Original research

Craig Barden ‍ ‍,1,2 Matthew V Hancock,1 Keith A Stokes ‍ ‍,1,3 Simon P Roberts,1
Carly D McKay1,4► Additional supplemental
material is published online
only. To view, please visit thejournal online (http://d​ x.​doi.​org/1​ 0.​1136/b​ jsports-​2021-​
105170).
1

Department for Health,
University of Bath, Bath, UK
2
School of Sport and Exercise,
University of Gloucestershire,
Gloucester, UK
3
Rugby Football Union,
Twickenham, UK
4
Centre for Motivation and
Health Behaviour Change,
University of Bath, Bath, UK
Correspondence to
Craig Barden, Department for
Health, University of Bath, BathBA2 7AY, UK;c​ b2171@​bath.a​ c.​uk
Accepted 24 March 2022
Published Online First
6 April 2022

ABSTRACT
Objective The efficacious Activate injury prevention
exercise programme has been shown to prevent injuries
in English schoolboy rugby union. There is now a need toassess the implementation and effectiveness of Activatein the applie setting.
Methods This quasi-­experimental study used a 24-­hour time-­loss injury definition to calculate incidence(/1000 hours) and burden (days lost/1000 hours) for
individuals whose teams adopted Activate (used Activate
during season) versus non-­adopters. The dose-­response
relationship of varying levels of Activate adherence(median Activate sessions per week) was also assessed.
Player-­level rugby exposure, sessional Activate adoption
and injury reports were recorded by school gatekeepers.
Rate ratios (RR), adjusted by cluster (team), were
calculated using backwards stepwise Poisson regression
to compare rates between adoption and adherencegroups.
Results Individuals in teams adopting Activate had a
23% lower match injury incidence (RR 0.77, 95% CI
0.55 to 1.07), 59% lower training injury incidence (RR
0.41, 95% CI 0.17 to 0.97) and 26% lower match injury
burden (95% CI 0.46 to 1.20) than individuals on non-­adopting teams. Individuals with high Activate adherence(≥3 sessions per week) had a 67% lower training injury
incidence (RR 0.33, 95% CI 0.12 to 0.91) and a 32%
lower match injury incidence (RR 0.68, 95% CI 0.50 to0.92) than individuals with low adherence (<1 session
per week). While 65% of teams adopted Activate during
the season, only one team used Activate three times per
week, using whole phases and programme progressions.
Conclusion Activate is effective at preventing
injury in English schoolboy rugby. Attention should
focus on factors influencing programme uptake andimplementation, ensuring Activate can have maximal
benefit.

INTRODUCTION© Author(s) (or theiremployer(s)) 2022. Nocommercial re-­use. See rights
and permissions. Publishedby BMJ.
To cite: Barden C,
Hancock MV, Stokes KA,
et al. Br J Sports Med
2022;56:812–817.

Rugby Union (henceforth rugby) is a contact sport
played in English schools by over 500 000 young
people weekly.1 Rugby has come under scrutiny
at all levels of the game due to the reported injury
risk2–4 and the consequences such injuries may haveon player health.5 6 The Rugby Football Union(RFU; governing body for English Rugby Union)
has been promoting the Activate injury prevention exercise programme to reduce injury risk
in youth rugby. Activate is a 15–20 min warm-­up
programme, designed to be completed prior totraining and matches, with progressive, age-­specificprogrammes.7
Activate efficacy was assessed in a 2015
randomised controlled trial of 31 independent
schools (83 teams across under-­15/16/18 age
month season.7
groups) in England over a 4-­
Intention-­to-­treat analysis found an unclear effectof using Activate on overall match injury incidence (rate ratio (RR)=0.85) but lower upper-­limb
injury (RR=0.66) and concussion (RR=0.71) incidence. Per-­protocol analyses (≥3 times per week)found teams using Activate had 72% fewer overall
match injuries (RR=0.28), 72% fewer contact
injuries (RR=0.28), and 59% fewer concussions(RR=0.41) compared with teams in the control
group.7 However, only 16% of teams managed tocomplete Activate thrice weekly. This is concerning,as adherence rates in applied settings are likely to
be lower given the contextual barriers in successfully implementing sports injury prevention
programmes.8 This may partly explain why injury
rates have not dramatically reduced in various
sports settings despite considerable efforts in the
injury prevention field to make sport safer.9 10
Neuromuscular training programmes appear tohave a dose–response relationship with injury rates,with three sessions per week providing the greatest
preventative effect.11 This evidence is supported
by findings of the Activate efficacy study, where
teams with high compliance (≥3 times per week)
had significantly lower match injury incidence vsthose with low compliance (0–2 times per week;
RR=0.61).7 There is evidence that neuromusculartraining programmes provide a preventative effectwhen completed once or twice per week.11 12 In
the Activate efficacy trial, teams with these levelsof compliance were clustered with those with zerocompliance, and the preventative effect of one-­two
sessions per week was not assessed.7 A recent surveyof English schoolboy rugby coaches reported that
adopting teams used Activate twice per week.13
Therefore, evaluating the effect of varying levels
of weekly dosage would empower end-­
users tomake an informed decision regarding their Activate
adherence.
The primary objective of this study was to assess
the effectiveness of Activate to lower match andtraining injury rates (incidence and burden) in
schoolboy rugby union (under-­12 to under-­19).
The secondary objective was to examine the dose–
response relationship between weekly Activate
adherence and injury incidence.

Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170   1 of 7

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Effectiveness of the Activate injury prevention
exercise programme to prevent injury in schoolboy
rugby unionOriginal research

Schoolboy rugby teams (under 12 to under 19) were invited tojoin the study through an email sent to their Head Coach or
Director of Rugby/Sport in June–August 2019. School names
were taken from the RFU competitions website, with contact
email addresses sought online.
Participants, players from school teams who had agreed toparticipate in the project, completed an electronic assent form
(http://www.onlinesurveys.ac.uk), with parental consent for
those under the age of 18 years old.

Activate

Activate is a warm-­up exercise programme designed to be used
three times per week prior to rugby training and matches. There
are three age-­
specific programmes (under-­15/16/18) incorporating balance, resistance and plyometric exercises, eachcontaining four phases to be progressed throughout the season(every 4–8 weeks).14 Activate was disseminated by the RFU in2017 following the publication of the efficacy study.7 Coaches
could access resources freely through the RFU website andattend regional workshops delivered by RFU community rugby
coaches, who received specific Activate training.15 In 2018, allresources became available open access and workshops were
replaced by a ‘workshop on demand’ system. These implementation and dissemination strategies, including the workshops, wereconducted by the RFU external to this study.

Data collection

Gatekeepers (generally the head coach) were provided with abespoke excel worksheet to collect their teams’ rugby attendance, rugby exposure (minutes), injury data and Activate use
throughout the season (July–September 2019 to December
2019–April 2020 depending on school and competitions). Operationalised definitions are presented in table 1.
Player-­level data were collected, allowing direct analysis
between individual exposure and injury risk.16 Team training
duration for each session was matched with session attendanceregisters, where gatekeepers recorded which players participated

Table 1

Operationalised study definitions

Terminology

Operationalised definition

InjuryAny injury resulting in the individual being unable to take partin full rugby activities for >24 hours from midnight after the
day the injury occurred19 37

Injury severity

Days lost starting from the day after they were unable toparticipate to when they were fully available for training or
match play38

Injury incidence

Injuries per 1000 player-­hours of rugby (training or match)
exposure19

Injury burden

Injury incidence × injury severity=days lost per 1000 player-­hours of rugby (training or match) exposure38

Adoption

Activate used in a team rugby session at least once during thestudy period (self-­reported ‘yes/no’ by the gatekeeper)Non-­adoption

Activate was not used in a team rugby session at all during
the study period (self-­reported ‘yes/no’ by the gatekeeper)

Adherence

Individual median no. of Activate sessions completed per
week

Cumulative
utilisation

Percentage of team rugby sessions Activate was used at26

Utilisation frequency Mean no. of team Activate sessions per week26
Utilisation fidelity

2 of 7

Mean no. of Activate exercises used per team session26

in each session, to record player training exposure. Individual
match exposure was calculated by dividing overall player
minutes (players on the pitch x match duration) and divided by
the number of players marked as present.
Activate adoption was self-­reported by the gatekeeper for every
training session and match (dichotomous: ‘yes/no’). Adopting
teams recorded which exercises were used for each session, withno minimum threshold to determine whether a team used theprogramme. No information regarding exercise parameters (setsand reps) or exercise fidelity (performing exercises competently)
was recorded. Median weekly Activate adherence was calculated
by cross-­referencing attendance registers and the team’s Activate
use for that session. Participants were not instructed whether to
use Activate. Instead, this type 1 effectiveness-­implementation
study17 observed end-­
users voluntarily using Activate (ie, no
implementation strategy was involved in the study). No training
was provided to participants outside of the RFU resources available to all coaches nationwide.
The injury report form detailed: player name, injury date,return to full participation (deemed so by the gatekeeper),training/match, mechanism, body location, injury type. Specificinjury diagnoses were not recorded except for suspected concussions where, as per RFU policy,18 any player suspected ofsustaining a concussion must be removed from play and stood
down for a minimum time prior to returning to play after clearance by a medical professional. Prepopulated categories forinjury mechanism, location and type, were used on the worksheet to ensure consistency of data collection.19
Missing attendance registers were imputed using a last observation carried forward method (408 missing registers/25 318
exposures=2%).20 No individuals had more than 10% of theirattendance registers missing and thus all records were retained
for analysis. Exposure for injured individuals participating in
training prior to their recorded return to play date were notincluded in the analysis until after they were cleared to return.
This was to create consistency as those injured might be training
but were likely imposed with training restrictions prior to
returning to play. If an individual was injured but the severity
was unknown (due to the season ending (n=19) or missing data(n=1)) they were not included in any subsequent analysis after
the injury date. Sessions missed due to injury were not included
when calculating adherence.

AnalysisAnalysis was completed using Microsoft Excel (V.16.0) and Stata(V.16.0). For the primary research question, individuals weregrouped by their team’s Activate adoption or non-­adoption.
For the secondary research question, individuals were groupedby their median weekly Activate adherence throughout theseason (low= <1 session per week, medium= 1 to <3 sessions,high=≥3 sessions). The low adherence group included all individuals from teams in the non-­adoption group with zero Activate adherence, plus those from the adoption group with low
adherence.
Injury incidence (injuries/1000 player-­hours) and injury
burden (days lost/1000 player-­hours), presented with 95%
CIs, were estimated for each group using backwards stepwise
Poisson regression, adjusted for cluster (team). Predictor variables included Activate adoption/adherence and playing age
group. Incidence and burden RRs were calculated using thesame method, with the non-­adoption group the referent for the
primary research question and the group with lower adherence
Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

Br J Sports Med: first published as 10.1136/bjsports-2021-105170 on 6 April 2022. Downloaded from http://bjsm.bmj.com/ on November 29, 2022 by guest. Protected by copyright.

METHODS
Recruitment and participantsOriginal research

the referent for the secondary research question. Statisticalsignificance was set at p<0.05.

Sample size

A sample size calculation was performed for the primaryresearch question, using a significance level of 0.05 and power of
80%.21 Injury incidence (34.3/1000 hours), mean cluster (team)size (n=24 players) and individual rugby exposure (9 hours)
were based on previous data collected from the same playing
cohort.22 A 40% lower injury incidence was estimated from ameta-­analysis investigating neuromuscular training programmes
and injury risk.11 As such, the number of teams required per arm
was 14. Anticipating each school would have two teams, thestudy required nine schools per arm. Using a conservative estimated drop-­out rate of 60%, 22 schools were needed.

RESULTS

In total, 289 schools were emailed to join the study (figure 1).
Fifty-­seven schools agreed to participate, with 15 dropping out
during the data collection phase and a further 22 schools notproviding data at the end of the season (likely due to COVID-­
19). Data were received from 20 schools (41 teams), with 7
schools (16 teams) subsequently excluded due to providing
incomplete datasets, predominately a failure to record individual
exposure (online supplemental file 1). Consequently, 13 schools(25 teams, 659 players) were included in the study.

COVID-19

The school rugby season was affected by COVID-­19 in March
2020, when the season was abruptly terminated due to a
Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

lockdown. Most schools that finished playing in December 2019
had already provided their datasets; however, after this point
many gatekeepers were unreachable and did not provide data,
being classified as study drop-­outs.

Activate implementation

Of the 25 teams included in the study, 16 adopted Activate
during the season. Of these 16 teams, 2 did not record which
exercises they used for each session and are excluded fromthis implementation section. Cumulative utilisation was 98%,
with thirteen teams using Activate at all sessions and one teamusing Activate at 70% of sessions. Adopting teams had a meanutilisation frequency of 3.2 Activate sessions per week (range
2.1–4.0) and a utilisation fidelity of 9.8 Activate exercises persession (range 4–15). Only four teams used Activate phases intheir entirety, with the remaining using exercises from various
phases. Half of the teams progressed the programme throughout
the season, but only two used exercises from phases 3 or 4. Only
one team implemented Activate three times per week, using eachphase in its entirety, while progressing the phases throughout
the season.

Activate adoption

Individuals from teams adopting Activate (n=16) amassed 16 853
player-­hours, sustaining 84 injuries (table 2). Individuals fromnon-­adopting teams (n=9) recorded 7828 player-­hours and 58
injuries. Individuals in teams adopting Activate had a 23% lower
match injury incidence (figure 2) and 59% lower training injury
incidence compared with non-­adopting teams (p<0.05). Match
injury burden was 26% lower in the adopting group. Descriptive
3 of 7Br J Sports Med: first published as 10.1136/bjsports-2021-105170 on 6 April 2022. Downloaded from http://bjsm.bmj.com/ on November 29, 2022 by guest. Protected by copyright.

Figure 1 Flow diagram highlighting the recruitment process, study participation and the impact of COVID-­19 on retention.

Original research
Descriptive statistics by Activate adoption
Activate adoption
Outcome measure

Yes

No

Schools

10

3

Teams

16

9

Team age group––

Under 12–14

2

3

Under 15–16

52

Under 17–19

94

Players

412

247

Mean age (years±SD)15.9 (±1.6)15.0 (±2.0)

Training

13 737

6304

Match

3116

1524

Training

25

18

Match

9

8

Median rugby sessions per Overall
week

3

2

Mean session attendance(%, range)

Overall

86%(10%–100%)80%(13%–100%)

Median weekly Activate
adherence

Overall

30Injuries (n)Training

10

11

Match

74

47

Median sessions to first
injury (n, range)

Overall15(1–82)

10(1–46)

Injury incidence
Injuries per/1000 hours*(95% CI)

Training

0.7(0.2 to 1.3)

1.8
(1.0 to 2.5)

Match

23.3
(17.9 to 28.7)

30.9(24.2 to 37.5)

Injury severity
Days lost(95% CI)

Training

50(27 to 93)

27(15 to 49)

Match

32
(25 to 40)

31(23 to 41)

Injury burdenDays lost/1000 hours*(95% CI)

Training

28(3 to 52)25
(11 to 59)

Match

660
(412 to 901)

887(600 to 1173)

Participating

Total exposure (hour)
Mean sessions per season(n)*Rate adjusted for playing age group and cluster (team).

information relating to injury types and mechanisms is presented
in online supplemental file 2.

Activate adherence

Individuals with high Activate adherence (≥3 sessions per week)
had a 67% lower training injury incidence (p<0.05; figure 3)
and 32% lower match injury incidence (p<0.05) than individuals

Figure 3 Training and match incidence rate ratios (RRs) (adjusted
for playing age group and cluster (team)) per Activate adherence level.
RR<1 favours the group with greater adherence. *p<0.05
with low adherence (<1 session per week). Descriptive statistics
by adherence groups is presented in table 3.

DISCUSSION

This is the first study to investigate the effectiveness of the Activate injury prevention exercise programme to prevent injuries inschoolboy rugby union. Individuals playing for teams adopting
Activate had a lower match and training injury incidence whencompared with those not using Activate. Individuals with highweekly Activate adherence (≥3 Activate sessions per week) had
a lower match and training injury incidence than those withlow adherence (<1 Activate session per week). Activate appears
effective at lowering injury risk in schoolboy rugby union, withmaximum benefit when completing the programme three times
per week.

Activate implementation

Two-­thirds of teams adopted Activate during the season, which is
positive as more established sports injury prevention programmes
have been hampered by poor programme uptake.23–25 Adopting
teams reported high cumulative utilisation (adopting Activate at
98% of sessions) and utilisation frequency (mean 3.2 Activatesessions per week). This level of implementation is surprising,as coaches from a similar cohort reporting only using Activate
twice per week.13 Utilisation fidelity varied (mean 9.8 exercises
per session), with some teams only using four exercises persession and only two teams using whole phases. Most teams
modified the programme content, which is commonplace inthe sports injury prevention literature.26–28 Modifications to theprogramme and its delivery may be necessary to ensure Activate
can be successfully used in a school context, where time, expertise and facilities are known barriers to implementation.13 29 30
However, the extent to which programmes can be modified
before losing their preventative effect is unknown and an areafor future research.

Activate adoption

Figure 2 Incidence and burden rate ratios (RRs) (adjusted for playing
age group and cluster (team)) by Activate adoption group. RR<1 favours
the adoption group. *p<0.05.
4 of 7Significantly different training injury incidence was found whencomparing individuals by their team’s Activate adoption. Furthermore, the RR point estimates for match incidence and burden
are clinically relevant, advocating Activate use in the applied
setting. There is strong evidence that neuromuscular training
programmes provide preventative effects in a variety of youth
sports,11 31 including rugby.7 32 However, programmes are often
evaluated in randomised controlled trials33 and this study is oneof the first studies to assess the effectiveness of a neuromusculartraining programme after efficacy has been established. This isBarden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

Br J Sports Med: first published as 10.1136/bjsports-2021-105170 on 6 April 2022. Downloaded from http://bjsm.bmj.com/ on November 29, 2022 by guest. Protected by copyright.

Table 2

Original research
Descriptive statistics by median Weekly Activate adherence groupMedian weekly activate Adherence
Outcome measures

Low (<1)Medium (1-<3)

High (≥3)

n

256

115

288

Mean Age (Years,±SD)15.1 (±2.0)

16.1 (±1.4)15.6 (±2.0)

Total exposure

Training

6350

2727

10 964

(h)

Match

1535

704

2401

Mean sessions completed over season (n)Training

17

16

29

Match

7

7

10

Median weekly rugby sessions (n)Overall22

3Mean session attendance (%, range)

Overall

78% (10%–100%)73% (33%–100%)94% (68%–100%)

Median weekly Activate Adherence

Overall023Injuries

Training

11

3

7

(n)

Match

47

19

55

Median rugby sessions to first injury (n, range)

Overall

10 (1–46)

8 (1–17)

16 (3–82)

Injury incidence: Injuries per/1000 hours*(95% CI)

Training

1.9 (1.1 to 2.7)

0.8 (0.4 to 2.0)

0.6 (0.0 to 1.2)

Match

31.3 (24.7 to 37.9)

28.8 (9.5 to 48.1)

21.7 (16.8 to 26.6)

Injury severity: Days lost
(95% CI)

Training

27 (15 to 49)

66 (21 to 205)

40 (19 to 84)

Match

31 (23 to 41)

37 (24 to 58)

30 (23 to 39)

Injury burden: Days lost/1000 hours*(95% CI)

Training

17 (5 to 29)

23 (0 to 65)

8 (1 to 15)

Match

909 (600 to 1173)

991 (67 to 1915)

569 (384 to 754)

Participants*Rate adjusted for playing age group and cluster (team).

important, as efficacious intervention are not guaranteed to beeffective in an applied environment, due to contextual barriers
which are not present in controlled studies.8 While there is aneed to assess Activate effectiveness in other populations, especially as the programme has been disseminated worldwide, focus
on English schoolboy rugby should be on improving Activate
implementation to ensure the programme can provide maximum
benefit nationwide.

Activate adherence
Individuals adopting Activate had a median weekly adherence of
three sessions per week, which is an improvement over the 16%of teams in the original efficacy study that managed to maintainthis level of exposure.7 The results confirm a dose–response relationship between adherence and injury incidence, with significantly lower training and match injury incidence found in thehigh adherence group compared with the low adherence group.
This is consistent with a meta-­analysis of neuromuscular training
programmes that showed maximum benefit is achieved withthree sessions per week (RR 0.40, 95% CI 0.31 to 0.53), andsmaller preventative effects when completed twice per week (RR
0.50, 95% CI 0.29 to 0.86).11 Using Activate thrice weekly isstrongly advocated to have maximum effect, but if that cannot
be achieved, end-­
users are encouraged to use Activate once
to twice per week to reduce injury risk. Completing Activate
outside of a rugby environment and away from the pitch may
increase Activate exposure. A recent study investigating the 11+
found removing strengthening exercises from the warm-­up andusing them postsession improved adherence without negating
preventative effects.34 A similar approach for Activate would
reduce the time needed to complete a warm-­up, overcoming acommonly reported barrier from rugby coaches.13 However, if
exercises have an acute preactivation effect, they may need tobe completed immediately prior to rugby exposure. The mechanistic effect of Activate has not been evaluated and this should
be investigated prior to advocating this approach.
Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

Limitations
To mitigate selection bias, the extensive recruitment databaseincluded all schools playing in RFU competitions and others forwhich contact details could be found. In an attempt to improve
the representativeness of the study, in comparison to the efficacy
study,7 which only included under-­15 to 18-­year-­old independent schoolboy rugby teams, government funded state schools
12 towere invited and the age range was increased (under-­under-­19). Despite more state schools than independent schools
being invited, a larger number of the latter participated in the
study, likely reflective of being better resourced to dedicate timeto the study and record the required information. This limits thegeneralisability of these results in this context. Furthermore, it
is unclear whether these results are generalisable to a schoolgirl
rugby population, where the aetiology and pathology of injury
is largely unknown but likely different from schoolboy rugby
players.
The number of schools recruited in preseason (n=57)
exceeded the required amount based on the sample size calculation (n=44). This study was a substudy of a longitudinal injury
surveillance project,22 which used team-­level exposure, and 15
teams were excluded as they did not record individual-­level
exposure required for this study. The season ended abruptly inMarch 2020 due to COVID-­19 and 22 participating schools
were unreachable after this point. The study is, therefore, likely
underpowered and there is a risk of type II error when comparing
results between groups.
Activate adoption and adherence was self-­reported by gatekeepers. This information was not verified as it was not permitted
to attend school sites to observe sessions. To mitigate reporting
bias, Activate was not used in any recruitment correspondence
and the aims of the study were not advertised to participants,
instead focusing on the injury surveillance aim of the wider
project. However, reporting bias and recall bias might explain
the higher than anticipated levels of adherence and cumulative
utilisation in comparison to similar studies.13 26
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Table 3

Original research

CONCLUSION

Individuals adopting Activate had a significantly lower
training injury incidence than non-­a dopters, with point
estimates suggesting lower match incidence and burden.
Participants completing Activate three times per week hadsignificantly lower training and match incidence comparedwith those with low (<1 session) weekly adherence. Two-­thirds of teams adopted Activate, with most completing Activate three times per week. However, Activate was often not
implemented as intended, with teams not using whole phases

Key messages
What is already known?
⇒ A randomised controlled trial found Activate to be efficacious
in reducing injury risk in schoolboy rugby union.
What this study adds?

⇒ Activate is effective at lowering youth rugby injury risk in theapplied setting.

⇒ Individuals with high Activate adherence (3+times per week)

had significantly lower training and match injury incidence
than those with low adherence (<1 time per week).

How might this research affect research, practice orpolicy?
⇒ Providing knowledge of Activate effectiveness can be used topromote greater adoption and adherence among end-­users.
⇒ Establishing Activate effectiveness means research should
now focus on maximising implementation.
6 of 7

or failing to progress the programme. Engaging end-­users to
explore barriers to Activate use is integral to understanding
how implementation can be maximised and schoolboy rugby
made safer.
Twitter Craig Barden @cigney, Keith A Stokes @drkeithstokes, Simon P Roberts@drsimonroberts and Carly D McKay @Dr_CMcKay
Acknowledgements The authors would like to thank all the schools, coaches andplayers who participated in this study.
Contributors CB, CDM and KAS devised the initial concept of the study, with
MVH and SPR providing advice and guidance. CB and MVH completed all the datacollection and data cleaning. CB analysed all the data. CB wrote all manuscript
drafts, with critical appraisal from CDM and KAS. All authors approved the final
version of the manuscript ready for submission. CB is listed as the guarantor for the
study.
Funding CB completed this study as part of his PhD, which is funded by the Rugby
Football Union.
Competing interests KAS is the medical research lead for the Rugby Football
Union.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval The study had ethical approval from the Research Ethics ApprovalCommittee for Health at the University of Bath (EP 17/18 167).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. All publicly available data
are available in the manuscript or online supplemental files. It is not possible toshare further information, individual injury and exposure data, due to its confidential
nature and the age of the participants.
Supplemental material This content has been supplied by the author(s).
It has not been vetted by BMJ Publishing Group Limited (BMJ) and may nothave been peer-­reviewed. Any opinions or recommendations discussed aresolely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all
liability and responsibility arising from any reliance placed on the content.
Where the content includes any translated material, BMJ does not warrant theaccuracy and reliability of the translations (including but not limited to local
regulations, clinical guidelines, terminology, drug names and drug dosages), andis not responsible for any error and/or omissions arising from translation andadaptation or otherwise.
ORCID iDs
Craig Barden http://orcid.org/0000-0001-5504-2548
Keith A Stokes http://orcid.org/0000-0002-5049-2838

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5 Hind K, Konerth N, Entwistle I, et al. Cumulative sport-­related injuries and longer term
impact in retired male Elite- and Amateur-­Level rugby code athletes and non-­contact
athletes: a retrospective study. Sports Med 2020;50:2051–61.
6 Davies MAM, D Judge A, Delmestri A, et al. Health amongst former rugby union
players: a cross-­sectional study of morbidity and health-­related quality of life. Sci Rep
2017;7:11786.
7 Hislop MD, Stokes KA, Williams S, et al. Reducing musculoskeletal injury andconcussion risk in schoolboy rugby players with a pre-­activity movement control
exercise programme: a cluster randomised controlled trial. Br J Sports Med
2017;51:1140–6.
8 Hanson DW, Finch CF, Allegrante JP, et al. Closing the gap between injury prevention
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Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

Br J Sports Med: first published as 10.1136/bjsports-2021-105170 on 6 April 2022. Downloaded from http://bjsm.bmj.com/ on November 29, 2022 by guest. Protected by copyright.

Warm-­
up strategies employed by non-­adopting teams was
not investigated as it was not deemed feasible to ask coaches torecord their individual warm-­up strategies. School rugby coaches
specific warm-­
have demonstrated knowledge that a rugby-­up, and certain components such as balance and strength, canlower rugby injury risk.13 35 If non-­adopting coaches possess thisknowledge and used similar exercises to those contained within
the Activate programme, it may have diminished any difference
between the groups.
Various confounders may influence an individual’s injury
risk, including previous injury, playing position, playing
experience and physical characteristics.36 A preseason
survey was developed to capture this information to allow
the results to be adjusted for covariates. Unfortunately, theage of the participants meant it was not possible to contact
them directly and surveys were sent to their gatekeepers topass on. The response level was inadequate, and the limited
returned information was insufficient for analysis. In thispopulation, playing age group is likely related to many ofthese confounders. For example, older players will likely
have a greater playing experience, injury history, and havemore mature physical attributes in comparison to younger
players. Playing age group was accounted for, partially mitigating the omission of these collinear variables, but their
independent effects could not be assessed. Training load
may also be a confounder for injury risk, although this has
not previously been explored in a youth rugby population.
In this study, those adopting Activate had a greater training
exposure than non-­adopters. It is unclear whether this is due
to fewer injuries resulting in greater training exposure, or
possibly greater training exposure resulting in a protective
effect for injury.

Original research

Barden C, et al. Br J Sports Med 2022;56:812–817. doi:10.1136/bjsports-2021-105170

24 Donaldson A, Callaghan A, Bizzini M, et al. Awareness and use of the 11+ injury
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BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceplaced on this supplemental material which has been supplied by the author(s)Supplemental material

Br J Sports Med

Supplementary File 1. Breakdown of schools (age group and type of school) submitting and data, what data theysubmitted and whether they were included/excluded in the study.

School
ID

Team
Age

School Type

001
002
002
003
004
005
005
006
007
007
007
008
008
009
010
011
011
011
012
012
012
012
013
014
015
015
016
017
017
017
017
017
017
017
017
017
018
018
019
020
020

U18
U18
U15
U18
U18
U15
U18
U18
U13
U15
U18
U15
U18
U18
U18
U13
U15
U18
U13
U14
U15
U18
U18
U18
U15
U18
U18
U12A
U12B
U13A
U13B
U14A
U14B
U15
U16
U18
U18A
U18B
U15
U15
U18

Independent
Independent
Independent
State
State
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
State
State
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
Independent
State
State
Independent
State
State

Recorded….
Exposure

Individual
Level Data

Training

Match

Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No

Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes

Activate
Non/Use
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No

Injuries

Included/
Excluded

No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes

Excluded
Included
Included
Included
Excluded
Included
Included
Included
Included
Included
Included
Excluded
Included
Excluded
Excluded
Included
Included
Included
Excluded
Excluded
Excluded
Excluded
Excluded
Included
Included
Included
Included
Excluded
Included
Included
Excluded
Included
Excluded
Included
Excluded
Included
Included
Included
Included
Excluded
Excluded

Barden C, et al. Br J Sports Med 2022;0:1–7. doi: 10.1136/bjsports-2021-105170

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceplaced on this supplemental material which has been supplied by the author(s)Supplemental material

Br J Sports Med

Supplementary Content 2. Targeted Injuries
Descriptive statistics [frequency, incidence, 95% CI] are reported for targeted match injuries(upper and lower limb, contact and non-contact mechanisms, concussion diagnoses and softtissue injuries) by Activate adoption group and adherence levels. Targeted injuries were preidentified based upon findings of the Activate efficacy study[1] and epidemiological literaturein schoolboy rugby[2, 3].
Table 4. Unadjusted match injury incidence (per 1000 player match-hours) of targetedinjuries by Activate adoption and adherence groups.

Sub-Groupn
Lower Limb

23

Upper Limb

16

Contact

56

The Tackle

41

Concussion

24Soft-Tissue

26

Activate Adoption
Yes
No
Incidence
Incidencenp/1000hp/1000h
7.4
11.2
17(4.9-11.1)(7.0-18.0)
5.1
5.3
8
(3.1-8.3)(2.7-10.6)
18.0
24.3
37
(13.9-23.4)(17.6-33.5)
13.2
17.1
26
(9.7-17.9)(11.6-25.1)
7.7
8.5
13
(5.2-11.5)(4.9-14.6)
8.3
17.1
26
(5.7-12.2)(11.6-25.1)

n
17
8
37
26
13
26

Median Weekly Activate Adherence
Low
MediumHigh
Incidence
Incidence
Incidencennp/1000hp/1000hp/1000h
11.1
11.4
6.2
8
15
(6.9-17.9)(5.7-22.8)(3.7-10.3)
5.2
7.1
4.6
5
11
(2.6-10.4)(3.0-17.1)(2.5-8.3)
24.1
21.3
17.1
15
41
(17.5-33.3)(12.8-35.3)(12.6-23.2)
16.9
12.8
13.3
9
32
(11.5-24.8)(6.7-24.6)(9.4-18.8)
8.5
4.3
8.7
3
21
(4.9-14.6)(1.4-13.3)(5.7-13.3)
16.9
11.4
7.5
8
18
(11.5-24.8)(5.7-22.8)(4.7-11.9)

NOTE: n = total injures per sub-group. Lower limb = hip/groin, thigh, knee, lower leg, ankle,
foot; Upper limb = shoulder, elbow, forearm, hand/wrist; Contact = accidental collision,
lineout, maul, ruck, scrum, tackled, tackling; Soft tissue = bruising/haematoma,
cut/abrasion, ligament sprain, muscle injury, tendon injury.
References1.
Hislop MD, Stokes KA, Williams S, et al. Reducing musculoskeletal injury andconcussion risk in schoolboy rugby players with a pre-activity movement control exercise
programme: a cluster randomised controlled trial. Br J Sports Med. 2017;51(15):1140-6. DOI:
10.1136/bjsports-2016-097434.
2.
England Rugby. Youth Rugby Injury Surveillance and Prevention Project. Season
Report 2019-20. 2021. [ 22nd October 2021]. Available from:https://www.englandrugby.com/dxdam/c0/c00b1760-d51a-4159-b815f561f12f316d/YRISP%20Report%2019-20.pdf.
3.
Leahy TM, Kenny IC, Campbell MJ, et al. Injury surveillance in school Rugby: A
systematic review of injury epidemiology & surveillance practices. Phys Ther Sport.
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Barden C, et al. Br J Sports Med 2022;0:1–7. doi: 10.1136/bjsports-2021-105170