Ep 265: Helping girls rule the rugby world, with Dr Isla Shill

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. The sport of rugby is seeing consistent growth in popularity and participation. And it's no secret that

[00:00:29] women's sport is also growing rapidly. Put both of those together and you enter the exciting and rapidly developing area of women's rugby. Now, of course, with playing sport comes inherent risk for injury, and I think you'd have to have been living under a rock to have missed the increasing attention, research, clinical, media and legal, that concussion has had in contact sports, including in rugby. My guest today knows the field inside out as a player,

[00:00:57] a coach and a researcher. Dr Isla Shill started her research work in injury prevention in girls rugby as a member of the University of Calgary's Sport Injury Prevention Research Centre, which is an IOC Centre for the Prevention of Injury and Protection of Athlete Health, led by Professor Carolyn Emery. Dr Shill is continuing her research work as a postdoctoral research fellow in sport injury and

[00:01:21] illness epidemiology at the University of Victoria in British Columbia, Canada. Today, we discuss some of her recent work in neuromuscular training programs for preventing injury, including concussion, in girls rugby. We chat about the key components and what it takes to implement an effective injury prevention program. Dr Isla Shill, welcome to JWSPT Insights. Hello.

[00:01:46] Ila, your work has had a big focus on preventing or at least reducing injuries in girls and women's rugby. And for people who don't know much about rugby, let's start today's discussion explaining the sport and explaining the typical injuries clinicians and athletes are likely to face and to want to prevent in rugby. Rugby is a collision-based sport, full contact. There are different codes.

[00:02:14] So you'll see rugby sevens, rugby union 15s, there's rugby league. I guess specifically towards my research, we lean towards rugby union 15s, but there's different types out there based on number of players, how long the games are, all those kinds of pieces. But in the typical 15s game, it's two 40-minute halves and the teams are trying to score a try in the opposing end goal.

[00:02:42] And the defending team uses a tackle to impede the progress of the attacking team. With the different injuries we will see, so concussion's a big one. We do see lower extremity injuries, knee injuries. When you hear full contact and people's minds are probably going to go directly to concussion and also knowing that it's a multi-directional sport, so the knee injury sticks out.

[00:03:08] But I guess particularly with the tackling, anything else that is common? Given the collision nature of the sport, most of the injuries are contact-related, unsurprisingly, and most of them stem from the tackle event. In the tackle event, we have the tackler, so the person that's initiating the contact, and then we have the ball carrier, so the person that's receiving the contact. Depending on the setting, you might see that the tacklers are at a higher rate of injury or concussion,

[00:03:36] rate of concussion, or you might see the ball carrier. We've kind of seen there's a bit of fluctuation depending on if we're looking at a younger group versus an older group. We're still teasing that apart a bit more. And given the nature of the tackle, when the tackler engages in it, they use their shoulder, so we do see a lot of shoulder injuries as well. The tacklers are typically aiming, we'll call it kind of mid-thigh to like torso range.

[00:04:02] So given that area and the engagement with the shoulder, if they slide further down, we might see some knee injuries in that general area. I was going to ask you, for people who have not seen a rugby game or are not as familiar, there are rules. So perhaps explain the rules a little bit about where people can or are supposed to aim their tackles. Typically, we'll have one ball carrier and then one or more tacklers. So it's not to say more than one tackler can't join the event.

[00:04:33] Right now, there is a legal tackle height, so obviously no head contact. And a really hot topic in the concussion, injury prevention, rugby space is where the height of the legal tackle sits. Historically, it's been at the line of the shoulder, but there's been a lot of movement towards pushing it down to the base of the sternum. So World Rugby made a recommendation, kind of promoted doing a base of sternum legal tackle height. So basically base of sternum lower.

[00:05:00] So now different international unions are trying to bring that on board or phase it in as they see fit. And I mentioned at the top, you focus very much on girls and women's rugby. What do we know about the injury mechanisms, injury prevalence estimates for girls and women versus boys and men in rugby? We have seen a higher rate of concussion in the girls and women's space.

[00:05:24] So some of my work in the high school girls setting, the girls did have a notably higher rate of concussion compared to their boy counterparts. And we think it's probably attributed to something in the tackle event. So then another piece of my work was really looking at breaking down the tackle characteristics to see what created the higher odds of concussion when considering non-concussive tackles. Interesting. And a lot more work obviously needs to happen in this space.

[00:05:49] And it feels like that's a constant refrain when we talk about girls and women's sport in particular, that there's just so underrepresented. So one of the many reasons why your work is so important, which is a nice segue into talking about how is it that you got into this area, Isla? People who were in the rugby space know that Canada in women's rugby in particular is incredibly strong. One has been a very strong team for a long time now. What got you into this sport and into this area of injury prevention?

[00:06:19] I come from a playing and a coaching background, actually. So I completed my undergraduate degree at the University of Calgary in kinesiology. But while I was completing my degree, I was also a varsity athlete with the University of Calgary Dinos. So I played on the women's varsity rugby team. I played out my five years of eligibility as youth sport athlete.

[00:06:41] And then towards the end of my undergraduate degree, I had a friend that was completing her master's in the sport injury prevention research center with Professor Carolyn Emery. And at the time, there was some funding available to bring on a thesis-based master's student to support injury surveillance work, which was supposed to be a pilot project in the Calgary High School Rugby setting. And this would have been 2018, 2019. And I said, sure, why not?

[00:07:09] It's a fun space to be in. It's cool that I get to work in an environment that I played in. And I was coaching high school girls at the time as well. My master's really looked at injury epidemiology in the girls' high school rugby setting from that pilot work. And then we also looked at how a neuromuscular training warm-up workshop changed high school coach behavior to better understand what their injury and concussion prevention practice was.

[00:07:39] We were supposed to evaluate originally the neuromuscular training warm-up workshop in 2020. March 2020, we rolled out all the workshops and we had really good buy-in from coaches. And then everyone knows what happens. But then there was more funding to continue the work into a PhD. And I just said, yes, why not? I love what I do. I'm really interested in the field and the environment. I'm enjoying having a kind of unique perspective from a player, coach, and researcher standpoint.

[00:08:09] We got to fully evaluate the neuromuscular training warm-up program at that point. And then we also embarked on some video analysis work to better understand type of characteristics and mechanisms in the high school girls. Wow. It's a great story. It's also really lovely to bring those different – as you talk about the different hats together of being an athlete, being a coach, and being a researcher. Because you look at things from different perspectives with each of those different hats on.

[00:08:34] Let's talk about some of the key messages that are coming out from the work you've been doing and others have been doing focusing on injury prevention in girls' and women's sport, particularly in rugby. What are the key messages you'd like to share with clinicians who are listening to us today? What do you suggest they think about when they're designing and implementing these types of injury prevention programs to help girls and women stay healthy and keep performing well in their sports?

[00:09:02] I think a lot of people listening and a lot of people in this space do know that we still don't have enough research is the big one. So when we're thinking about implementing designing programs, I think the first piece ultimately is to have a solid basis of injury surveillance and a solid basis of understanding of risk factors and kind of the injury profile. With girls' rugby as an example, I think we're starting to scratch the surface a bit and better understand what's happening. It's really important to integrate an athlete voice into it.

[00:09:32] So a lot of the research we have and evidence we have in the space is in this boys-men setting. And there is evidence to suggest it works, but we need to translate that now into a woman and girl's place. So I think integrating an athlete, a girl or woman athlete voice into the development or redevelopment of these programs to better understand if it suits these athletes is always the first step moving forward, I would say at this point. Yeah, absolutely.

[00:09:58] And then in terms of designing programs, is it simply taking the Activate program because it's the best we've got or are there some other elements that people might think about? They're wanting to design something that's a little bit modified for their particular population, Isla. What would you suggest? At the Sport Injury Prevention Research Centre, they've kind of had a longstanding history of developing these neuromuscular training warm-ups across different sport settings.

[00:10:22] And we knew the next sport that was kind of coming was rugby to help better address the injury and concussion rates we were seeing in that high school pilot I spoke about earlier. So we worked with the developers of Activate. We worked with School Sport Canada, Rugby Canada, a bunch of different community partners, coaches, players to inform the program that eventually we evaluated as part of my doctoral work. We also took into consideration the setting.

[00:10:47] So the English rugby setting is vastly different than the Canadian rugby setting is a big thing. So with the Activate program, it's meant for a season that's about eight months long because they start playing in September. It's a winter sport that goes through to call it March-April. And then the Activate program actually has six phases that intensifies over time.

[00:11:10] But when you check that into a Calgary or like the Calgary high school setting I was referring to, that's not overly applicable. Just because in Calgary, especially giving the snow, the weather you might see in mid-March, the season technically starts mid-March, but they wrap up early June. And they might get six weeks of an actual playing season.

[00:11:32] So we had to kind of think about those environmental contextual factors as well just to see if it was applicable even just beyond the girls-women space, but thinking about the actual environment of the sport in Canada broadly. And what have you found with modifying and then applying and evaluating these programs? What are the effects these programs have had in the particular Calgary setting you're talking about, Isla?

[00:11:57] So with the, I'll call it the Shred Injuries Rugby Noir Muscular Training Warm-Up Program is the one I've kind of been referring to this whole time. When we evaluated it in our high school girls, we did see it reduce the burden of training injury as well as the burden of head game head injury. Burden is the number of injuries that occurred times how long they've been out for. So obviously we want to reduce injuries that have the highest burden.

[00:12:26] So what we saw was training injury burden decreased and game head related injury burden decreased as well. We also saw clinically relevant, although it was not statistically significant, we did see a clinically relevant 21% reduction in game concussion, which is in alignment with what the Activate evaluation found. So when the Activate program evaluated in the schoolboy setting, they found that it reduced match related concussion by 62%, I believe.

[00:12:54] 60-ish. Quite a lot. So match related injury is like 70%, concussion 62%. It might be swapped. I can't remember off the top of my head. But when they use it three or more times per week, which is quite substantial when we think about injury and concussion in the sport. And so we did see similar trends in the study, although we didn't totally replicate the same unprotected effect necessarily. And it's sounding like, again, we hear there's so many different injury prevention programs out there for different things.

[00:13:24] Some are focused on particular injuries like concussion or like preventing knee injuries and others are more general. It sounds like neuromuscular training programs work. The biggest issue is getting them implemented and getting people to do them. We hear this all the time and our listeners today will have heard this. No doubt many people have struggled with getting people to do these injury prevention programs. I think we all know too that girls and women are not small boys and men.

[00:13:52] And you alluded to this earlier that we really need a lot more work in this space focused on girls and women and their particular requirements for sport and the injuries and injury burden, injury epidemiology that they see. So all of that to say, there's some particular characteristics of the setting and the way that you might implement or think about implementing these programs.

[00:14:14] With your coach and with your athlete hats on, Isla, how do you think about applying these different injury prevention programs in the particular girls and women's rugby? What are you thinking about? What do you know are the things that you need to consider when you're trying to implement a program? So the very first thing that comes to mind, I would say, is the age of introduction of the sport in girls and women.

[00:14:39] Not so much in Canada, because I would say, generally speaking, rugby in Canada has a lower playing population. It's not ice hockey. It's not soccer. Globally, I would say the age of introduction for girls and women in rugby is later. So especially in, well, not just Canada, but other areas as well. A big entry point for the sport is when school, high school settings, you're seeing girls, women come in around 15, 16.

[00:15:08] They might also join into their 20s as well. Versus the boys and men have started quite a bit earlier. In Canada specifically, boys are introduced to contact and collision sports. I'll say, like when you think of American football, body checking and ice hockey, they're more integrated into their movement patterns.

[00:15:28] Versus the girls, typically, especially when I was coaching and me as a player as well, I had never dealt with delivering a tackle until I was 16 years old. So when you're thinking about someone coming into the sport for the first time, they might be learning to run with the ball for the first time. They're learning to catch, they're learning to pass, they're learning to kick. But now you're also adding this whole new variable of trying to teach someone a tackle, how to tackle, how to also receive a tackle is a big one.

[00:15:58] I think especially a really emerging area in this field is how girls and women fall. We're seeing maybe a bit more whiplash mechanism with falling in these women. So that's a whole piece about how to teach someone to fall and receive a tackle, not just the technique to the tackler as well. And there's a lot of parallels I'm hearing with Australian football and particularly the AFLW and Dr. Brooke Patterson has done a lot of work in this area too.

[00:16:26] And they're particularly focused on tackling and also this training age issue where a lot of girls and women are not exposed to the gym-based setting from as young an age. So it's when are you introduced to the sport, but also when are you introduced to strength training and the opportunities you have for strength training and really developing your physical skills in the sport? Yeah. And then the other thing I always think about is the burden on the coaches as well.

[00:16:53] So if you have a coach that's coming in to coach a high school team, you're going to have a huge range of abilities. So you might have someone that is now 18 years old. They've been playing for the last three or four years and they know the sport versus you're also dealing with individuals that are 14, 15 who've never played before. They've never held a rugby ball before. So now when we're integrating these training programs as a coach, it's really hard to integrate all that together.

[00:17:21] So the development of these programs is also a bit of a balancing act because you want it to be basic enough to get those fundamental movement patterns for the individuals that are newer and experienced. But you also need to make sure that there's a bit of complexity and challenge for the older players as well or more experienced players, I should say. Yeah, it's a hard job being a coach. You've got to really cater to lots of different ability levels and skill sets and playing positions in rugby.

[00:17:51] Let's get into the nuts and bolts of exactly what these injury prevention programs for concussion look like. What are the components of these programs? Thinking back to our shred injuries, the shred injuries program that we evaluated, when you break down our muscular training warmup, there's traditionally four components. So we look at aerobic exercises that fall into four components, I should say. So we have aerobic, balance, strength and agility.

[00:18:16] And then for the concussion piece, we actually had integrated neck control and endurance section. So we're looking at that head-on neck control. And that was very much led and supported by, the development of these pieces was very much led and supported by Dr. Catherine Schneider at the University of Calgary. We've got a podcast with Catherine, so we'll link to the podcast in the show notes. Perfect. And so a lot of the exercises in those pieces, we do a little bit of isometric neck strengthening, but not a whole lot. It's a lot of kind of head perturbations.

[00:18:46] The big thing that we really focused on was activating that vestibular system so our body knows where we are in space. What we really wanted to integrate for the rugby specificity of the program was making sure they were in rugby positions or making it more applicable. So in rugby, there's a bear crawl position that's quite fundamental to any kind of contact event. So you would think about it for scrumming. It's a good way to warm up for rucks, tackles as well.

[00:19:15] And that's just basically, you're on all fours, your shins are, your knees are off the ground, you're on all fours, and then your shins are parallel to the floor. You have a 90 degree at your ankles, knees, hips, and then your hands are directly below your shoulder. And that's quite a fundamental position generally for rugby. And then we integrated some of these neck strengthening, neck head perturbations, all those kinds of exercises into that piece to make sure that they were learning these movement patterns in a strong sport position as well.

[00:19:45] Really important because if we're talking about the vestibular system, and you're in a different position than when you're standing upright in the clinic in a quiet space, you really need to get that vestibular system going in a position that's appropriate for the sport, as you say. Isla, it would be remiss of me not to mention, given that we've been talking and had a really big focus on female women and girl athletes today, it would be remiss of me not to ask you about the FAIR consensus.

[00:20:13] You are among more than 100 different authors who have been involved in this FAIR process. Tell us a little bit about the FAIR consensus, what FAIR is about, and how it relates to the work you're doing in women's and girls' rugby in particular. The FAIR consensus is the female woman and or girl athlete injury prevention consensus, and that was led by Professor Carolyn Emery at the University of Calgary, and then Professor Kay Crosley at La Trobe University.

[00:20:42] They were basically looking to aggregate the most up-to-date evidence to make female woman and or girl athlete recommendations around the prevention of injury. So there was five evidence-informed systematic reviews that came out of it. There was a concept mapping activity for sex and gender considerations, and then there was a dissemination and implementation scoping review as well. I was fortunate enough to be invited as a methods author for the concussion prevention-specific evidence-informed review.

[00:21:10] So I led a team of about 25 individuals globally, and we went through systematic review to aggregate all the evidence that we could find on female and women and girl athletes for concussion modifiable risk factors and prevention strategies of concussion in the space. After all these different endeavors were taken, the expert group met and there was a consensus meeting held

[00:21:34] where basically a list of practical recommendations were made for the prevention of injury female and or woman and girl athletes. And I believe there's about 56 recommendations across policy rule change, personal protective equipment, training programs, approaches to dissemination and implementation, and then promoting gender and sex-supportive environments as well. And this would stem across lower extremity, upper extremity, spinal, concussion,

[00:22:04] injury-related or injuries. There's a link to the FAIR consensus in the show notes and to all of the resources you're talking about and the FAIR website as well. Full disclosure, I was also involved in some of the FAIR consensus work and really believe in it for all of the reasons we've been talking about today, Isla. So thank you for bringing it up. I think the point here is, as we've been talking about, there's really not a lot of research, sadly, on injury prevention strategies,

[00:22:34] all of the issues around keeping female women and girl athletes healthy and performing well in their sport. So the FAIR process was about recognizing that, figuring out what was available and then directing some of the strategies we, as clinicians and researchers, can deal with now. What do we have available now? And then importantly, what's the roadmap for the future? What needs to happen to improve outcomes for female women and girl athletes in sport? We're very fortunate that you're working in this area.

[00:23:02] As we're seeing rapid growth in people playing rugby, it's important, as you know, and as all our listeners know, to mirror that with good research to understand, how do we help people continue to play happy, healthy and fun and have fun opportunities in rugby. So we're really fortunate to have you working so hard in that area, Isla. It's been wonderful listening to your, a little bit about your journey today. So Dr. Isla Schill, thanks for joining me on JOSPT Insights.

[00:23:31] Thank you so much for having me. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple Podcasts, Spotify, TuneIn, Stitcher, Google, or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and rate and review us.

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