6 to 14.3)

Control

19

9660

73

7.6 (6.2 to 9.2)

0.8 (0.6 to 1.3)

Unclear (63/25/12)

Intervention

22

9900

62

6.3 (5.1 to 7.7)

Control

19

9660

6918

716 (621 to 826)

0.8 (0.5 to 1.4)

Unclear (62/22/16)

Intervention

22

9900

5783

584 (503 to 678)

Control

19

9660

96

9.9 (8.4 to 11.8)

0.6 (0.4 to 1.0)

Likely beneficial (92/7/1)

Intervention

22

9900

62

6.3 (5.1 to 7.7)

Control

19

9660

56

5.8 (4.7 to 7.2)

0.6 (0.3 to 1.0)

Likely beneficial (92/6/2)

Intervention

22

9900

33

3.3 (2.5 to 4.4)

Control

19

9660

5288

547 (463 to 647)

0.6 (0.3 to 1.3)

Unclear (80/11/9)

Intervention

22

9900

3472

351 (285 to 432)

Overall Injury All incidence Severe incidence Injury burden
Targeted injury Injury incidence Severe incidence Injury burden

Overall injuries

Overall injury burden was 649 (90% CI 570 to 740) days/1000
player match-hours where the incidence (≥8 days time-loss) for
both trial arms combined was 13.0 (90% CI 11.8 to 14.4) injuries/1000 player match-hours. There were 135 severe injuries(>28 days time-loss) with an incidence of 6.9 (90% CI 6.0 to7.9) injuries/1000 player match-hours. Intention-to-treat analysis indicated no clear difference in overall injury burden (RR,
0.8; 90% CI 0.5–1.4), overall injury incidence (RR, 0.9; 90% CI
0.6–1.3) or severe injury incidence (RR, 0.8; 90% CI 0.6–1.3)
for the intervention compared with control group (table 2 andfigure 2).

Targeted injuries

One hundred and fifty-eight injuries (62% of all injuries) acrossboth trial arms met the ‘targeted injury’ definition with a burdenof 448 (90% CI 393 to 510) days/1000 player match-hours andan incidence of 8.1 (90% CI 7.1 to 9.2) injuries/1000 player
match-hours. There were 89 severe targeted injuries with anincidence of 4.6 (90% CI 3.8 to 5.4) injuries/1000 player matchhours. Poisson regression analysis indicated no clear difference(RR, 0.6; 90% CI 0.3–1.3) in targeted injury burden for theintervention (table 3 and figure 3) compared with the control
group. A likely beneficial 40% (RR, 0.6; 90% CI 0.4–1.0) reduction in both overall targeted injury incidence and severe targetedinjury incidence (RR, 0.6; 90% CI 0.3–1.0) was identified forthe intervention compared with control group.

Specific body locations

There was a likely beneficial 70% reduction in both burden (RR,
0.3; 90% CI 0.2–0.7) and incidence (RR, 0.3; 90% CI 0.2–0.6)
of head and neck injury for the intervention group over control

Figure 2 Rate reduction ratio (RR) and 90% CI of overall and targeted injury outcomes for the intervention group based on Poisson regression
analysis adjusted for cluster and playing level. Clinical inference (right column) indicates the likelihood of effect. Vertical dashed lines represent 10%
minimum effect thresholds, and the vertical solid line represents no effect compared with the control group.
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Table 3 Incidence rate ratios for targeted injuries, stratified by region (head and neck, shoulder and lower limb) based on Poisson regression
analysis adjusted for cluster and playing level
Target injury and arm

Injuries/days lostcount
IIR(90% CI)

Clubs (n)Player match-hours Control

19

9660

35

3.6 (2.7 to 4.8)

 Intervention

22

9900

12

1.2 (0.8 to 1.9)

 Control

19

9660

33

3.4 (2.6 to 4.5)

 Intervention

22

9900

12

1.2 (0.8 to 1.9)

 Control

19

9660

10

1.0 (0.6 to 1.7)

 Intervention

22

9900

17

1.7 (1.2 to 2.6)

 Control

19

9660

50

5.2 (4.1 to 6.5)

 Intervention

22

9900

33

3.3 (2.5 to 4.4)

 Control

19

9660

1164

120 (92 to 159)

 Intervention

22

9900

378

38 (24 to 61) Control

19

9660

983

102 (76 to 136)

 Intervention

22

9900

378

38 (24 to 61) Control

19

9660

436

45 (27 to 76) Intervention

22

9900

673

68 (46 to 101)

 Control

19

9660

3688

382 (303 to 482)

 Intervention

22

9900

2421

245 (184 to 326)

RR (90% CI)

Magnitude-based inference(beneficial/trivial/harmful) (%)

0.3 (0.2 to 0.7)

Very likely beneficial (99/1/0)

0.4 (0.2 to 0.7)

Very likely beneficial (99/1/0)

1.7 (0.7 to 3.8)

Likely harmful (11/10/79)

0.6 (0.4 to 1.0)

Likely beneficial (89/9/2)

0.3 (0.2 to 0.7)

Very likely beneficial (99/1/0)

0.4 (0.2 to 0.8)

Very likely beneficial (97/2/1)

1.5 (0.6 to 3.7)

Possibly harmful (17/11/71)

0.6 (0.3 to 1.5)

Unclear (75/11/14)

Head and neck incidence

Concussion incidence

Shoulder Incidence

Lower-limb incidence

Head and neck burden

Concussion burden

Shoulder burden

Lower-limb burden

IIR, injury incidence rate; RR, rate ratio.

group (figure 3 and table 3). Forty-five of 47 ‘head and neck’injury diagnoses were concussion, and there was a likely beneficial 60% reduction in burden (RR, 0.4; 90% CI 0.2–0.8) and
incidence (RR, 0.4; 90% CI 0.2–0.7) for this specific diagnosis
in the intervention compared with the control group. Overall,twenty-seven injuries were reported for the shoulder (table 3)
where a possibly harmful 50% (RR, 1.5; 90% CI 0.6–3.7) higher
injury burden and likely harmful 70% (RR, 1.7; 90% CI 0.7–3.8)
higher injury incidence was found for the intervention groupover control. There was no clear difference (RR, 0.6; 90% CI

Figure 3 Rate reduction ratio (RR) and 90% CI for targeted injury outcomes stratified by location for the intervention group based on Poisson
regression analysis adjusted for cluster and playing level. Clinical inference (right column) indicates the likelihood of effect. Vertical dashed lines
represent 10% minimum effect thresholds, and the vertical solid line represents no effect compared with the control group.
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0.3–1.5) in lower-limb injury burden but likely beneficial 40%(RR, 0.6; 90% CI 0.4–1.0) reduction in lower-limb injury incidence for the intervention compared with the control group.

Programme compliance

Programme compliance was high and was similar in both intervention (2.1±0.7 sessions/week, median=85%, IQR=62–90)
and control (2.2±0.6 sessions/week, median=83%, IQR=65–92) study arms. Four clubs (intervention n=3, control n=1)
completed their programme less than once weekly, 8 clubs(intervention n=3, control n=5) completed their programme atleast once but less than twice weekly and 29 clubs (intervention
n=16, control n=13) completed their programme at least twice
weekly.
For clubs that completed the exercise programmes at least
once weekly (n=37), no clear difference in targeted injury
burden (RR, 0.7; 90% CI 0.3–2.0) and likely beneficial 40%
reduction (RR,0.6; 90% CI 0.4–1.0) in targeted injury incidence
was found for the intervention compared with the control group.
Median compliance was used to divide clubs into higher(≥median) and lower (<median) compliance groups. Intervention clubs (n=11) with higher compliance displayed a very
likely beneficial 60% reduction in both targeted injury burden(RR, 0.4; 90% CI 0.2–0.7) and targeted injury incidence(RR, 0.4; 90% CI 0.2–0.8) compared with the control clubs withhigher compliance (n=9).
Within the intervention arm, comparison of clubs with higher
compliance (n=11) to lower compliance (n=11) indicateda likely beneficial 50% reduction (RR, 0.5; 90% CI 0.2–1.2)
in targeted injury burden with no clear difference (RR, 0.7;
90% CI 0.4–1.4) in targeted injury incidence for higher compliance clubs.

Discussion

This is the first cluster randomised controlled trial to evaluate theefficacy of an injury prevention exercise programme to reduce
injuries in adult men’s community rugby players. No clear differences were found between intervention and control arms using
intention-to-treat analysis and established clinical inference
thresholds for overall injury burden, overall injury incidence orsevere injury incidence. However, for injuries targeted by theintervention, overall injury incidence and severe injury incidence
were both reduced by 40% in the intervention group comparedwith control, which were clear beneficial effects. Of particularnote is that the intervention group benefited from a 60% reduction in concussion and a 40% reduction in lower-limb incidencecompared with the control group.

intervention and control groups in this study, this is evidence
to suggest that all adult men’s community rugby players should
engage in weekly neck conditioning exercises.
A likely beneficial reduction of 40% was found for targeted
lower-limb injury incidence for the intervention group overcontrol group (3.3 vs 5.2 injuries/1000 player match-hours).
The intervention programme incorporated lower-limb balance,
proprioception and movement control exercises similar in nature
to exercises in FIFA 11+,32 indicating that this approach is also
efficacious for reducing injury in rugby, despite the high proportion of contact-related injuries. Intention-to-treat analysis froma neuromuscular-control intervention study in community adultmen’s Australian Rules Football,33 another sport with a highlevel of physical person-to-person contact, displayed a likely
beneficial 20% reduction (RR, 0.8; 90% CI 0.6–1.0) in lowerlimb injury incidence and a likely beneficial 50% reduction (RR,
0.5; 90% CI 0.3–1.0) in knee injuries. Given that ~50% of allcommunity rugby injuries are lower-limb injuries,11 our findings
support the completion of these lower-limb exercises as part of awarm-up before training and matches.
Shoulder injury incidence (1.7 vs 1.0 injuries/1000 player
match-hours, respectively) and injury burden (68 vs 45
days/1000 player match-hours, respectively) was higher for theintervention group over control. Despite the higher rate ofshoulder injuries, the intervention group had fewer shoulder
dislocations (1 vs 5 dislocations) but more muscle/tendon
injuries (15 vs 4 injuries) than the control group. There is no
obvious explanation for the higher injury rate in the intervention
group, though this trial was not powered to detect differencesin shoulder injury rates as specific outcome. Reduced head andneck and lower-limb injuries likely resulted in greater individual
player match exposure for players in the intervention arm.
Greater player match exposure may have led to more shoulder
contact events including tackles, thus increasing the risk forshoulder injury. All shoulder injuries were contact injuries andtherefore may be harder to reduce via conditioning exercises
alone. As reductions in both shoulder and head injury are likely
achieved via good tackling technique,34 35 it may be prudent thattackle education is recommended alongside implementation ofthis study’s intervention.

Compliance and injury risk

Concussion was 60% lower for both incidence (1.2 vs 3.4 injuries/1000 player match-hours) and burden (38 vs 102 days/1000
player match-hours) in the intervention compared with thecontrol group. This reduction is possibly a result of the isometricneck conditioning exercises included in every phase of the intervention programme. These exercises were included based on
existing evidence that isometric neck exercises increase neckstrength in male rugby players29 and that higher neck strengthis suggested to decrease head accelerations during rugby collision events associated with concussion.30 For amateur rugby,
this finding is very encouraging in the context of a proposed
link between concussion sustained during a playing career anddeficits in cognitive functioning in later life.31 Given the magnitude of the difference in concussion incidence between theClubs’ compliance rates were high, reflected by median compliance of 85% for the intervention group and 83% for the control
group, where on average clubs implemented the programmes
at least twice/week. Between-group comparison for clubs thatcompleted the programme at least once/week during the season
indicated a 40% reduction in targeted injury incidence for theintervention group over the control group. As some clubs only
train once/week, it is encouraging to find that injury incidence
was reduced provided clubs implemented the intervention once
weekly. In soccer, higher FIFA 11+ compliance produced avery likely beneficial 35% reduction in injury rates comparedwith intermediate FIFA 11+ compliance.8 In the present study,
comparison between intervention clubs with higher complianceto lower compliance (≥85% to <85% of possible sessions) indicated a likely beneficial 50% reduction in targeted injury burden.
This indicates that additional benefit can be achieved when theintervention is implemented in the majority of training sessions
and before matches.
The control exercises reflected normal ‘good practice’ for thislevel of rugby and consisted of dynamic stretching and non-targeted resistance exercises. Overall injury incidence in the control

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Targeted injuries

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group was 13.8 (90% CI 11.9 to 15.9) injuries/1000 player
match-hours, which is 18% lower than the incidence previously
reported for similar populations of adult men’s community
rugby players (16.9 injuries/1000 player match-hours; 90% CI
14.9–16.5).11 Control exercises may have offered better physicalpreparation for players than current ‘normal practice’, which is
supported by feedback from pilot study delivery agents (unpublished data; Attwood, 2017). Results may indicate that there is aneed to improve warm-up practices in this population.
Implementation in the ‘real-world’ setting is needed before
intervention effectiveness can be determined.36 The full potential of this intervention programme will only be realised if it isadopted, executed correctly and maintained36 37 by community
rugby clubs. The RFU has identified player welfare as a strategic priority and is ideally placed to disseminate the intervention to community rugby clubs in England with its employed,field-based workforce. However, this will not be without its
challenges and following nationwide dissemination, intervention programme effectiveness will need to be evaluated using the
RE-AIM framework.38

Strengths and limitations

Random checks of club compliance through unannounced visitswere not made, which would have increased the validity of
the compliance results. Regarding compliance, it was assumed
participants must ‘do as they are told’39 and thus completed theirprogramme in full as was designed. The efficacy of the intervention reflects reductions in musculoskeletal injury and concussion found in schoolboy rugby40 using a similar intervention.41 A
cluster randomised controlled trial reduces biases associated withthe results and the pragmatic, coach (delivery agent)-led delivery
approach increased the generalisability of the study results. Thiscoach-led, club-based warm-up intervention programme, which
included balance and proprioception exercises, resistance andperturbation exercises and sport-related landing, cutting andplyometric exercises, is efficacious in reducing overall targetedinjury and severe injury in adult men’s community rugby andshould be implemented nationwide.

Conclusion

This is the first cluster randomised controlled trial to examine
the efficacy of a movement control injury prevention programme
in adult men’s community rugby players. The intervention
programme demonstrated clear beneficial effects by reducing
concussion incidence by 60% and lower-limb injury incidenceby 40% compared with control. It is recommended that adultmen’s rugby players complete the intervention programme exercises prior to training and match play.
Acknowledgements The authors would like to acknowledge the input of the
project’s technical groups’ participants: Matthew Cross, Alasdair Dempsey, Carolyn
Emery, Michael Hislop, Tim Lawrenson, Richard Mack, Carly McKay, Katie Morris,
Simon Roberts, Des Ryan, Vincent Singh, Paul Tompkins, Evert Verhagen, Shaun
Williams.
Contributors KAS, GT, SPR and MEE initiated the overall project. MJA, KAS, GT,
SPR and MEE conceived and designed the study. MJA, KAS, GT and SPR collected
and analysed data. MJA prepared the first draft of the manuscript. All authors madesubstantial contributions to revision of the document prior to submission.
Funding This research is funded by the Rugby Football Union and the Private
Physiotherapy Education Fund.
Ethics approval Research Ethics Approval Committee for Health at the Universityof Bath.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are currently available.
Open Access This is an Open Access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work
is properly cited and the use is non-commercial. See: http://​creativecommons.​org/​
licenses/​by-​nc/​4.​0/© Article author(s) (or their employer(s) unless otherwise stated in the text of thearticle) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.

What are the findings?
►► This study is the first to demonstrate the efficacy of an injury

prevention exercise programme in adult men’s community
rugby.
►► Performing at least one movement control session per week
led to reduced injury rates.
►► Lower-limb injury, head and neck injury and concussion
were reduced, but shoulder injuries were increased in theintervention group undertaking exercises during warm-ups attraining and before matches.
►► Higher compliance with the intervention programme wasassociated with the greatest injury reduction.

How might it impact on clinical practice in the near
future?
►► The injury prevention exercise programme should be

performed prior to training and matches in all adult men’s
rugby union.
►► Given the evidence for the efficacy of this and similar
injury prevention exercise programmes, practitioners
should consider the content of the ‘warm-up’ and consider
employing the principles of these exercise programmes
regardless of which sport they are working in.
Attwood MJ, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-098005

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Attwood MJ, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-098005

Downloaded from http://bjsm.bmj.com/ on December 13, 2017 - Published by group.bmj.com

Efficacy of a movement control injury
prevention programme in adult men's
community rugby union: a cluster
randomised controlled trial
Matthew J Attwood, Simon P Roberts, Grant Trewartha, Mike E Englandand Keith A Stokes
Br J Sports Med published online October 21, 2017

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