692 of BokSmart’s mandate is to record seri- ous and catastrophic head, neck and spine rugby injuries in South Africa (SA), and to formulate appropriate initiatives aimed at prevention of these injuries.4 Even though spinal cord injuries in rugby union are few, there are inherent risks associated primarily with the tackle and scrum6 that are the main contribu- tors to spinal injuries, with scrum inju- ries consistently being more severe.3–5 7 10 Over the last 4 years in SA, these phases contributed to 78% of all serious and cata- strophic head, neck and spine injuries in rugby, with the tackle and scrum contrib- uting to 41% and 37% respectively; 55% and 74% of these injuries being perma- nent in nature, that is, with neurological deficit, quadriplegia or death. Considering that tackle events are more common in a match, the relative risk of catastrophic outcome in scrums is therefore consider- ably higher. IntErvEntIon – what can bE donE about nEck InjurIEs? Targeted interventions on scrum-related spinal cord injuries are effective.4 7 10 The French Rugby Union instituted new laws for scrumming, for non-professional players, and a new medical licensing procedure for front-row players called the ‘rugby passport’.7 New Zealand’s RugbySmart programme had similar results using a different strategy.7 10 It is possible that the scrum may be more amenable to education-based injury-prevention initia- tives than the unstructured tackle, ruck and maul.10 RugbySmart provides evidence that educational programmes are indeed a viable option for decreasing serious spi- nal injuries in scrums.10 12 For this reason, BokSmart implemented an educational approach akin to that of RugbySmart, but incorporated additional elements outlined in the 4-part programme to accommodate the South African rugby landscape. concussIon and fatal hEad Injury Another key component to address proac- tively is concussion, the consequences of boksmart – implementing a national rugby safety Programme W Viljoen,1 J Patricios2 The BokSmart National Rugby Safety Programme is a joint initiative between the South African Rugby Union and the Chris Burger/Petro Jackson Players Fund aimed at implementing evi- dence-based sports medicine and exercise research to prevent injury and enhance performance at all levels of rugby union in South Africa. The BokSmart programme has four main elements: the BokSmart Rugby Safety Work- f shops, a compulsory DVD-facilitated course that all coaches and referees in SA attend on a biennial basis, the BokSmart Rugby Medic f Programme, an entry-level rugby first aid short course aimed at training members of underprivileged rugby- playing communities, the toll-free BokSmart Spineline num- f ber, which assists in the management and road transport of head-, neck- and spine-injured rugby players to the near- est appropriate medical facility, and the freely accessible online educa- f tional resource www.boksmart.com, which provides researched documen- tation and practical advice on a vari- ety of rugby-related topics. Injury survEIllancE – a kEy ElEmEnt Head and neck trauma form a large part of the injuries associated with contact and collision sport.6 Rugby Union is a collision sport that exposes players to cervical spinal injuries, with permanent disabling injuries being the most serious and highly publicised complication.7 Part which have seen a number of concussion- related fatalities in South African rugby. The BokSmart philosophy is that the out- come of a properly managed concussion should never be catastrophic in nature, and proper education on preventing, iden- tifying, managing, treating and rehabilitat- ing a player before returning to match play forms an integral part of the programme. BokSmart’s education programme reflects the most recent International Consensus Statement on Concussion in Sport.13 14 A toll-free hotline manned by emergency medical service personnel who have received additional BokSmart training, enables coaches and referees to access appropriate emergency medical advice and treatment. The programme also developed a simple preparticipa- tion screening tool for coaches,15 which recognises concussion and neck injury history as an important predictor of cata- strophic injury.6 13 Each coach and referee also receives a pocket Concussion Guide, which assists in providing appropriate guidance for managing potentially con- cussed players on field. turnIng rEsEarch Into PractIcE – EffIcacy to EffEctIvEnEss A major challenge is turning injury pre- vention research into behaviour change. If causative behaviour can be amended, injuries may be prevented. In practice, one needs to find a realistic solution combin- ing both science and pragmatism to lead to positive behavioural change.8 9 Even the most scientifically proven, effective interventions do not necessarily guarantee compliance, or translate into success, in preventing injuries in the real-world con- text.1 8 9 Only proven and effective inter- ventions that become standard practice will stand a chance of preventing these injuries.8 Many interventions do not take this into account and sometimes are sim- ply not usable in the field.8 If one explores the current literature available, there are various models to strategically align injury-prevention ini- tiatives.1 2 8 9 In practice, your approach sometimes becomes a myriad of these, especially when the sporting landscape, as in SA, is extremely diverse with dif- ferent cultures, languages, socioeconomic statuses and disparate levels of education. Planning, developing and implementing an evidence-based, effective intervention in all communities is complex. BokSmart has used a multifaceted approach1 6 10 incorporating as many of its rugby stakeholders as possible, and avail- ing its content via different educational 1South African Rugby Union, Cape Town, South Africa 2Morningside Sports Medicine, Johannesburg and Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa correspondence to Dr Wayne Viljoen, South African Rugby Union, 5th Floor, Sport Science Institute Building, Boundary Road, Newlands, 7700, Cape Town, South Africa; waynev@sarugby.co.za Br J Sports Med August 2012 Vol 46 No 10 Editorial group.bmj.com on February 4, 2016 - Published by http://bjsm.bmj.com/Downloaded from http://bjsm.bmj.com/ http://group.bmj.com Editorial 693 rEfErEncEs 1. finch cf, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J Sports Med 2010;44:973–8. 2. finch cf. Getting sports injury prevention on to public health agendas - addressing the shortfalls in current information sources. Br J Sports Med 2012;46:70–4. 3. maclean jg, Hutchison JD. Serious neck injuries in U19 rugby union players: an audit of admissions to spinal injury units in Great Britain and Ireland. Br J Sports Med 2011 (In press). 4. hermanus fj, Draper CE, Noakes TD. Spinal cord injuries in South African Rugby Union (1980-2007). SAMJ 2010;100:230–234. 5. dunn rn, Van der Spuy D. Rugby and cervical spine injuries – has anything changed? A 5-year review in the Western Cape. SAMJ 2010;100:235–238. 6. mcIntosh as, McCrory P. Preventing head and neck injury. Br J Sports Med 2005;39:314–8. 7. bohu y, Julia M, Bagate C, et al. Declining incidence of catastrophic cervical spine injuries in French rugby: 1996-2006. Am J Sports Med 2009;37:319–23. 8. verhagen E, Finch CF. Setting our minds to implementation. Br J Sports Med 2011;45:1015–6. 9. verhagen Ea, van Mechelen W. Sport for all, injury prevention for all. Br J Sports Med 2010;44:158. 10. Quarrie kl, Gianotti SM, Hopkins WG, et al. Effect of nationwide injury prevention programme on serious spinal injuries in New Zealand rugby union: ecological study. BMJ 2007;334:1150. 11. noakes td, Draper CE. Preventing spinal cord injuries in rugby union. BMJ 2007;334:1122–3. 12. gianotti sm, Quarrie KL, Hume PA. Evaluation of RugbySmart: a rugby union community injury prevention programme. J Sci Med Sport 2009;12:371–5. 13. mccrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport – the 3rd International conference on concussion in sport held in Zurich, November 2008. J Sci Med Sport 2009 2009;12:340–51. 14. Patricios js, Kohler RMN, Collins RM. Sports- related concussion relevant to the South African rugby environment – A review. SAJSM 2010;22:88–94. 15. Patricios js, Collins RM. BokSmart: preparticipation screening of rugby players by coaches based on internationally accepted medical standards. SAJSM 2010;22:62–65. 16. van mechelen w, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992;14:82–99. 17. Posthumus m, Viljoen W. BokSmart: safe and effective techniques in rugby union. SAJSM 2008;20:64–70. play a critical role in seeking maximum effect and compliance. BokSmart regu- larly engages with relevant stakeholders, and partners with them around delivery developments.2 Each course builds on the previous course, and the format of these courses progressively adapts to the edu- cational needs of the participants. This also ensures that the educational materi- als remain up to date and provide current evidence-based best practice information to rugby participants.10 12 To increase commitment to the programme, the content also needs to be suitable for the audience with plain language take-home messages.12 The main requirement is now to estab- lish whether the knowledge and skills acquired by the coaches and referees are actually being translated into their practices on field.8 An expert, interna- tional research team is currently evaluat- ing the implementation of the BokSmart programme9 in collaboration with the University of Cape Town’s Research Unit for Exercise Science and Sport Medicine. In summary – BokSmart is an example of acknowledging a major problem, iden- tifying risk factors, developing strate- gies to target the problem, implementing these initiatives and putting independent processes in place to evaluate the suc- cess of the programme. The elements of the programme demonstrate the practi- cal implementation of an injury preven- tion and rugby safety programme using an evidence-based approach, yet keep- ing in mind the rugby landscape within a South African context in an attempt to maximise adoption and impact of the pro- gramme. The ultimate result is aimed at safer rugby, and fewer catastrophic inju- ries. Key to maximise compliance and uptake is ongoing research, keeping cur- rent with the injury patterns of the game, regular interaction and collaboration with all rugby stakeholders, constant education of all role players, and fluid and modifi- able implementation strategies that are moulded to the needs of the times. competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. Received 12 April 2012 Accepted 13 April 2012 doi:10.1136/bjsports-2012-091278 platforms.2 This helps ensure that the strong evidence base or interventions can be applied effectively in the ‘real world’.1 lEssons – what workEd? One of the key pillars of the programme is the educational courses modelled on the DVD-facilitated approach utilised in New Zealand.12 RugbySmart10 12 was originally modelled on van Mechelen’s16 approach and built on the foundation work of ear- lier initiatives.10 As with RugbySmart, the BokSmart programme is focused at community level, and is implemented throughout the country.12 17 In the first 2-and-half years, BokSmart has trained roughly 38 500 coaches and referees on the rugby safety course. On-going research into the primary problem is critical in ensuring effective- ness in one’s approach, and proactively addressing the identified risk factors as they surface.10 We monitor feedback from the target audience, that the desired level of interaction is being achieved, and that the product is being well received. We regularly engage with field-related experts to ensure that the intervention strategy is fluid and modifiable. This guarantees the best possible chance of learning and transfer. Understanding the barriers and enablers to the extensive adoption and sustainability of your intervention, is a crucial component in focusing your imple- mentation efforts.1 BokSmart recognises that programme leaders must continually consider different implementation and intervention delivery approaches.2 One method of structuring a preven- tion programme is using the Intervention Mapping (IM) protocol, which is made up of five steps, that is, (1) defining the pro- gramme objectives based on the extent of the problem, (2) selecting the most appro- priate method(s) to change the targeted behaviour or outcome, (3) designing the intervention and selecting, testing and producing the materials, (4) developing the implementation plan and (5) evalu- ating the intervention’s effect.9 The IM protocol is a continuous and consistent dialogue with all stakeholders involved to make sure that the intervention is accept- able and feasible from an implementation perspective.9 Hence, the BokSmart pro- gramme has stakeholder expert advisory and ground-level operational panels that Br J Sports Med August 2012 Vol 46 No 10 Br J Sports Med 2012;46:692–693. group.bmj.com on February 4, 2016 - Published by http://bjsm.bmj.com/Downloaded from http://bjsm.bmj.com/ http://group.bmj.com Safety Programme implementing a National Rugby−BokSmart W Viljoen and J Patricios doi: 10.1136/bjsports-2012-091278 2012 2012 46: 692-693 originally published online May 19,Br J Sports Med http://bjsm.bmj.com/content/46/10/692 Updated information and services can be found at: These include: References #BIBLhttp://bjsm.bmj.com/content/46/10/692 This article cites 15 articles, 7 of which you can access for free at: service Email alerting box at the top right corner of the online article. 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