Meliora Medical Group’s Head of Medical Services, Dr Alex Maxwell, has written a blog about Sport England’s report on the activity levels and perceptions of our Nation’s children and young people for the British Society of Lifestyle Medicine, in his role as the BSLM London Director & Social Prescribing Chair.
Head to the BSLM news page to read the full blog: https://bslm.org.uk/sport-england-survey-sig-comments/
Concussion – is rugby safe for kids? BBC Newsround Special
Thousands of kids across the UK have returned to the pitch for the new grassroots rugby union season.
But, with concerns about the dangers of repeated head injuries looming large at the elite level, questions are being asked about safety in the community game.
Concussion is one of the most frequently suffered injuries at all levels of the sport.
In the show Dr Sam Barke, Head of Sports Medicine at Return2Play & Meliora Medical Group, explains concussion and why it is so important that we manage it well.
Watch the show by clicking here
The Digital, Culture, Media and Sport (DCMS) Committee released it’s report today into concussion in sport and has highlighted that urgent action is needed by both Government and sporting bodies to address the long-term failure to reduce the risks of brain injury in sport.
The key recommendations relevant to grassroots sport are that:
Meliora Medical Group fully supports the recommendations of the DCMS Committee and is pleased to see grassroots sport receiving the attention it deserves in a conversation that all too often only focuses on the elite level.
We are delighted that all of the areas that the DCMS Committee highlight as requiring improvement already form part of Return2Play’s service – education, early access to expert medical care, player injury passports and use of data to guide injury prevention strategies – and we look forward to continuing to refine the service we provide to ensure the organisations we work with can continue to provide safe sport.
Dr Sam Barke, Head of Sports Medicine at Meliora Medical Group and Return2Play, said of the report:
“As the report highlights, enhancing knowledge among all stakeholders involved in sport is the leading key to success in reducing risk and improving care – if the coach on the side-line isn’t able to identify a concussion then we fall at the first hurdle. While sporting bodies have gone some way to try and address this, we know that knowledge remains poor and I hope that a Government led campaign will go some way to rectify this.
I am pleased to see that lack of knowledge among doctors has been highlighted as an area of concern. This, in some part at least, is a reflection of sporting bodies having taken the lead on advising on management and, with that, there has been a “de-medicalisation” of the injury. A change in this and acknowledgment that outcomes can be improved by access to early expert care is most welcome.”
The full report can be found here
More information about the concussion service that Return2Play offers can be found here
In the latest in The Times series on rugby’s ‘brain injury crisis’, rugby correspondent Owen Slot takes a “careful, considered and balanced look at the latest concussion research”, including that of Meliora Medical Group’s Head of Sports Medicine, Dr Sam Barke.
Dr Barke’s research looks at whether the risks that are evident in professional level rugby are applicable to the school game. Building on data collected by Return2Play’s Injury Management System and experience working with over 50 of the UK’s leading schools, Dr Barke explains why the concerns from the elite level shouldn’t be shared by those putting on their school kit.
Read Dr Barke’s full article by clicking here and Owen Slot’s article in The Times by clicking here.
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.
Dr Alex Maxwell and Jordan Lewis are back with another episode in our podcast series.. This time, they discuss the basis of nutrition and bust some common myths about fad diets.
This webinar is also available as a podcast from iTunes, Spotify and Google Podcasts. Search for ‘Meliora Medical Group’ and make sure to subscribe!
Why do we need to sleep? What benefits does good quality sleep bring to our health and wellbeing? What can we do to sleep better? Dr Alex Maxwell, explores the topic of sleep with Jordan Lewis.
This webinar is also available as a podcast from iTunes, Spotify and Google Podcasts. Search for ‘Meliora Medical Group’ and make sure to subscribe!
During the COVID-19 pandemic, the response of everyone involved in the NHS has been widely regarded as outstanding. 👏
Outpourings of public support for the NHS can be seen everywhere, from rainbows 🌈 and flags in house windows to the weekly #clapforourcarers ritual on Thursday evenings.
We spoke to a number of Return2Play’s doctors who are currently working on the frontline about their experience during COVID-19; what it’s like putting themselves at risk every day, how it has changed their working lives and how it may change the future of our National Health Service.
Away from Return2Play I work in elective orthopaedic surgery in London. Elective operating was stopped early on in the crisis and I was asked to go to NHS Nightingale North-West in Manchester for the first weeks of its existence. Like most Nightingale hospitals we ended up receiving far fewer patients than we’d prepared for. This is obviously a positive thing as it means the NHS has been able to manage cases within its existing resource. I have now moved back to London and am working in an Intensive Care Unit (ICU).
My biggest take-away when this is all over will be what can be achieved when “needs must”. People will have seen much in the news about how quickly the Nightingale hospitals have been built but, for me, what has been far more impressive is how quickly working practices have been conceived and implemented across all NHS hospitals in a situation that we had no blueprint for. Healthcare workers have had to adapt quickly and have been required by necessity to work out of their comfort zone and deal with situations that many have not felt prepared for. I have felt great pride in seeing my junior colleagues – many who are only a year or two out of medical school – take on responsibility that is usually reserved for far more experienced doctors and doing so with great professionalism. This is a credit to them but has only been possible because of a flattening of hierarchy and the return of feeling truly part of a team and being supported, something that I hope will remain when this is over.
While much of our work has been upsetting – the mortality rates in intensive care units is well documented – it has also been rewarding. I feel hugely privileged to have watched patients talk to their families (via FaceTime, of course) after weeks on a ventilator, see them take joy in eating for the first time in over a month, and clap them as they are discharged from the intensive care unit. But, as hard as it has been, I also feel privileged to have been able to care for the dying. To pass on messages of love from their loved ones who can’t be by their side, to hold their hand in their last moments, to be there to say goodbye.
It looks like we will shortly be starting to reopen non-emergency health services and I will await the call as to when I can return to orthopaedics. It is becoming increasingly clear that there are indirect health issues that have been created from delays in access to treatment during the crisis and will take significant resource to try and clear that back log and minimise the long-term impact. We’ve learnt a lot from this crisis and I hope some of the positives will force change that is long overdue.
As a GP my working day has changed tremendously with the arrival of COVID-19. I am now telephoning almost all my patients, only bringing them in when absolutely necessary. This has highlighted how much can actually be done over the phone or via a video call and I believe will change how General Practice works forever. We have been able to manage with our PPE and various local schools and groups have been generous with their time to help create more for us which is incredibly kind and much appreciated!
As the lead within my practice tasked with looking after the vulnerable people in our community, it has been very satisfying working with a motivated group to work out who best to contact and how best we can support them with their medical, social, mental and physical health needs. Outside of my GP role, being Clinical Director for Croydon’s social Prescribing service (“Croydon SocialP”) has provided an opportunity to support our community from a more holistic viewpoint which I am grateful to be able to contribute to. We have made an incredible 80+ page resource and disseminated it to anyone requiring it to help support people with anything they might require during this unique time. We have also provided appointments to talk to someone who can guide them to appropriate resources which has made real changes to their quality of life.
I think that COVID-19 has highlighted just what can be done if necessary and if the “red tape” we have become so accustomed to within the NHS is circumvented, just how effectively change can be implemented. Something to consider for the future.
This is my second time responding to a large-scale public health crisis, having previously been deployed to Sierra Leone during the Ebola crisis. During testing times, I try to stick to a motto: “You cannot calm the storm, so stop trying. What you can do is calm yourself, for the storm will pass.”
I caught COVID early on in the crisis from a patient on my ward. I think my previous experience with Ebola made me less worried; the chance of death from catching COVID is much smaller than if you catch Ebola and, luckily, I wasn’t badly ill.
Currently my response involves treating mental health patients in the South London trying to keep them out of hospital. This sometimes means we are managing deteriorating physical and mental health in far from optimum environments. During emergency shifts I also cover London’s psychiatric hospital inpatient wards often with unwell patients that have COVID. Aggression or other harmful behaviours as well as not understanding the need to self-isolate makes it a challenge. This is a unique experience.
I expect that the mental health impact this crisis has on both patients, staff and those in the wider community will remain far after the virus has passed.
Alongside my work with Return2Play I also work within rugby with Saracens as their match day Doctor and with the RFU as team Doctor with the England U18 and England U20s sides. The COVID-19 pandemic has abruptly halted the season and whilst we wait to see what will happen with the rest of the Premiership and European rugby season, the June U20s Junior Rugby World Cup in Italy, the U18s stand-alone fixtures and Six Nations Championship 2020 have now all been cancelled for the season.
As a result of these postponements/ cancellations at the beginning of March, I returned to work in General Practice full time during the COVID-19 Pandemic. It has been fascinating and rewarding to see how much we have changed in the space of a few weeks. Changes that may have previously taken years have been brought about in a short space of time and many things will be here to stay. For example, all patients are now triaged by a Doctor on the day and if possible their problems or issues are often dealt with via telephone or video consultation, something that patients find convenient and we find efficient!
As a GP we have seen a complete change to our way of working. New technology made available to us since the crisis begun has allowed us to conduct video consultations which has helped us reduce our face to face contacts from over 75% of consultations prior to COVID-19 to less than 5% now. This has reduced risk to both staff and patients, has largely been well received by patients who prefer video to attending the surgery and is likely to change how we work going forward after the pandemic is over.
In one of my other roles working in the Urgent Care Centre at North Middlesex Hospital all the GPs have been redeployed to the A&E where we screen all patients arriving for COVID. Those with signs or symptoms of COVID-19 get assessed at the front door, and if they are well enough to not require admission, we discharge them quickly from there – preventing those who are potentially infectious having to wait in the department exposing other patients and staff to the virus.
My regular job is in A&E as a senior registrar and I continue to work in the same role during the COVID-19 crisis. Over the past weeks I have welcomed multiple redeployed colleagues from different specialties who have enriched and reinforced our emergency team. It’s been a unique opportunity to exchange skills and perspectives.
It has been impressive to see how the Health Service can adapt to changes quickly. We had prepared ourselves to cope with a high number of patients but fortunately we have seen fewer cases than expected, both COVID and non-COVID related.
I’m proud of my team because the care of patients has always been at the top of our priorities throughout this pandemic time. Being there in an emergency is what we do best and we will continue to do it in every setting. We thank everyone for their support given to us as healthcare practitioners and for keeping themselves safe and at home.
In the Pre-COVID world I was a GP trainee undertaking a placement in Paediatrics. Since the outbreak I have been working on an emergency COVID rota at my local hospital. Even though this period has been emotionally challenging and there have been many difficulties, the collective team spirit within the NHS has been incredible. From unbelievably supportive senior staff, to mentoring newly graduated doctors fast-tracked from medical school, to bonding with new colleagues over donated food in the mess – the positivity shown in these scary unprecedented times has been staggering.
From everyone at Return2Play and Meliora Medical Group, a huge thank you to all of our doctors who are currently working on the frontline! 🙌
Watch the first in our series on how to stay healthy and happy during the COVID-19 pandemic.
In this video, our Medical Director Dr Alex Maxwell discusses his top tips for promoting the wellbeing of teenagers during this period.
In Wales’ Six Nations fixture against France, winger George North suffered his sixth concussion of his professional career after a collision with France winger Gael Fickou.
After just 11 minutes of the match, the collision left North motionless on the pitch before he was eventually able to leave the field to undergo a Head Injury Assessment which he failed.
This has resulted in a number of questions being raised about whether North should continue to play rugby, given his history of concussions.
Dr Sam Barke, Return2Play’s Medical Director spoke to The Times to discuss North’s next steps and how concussions are treated in Rugby.
The full original text can be found below.
By Alex Bywater 25 Feb 2020
George North will return to the Wales camp today (TUES) after being urged to undertake independent and specialist advice on the long-term impact of his latest concussion.
North was removed from the field in the 11th minute of Wales’ 27-23 Six Nations defeat by France on Saturday after colliding with Gael Fickou.
The 27-year-old briefly lay motionless following the incident before stirring and was then taken away for a head injury assessment – one he subsequently failed.
Wing North has had a long history of concussion and the France game was the sixth time he has suffered a head knock while playing. It has again led to questions over whether the 94-cap wing – who has 40 tries for Wales – should continue with his career amid ongoing worries over his health. “George has a history of concussion and after the France game there is a lot of talk out there about his long-term health,” said Dr Sam Barke, medical director of Return2Play, one of the UK’s leading sports medicine organisations who specialise in concussion. “The important thing at this stage is that his early recovery is managed properly – it doesn’t matter if you’ve had 10 previous incidents or one, the first priority is ensuring optimum recovery this time around. I understand that George had an extended recovery of 5 months from a previous concussion but there is no guarantee he will have the same problems this time around. It’s important each player, and to some extent each incident, is treated on an individual basis.
“My advice to George would be to seek independent and external advice from specialists so he can get the full picture. Only then will he get all the details on the risks of carrying on playing. I’m sure this is something that will already be being looked at”
North suffered four head injuries in the space of five months between November 2014 and March 2015 and took five months out of the game in 2015. Prior to Saturday his last knock was in 2016.
Wales were given two days off after the France game but will return to training today (TUES) where North – who is expecting a child with his wife and former Olympic cyclist Becky James after the Six Nations – will continue the usual return to play protocols employed following a head injury.
After failing his head injury assessment, he watched the rest of the France game from the bench as his team’s Six Nations title hopes ended. Wales have two weeks until their next game with England. The Welsh Rugby Union place the utmost importance on player welfare and in the build-up to the France game, they called in a globally renowned concussion expert to assess if fly-half Dan Biggar was fit to face Les Bleus. Biggar had failed a head injury assessment against Ireland on February 8 after suffering two head knocks against Australia and Fiji at last year’s World Cup in Japan.
The decision to seek external assistance on Biggar’s welfare was actively sought out by the WRU’s medical team. It is unclear at this stage whether North will receive the same treatment.
“The first thing for any player when they suffer a head injury is to ensure they are treated correctly and there is no doubt that happened in the case with George against France,” said Barke.
“From the moment he collided with Fickou he was removed from the field immediately, undertook a head injury assessment and when he failed that assessment, he didn’t return.
“Long-term brain injury is a concern with concussion, but it is too simple to say that will be the result in George’s case. While multiple concussion is undoubtedly a risk factor for long term harm there are plenty of other factors that are likely to play a role and we simply don’t know at this stage how to quantify that risk.
“We don’t have all the answers. The impact of heading a football and the potential impact that might have on long-term brain health is in the news at the moment. While there’s no proven link between heading and that harm there is enough concern that the FA has taken precautionary measures.
“Similarly in rugby, we aren’t at a stage where we can prove that harm will be done from multiple concussions but it is right to be cautious. Rugby has been ahead of the game on head injuries and concussion. No other sport does it better.
“Their head injury assessment and return to play protocols are the best we have to protect players.”
Whether you are interested in our Sports Medicine, Schools Medicine or Lifestyle medicine services, we’d love to hear about how we can help you so please get in touch.
Meliora Medical Group’s Sports Medicine service operates under the name ‘Return2Play’ and has it’s own website.
Return2Play are the UK’s leading sports medicine provider for schools, clubs and universities.
Visit return2play.org.uk