On November 4th our own Marelise Badenhorst successfully defended her PhD thesis entitled “Life After the Game: Consequences of acute spinal cord injuries in South African rugby union players”. Her thesis combined quantitative and qualitative research methods to come to recommendations on how immediate and longer term care for these players can be improved. A summary of her work can be found below. For a full read, please follow this link for a pdf version (3 Mb).
Introduction
Rugby union is characterised by high-impact collision and associated injuries. Although serious injuries, such as spinal cord injuries (SCIs) are rare in rugby, the permanent nature of such an injury results in a life-altering event for the player and his family and remains a serious concern. The consequences of these injuries are worsened by the socio-economic disparities in South Africa, that affects many factors including the accessibility to adequate healthcare. Socio-economic disparities are also reflected in the rugby-playing society, where differences between playing facilities, level of coaching and medical assistance pose additional challenges for players from disadvantaged backgrounds. Little is known about the context in which these injuries occur and the effect of the injury on the players who sustain them. The overall aim of this thesis is to investigate the risk, immediate management and quality of life (QoL) of persons with acute spinal cord injuries within the South African rugby playing population.
Five objectives were investigated through multiple methodological approaches. The incidence of serious injuries was compared between the 14 rugby regions of South Africa. Three qualitative studies investigated the injury experience from the players’ perspective, the factors related to optimal immediate medical management, as well as the barriers and facilitators to healthcare in both the public and private healthcare sectors. Additionally, QoL and associated factors were investigated, by means of the International Classification of Functioning, Disability and Health (ICF) framework.
1. Are there differences in catastrophic injury incidence rates between the 14 South African Provincial Rugby Unions?
Yes, the different provincial unions presented with different incidence rates as well differences in proportional distributions of injuries (traumatic brain injuries and spinal cord injuries). The highest serious injury rate occurred in Boland and Griquas. However, Boland had the highest occurrence of SCIs that resulted in permanent disability. In contrast, the incidence of serious SCIs in Griquas was much lower. When looking at the types of injuries, Boland, Bulldogs, and Bulls had more permanent SCIs, while the Lions, Kings and Cheetahs had more traumatic brain injuries. This study has shown that all fourteen unions do not necessarily have the same level of associated risk for serious injuries. Ongoing research is important to ensure the effectiveness of rugby safety programmes and where support could be better tailored to specific rugby unions or teams. Understanding the available resources, barriers and areas of need that are specific to an area or teams, may further enhance rugby safety. Thus, these findings can be utilised by BokSmart to direct further investigations around injury patterns within high risk provincial rugby unions.
2. What are the experiences of players when sustaining a rugby-related acute spinal cord injury on the field?
Participants described the context around the injury incident, which may be valuable to help understand the mechanism of injury and potentially minimise risk. Players specifically described not being ready or being properly aligned in the scrum, not seeing the tackler before being tackled or tackling with incorrect technique. Participants also described certain contributing factors to their injury, which included descriptions of foul play and excessive aggression, playing in positions that they had not played in before, pressure to perform and being physically unprepared or unconditioned (weekend warriors). Participants described signs and symptoms of SCIs. Especially in amateur games and communities that have less resources and medical support, these signs and symptoms are important to recognise by fellow team mates, coaches and referees, as they are often the closest and first to respond to an injured player. Lastly, participants described the emotional experience which has important lessons for all first aiders or medics.
3. What are the barriers and facilitators to optimal immediate management of a rugby- related acute spinal cord injury?
These barriers and facilitators were investigated in the periods before and after the BokSmart Rugby safety program was implemented in South Africa. The most frequently reported barriers in the both the periods before and after BokSmart, were transportation delays after injury and admission to appropriate medical facilities capable of dealing with SCIs. Other barriers included incomplete sets of equipment and the quality of first aid care. Barriers were more prevalent in rural and lower socio-economic areas. This study showed how important it is for every team to have a specific action plan that includes the use of Spineline (as described in the BokSmart programme), information of the nearest appropriate hospitals capable of dealing with SCIs, the logistics of the ambulance’s entrance point to the field and sufficient background information on players. It also showed that these immediate management protocols should be monitored, to ensure that everyone involved knows what to do in case of a suspected SCI. Some areas and teams may need more support to ensure that they have the equipment and trained personnel that they need.
4. What is the current quality of life and factors associated with quality of life, among individuals with rugby-related SCI?
On average, these individuals with rugby-related SCI presented with higher QoL scores than other comparable SCI studies, which may be explained by the support received from a dedicated rugby welfare organisation. However, lower levels of participation and income, certain levels of education, increased health concerns and use of public healthcare were associated with lower levels of QoL. This study has also shown the importance of participation in activities or roles that is important to the individual and was found to be the most important component of QoL.
5. What are the barriers and facilitators to healthcare for individuals that have sustained a rugby-related SCI?
Participants described long-term, accessible, affordable, quality healthcare as an important contributor to their QoL. In the public system, quality of care, waiting time and availability of healthcare providers, transport and availability of stock were identified as the main barriers. In the private system, a good income acted as a facilitator, while the cost of private healthcare acted as barrier for both low and middle-income participants. Across both sectors, cost of health-related equipment and products, the awareness of health care professionals in dealing with SCI and information and education acted as barriers, while specialised spinal units, rehabilitation specialists and external funding sources acted as facilitators. The interactions between personal factors such as socio-economic status and environmental factors demonstrate that even though public healthcare is accessible from a cost point of view, quality of care and factors such as affordability and availability of adequate transport remain a barrier for lower socio-economic groups. This population was unique, as the support from a dedicated organisation enabled participants to overcome some healthcare barriers, highlighting the inadequacies of the healthcare system in maintaining the health of people with SCIs.
Conclusion
This thesis identified contextual factors surrounding the SCI injury itself, but also, importantly, within the management of such injury. These contextual factors may affect the effectiveness of injury prevention interventions and the outcome of the injury. Therefore, they should be considered when implementing injury prevention and management options in general and by BokSmart specifically. The findings show that certain regions and lower socio-economic status communities require tailored injury prevention and management interventions, that is context specific. Additionally, this thesis also provided insight into the long-term effects of the injury, which indicated that the healthcare needs and QoL of lower SES players once injured, are important interventions points.
This information is relevant for rugby stakeholders, who should further investigate the high- risk rugby regions, and contextual and contributing factors to injury. The immediate management interventions for players from lower socio-economic status and rural areas should be further investigated and addressed. Every effort should be made to address factors associated with decreased QoL and to create equitable access to healthcare for persons with SCIs. Although rugby-related SCIs are rare, all rugby stakeholders must remain cognisant of the far-reaching consequences of such an injury and as such, prevention of these injuries should remain a priority. However, the responsibility of player welfare should not stop at injury prevention, and every effort should be made to improve the quality and efficiency of the immediate medical management of these injuries, as well as the long-term health, welfare and QoL of these players once injured.