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A cross-sectional study of the prevalence of neck pain, decreased cervical range of motion and head repositioning accuracy in forwards and backs in rugby union
Clinical Chiropractic (2007) 10, 187—194
intl.elsevierhealth.com/journals/clch
ORIGINAL PAPER
A cross-sectional study of the prevalence of neck pain, decreased cervical range of motion and head repositioning accuracy in forwards and backs in rugby union Hugh Gemmell *, Paul J. Dunford AECC Chiropractic College, 13-15 Parkwood Road, Bournemouth BH5 2DF, United Kingdom Received 9 January 2007; received in revised form 13 July 2007; accepted 10 September 2007
KEYWORDS Cervical pain; Neck pain; Proprioception; Range of motion; Rugby
Summary Objective: The aim of this study was to determine the prevalence of neck pain, decreased cervical range of motion and head repositioning accuracy in forwards and backs in amateur rugby union. As forwards in rugby union have a more physical role, we theorise that they will have a higher prevalence of neck pain and decreased cervical range of motion and head repositioning accuracy. Design: Analytical cross-sectional study. Setting: Amateur rugby union clubs in Bournemouth and Bristol, England. Subjects: Thirty-five active, adult amateur male rugby union players, 18 forwards, mean age 28.39 years (S.D. 8.83) and 17 backs, mean age 25.88 years (S.D. 4.41) from two amateur rugby clubs. Methods: Subjects were required to complete a pain questionnaire which included indicating their average pain over the preceding four weeks on a 100 mm visual analogue scale (VAS). Cervical range of motion was measured using a CROM device and proprioception by the subject’s ability to accurately relocate the head on the trunk to a subjective straight ahead position following a near maximal rotation movement. Results: There was an 83% prevalence of neck pain in forwards compared to 41% prevalence for backs. Decreased cervical range in motion was present for all of the backs and forwards. Decreased head repositioning accuracy occurred in 33% of forwards and 35% of backs. Conclusions: The prevalence of neck pain was higher in forwards; however, the prevalence of decreased head repositioning accuracy was not statistically different
* Corresponding author. Tel.: +44 1202 436200; fax: +44 1202 436312. E-mail addresses: [email protected] (H. Gemmell), [email protected] (P.J. Dunford). 1479-2354/$32.00 # 2007 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2007.09.002
188
H. Gemmell, P.J. Dunford from that of backs. All the forwards and backs demonstrated decreased cervical range of motion. # 2007 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Rugby union involves considerable physical contact, and the cervical spine is especially at risk due to its mechanical design, i.e. a relatively small structure supports a relatively large head. Cervical trauma can occur in any contact scenario, but seems to be a particular risk during scrummaging and at the tackle area.1 Targett2 states that the phase of play responsible for the majority of injuries is the tackle. Support for this contention is found in the research of Brooks et al.,3 who found the highest incidence of match injuries (36%) occurred during this facet of the game. In rugby union, hyperflexion has been reported as the most common mechanism of cervical spine injury1; however, Browne,4 who studied rugby injuries in children, states that hyperextension is a factor as well. The risk of degenerative changes in the cervical spine through repeated exposure to the stressors involved in playing rugby union has been proposed by both Milburn5 and O’Brien.6 Scher7 analysed the radiographs of 150 rugby players and found that, compared to a control group, rugby players showed premature and advanced degenerative changes in the cervical spine. These changes were most marked in the front row and locks, the forwards who are bound into the scrum. Berge et al.8 also found that, compared to age-matched controls, rugby union players showed greater early degenerative changes in the cervical spine on magnetic resonance imaging (MRI). There could be a difference between forwards and backs in the frequency of abnormal cervical functional parameters as forwards have a more physical role. Quarrie et al.1 reviewed studies of cervical spine injuries in rugby union players and found hookers and props to be at a disproportionately higher risk of cervical spine injury, owing to additional forces that are transmitted to the cervical spine during scrummaging. Secin et al.9 looked at 18 cases of disabling injury of the cervical spine in Argentine rugby union over a 20-year period. Fourteen cases involved forwards and four involved backs. The nature of the roles of the two groups of players in rugby union, forwards and backs, may lead to disparity in presence of neck pain, range of motion and proprioception, with forwards displaying more prevalent changes as compared to backs. We were unable to find any studies in the literature
that specifically tested this. Therefore, the purpose of this study was to determine if differences between forwards and backs playing amateur rugby union existed in the prevalence of decreased cervical range of motion, neck pain and decreased cervicocephalic kinaesthetic sense.
Methods The study base consisted of 35 rugby union players from two amateur rugby clubs in Bournemouth and Bristol, England. The players were males, aged 18 years and over, who had played during the preceding season (2004/2005), although there were no minimum or maximum limits for the number of games participated in, and no criteria for previous experience. The participants were asked to name the position in which they had played most commonly during the preceding season, and this was used to allocate them into the forward or back group. Data collection was carried out at midweek club training sessions during April and May 2005. The end of season was chosen as this ensured that the players had been playing over the preceding months, as opposed to participating in other activities during the off-season that could have influenced the results.
Outcome measures The cervical range of motion (CROM) device is a type of goniometer designed specifically for the cervical spine and was used to measure cervical range of motion. The CROM has been shown to have good reliability and validity for measuring cervical range of motion.10—15 The visual analogue scale (VAS) was used to rate the players’ neck pain. The VAS used was a 100 mm horizontal line with polar anchors of no pain (0) and worst possible pain (100). The VAS has been shown to be valid and reliable for clinical and research applications.16—19 Cervicocephalic kinesthetic sensibility (proprioception) can be investigated using the head repositioning accuracy (HRA) test. The test was developed by Revel et al.20 It has been shown that patients with cervical pain have a poorer ability to relocate the head on the trunk after an active head movement.21—23
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Procedure Each participant was given time to read the study information sheet, sign a consent form and complete the demographic data form. Participants indicated their average level of pain over the previous 4 weeks on a VAS. This was done in isolation from other subjects, but with the examiner present to answer any questions. Once this was completed, cervical range of motion was tested. The participant was asked to sit upright in a chair with the back against the backrest, feet flat on the floor and arms hanging by the side. The CROM unit (Fig. 1) was placed on top of the head and attached posteriorly using the Velcro strap. The magnetic part of the unit was then placed so that it sat squarely over the shoulders (Fig. 2). The participant was then asked to move the head into each of the six positions in order to acclimatise to moving the head with the CROM attached. The participant was then instructed to perform the neck movements and return the head to neutral between each of the following movements: flexion of head to chest extension back as far as possible to look up to the ceiling rotation to the left as far as possible rotation to the right as far as possible lateral flexion to the left lateral flexion to the right. Following this, HRA was determined. The participant was moved to a pre-prepared area of the room and sat on a chair that had been positioned so
Figure 1
The CROM device.
Figure 2 The CROM headpiece and magnetic yoke as used experimentally.
that the centre of the seat was 90 cm from the wall. On the wall, directly in front of the chair, a piece of A3 graph paper had already been secured and a spirit level was used to ensure that it was horizontal. The participant sat on the chair so that they were positioned with their back straight against the backrest. A cycle helmet with attached laser pen was placed on the head and secured using the chinstrap (Fig. 3). The distance from the front of the laser pen to the graph paper was then measured and the patient moved forwards or backwards as necessary so that the distance was 90 cm. The laser pen was then turned on and the subject asked to ‘centre’ the laser at what they considered a middle point, by having their head in a neutral position. In some circumstances the graph paper was adjusted vertically for very tall or short people so that the laser spot was in the centre of the graph paper. If moved, it was rechecked using the spirit level. To begin, an acclimatisation movement was performed where the subject closed their eyes and turned the head all the way to the left and then back to the middle. This was repeated to the right. The point they perceived as the neutral position was marked as a dot on the graph paper using a black pen. They were then asked to centre the laser spot on the mark and close their eyes. The next instruction was to turn the head fully to the left and back to what they considered the starting point in a controlled fashion without opening their eyes. Where the laser spot stopped was marked on the sheet with a cross and the notation ‘L1’ in a red pen. Following this, the subject was asked to open their eyes and re-centre the laser beam on the black spot. They were then told to close the eyes again and asked to turn the head fully to the right and back. This time, a cross, and the notation ‘R1’ with a blue pen
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Prevalence of neck pain Neck pain during the last 4 weeks was reported by 15 out of the 18 (83%) forwards and 7 of the 17 (41%) backs. The prevalence odds ratio was 7.14 (95% CI: 1.48 to 34.39). Forwards were seven times more likely to have neck pain as compared to backs. Pain data for forwards and backs are shown in Table 2.
Prevalence of decreased HRA
Figure 3 Experimental apparatus as used when analysing head repositioning accuracy.
marked the position of the laser spot. The process was repeated three more times on each side with the notations ‘L2’, ‘R2’, ‘L3’, etc. in the respective colour pens. Once this was completed, the sheet of graph paper was removed from the wall and stapled to the range of motion (ROM) result sheet, the information sheet, the consent form and the pain data form so that the data collected could be kept together and analysed at a later date. Prevalence of each of the outcome measures was calculated for the forwards and backs. Prevalence odds ratios were also calculated with 95% confidence intervals.24 For neck pain, we considered any level of pain to indicate presence of neck pain. Total cervical range of motion was determined by adding all six components and determining overall mean ROM. Any overall mean cervical ROM less than 638 was considered decreased ROM. This value was based on an overall normal mean ROM as suggested by Magee.25 HRA measurements in millimetres were converted to degrees and the overall mean of right and left HRA was determined. We used the threshold value of 4.58 as suggested by Revel et al.20 and any value greater than this was considered error in HRA.
Results Thirty-five subjects were included in the study, consisting of 18 forwards and 17 backs. Demographic data for both groups are shown in Table 1.
Decreased HRA occurred in 6 of the 18 forwards (33% prevalence) and in 6 of the 17 backs (35% prevalence). The prevalence odds ratio was 1.09 (95% CI: 0.27 to 4.41). This was not statistically significant. Means for HRA for backs and forwards are shown in Tables 3 and 4.
Prevalence of decreased CROM Total CROM was decreased in all of the forwards and all of the 17 backs for 100% prevalence in both groups. Due to this equal prevalence an odds ratio could not be calculated. Means for cervical ROM of forwards and backs are shown in Tables 5 and 6.
Discussion The purpose of this study was to determine if there were any differences between forwards and backs in a sample of amateur rugby union players in the prevalence of decreased cervical range of motion, neck pain and decreased cervicocephalic kinesthetic sense. The finding of increased prevalence of neck pain in forwards agrees with the work of Secin et al.9 However, our study was not large enough to determine if players in certain positions are more at risk of neck pain than others. Previous studies have found the hooker to be the player most at risk of cervical injury.26,27 Also, due to the descriptive nature of cross-sectional studies, it is not possible to infer that playing rugby actually caused the outcomes of interest in this study. Further, the wide confidence interval (1—34) suggests the small study population (n = 35) results in these data that are unable to establish where the true prevalence
Table 1 Demographic data for forwards and backs Group
Age, years (S.D.)
Weight, kg (S.D.)
Height, cm (S.D.)
Forwards Backs
28 (8.8) 26 (4.4)
104.9 (12.6) 80.0 (10.9)
183.5 (6.3) 179.7 (6.7)
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Table 2 Pain data for forwards and backs Subject
Forwards
Backs
VAS
a
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
5 0 0 29 4 4 0 11 0 26 6 44 0 32 12 23 48 33
Few times/yr No Few times/yr Weekly Few times/yr Few times/yr <1/yr No Few times/yr Weekly No Monthly Few times/yr Weekly Few times/yr Few times/yr Few times/yr Few times/yr
Mean (S.D.)
15.4 (16.3)
Previous Cx Px
b
VAS
a
No No <1 mth >12 mth >12 mth No >12 mth No No No <6 mth >12 mth <12 mth No >12 mth No <1 mth <6 mth
0 0 0 0 3 0 14 0 2 0 11 0 0 10 4 0 4
No No <1/yr No No No Few times/yr No No <1/yr Few times/yr No No Few times/yr No Few times/yr <1/yr
Prev. inj.
Previous Cx Px
b
Prev. inj.
No No >12 mth No No No <6 mth >12 mth No >12 mth No No No No No No >12 mth
2.8 (4.5)
Cx = cervical, Px = pain, Prev = previous, Inj = injury, VAS = visual analogue scale, S.D. = standard deviation, yr = year, mth = month, < = less than, > = more than. a Episodes of neck pain over the prior 12 months. b Previous injury to the neck and how long ago the injury occurred.
lies. This study does, however, reveal an interesting observation, which may warrant a larger study to confirm the actual prevalence of neck pain in this group of sportsmen.
Table 3 Means (degrees) for head repositioning error for backs
R mean
L mean
Mean R + L
3.55 2.59 3.20 4.71 2.12 2.44 2.95 2.99 3.47 5.43 3.32 8.37 2.47 8.97 4.19 4.80 5.15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
2.80 4.34 3.04 3.86 3.37 4.54 5.43 7.31 2.21 2.37 5.60 1.42 5.33 6.17 5.05 10.07 5.43 3.73
4.32 3.99 4.38 2.96 3.47 5.28 3.05 8.25 2.61 2.18 1.72 2.97 10.25 3.59 1.78 3.99 6.91 1.93
3.56 4.17 3.71 3.41 3.42 4.91 4.24 7.78 2.41 2.28 3.66 2.20 7.80 4.88 3.42 7.03 6.17 2.83
4.16 (1.97)
Mean (S.D.)
R mean
L mean
Mean R + L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1.77 3.32 1.35 3.36 2.59 3.40 3.13 3.94 2.74 5.82 3.16 8.97 2.70 7.45 3.75 6.26 4.72
5.33 1.85 5.05 6.06 1.64 1.48 2.76 2.04 4.19 5.03 3.48 7.77 2.23 10.48 4.62 3.34 5.58
Mean (S.D.)
4.03 (2.03)
S.D. = standard deviation, R = right, L = left.
Table 4 Means (degrees) for head repositioning error for forwards Subject
Subject
4.29 (2.40)
With regards to cervicocephalic kinesthetic sensibility, no significant difference in prevalence between the two groups was apparent in the results. Garraway et al.27 found that more than 85% of
4.56 (2.06)
4.09 (2.31)
S.D. = standard deviation, R = right, L = left.
4.33 (1.78)
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Table 5 Means for cervical range of motion (ROM) for forwards Subject
Flexion
Extension
RR
LR
RLF
LLF
Mean total ROM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
52 40 48 36 32 52 50 18 40 32 38 72 42 66 42 62 58 58
55 40 50 50 40 56 48 30 40 50 58 50 38 34 42 60 54 56
62 68 70 58 46 50 60 50 70 70 62 62 58 64 56 68 64 72
70 52 72 60 38 70 68 42 60 60 62 50 48 58 54 64 62 66
34 40 40 32 20 36 48 15 28 30 32 34 30 30 24 30 42 22
36 38 30 36 28 40 32 12 32 28 30 32 24 30 26 42 40 18
51.5 46.3 51.6 45.3 34.0 50.7 51.0 27.8 45.0 45.0 47.0 50.0 40.0 47.0 40.7 54.3 53.3 48.7
Mean (S.D.) 46.56 (13.61) 42.28 (8.78) 61.67 (7.62) 58.67 (9.68) 31.5 (8.16) 30.78 (7.71) 46.1(6.9) S.D. = standard deviation, RR = right rotation, LR = left rotation, RLF = right lateral flexion, LLF = left lateral flexion.
led to lost playing time. As a result, the self reporting in this study could have led to under-reporting of injury by all players, including the backs, thus affecting the results. If this were to be the case, then it could be a potential reason for all rugby players having decreased cervical ROM and hence no difference in prevalence in cervical ROM and HRA being seen between the two groups. As this was a comparison between forwards and backs, a major limitation of this study is that reasons
players injured while tackling were backs, which did not correlate with the answers given by subjects in this study. However, the contradiction in findings could be explained by the fact that previous injury was only a small component of the pain questionnaire, and with involved interpretation of the term ‘injury’ by the player. For most of those involved in the game, neck pain following a blow to the head while on the pitch would not be considered an injury unless it resulted in a hospital visit or subsequently
Table 6 Means for cervical range of motion (ROM) for backs Subject
Flexion
Extension
RR
LR
RLF
LLF
Mean total ROM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
38 70 46 48 46 60 48 58 34 40 50 56 56 48 58 46 56
50 46 62 52 60 60 38 42 60 58 64 62 70 74 70 54 70
60 64 72 70 70 68 50 72 62 64 56 64 70 64 74 62 68
60 62 68 70 62 60 52 72 56 68 60 52 72 68 62 64 68
42 34 52 30 40 40 40 30 40 42 30 40 36 36 32 40 32
40 32 48 32 36 44 32 40 40 34 32 40 38 38 40 32 42
48.3 51.3 58 50.3 52.3 55.3 43.3 52.3 48.7 51 53.7 52.3 57 54.7 56 49.7 56
Mean (S.D.) 50.47 (8.98) 58.35 (10.25) 65.29 (6.24) 63.29 (6.28) 37.41 (5.78) 37.65 (4.81) 52.4 (3.7) S.D. = standard deviation, RR = right rotation, LR = left rotation, RLF = right lateral flexion, LLF = left lateral flexion.
Neck pain, decreased cervical range of motion and head repositioning accuracy for the difference in prevalence in neck pain could be due to variables other than playing position. A future investigation could look at the effect of one season of rugby by taking a pre-season measurement of each research component and then conducting the data collection at the end of the season. This would provide more substantial evidence for any differences seen being attributable to a position in the game of rugby union. The results cannot be extrapolated to the whole game as the sample was not representative of all rugby players. However, in order to overcome this, a significantly larger study would be required involving players from all levels of the game. This study used a convenience sample of two amateur clubs rather than randomly selected teams, which could lead to bias by those chosen not being typical of all rugby clubs. A further limitation is the fact that no minimum or maximum limits were set for the number of games played. This was not done to ensure an adequate sample size and due to time constraints in collecting the data. The subject’s perception of neutral in HRA was used to determine the neutral point. This may have allowed the subject to compensate and may have affected the results by reducing the actual level of head repositioning error.
Conclusions Forwards playing amateur regional rugby union had a higher prevalence of neck pain. There was no significant difference in prevalence of decreased HRA between forwards and backs. There was an equal prevalence of decreased cervical ROM in forwards and backs.
Conflict of interest statement The authors declare they have no conflicts of interest.
Acknowledgement Support for this study in the form of equipment was provided by the Anglo-European College of Chiropractic (AECC). Author contribution statement: PD conceived the idea for the study. HG and PD contributed to the design and planning of the research. PD was involved in data collection. HG and PD analysed the data. HG wrote the first draft of the manuscript. Both authors edited and approved the final version of the manuscript.
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References 1. Quarrie KL, Cantu RC, Chalmers DJ. Rugby union injuries to the cervical spine and spinal cord. Sports Med 2002;32:633— 53. 2. Targett SG. Injuries in professional rugby union. Clin J Sports Med 1988;8:280—5. 3. Brooks JHM, Fuller CW, Kemp SPT, Reddin D. A prospective study of injuries and training amongst the England 2003 Rugby World Cup squad. Br J Sports Med 2005;39:288—93. 4. Browne GJ. Cervical spinal injury in children’s community rugby football. Br J Sports Med 2006;40:68—71. 5. Milburn PD. Biomechanics of rugby union scrimmaging. Technical and safety issues. Sports Med 1993;16:168—79. 6. O’Brien CP. ‘‘Rugby neck’’: cervical degeneration in two front row rugby union players. Clin J Sports Med 1996;6:56—9. 7. Scher AT. Premature onset of degenerative disease of the cervical spine in rugby players. S Afr Med J 1990;77:557—8. 8. Berge J, Marque B, Vital JM, Senegas J, Callie JM. Age-related changes in the cervical spines of front-line rugby players. Am J Sports Med 1999;27:422—9. 9. Secin FP, Poggi EJ, Luzuriaga F, Laffaye HA. Disabling injuries of the cervical spine in Argentine rugby players over the last 20 years. Br J Sports Med 1999;33:33—6. 10. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of cervical spine range of motion — comparison of three methods. Phys Ther 1991;71:98—104. 11. Capuano-Pucci D, Rheault W, Aukai J, Bracke M, Day R, Pastrick M. Intratester and intertester reliability of the cervical spine range of motion device. Arch Phys Med Rehabil 1991;72:338—40. 12. Hole DE, Cook JM, Bolton JE. Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender. Man Ther 1995;1:36—42. 13. Ordway NE, Seymour R, Donelson R, Hojnowski L, Lee E, Edwards T. Cervical sagittal range of motion analysis using three methods: cervical range of motion device, 3 space and radiography. Spine 1997;22:501—8. 14. Tousignant M, de Bellefeuille L, O’Donoughe S, Grahovac S. Criterion validity of the cervical range of motion (CROM) goniometer for cervical flexion and extension. Spine 2000;25:324—30. 15. Tousignat M, Duclos E, Lafleche S, Mayer A, TousignantLaflamme Y, Brosseau L, et al. Validity study for the cervical range of motion device used for lateral flexion in patients with neck pain. Spine 2002;27:812—7. 16. Ho K, Spence J, Murphy MF. Review of pain measurement tools. Ann Emerg Med 1996;27:427—32. 17. Grant S, Aitchison T, Henderson E, Christie J, Zare S, McMurray J, et al. A comparison of the reproducibility and the sensitivity of visual analogue scales, Borg scales and Likert scales in normal subjects during submaximal exercise. Chest 1999;116:1208—17. 18. Coll AM, Ameen JR, Mead D. Postoperative pain assessment tools in day surgery: literature review. J Adv Nurs 2004;46:124—33. 19. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007—19. 20. Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil 1991;72:288—91. 21. Loudon JK, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine 1997;22:865—8. 22. Heikkila HV, Wenngren BI. Cervicocephalic kinaesthetic sensibility, active range of cervical motion, and oculomotor
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function in patients with whiplash injury. Arch Phys Med Rehabil 1998;79:1089—94. 23. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med 2003;35:36—43. 24. Ibrahim M, Alexander L, Shy C. Cross-sectional studies. Department of Veterans Affairs ERIC Notebook 1999; issue 7.
25. Magee DJ. Orthopedic physical assessment. London: WB Saunders Company; 1992. 26. Haughie LJ, Fiebert IM, Roach KE. Relationship of forward head posture and cervical backward bending to neck pain. J Man Manipulative Ther 1995;3:91—7. 27. Garraway WM, Lee AJ, Hutton SJ, Russell EBA, Macleod DA. Impact of professionalism on injuries in rugby union. Br J Sports Med 2000;34:348—51.
Available online at www.sciencedirect.com
intl.elsevierhealth.com/journals/clch
ORIGINAL PAPER
A cross-sectional study of the prevalence of neck pain, decreased cervical range of motion and head repositioning accuracy in forwards and backs in rugby union Hugh Gemmell *, Paul J. Dunford AECC Chiropractic College, 13-15 Parkwood Road, Bournemouth BH5 2DF, United Kingdom Received 9 January 2007; received in revised form 13 July 2007; accepted 10 September 2007
KEYWORDS Cervical pain; Neck pain; Proprioception; Range of motion; Rugby
Summary Objective: The aim of this study was to determine the prevalence of neck pain, decreased cervical range of motion and head repositioning accuracy in forwards and backs in amateur rugby union. As forwards in rugby union have a more physical role, we theorise that they will have a higher prevalence of neck pain and decreased cervical range of motion and head repositioning accuracy. Design: Analytical cross-sectional study. Setting: Amateur rugby union clubs in Bournemouth and Bristol, England. Subjects: Thirty-five active, adult amateur male rugby union players, 18 forwards, mean age 28.39 years (S.D. 8.83) and 17 backs, mean age 25.88 years (S.D. 4.41) from two amateur rugby clubs. Methods: Subjects were required to complete a pain questionnaire which included indicating their average pain over the preceding four weeks on a 100 mm visual analogue scale (VAS). Cervical range of motion was measured using a CROM device and proprioception by the subject’s ability to accurately relocate the head on the trunk to a subjective straight ahead position following a near maximal rotation movement. Results: There was an 83% prevalence of neck pain in forwards compared to 41% prevalence for backs. Decreased cervical range in motion was present for all of the backs and forwards. Decreased head repositioning accuracy occurred in 33% of forwards and 35% of backs. Conclusions: The prevalence of neck pain was higher in forwards; however, the prevalence of decreased head repositioning accuracy was not statistically different
* Corresponding author. Tel.: +44 1202 436200; fax: +44 1202 436312. E-mail addresses: [email protected] (H. Gemmell), [email protected] (P.J. Dunford). 1479-2354/$32.00 # 2007 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2007.09.002
188
H. Gemmell, P.J. Dunford from that of backs. All the forwards and backs demonstrated decreased cervical range of motion. # 2007 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Rugby union involves considerable physical contact, and the cervical spine is especially at risk due to its mechanical design, i.e. a relatively small structure supports a relatively large head. Cervical trauma can occur in any contact scenario, but seems to be a particular risk during scrummaging and at the tackle area.1 Targett2 states that the phase of play responsible for the majority of injuries is the tackle. Support for this contention is found in the research of Brooks et al.,3 who found the highest incidence of match injuries (36%) occurred during this facet of the game. In rugby union, hyperflexion has been reported as the most common mechanism of cervical spine injury1; however, Browne,4 who studied rugby injuries in children, states that hyperextension is a factor as well. The risk of degenerative changes in the cervical spine through repeated exposure to the stressors involved in playing rugby union has been proposed by both Milburn5 and O’Brien.6 Scher7 analysed the radiographs of 150 rugby players and found that, compared to a control group, rugby players showed premature and advanced degenerative changes in the cervical spine. These changes were most marked in the front row and locks, the forwards who are bound into the scrum. Berge et al.8 also found that, compared to age-matched controls, rugby union players showed greater early degenerative changes in the cervical spine on magnetic resonance imaging (MRI). There could be a difference between forwards and backs in the frequency of abnormal cervical functional parameters as forwards have a more physical role. Quarrie et al.1 reviewed studies of cervical spine injuries in rugby union players and found hookers and props to be at a disproportionately higher risk of cervical spine injury, owing to additional forces that are transmitted to the cervical spine during scrummaging. Secin et al.9 looked at 18 cases of disabling injury of the cervical spine in Argentine rugby union over a 20-year period. Fourteen cases involved forwards and four involved backs. The nature of the roles of the two groups of players in rugby union, forwards and backs, may lead to disparity in presence of neck pain, range of motion and proprioception, with forwards displaying more prevalent changes as compared to backs. We were unable to find any studies in the literature
that specifically tested this. Therefore, the purpose of this study was to determine if differences between forwards and backs playing amateur rugby union existed in the prevalence of decreased cervical range of motion, neck pain and decreased cervicocephalic kinaesthetic sense.
Methods The study base consisted of 35 rugby union players from two amateur rugby clubs in Bournemouth and Bristol, England. The players were males, aged 18 years and over, who had played during the preceding season (2004/2005), although there were no minimum or maximum limits for the number of games participated in, and no criteria for previous experience. The participants were asked to name the position in which they had played most commonly during the preceding season, and this was used to allocate them into the forward or back group. Data collection was carried out at midweek club training sessions during April and May 2005. The end of season was chosen as this ensured that the players had been playing over the preceding months, as opposed to participating in other activities during the off-season that could have influenced the results.
Outcome measures The cervical range of motion (CROM) device is a type of goniometer designed specifically for the cervical spine and was used to measure cervical range of motion. The CROM has been shown to have good reliability and validity for measuring cervical range of motion.10—15 The visual analogue scale (VAS) was used to rate the players’ neck pain. The VAS used was a 100 mm horizontal line with polar anchors of no pain (0) and worst possible pain (100). The VAS has been shown to be valid and reliable for clinical and research applications.16—19 Cervicocephalic kinesthetic sensibility (proprioception) can be investigated using the head repositioning accuracy (HRA) test. The test was developed by Revel et al.20 It has been shown that patients with cervical pain have a poorer ability to relocate the head on the trunk after an active head movement.21—23
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Procedure Each participant was given time to read the study information sheet, sign a consent form and complete the demographic data form. Participants indicated their average level of pain over the previous 4 weeks on a VAS. This was done in isolation from other subjects, but with the examiner present to answer any questions. Once this was completed, cervical range of motion was tested. The participant was asked to sit upright in a chair with the back against the backrest, feet flat on the floor and arms hanging by the side. The CROM unit (Fig. 1) was placed on top of the head and attached posteriorly using the Velcro strap. The magnetic part of the unit was then placed so that it sat squarely over the shoulders (Fig. 2). The participant was then asked to move the head into each of the six positions in order to acclimatise to moving the head with the CROM attached. The participant was then instructed to perform the neck movements and return the head to neutral between each of the following movements: flexion of head to chest extension back as far as possible to look up to the ceiling rotation to the left as far as possible rotation to the right as far as possible lateral flexion to the left lateral flexion to the right. Following this, HRA was determined. The participant was moved to a pre-prepared area of the room and sat on a chair that had been positioned so
Figure 1
The CROM device.
Figure 2 The CROM headpiece and magnetic yoke as used experimentally.
that the centre of the seat was 90 cm from the wall. On the wall, directly in front of the chair, a piece of A3 graph paper had already been secured and a spirit level was used to ensure that it was horizontal. The participant sat on the chair so that they were positioned with their back straight against the backrest. A cycle helmet with attached laser pen was placed on the head and secured using the chinstrap (Fig. 3). The distance from the front of the laser pen to the graph paper was then measured and the patient moved forwards or backwards as necessary so that the distance was 90 cm. The laser pen was then turned on and the subject asked to ‘centre’ the laser at what they considered a middle point, by having their head in a neutral position. In some circumstances the graph paper was adjusted vertically for very tall or short people so that the laser spot was in the centre of the graph paper. If moved, it was rechecked using the spirit level. To begin, an acclimatisation movement was performed where the subject closed their eyes and turned the head all the way to the left and then back to the middle. This was repeated to the right. The point they perceived as the neutral position was marked as a dot on the graph paper using a black pen. They were then asked to centre the laser spot on the mark and close their eyes. The next instruction was to turn the head fully to the left and back to what they considered the starting point in a controlled fashion without opening their eyes. Where the laser spot stopped was marked on the sheet with a cross and the notation ‘L1’ in a red pen. Following this, the subject was asked to open their eyes and re-centre the laser beam on the black spot. They were then told to close the eyes again and asked to turn the head fully to the right and back. This time, a cross, and the notation ‘R1’ with a blue pen
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Prevalence of neck pain Neck pain during the last 4 weeks was reported by 15 out of the 18 (83%) forwards and 7 of the 17 (41%) backs. The prevalence odds ratio was 7.14 (95% CI: 1.48 to 34.39). Forwards were seven times more likely to have neck pain as compared to backs. Pain data for forwards and backs are shown in Table 2.
Prevalence of decreased HRA
Figure 3 Experimental apparatus as used when analysing head repositioning accuracy.
marked the position of the laser spot. The process was repeated three more times on each side with the notations ‘L2’, ‘R2’, ‘L3’, etc. in the respective colour pens. Once this was completed, the sheet of graph paper was removed from the wall and stapled to the range of motion (ROM) result sheet, the information sheet, the consent form and the pain data form so that the data collected could be kept together and analysed at a later date. Prevalence of each of the outcome measures was calculated for the forwards and backs. Prevalence odds ratios were also calculated with 95% confidence intervals.24 For neck pain, we considered any level of pain to indicate presence of neck pain. Total cervical range of motion was determined by adding all six components and determining overall mean ROM. Any overall mean cervical ROM less than 638 was considered decreased ROM. This value was based on an overall normal mean ROM as suggested by Magee.25 HRA measurements in millimetres were converted to degrees and the overall mean of right and left HRA was determined. We used the threshold value of 4.58 as suggested by Revel et al.20 and any value greater than this was considered error in HRA.
Results Thirty-five subjects were included in the study, consisting of 18 forwards and 17 backs. Demographic data for both groups are shown in Table 1.
Decreased HRA occurred in 6 of the 18 forwards (33% prevalence) and in 6 of the 17 backs (35% prevalence). The prevalence odds ratio was 1.09 (95% CI: 0.27 to 4.41). This was not statistically significant. Means for HRA for backs and forwards are shown in Tables 3 and 4.
Prevalence of decreased CROM Total CROM was decreased in all of the forwards and all of the 17 backs for 100% prevalence in both groups. Due to this equal prevalence an odds ratio could not be calculated. Means for cervical ROM of forwards and backs are shown in Tables 5 and 6.
Discussion The purpose of this study was to determine if there were any differences between forwards and backs in a sample of amateur rugby union players in the prevalence of decreased cervical range of motion, neck pain and decreased cervicocephalic kinesthetic sense. The finding of increased prevalence of neck pain in forwards agrees with the work of Secin et al.9 However, our study was not large enough to determine if players in certain positions are more at risk of neck pain than others. Previous studies have found the hooker to be the player most at risk of cervical injury.26,27 Also, due to the descriptive nature of cross-sectional studies, it is not possible to infer that playing rugby actually caused the outcomes of interest in this study. Further, the wide confidence interval (1—34) suggests the small study population (n = 35) results in these data that are unable to establish where the true prevalence
Table 1 Demographic data for forwards and backs Group
Age, years (S.D.)
Weight, kg (S.D.)
Height, cm (S.D.)
Forwards Backs
28 (8.8) 26 (4.4)
104.9 (12.6) 80.0 (10.9)
183.5 (6.3) 179.7 (6.7)
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Table 2 Pain data for forwards and backs Subject
Forwards
Backs
VAS
a
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
5 0 0 29 4 4 0 11 0 26 6 44 0 32 12 23 48 33
Few times/yr No Few times/yr Weekly Few times/yr Few times/yr <1/yr No Few times/yr Weekly No Monthly Few times/yr Weekly Few times/yr Few times/yr Few times/yr Few times/yr
Mean (S.D.)
15.4 (16.3)
Previous Cx Px
b
VAS
a
No No <1 mth >12 mth >12 mth No >12 mth No No No <6 mth >12 mth <12 mth No >12 mth No <1 mth <6 mth
0 0 0 0 3 0 14 0 2 0 11 0 0 10 4 0 4
No No <1/yr No No No Few times/yr No No <1/yr Few times/yr No No Few times/yr No Few times/yr <1/yr
Prev. inj.
Previous Cx Px
b
Prev. inj.
No No >12 mth No No No <6 mth >12 mth No >12 mth No No No No No No >12 mth
2.8 (4.5)
Cx = cervical, Px = pain, Prev = previous, Inj = injury, VAS = visual analogue scale, S.D. = standard deviation, yr = year, mth = month, < = less than, > = more than. a Episodes of neck pain over the prior 12 months. b Previous injury to the neck and how long ago the injury occurred.
lies. This study does, however, reveal an interesting observation, which may warrant a larger study to confirm the actual prevalence of neck pain in this group of sportsmen.
Table 3 Means (degrees) for head repositioning error for backs
R mean
L mean
Mean R + L
3.55 2.59 3.20 4.71 2.12 2.44 2.95 2.99 3.47 5.43 3.32 8.37 2.47 8.97 4.19 4.80 5.15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
2.80 4.34 3.04 3.86 3.37 4.54 5.43 7.31 2.21 2.37 5.60 1.42 5.33 6.17 5.05 10.07 5.43 3.73
4.32 3.99 4.38 2.96 3.47 5.28 3.05 8.25 2.61 2.18 1.72 2.97 10.25 3.59 1.78 3.99 6.91 1.93
3.56 4.17 3.71 3.41 3.42 4.91 4.24 7.78 2.41 2.28 3.66 2.20 7.80 4.88 3.42 7.03 6.17 2.83
4.16 (1.97)
Mean (S.D.)
R mean
L mean
Mean R + L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1.77 3.32 1.35 3.36 2.59 3.40 3.13 3.94 2.74 5.82 3.16 8.97 2.70 7.45 3.75 6.26 4.72
5.33 1.85 5.05 6.06 1.64 1.48 2.76 2.04 4.19 5.03 3.48 7.77 2.23 10.48 4.62 3.34 5.58
Mean (S.D.)
4.03 (2.03)
S.D. = standard deviation, R = right, L = left.
Table 4 Means (degrees) for head repositioning error for forwards Subject
Subject
4.29 (2.40)
With regards to cervicocephalic kinesthetic sensibility, no significant difference in prevalence between the two groups was apparent in the results. Garraway et al.27 found that more than 85% of
4.56 (2.06)
4.09 (2.31)
S.D. = standard deviation, R = right, L = left.
4.33 (1.78)
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Table 5 Means for cervical range of motion (ROM) for forwards Subject
Flexion
Extension
RR
LR
RLF
LLF
Mean total ROM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
52 40 48 36 32 52 50 18 40 32 38 72 42 66 42 62 58 58
55 40 50 50 40 56 48 30 40 50 58 50 38 34 42 60 54 56
62 68 70 58 46 50 60 50 70 70 62 62 58 64 56 68 64 72
70 52 72 60 38 70 68 42 60 60 62 50 48 58 54 64 62 66
34 40 40 32 20 36 48 15 28 30 32 34 30 30 24 30 42 22
36 38 30 36 28 40 32 12 32 28 30 32 24 30 26 42 40 18
51.5 46.3 51.6 45.3 34.0 50.7 51.0 27.8 45.0 45.0 47.0 50.0 40.0 47.0 40.7 54.3 53.3 48.7
Mean (S.D.) 46.56 (13.61) 42.28 (8.78) 61.67 (7.62) 58.67 (9.68) 31.5 (8.16) 30.78 (7.71) 46.1(6.9) S.D. = standard deviation, RR = right rotation, LR = left rotation, RLF = right lateral flexion, LLF = left lateral flexion.
led to lost playing time. As a result, the self reporting in this study could have led to under-reporting of injury by all players, including the backs, thus affecting the results. If this were to be the case, then it could be a potential reason for all rugby players having decreased cervical ROM and hence no difference in prevalence in cervical ROM and HRA being seen between the two groups. As this was a comparison between forwards and backs, a major limitation of this study is that reasons
players injured while tackling were backs, which did not correlate with the answers given by subjects in this study. However, the contradiction in findings could be explained by the fact that previous injury was only a small component of the pain questionnaire, and with involved interpretation of the term ‘injury’ by the player. For most of those involved in the game, neck pain following a blow to the head while on the pitch would not be considered an injury unless it resulted in a hospital visit or subsequently
Table 6 Means for cervical range of motion (ROM) for backs Subject
Flexion
Extension
RR
LR
RLF
LLF
Mean total ROM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
38 70 46 48 46 60 48 58 34 40 50 56 56 48 58 46 56
50 46 62 52 60 60 38 42 60 58 64 62 70 74 70 54 70
60 64 72 70 70 68 50 72 62 64 56 64 70 64 74 62 68
60 62 68 70 62 60 52 72 56 68 60 52 72 68 62 64 68
42 34 52 30 40 40 40 30 40 42 30 40 36 36 32 40 32
40 32 48 32 36 44 32 40 40 34 32 40 38 38 40 32 42
48.3 51.3 58 50.3 52.3 55.3 43.3 52.3 48.7 51 53.7 52.3 57 54.7 56 49.7 56
Mean (S.D.) 50.47 (8.98) 58.35 (10.25) 65.29 (6.24) 63.29 (6.28) 37.41 (5.78) 37.65 (4.81) 52.4 (3.7) S.D. = standard deviation, RR = right rotation, LR = left rotation, RLF = right lateral flexion, LLF = left lateral flexion.
Neck pain, decreased cervical range of motion and head repositioning accuracy for the difference in prevalence in neck pain could be due to variables other than playing position. A future investigation could look at the effect of one season of rugby by taking a pre-season measurement of each research component and then conducting the data collection at the end of the season. This would provide more substantial evidence for any differences seen being attributable to a position in the game of rugby union. The results cannot be extrapolated to the whole game as the sample was not representative of all rugby players. However, in order to overcome this, a significantly larger study would be required involving players from all levels of the game. This study used a convenience sample of two amateur clubs rather than randomly selected teams, which could lead to bias by those chosen not being typical of all rugby clubs. A further limitation is the fact that no minimum or maximum limits were set for the number of games played. This was not done to ensure an adequate sample size and due to time constraints in collecting the data. The subject’s perception of neutral in HRA was used to determine the neutral point. This may have allowed the subject to compensate and may have affected the results by reducing the actual level of head repositioning error.
Conclusions Forwards playing amateur regional rugby union had a higher prevalence of neck pain. There was no significant difference in prevalence of decreased HRA between forwards and backs. There was an equal prevalence of decreased cervical ROM in forwards and backs.
Conflict of interest statement The authors declare they have no conflicts of interest.
Acknowledgement Support for this study in the form of equipment was provided by the Anglo-European College of Chiropractic (AECC). Author contribution statement: PD conceived the idea for the study. HG and PD contributed to the design and planning of the research. PD was involved in data collection. HG and PD analysed the data. HG wrote the first draft of the manuscript. Both authors edited and approved the final version of the manuscript.
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