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Evaluation of the Effectiveness and Implementation of the BokSmart Safe Six Injury Prevention Programme: a study protocol
  1. Nicola Sewry1,
  2. Evert Verhagen1,2,
  3. Mike Lambert1,2,
  4. Willem van Mechelen1,2,
  5. James Brown1,2
  1. 1Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
  2. 2Department of Public and Occupational Health and EMGO+ Institute, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Nicola Sewry, Division of Exercise and Sports Medicine, Sports Science Institute of South Africa, Boundary Road, Newlands, Cape Town 7700, South Africa; nicolasewry{at};


Background The injury burden in rugby union (‘rugby’) is high. While exercise-based injury prevention programmes have successfully reduced injuries in other sports such as football, there is minimal research on this topic in rugby union.

Objective To evaluate the effectiveness and implementation of an exercise-based intervention (BokSmart Safe Six) in junior rugby players that aims to reduce the injury risk profile and burden of injury.

Setting 14–16-year-old junior rugby players in two geographically separated locations in South Africa over the 2017 rugby playing season.

Methods A cluster-randomised controlled trial where the teams are allocated to groups that either (1) have a coach-delivered exercise intervention in their warm-up (BokSmart Safe Six) or (2) continue with their warm-up ‘as usual’ (control group). Injury risk profiles will be assessed through musculoskeletal screening on all players performed at the beginning, middle and end of the trial. Epidemiological measurements include injury surveillance at all matches and training sessions, and exposure to the various warm-up exercises (including BokSmart Safe Six exercises). Behavioural determinants of coaches will be assessed through standardised theory of planned behaviour questionnaires and focus groups before and after the intervention.

Outcome measures Comparison in injury risk profiles and burden of injury between the intervention and control groups. Changes in the behavioural determinants of coaches.

Trial registration number: PACTR201608001730223. Pre-Results.

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  • Twitter Follow Nicola Sewry at @nsewry, Evert Verhagen at @evertverhagen and James Brown at @jamesbrown06

  • Contributors NS, EV, ML, WvM and JB designed the study. NS prepared the first draft of this manuscript, and all other authors contributed substantially to the final manuscript for submission.

  • Funding The BokSmart Safe Six study was initiated by BokSmart and supported by the University of Cape Town (UCT) and VU University Medical Center (VUmc), the Netherlands. The study is funded by BokSmart, the Desmond Tutu/NRF collaboration and UCT. SA Rugby has been instrumental in the support of the project.

  • Competing interests WvM declares interests not relevant to this study: he is shareholder-director of VU University Medical Center spin-off company Evalua Nederland B.V. ( and non-executive board member of Arbo Unie B.V. ( Both companies operate in the Dutch occupational healthcare market.

  • Patient consent Not Applicable as trial has not yet begun.

  • Ethics approval The Human Research Ethics Committee (HREC 850/2015), University of Cape Town, and the South African Department of Health.

  • Provenance and peer review Not commissioned; internally peer reviewed.