The results were interesting and can be summarised as follows:

• 64% of the players believed that headgear could prevent concussion.
• 33% of coaches felt the same.
• 27% of players reported wearing headgear.
• 24% of players felt that the wearing of headgear should be mandatory.

The principle conclusions of the study were that
although most players felt that headgear may prevent concussion, only a minority reported wearing it. Coaches were less convinced than the players that rugby headgear can prevent concussion, and some felt that its use could actually lead to more concussion as the players may have a false sense of security.

The findings of the study need to be seen in the light about what we currently know about this area. Our current understanding can be summarised as follows:

• The potential for concussive injury in rugby is high.
• However, actual rates of concussion are not known.
• Rugby headgear use is currently not mandatory in all countries.
• Japan insists on mandatory use.
• Headgear use worldwide is variable and unknown although some countries have attempted to measure use.
• Headgear must comply with IRB standards.
• It is the referee who determines if a particular piece of headgear is acceptable or not, i.e. does it display the IRB logo?
• Law 4 (players’ dress) states that headgear must be made of soft and thin materials with no part of the headgear thicker that 1cm when uncompressed, no part to have a density of more than 45kg/m3 and headform acceleration must be restricted to 200-550g in a drop test from 0.3 metres.
• Laboratory tests have shown relatively poor attenuation of impact energy observed for a range of available IRB approved headgear. The authors of the best study to date felt that the current commercially available headgear would not reduce the likelihood of concussion. (Br J Sports Med 2000; 34:337-341).

The primary reason for wearing headgear is to prevent lacerations and abrasions to the scalp. Headgear is generally accepted to do this. It is claimed that its use will minimise the risk of concussion. There is no evidence currently to support this claim.

The Canadian study focussed on attitudes to use, and not outcomes as a consequence of use. The study was small and the sample was not truly random. The authors agree that the findings cannot therefore be used to generalise to all rugby players in Canada and certainly not to all rugby players worldwide.

The authors made specific recommendations. These were:

• More research is needed to establish the influence of wearing headgear on rates of concussion. It is not impossible that these studies will show an increased risk rather than a reduced risk.

• Players and coaches need to be made aware of the lack of research evidence to support the use of headgear. Despite this lack of research, players and coaches have developed their own beliefs.

If future research supports the use of headgear it needs to be better designed and cheaper. Reasons quoted for not wearing it included the fact that its use was not mandatory, often uncomfortable, that it cost too much and needed better ventilation.

Discussion

To move the debate forwards we need more evidence of the positive (or negative) effect of headgear use on concussion rates. Two important studies will, in due course, provide more information.

A pilot study from New South Wales looking at the effectiveness of headgear in under 15 rugby union players found that wearing headgear did not provide protection against concussion (Br J Sports Med 2001; 35:167-169). The study was limited by the relatively small number of cases of concussion observed during the study time. The study is continuing to increase the power of such observations.

The Performance Department, in partnership with the University of Leicester is currently piloting an injury and training audit, which will embrace all the Premiership clubs for the 2002-3 season. This will give us important information about the incidence of concussion and will specifically look at the relationship with headgear use.

This is OK for the professional player but what about the community player whose basic fitness, awareness, skill and belief in their abilities is vastly different from a professional player? There are over 200,000 community players and some 400 professional players - should this research be more embracing of the game at large?

These were the concerns of the RFU prior to the introduction of the law which permitted the use of padded garments. Additionaly, do we know the effects and/or perceived benefits (or lack thereof) of wearing shoulder pads and other padded clothing?

We need to be careful with our terminology and refer to ‘padded’ rather than ‘protective’ clothing. There is no evidence currently to suggest that the use of headgear protects against concussion and many of the current marketing claims by manufacturers are inappropriate. It is important that players, coaches and parents are aware of paucity of evidence to support these claims.