Dr Sam Barke

Head of Sports Medicine

Meliora Medical Group, Return2Play

Disclaimer:  This article was written in December 2020. The science and data around risk of head injuries is constantly evolving and the below may not be representative of the current landscape or Dr Barke’s current views.

It’s taken me a little while to put pen to paper with my thoughts on the recent headlines regarding long term health risks from playing rugby. I feel there is merit in letting the dust settle a little so as to avoid knee-jerk comment that fails to show a balanced view.

Firstly, I should make it extremely clear that I have nothing but sympathy for Steve Thompson & Co. I fully support their hope that by taking the action they are, further focus will be placed on player welfare.

It is always important when making comment on such sensitive issues to acknowledge conflicts of interest. Professionally, a significant amount of my time is spent managing head injuries in adolescent athletes and working with schools to reduce injuries and ensure that when they do occur, they are managed properly (see bio). But I make no denial of the fact that I am a rugby lover. There are those that will argue that this means I can’t have a balanced view on the topic – that I’ll look at the issues through rose tinted glasses – but I believe that it is my love of the sport alongside my professional interests which is precisely what qualifies me to give a balanced view. How can someone who doesn’t appreciate the joy rugby brings understand why people would want the game to continue to be played? Of course someone who hasn’t seen and felt the benefits would immediately make the call to “ban it” in the face of concerns around safety.

So, what do I see as the key questions around to the wider issue of head injuries in rugby?

Q: Are head injuries bad for you?
A: Yes.
I believe this is indisputable. We can go back and forth over whether scientific studies have firmly proven the link between head injuries and poor long term brain health, but the growing weight of evidence points us towards the fact that it simply isn’t a good idea to hit your head a lot. And keeping things simple I’d suggest that this is obvious – the human instinct of self preservation tells us that it’s a good idea to protect our heads.

Q: Does the way the modern elite-level game is played contribute to risk?
A: Yes.
The average number of tackles – where head injuries are most likely to occur – made per team has increased from 52 in 1991 to 128 in 2019. Add to this that tackles tend to now be more upright and that players are bigger and potential for harm increases further. Reduce those collision incidents and clearly you will reduce risk. (Those who use the argument “we don’t want to change the game” to prevent interventions that improve welfare, presumably hadn’t noticed this steady change over the last 30 years).

Q: Have efforts already been taken to mitigate risk?
A: Yes.
There is absolutely no doubt that rugby has been at the forefront of making efforts to reduce risk.  Head injury awareness campaigns, law changes to reduce risk and increased sanctions to encourage safer play. Then there are the clear protocols to manage head injuries – the Head Injury Assessment process used in elite rugby has been shown to reduce the number of missed concussions from around 50% to less than 10%.

Q: Can more be done?
A: Yes.
We have started from a relatively poor knowledge base but expertise and understanding is constantly evolving.  The challenge for the game’s authorities is to ensure they keep up with the latest evidence.  The problem is that hasty reactions are not necessarily useful.  A good example was a trial of a law change that enforced lower tackle heights in the 2018/19 Championship season.  It made perfect sense – keep tacklers away from the tackled players head/neck and you would reduce the risk of head injury.  But there was an unexpected rise in the number of concussions sustained by the tackling players and the trial was abandoned.

But is any of this relevant to the school game?

Reducing incidence of head injury is beneficial at all levels of the game. This is obvious. But it would be over simplistic to say that the risks in the adult elite game can be applied to those in school-age rugby.

Again, I think there are some key questions:

Q: Are the number of collision incidents comparable?
A: No.
Anecdotally school coaches will tell you that the game is far more “open” with less contact. Youth players are still taught to “find space” and avoid contact. Data is scant but two leading rugby playing schools I work with were able to provide data on tackles for their U18 sides. This showed an average of less than 80 tackles made per game per team – almost 40% less than the elite game.  It would be a fair assumption, although it clearly needs validating, that if you go down the ages those numbers would decrease further.

Q: Are the number of injuries comparable?
A: No.
Studies have consistently shown significantly lower injury rates in youth players compared to elite adult.  A systemic review in 2015 showed a 67% lower incidence (injuries per 1000 playing hours) in those aged 6 to 21. This was for pooled data on that whole age range.  Much like with number of collision incidents we would expect the rates to lower in younger ages and this has been confirmed by various other studies.
Combine lower rates of injury with shorter games, far fewer matches in a season and reduced training sessions and an individuals risk of injury at school-age becomes incomparable compared to the elite player.

Q: Is the management of head injuries comparable?
A: No.
School-age rugby follows the rule “Recognise and Remove” when it comes to head injuries.  If an injury is suspected the player is removed and not allowed to return.  There is no place for a Head Injury Assessment.
A school-age player with suspected concussion must have 2 weeks complete rest from sport and then follow a graduated return to play pathway.  They should not return until cleared to play by a doctor.  The minimum time away from matches is 23 days.
What about an elite player? Just 6 days. Incomparable.

So, I think it is reasonably clear that the risks in school-age rugby are significantly lower than those in the elite adult game.

But is that level of risk acceptable?

This is where it becomes far more difficult and we move away from science and data. Acceptance of risk is different for everyone so it is impossible for anyone to answer this question with anything other than a personal view.

However, it would be impossible to make a valid judgement without mentioning the benefits of rugby – something that rarely seems to put forward as part of the argument. We know that rugby has physical and mental health benefits which are quantifiable. But there are also the countless unquantifiable benefits – skills in teamwork, leadership, communication, respect and sportsmanship that those who are involved in rugby know all too well about.

Should we just play other sports?

Some would argue that all these benefits can be gained from other, safer sports. But are the risks in those sports acceptable? There are complexities in comparing sports but studies have shown that up to the age of 15 the injury rates between sports don’t vary hugely.

What if I told you that at one of the schools I work with cross-country had the highest number of concussion this term per participation hours?

I am not using this to dismiss the concerns around rugby, nor does it reduce my desire to continue to improve safety in the sport, but it is important to keep things in perspective.

What should schools be doing to protect their players and safeguard the sport?

While I’ve discussed the incomparable head injury protocols between school-age players and elite adults, I don’t believe these rules are adhered to nearly as well as they should be by the majority of schools.  Some of this comes down to continued misunderstanding of the injury, its diagnosis, and the management pathway. There really should be no-excuse for this.  The right information is easily available and those involved in the game have a responsibility to know it.  Schools should ensure their pupils and parents are educated on the subject too.

And then sometimes lack of adherence is simply down to logistical issues, high administrative burden and lack of access to medical care.

But I’m afraid all too often old school attitudes and a fear of “opening a can of worms” play a part. I still regularly speak to schools that say “we don’t get many concussions” – impossible.  The rates across the 50 schools we work with are pretty consistent, why would you be any different?

The future.

While I have shown that risks are significantly lower in school rugby the bigger threat to the game is reputational.  I truly believe that openly acknowledging concerns and engaging in methods to improve the safety of the game is the only sensible way forward. Not doing so is a far greater threat to the game then the injuries themselves.  Managing head injuries well is a significant task that needs to be fully committed to by schools. But it is achievable and if we want the game to survive we simply don’t have a choice but to do it properly.