Rolling injuries out of lawn bowls: a review of the literature

Monash University Accident Research Centre - Report #138 - 1998

Authors: A.C. McGrath & E. Cassell

Abstract:

Lawn bowls is a popular sport and leisure activity in Australia played by an estimated 75,000 to 80,000 Victorians. Health professionals recommend the sport to older people because it provides low impact, therapeutic exercise in a social and supportive atmosphere.

There are no comprehensive data on lawn bowls injuries. Data from hospital emergency department surveillance systems revealed that presentations for lawn bowls injuries are uncommon. This is possibly explained by the lower physical intensity of bowls compared with other sports and the likelihood that bowlers may seek treatment elsewhere (for example from General Practitioners, physiotherapists and chiropractors ) or self treat their injuries.

In total there were 29 lawn bowls injury cases recorded on the new Victorian Emergency Minimum Dataset (VEMD) and the superseded Victorian Injury Surveillance System (VISS). Approximately three-quarters (76%) of the injured players were female, indicating they may be at higher risk of injury because ABS sports participation data indicate they comprise only 39% of participants in lawn bowls. Injuries were caused by falls (59%, including trips and slips on the green during play, when traversing the ditch and on steps and paths in areas around the clubhouse or carpark); overexertion (31%, sprains and strains); and being struck by a bowl (7%). Injuries included: sprains and strains (35%); fractures (35%); cuts and bruises (23%). Eight of the 29 cases (28%), all female and aged over 60 years, were admitted to hospital.

The research literature search found no published or unpublished studies on the patterns, causes and prevention of lawn bowls injury. Consequently, this report covers studies that examine injury among older athletes engaged in other sporting activities and includes a detailed discussion of countermeasures to injury implemented in other sports that are transferable (with appropriate modifications) to lawn bowls. Recommendations include: extension of coaching to improve players’ technique, pre-participation screening, pre-season conditioning, warm-up and stretching programs, improved footwear design, education of coaches and trainers and the provision of appropriate first aid and rehabilitation. Fall hazards need to be eliminated from the sport, playing environment and club facilities.

It is strongly recommended that lawn bowls clubs collect comprehensive injury data that need to be collated, analysed and reported periodically to assist the development of targeted injury prevention measures.

Executive Summary

Lawn bowls is a popular sport and leisure activity in Australia. It is estimated from the 1995/96 Australian Bureau of Statistics (ABS) population household survey that 296,000 Australian men and women play bowls. It is the fifth most popular sport in Australia behind aerobics, golf, tennis and netball. Most participants (92%) are over 45 years old, 61% are male and 39% are female. The sport is played for the challenge and competition, personal enjoyment in terms of being active and spending time outdoors, and social reasons. Also, participation is recommended to older people by health professionals because the sport provides low impact, therapeutic exercise in a social and supportive atmosphere.

There is a notable lack of information on lawn bowls injuries. No data are collected at club or association level. Also, there are no published or unpublished epidemiological studies indicating the frequency and pattern of injury among bowls players. The only information that was available was from hospital emergency department surveillance systems.

Data on lawn bowls injury from Victorian, Australian and New Zealand hospital emergency department databases reveal that presentations are uncommon. The low frequency of cases presenting to E.D. departments is probably explained by the lower physical intensity of bowls compared with other sports. Also, anecdotal evidence and research on sports injuries among other groups of older athletes suggest that lawn bowls injuries are more likely to be intrinsic in nature – sprains, strains and joint problems – which are not well-captured in hospital emergency department data collections. Players with these injuries are more likely to consult general practitioners, other health and sports injury treatment practitioners (for example physiotherapists, chiropractors and masseurs) or self-manage their injury. There are no comprehensive data collections on these types of treatments in Victoria, although a survey of sports medicine clinics is in progress.

There were 29 cases of lawn bowls injury recorded on Victorian hospital emergency department surveillance systems. Fifteen cases (3 males; 12 females) were identified on the new Victorian Emergency Minimum Database (VEMD) over the two-year period (1995-97). These data are drawn from 25 Victorian hospitals. The number of cases extracted from the database probably underestimates the actual number of lawn bowls injury presentations because the specific sport being played at the time of injury is inconsistently reported in VEMD sports injury case records. Another 14 cases (4 males; 10 females) were recorded on the superseded Victorian Injury Surveillance System (VISS) database that collected adult injury data from 4 Victorian hospitals for various periods between 1988 and 1995.

Injuries were caused by falls (59%, including trips and slips on the green during play, when traversing the ditch and on steps and paths in areas around the clubhouse and car park); overexertion (31%, sprains and strains); being struck by a bowl (7%) and foreign body in eye (3%). Injuries included: sprains and strains (35%); fractures (35%); cuts and bruises (23%); and one case of shoulder injury, not specified (3.3%). The most common sites of injury were the ankle and the wrist. Approximately three-quarters (76%) of the injured players were female, indicating they may be at higher risk of injury because ABS sports participation data indicate they comprise only 39% of bowls participants. Eight of the 29 cases (28%), all female and aged over 60 years, were admitted to hospital.

A similar pattern of injury was evident when Australian data on lawn bowls injuries, from the National Injury Surveillance Unit (NISU) in Adelaide, were analysed. The NISU database recorded 65 lawn bowls injury cases (from 50 participating hospitals across Australia) during the period 1986-1997. Seventy-one per cent of injured bowlers were female; 65% were aged over 60 years. The major causes of injuries were falls, including trips and slips (54%); overexertion resulting in sprains and strains (28%); and being hit by the bowl (18%). The injurious falls were fairly evenly divided between loss of balance, slips (mostly on the green but a few on steps, bank and paths) and trips (mostly over bowls). Fractures (37%) and sprains and strains (31%) were the most common types of injury. Eleven cases (17%) were admitted to hospital.

Anecdotal evidence from the Royal Victorian Bowls Association (RVBA) suggests that the common scenarios for falls in lawn bowls are:

when crossing the ditch from the bank to the green, players step forward over the ditch, instead of sideways, and stumble or slip into the ditch;
players deliver the bowl when unbalanced (there needs to be 65-70% weighting on the leading foot to maintain balance, otherwise a bowler falls over); and
players step backwards during play and fall over the bowls that are behind them.

Older people, especially older women, are particularly vulnerable to fall-related fractures that can cause longer-term disability and may reduce quality of life and independence. Because of the older age of participants in lawn bowls, clubs and associations need to be vigilant about eliminating fall hazards from the game, the playing environment and club facilities (including the car park).

Our literature search found no published or unpublished research studies on the pattern, causes and prevention of injury in lawn bowls. Consequently, this review covers studies that examine sports-related injury in active older people (mostly athletes) and provides a detailed discussion of measures to prevent injury in other sports that are transferable (with appropriate modifications) to lawn bowls.

Generally, the research evidence on the effectiveness of many of the countermeasures to sports injury is inconclusive. Sports injury research on recreational players is a relatively new discipline and large controlled studies that can provide definitive answers are rare. More large-scale epidemiological studies are needed to identify the pattern of sports injury in the general population of lawn bowls players and the role of various risk factors in causation. Clubs and associations can contribute to this endeavour by systematically collecting injury data. Basic scientific studies are also required to better understand the mechanisms of injury. Lastly, controlled evaluations ‘in the field’ are needed to trial whether the various countermeasures to injury are effective. The recommendations for research and countermeasure implementation in this report are based on a critical analysis of available research evidence as well as discussions with the experts acknowledged in this report.

GENERAL RECOMMENDATIONS

Lawn bowls clubs and associations should collect data on lawn bowls injuries that occur in practice, social and competition games and in and around the club facilities, along with information on the circumstances of the injuries. These data need to be collated, analysed and reported periodically by a central agency.
Data collections should conform to the guidelines for sports injury surveillance being developed and promoted nationally.
Information about preventing lawn bowls injuries should be disseminated widely through lawn bowls broadcasts, lawn bowls equipment points of sale, lawn bowls magazines and more general magazines, and media outlets.
Risk management plans for sporting bodies, clubs and associations should be developed, implemented and regularly reviewed.
Guidelines for minimum safety requirements for lawn bowls events (including the need for emergency telephone contact list, first aid kit etc.) should be developed and widely disseminated.
Future research to determine injury risk factors or to evaluate the effectiveness of countermeasures need to be controlled studies.

SPECIFIC RECOMMENDATIONS FOR COUNTERMEASURE IMPLEMENTATION, RESEARCH AND DEVELOPMENT

Playing technique

Investigate the role of incorrect technique in the occurrence of overuse and fall-related injuries in bowls.
Promote coach training and ensure there is at least one trained coach at every club to advise, monitor and improve the bowling technique of players at all skill levels.

Pre-participation screening

Conduct more research into the physical well-being and anthropometric measures on which to base pre-participation screening for lawn bowls players.
Develop a pre-participation screening program specifically for lawn bowls players.
Promote pre-participation screening and pre-season medical assessment to bowlers.

Footwear

Advise bowlers to seek professional advice when choosing bowling shoes.
Encourage players to change their footwear to shoes with grip on the undersole when they finish bowling.
Develop material for the soles of lawn bowls shoes that is slip resistant yet does minimal damage to the greens.
Investigate barriers to the use of bowling shoes with grip soles and revise rules accordingly.
Investigate the involvement of wet greens, especially synthetic greens, in slips and falls.
Re-design bowling mats so that they have significant grip on the top surface to provide some traction between the shoe and the mat.
Research questions that need to be answered include:
- Which features of footwear are protective against injuries?
- Where should the balance lie between foot protection, the stabilising effects of footwear and flexibility of shoes?
- What is the interaction between footwear, specific playing surfaces and injury?

Bowling arms

Widely promote the use of bowling arms to players with physical restrictions as a means of preventing repetitive strain injuries.
Continue to promote participation in lawn bowls to wheelchair-bound people and those who have disabling back and hand conditions.

'Non-slip' mats

Incorporate a ridged upper surface in the design of 'non-slip' mats and test to see if the ridging protects players from slipping. If the surface provides improved protection then ridged mats should be adopted.

Environmental conditions

Develop, implement and monitor risk management plans for bowling facilities to control environmental hazards.
Reduce the risk of injurious falls in lawn bowls through a multi-faceted approach which could include:
- the provision of slip resistant steps or a ramp over the ditch onto the green;
- the installation of hand rails around the footpaths;
- regular inspection and repair of footpaths;
- application of anti-slip treatments to walking surfaces;
- the promotion of changes to bowls footwear to improve its slip resistance;
- the provision of good lighting at night games;
- the installation of ramps around the club house; and
- the provision of plenty of seating.
Introduce a consistent rule that restricts play in extreme weather conditions.
Educate players to sip water throughout the game, especially in hot weather, to ensure adequate hydration.
Promote the use by players of a broad spectrum sunscreen even on cloudy days.
Advise players to keep undergarments to a minimum in hot conditions.
Undertake studies to determine the influence of environmental conditions, such as playing surface and weather conditions, on injury.
Conduct research on the interaction between footwear, specific playing surfaces and injury.

Bowls and bags

Players should seek professional advice when purchasing bowls.
As players get older they should review the weight and size of their bowls.
Players who have difficulty lifting their bowls bag should use a trolley.

Physical preparation

Develop and promote guidelines on current best practice regarding warm-up, cool-down and stretching techniques. These exercise routines should be promoted to all competition and social players through the RVBA, clubs and the Arthritis Foundation.
Conduct simple fitness testing prior to each lawn bowls season to ensure players are fit for competition.
Introduce training sessions to improve fitness and for skills development.
Educate players about the nutritional and hydration demands of playing lawn bowls, particularly in hotter climates and warmer weather.
Skills and fitness should be built-up gradually when a player is learning the sport.
Investigate, through controlled research studies, the role of training and warm-up/cool down in injury prevention and the relative benefits of different types of warming-up, cooling-down and stretching practices.

Education and coaching

Each club committee should appoint at least one well-respected and advanced bowls player to act as club coach.
All coaches should be accredited and undergo regular training and re-accreditation.
Coach education schemes should be updated regularly to ensure they provide current information.
The coaching manual should be reviewed to include more information on sports injury prevention, treatment and rehabilitation.
Prevention of injury should be a key responsibility of coaches and the subject should be included in the coaching manual.
Educational resources for social lawn bowls players need to be developed and disseminated.
Instruction clinics for the social bowler should be developed and advertised widely.

Preventing overuse injuries

Investigate the role of conditioning (to improve strength and flexibility) in the prevention of overuse injuries.
Educate lawn bowlers about the risks and potentially severe consequences of overuse injuries.
All lawn bowls players should practise appropriate warm-up and stretching routines prior to games and cool downs after games.
Undertake research into the frequency, patterns and causes of overuse injuries among lawn bowlers.

First aid and rehabilitation

At least one qualified first aider should be on duty at all bowls events.
All bowling clubs should have a well-stocked first aid kit, telephone and emergency contact numbers on display.
Return to play after injury should only occur after full recovery.
More controlled research is needed to determine the effectiveness of taping and bracing of body joints, for example the ankle, as a primary prevention injury countermeasure.

Sponsoring Organisation: Sport and Recreation Victoria