Results
Search results
The study selection process is described in a PRISMA flow chart (online supplemental figure S1: PRISMA flow chart displaying the study selection process). Following the search, 573 citations were identified and after removing duplicates, 444 remained. After screening the remaining articles a further 391 were removed due to not meeting the inclusion criteria. The full text articles of the remaining 53 studies were assessed for eligibility. Subsequently, 37 articles were exluded due to having the incorrect outcome (6), incorrect population (10), incorrect study design (3), incorrect publication type (16) or the results were presented in another included study (2). Ultimately, 16 studies were included in the scoping review.2 3 9 13 21–32
All 16 included articles describe studies conducted only among male participants. Nine articles focused on retired rugby union players, five on retired rugby league players and two on retired players from both versions. The studies included participants from various countries: France (2), the UK (6), Australia (4) and New Zealand (1). Two studies included participants from multiple countries, and one did not specify which country the participants were from.
Six articles provided prevalence rates on musculoskeletal health conditions, 2 on cardiovascular health conditions, 10 on psychological health conditions and 6 on neurological health conditions. Several studies reported on combined health conditions while three reported on other health conditions that did not fall into the previously mentioned categories, namely asthma, diabetes, stroke and disabling headaches . No studies on gynaecological health were found.
Critical appraisal
Two studies did not meet the appropriate sample frame of the research problem.23 25 Gouttebarge et al focused only on retired elite rugby players who were younger than 51 years of age,25 while Gallo et al23 studied participants who were 50 years and older.23 An appropriate statistical analysis was given in four studies.25 27–29 In the other 12 studies, there was no 95% CI provided with the prevalence rates.3 9 13 21–26 30–33 In 10 studies, the response rate was not described.2 3 13 21 24 26 27 30–32 The full results of the critical appraisal are presented in online supplemental appendix S3C.
Musculoskeletal health conditions
Six articles described outcomes relating to the musculoskeletal health of retired elite rugby players.3 9 21 27–29 Four studies provided prevalence rates for OA (including hand OA, wrist OA and ankle OA),3 9 27 29 three for pain (including neck, back, joint and hand pain),3 21 27 one article described prevalence rates for joint replacement (including hip and knee replacement)9 and one provided prevalence rates for chronic orthopaedic problems as well as osteoporosis. The essential information from the six studies is summarised in online supplemental appendix table S1–musculoskeletal health conditions in retired elite rugby players.
The presence of general OA was measured through self-report questionnaires that required participants to indicate if they had been diagnosed with this health condition, and the prevalence range was 51%–60%.3 9 Hind et al3 reported a significant difference in the prevalence of OA in elite retired rugby players (51%) compared with non-contact retired sportsmen (22%) (p<0.05).3 There was no significant difference in the prevalence of hand OA (4%) and wrist OA (2%) compared with former professional cricket players (hand OA: 2%, wrist OA: 2%).27 There was also no significant difference in the prevalence of ankle OA (5%) compared with retired professional football players (9%).29
Pain was assessed using self-report questionnaires and standardised instruments.3 21 27 Neck pain, assessed with the Neck Disability Index, was significantly more prevalent in retired rugby players (51%) compared with matched controls from the general population (32%) (p=0.01).21 The prevalence of disabling neck pain was also higher in retired rugby players (3%) compared with the general population (1%).21 The prevalence of hand pain, assessed with the National Health and Nutrition Examination Survey (NHANES) criteria, was significantly higher in retired elite cricket players (20%) compared with retired elite rugby players (10%).27 Back pain and severe and regular joint pain, assessed through self-report questions, were more prevalent in retired professional rugby players (80%–64%) than in retired amateur rugby players (75%–53%) and retired non-contact athletes (69%–47%). However, no significant difference was indicated.3
Joint, knee and hip replacement were measured through self-reported questions that required participants to indicate if they had been diagnosed with this health condition.9 The prevalence rate of joint replacement was 24%, hip replacement was 15%, knee replacement was 9% and no control group was used in this study.9
The prevalence of osteoporosis was assessed by asking if this health condition had been diagnosed by a physician.9 The prevalence of osteoporosis was 4%, and there was no control group in the study.9
Chronic orthopaedic problems (no specific definition provided) were examined through a self-report inventory, revealing a higher prevalence rate in retired rugby players (14%) compared with the matched control group (3%); however, no significance value for this difference was provided.28
Cardiovascular health conditions
Three articles described the prevalence of cardiovascular health conditions in retired elite male rugby union players.9 23 28 Heart conditions were measured through self-report questionnaires, and prevalence rates for heart problems, cardiovascular disorder and hypertension were provided. The essential information from the three studies is summarised in online supplemental appendix table S2—cardiovascular health conditions in retired elite rugby players.
The prevalence rate for heart problems in former elite male rugby players was 18% and hypertension had a prevalence range of 28%–32%.9 23 There were no control groups in these studies.9 Retired elite male rugby players had a prevalence rate of 2% for cardiovascular disorder, while the control group matched for age and social deprivation had a prevalence rate of 21%.28
Neurocognitive health conditions
Six articles described the prevalence of the following neurocognitive health conditions: neurological abnormalities, dementia, neurological disease, mild cognitive disorder, cognitive decline, the presence of abnormal cavum septum pellucidum (CSP) and Parkinson’s disease.9 21 22 28 30 31 The studies used questionnaires, standardised assessment tools and MRI scans to obtain information. The essential information from the six studies is included in online supplemental appendix table S3: neurocognitive health conditions in retired elite rugby players.
Neurological
Neurological abnormalities were assessed using Japanese Orthopaedic Association scores (JOA scores).21 A JOA score of 15/17 was the limit value of neurological abnormality. In the study, 1 of the 101 participants had a neurological abnormality, giving a prevalence rate of 1%. The prevalence rate in the control group was not provided.
A prevalence rate of 3% was reported for neurological disease in retired elite rugby players, which was less than the prevalence rate in retired elite sportsmen from other sports (4%).22 However, the difference was not statistically significant (p=0.763).
Dementia was reported with a prevalence rate of 1% in former rugby players, while the prevalence rate for the control group was not provided.9 One of 52 participants reported they had been diagnosed with Parkinson’s disease (prevalence of 2%), and the prevalence rate in the control group of 29 was 0%.28
Cognitive
Mild cognitive disorder was assessed with the French Telephone Interview for Cognitive Status, with a score below or equal to 30 considered a mild cognitive disorder. The prevalence of mild cognitive disorder in rugby participants (57%) was significantly higher compared with other retired sportsmen (40%) (p=0.005).22
Cognitive decline was assessed with the Informant Questionnaire Cognitive Decline in the Elderly.31 Cut-off scores indicating likely dementia vary from 3.3 to 3.6 and above.34 The prevalence of cognitive decline with a cut-off point of 3.88 was 8%, and the prevalence of cognitive decline with a cut-off point of 3.38 was 29%. There was no control group.
An abnormal CSP was measured with an MRI scan, which two raters assessed.30 A non-significant difference was reported for abnormal CSP in former rugby players (61%), compared with the controls (42%)(p=0.08).
Psychological health conditions
Ten studies describe the following mental health conditions in retired elite rugby players: depression, anxiety, stress, distress, sleep disturbance, alcohol misuse, nutrition behaviour, irritability, smoking behaviour and drug use.2 9 13 22 24–26 28 31 32 The essential information from the 10 studies is included in online supplemental appendix table S4: psychological health conditions in retired elite rugby players.
Depression and anxiety
Seven studies described depression in retired professional rugby players,2 9 13 22 26 28 31 four described the prevalence of anxiety,2 9 13 26 while one study described the prevalence rate of depression or anxiety.25
The prevalence of depression or anxiety was 28% and was measured with the 12-Item General Health Questionnaire (GHQ-12).25 There were no control groups in the studies. The depression prevalence range in the other studies was 6%–49%.2 9 13 22 26 28 31 One study used the GHQ-12,13 two used the Depression Anxiety Stress Scales (DASS),26 31 one used the Patient Health Questionnaire-922 and three used self-report questionnaires.2 9 28 One study showed a significant difference in self-reported depression prevalence between professional ex-rugby players (49%) and retired non-contact athletes (21%) (p=0.001).13 In another study, there was a non-significant difference in depression prevalence between professional ex-rugby players (11%) and amateur rugby players (10%) as well as non-contact players (9.5%) (elite rugby vs community rugby, relative percentage 1.1 (95% CI 0.6 to 2.0)) (elite rugby vs non-contact players, relative percentage 0.9 (0.4–1.9)).2 Two studies described the prevalence of depression in multiple stages. The prevalence of moderate depression was 10%–11% and severe depression was 4%–5%.26 31
The prevalence of anxiety among retired professional rugby players varied between 5% and 42%.2 9 13 26 A significantly higher prevalence of self-reported anxiety among retired elite rugby players (42%) compared with amateur rugby players (23%) was reported (p=0.009).13 One study reported a non-significant difference between retired elite rugby players (5%) and community rugby players (8%) (elite rugby vs community rugby, relative percentage 0.6 (95% CI 0.3 to 1.5)), and retired elite rugby players and non-contact sportsmen (7%) (elite rugby vs non-contact sports, relative percentage 0.7 (95% CI 0.2 to 2.2)).2 One study also reported the prevalence of multiple anxiety stages.26 This study reported an 8% prevalence of mild anxiety, 6% moderate anxiety and 5% severe anxiety.
Stress
The prevalence of stress was described in one study using the DASS-21.26 The prevalence rate of retired rugby players with moderate stress was 9%, and severe stress was 6%. Distress was described in one study that used the four-dimensional symptom questionnaire and reported a prevalence rate of 25%.25
Sleep disturbance
One study assessed sleep disturbance using the Patient-Reported Outcome Measurement Information System, where a score of 1 or more indicated a sleeping disturbance.25 The prevalence rate in retired rugby players was 28%.
Irritability
Irritability was assessed using the Spielberger Anger Expression Scale.13 There was a significant difference in the prevalence of irritability in retired elite rugby players (52%) compared with retired amateur rugby players (42%) (p<0.001). No p value was mentioned for the difference between the prevalence in retired elite rugby players and non-contact athletes (18%).
Nutrition behaviour
Nutrition behaviour was assessed with questions about the participants’ eating habits.25 Adverse nutrition behaviour was reported when individuals consumed healthy meals less than 5 days (per week, had irregular eating patterns on less than 3 days per week, had breakfast before 10:30 less than 3 days per week, and had a final meal before 20:30 less than 3 days per week).25 The prevalence of adverse nutrition behaviour was 24%.25
Alcohol use
All the studies that described alcohol misuse in retired professional rugby players used the Alcohol Use Disorder Identification Test.2 13 24–26 31 32 The two studies that used a value of 5 or above to indicate adverse alcohol behaviour reported 24%–59% prevalence rates.13 25 One study used a value of 8 or above to indicate hazardous drinking and reported a prevalence of 38% in retired elite rugby players.2 This was slightly lower than the prevalence rate in retired community rugby players (40%) (elite rugby vs community rugby, relative percentage 1.0 (95% CI 0.7 to 1.2)), but was significantly higher compared with retired non-contact sport players (25%) (non-contact players vs elite rugby, relative percentage 1.5 (95% CI 1.0 to 2.4)). The two studies that provided multiple breakdown limit values reported prevalence ranges of 46%–54% for hazardous alcohol use, 8%–9% for harmful levels and 9%–15% for high-risk levels.24 32 In both studies, there were significant differences compared with the control groups matched for age and education (p<0.01). Two studies reported the prevalence of multiple levels of alcohol use.26 31 The prevalence of a risky or hazardous level was 36%–37%, a harmful level was 5%, and a high risk was 2%.26
Smoking, cannabis and drug use
Adverse smoking behaviour and cannabis and drug use in retired professional rugby players were assessed using a questionnaire.25 26 31 A prevalence rate of 15% was indicated for adverse smoking behaviour.25 The prevalence range for cannabis use in the past 6 months was 2%–5%, and the prevalence of illicit drug use in the past 6 months was 5%–13%.26 31 No control groups were used in the studies.
Other health conditions
Three studies described health conditions that did not fit into the above-mentioned categories using questionnaires: asthma, diabetes, stroke and disabling headaches.9 22 23 The essential information from the three studies is included in online supplemental appendix table S5: other health conditions in retired elite rugby players.
Asthma was present in 10% of the retired elite male rugby players,9 diabetes had a prevalence range of 2%–4%9 23 and one study provided the prevalence rate of stroke as 3%.9
The prevalence of disabling headaches among retired rugby players was assessed using the Head Impact Test-6 (HIT-6).22 A headache was considered disabling, with a HIT-6 score of 50. The prevalence rate of 16% in the rugby participants was not significantly different compared with that of participants who played another sport (13%) (p=0.503).22