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Exploring Return2Play’s Complex Case Clinic

By Harry Black,

Where to turn when concussion recovery isn’t straightforward.

Anyone who works in sport will know that diagnosing a concussion is at times far from straightforward. The symptoms are vague and non-specific, and identifying the concussion amongst the numerous tackles, collisions, trips, and falls can sometimes be akin to spotting the proverbial needle in a haystack. But as long as they’re appropriately removed from play and the diagnosis is confirmed, the process of managing the player’s graduated return to sport and exercise is usually fairly straightforward.

Until, of course, it isn’t.

It is commonly quoted that between 80-85% of people suffering from a concussion will feel back to normal within the first 14 days of their injury, but that leaves a not inconsiderable number with ongoing symptoms. Sometimes these symptoms are far from insignificant; difficulty returning to school can quickly spiral into anxiety relating to academic performance, and impact upon mental health and wellbeing.

And what about those for whom a concussion isn’t a new injury? Are they safe to be returning to contact sport at all?

Return2Play boasts a medical team with unrivalled experience in dealing with concussions. Our clinicians completed over 10,000 head injury and concussion appointments last year alone, and along with the diagnosis and management of Graduated Return to Sport (GRTS) following a concussion, an important aspect of the role involves the identification of people who require more specialist input from our most senior and experienced doctors.

 

What is the Complex Case Clinic?

The Complex Case Clinic is, as the name suggests, a clinic staffed by the most senior and experienced doctors at Return2Play who manage more complicated cases of concussion. Referrals are usually made following assessment by a Return2Play clinician, and the most common reasons include:

·       Prolonged symptoms at 2 weeks post injury

·       Severe and debilitating symptoms preventing return to school/university/work within 1 week

·       History of multiple or repeated concussions

 

What causes more severe or prolonged symptoms?

There are several different reasons as to why symptoms following a concussion may persist. On occasion it is simply that the brain hasn’t fully recovered from the injury – this is more likely to be the case if a concussion has been missed or ignored – but this is far from the sole cause. Given the area of injury, along with the subsequent effect on routine, structure, and daily activities that a concussion can have, there are often multi-factorial causes for ongoing symptoms. The infographic at the top of this article summarises some of these.

 

What treatment options are available?

Traditionally the advice for people suffering from persistent concussion symptoms has been to continue to rest until the symptoms resolve. And whilst rest plays an important part in the very early stages following a concussion, more recent research suggests that it is far from the most effective strategy in achieving symptom resolution.

The Complex Case Clinic will often take a much more proactive route and treat ongoing symptoms. Our doctors take a holistic approach in identifying the specific cause – or causes – of ongoing symptoms, and tailor their management plan accordingly. Often this involves rehab exercises focusing on the neck or the vestibulo-ocular system, along with targeted and specific return to graded exercise.

 

Case study

By way of example, take the case of AB, a 16-year-old boy passionate about hockey. He clashed heads with an opponent during the final game before school finished with the Christmas holidays. He didn’t lose consciousness, but was dazed, dizzy and felt ‘out of it’ immediately and for the remainder of the day. He was thoroughly assessed by the school nursing team and felt likely to have suffered a concussion, and this was confirmed following an appointment the following day with a Return2Play clinician.

Despite following the advice he was given religiously, AB’s symptoms persisted, leaving him fatigued, irritable, and unable to focus on any of the work he was hoping to complete over the Christmas break. He wasn’t himself at all – so much so that his mother took him to Accident & Emergency for further assessment. He was deemed not to require a scan and told to rest; his symptoms would likely resolve over time.

At his two-week review with Return2Play there had still been very little improvement, so he was referred to the Complex Case Clinic and seen the following day. Thorough assessment revealed a significant issue with his visual and balance system, as well as a stiff and painful neck. Both were likely contributing to his ongoing symptoms. It was felt highly likely that AB’s anxiety related to ongoing symptoms – and the potential impact this might have upon his preparations for GCSEs – was also playing a part in the severity of his presentation.

He was provided with exercises for both his vestibular system and his neck, and on review the following week had already started to show signs of improvement. He was followed up by the same doctor throughout his recovery, and experienced full resolution of symptoms by the start of the new school term.

 

How many patients does the clinic see?

12% of the patients diagnosed with a concussion in the last year were referred to the Complex Case Clinic.  About half of these were due to persistent symptoms at 2 weeks post-injury, which equates to approximately 6% of total recorded concussions.

This is quite a low number compared to published data, which we believe can be attributed to good medical advice (all patients referred are seen by our medical team and those with severe, debilitating symptoms are seen within 48hrs of injury) and early implementation of vestibular and cervical rehabilitation in cases that would benefit.

 

What about repeated concussions?

Repeated or multiple concussions have understandably caused significant concern in the last few years, with evidence showing a link between repeated head impacts and permanent cognitive impairment. There is no ‘one size fits all’ when it comes to advice regarding ongoing participation in contact sport, but our clinicians will generally offer a referral to the Complex Case Clinic in situations where they believe someone might benefit from a more detailed discussion around the risks associated with repeated head injuries.

 

Further information

In the realms of sporting and non-sporting settings, diagnosing concussion presents a challenge due to the vague and non-specific symptoms. Whilst in most cases symptoms resolve within 14 days, a significant minority endure, impacting daily life and mental health. Return2Play’s Complex Case Clinic steps in for such scenarios, offering tailored treatment for those with prolonged symptoms or a history of multiple and repeated concussions. The clinic’s proactive approach includes holistic management plans, rehab exercises, and specialised care from our most experienced doctors.

 

For more information regarding the Complex Case Clinic, or if you are interested in the services Return2Play can provide, please email support@return2play.org.uk.

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R2P feature on front page of The Sunday Times

By Harry Black,

Return2Play feature on the front page of The Sunday Times  in an article about concussion in school rugby.

Dr Sam Barke, Head of Sports Medicine, said in response to the article:
“Stand-alone statistics can look worrying, but sometimes they can actually reveal positives. These are injuries that have been identified, had their recovery closely managed and only returned to sport after an appropriate stand-down and gradual return to sport process. This is by far the most important intervention to reduce short and long term risk.

Our biggest concern should be the large number of injuries that go unrecognised – not through lack of want, but through lack of knowledge. Recognition is the most important step in good management. This injury has always existed and the steps being taken by an ever increasing number of schools to reduce risk and improve care of their pupils should be applauded.”

 

Read the full article here

Harrow School pioneer use of Head Impact Monitoring Mouthguards

By Harry Black,

Return2Play is supporting the deployment of the technology which is helping Harrow School add further welfare initiatives to its continuous commitment to player health and student experiences.

Prevent Biometrics and OPRO, providers of the world’s most rigorously validated Instrumented Mouthguard (“iMG”) technology, have equipped players from Harrow School, an institution with a rich rugby tradition, with the latest Prevent v2.0 iMGs. This research partnership was implemented in August 2023 and aims to learn lessons on how the technology will benefit the age-grade game in advance of wider deployment.  A group of 25 senior players have been equipped with a mouthguard capable of detecting head impacts, or Head Acceleration Events (HAEs), experienced during rugby training and games.

 

The technology is overseen by Harrow’s sports medicine team, led by Dr. Sam Barke, who also serves as the Head of Sports Medicine at Return2Play. The team can use the data from the iMGs to ensure that any player who has experienced a significant head impact receives the necessary assessment and care. Additionally, the monitoring of cumulative head impact exposure enables more precise management of contact training loads, thereby reducing the risk of injuries.

 

Alastair Land, Head Master, commented on the project saying; “At Harrow School, prioritising student welfare is central to both our educational mission and our approach to sports. We aim to empower our students to make a positive impact on the world through their experiences here, which is why being at the forefront of a project which aims to benefit the game as a whole and ultimately all schools is of utmost importance to us. Aligning ourselves with the same level of technology used by professional rugby players worldwide underscores our dedication to student well-being and the quality of the Harrow experience.”

 

Prevent Biometrics VP Rugby, Erik Lund, who is an ex-professional Rugby Union player commented; “Our technology is user-friendly, suitable for professional teams, community clubs, and schools. It’s as simple as charging the mouthguards, wearing them during training or matches, and relying on our app to alert you if any players experience significant head impacts. While we don’t diagnose concussions, our iMG excels at detecting and reporting head impacts, especially those that might go unnoticed during a game. In this way, the technology can serve as a valuable safety net for coaches and medical staff.”

 

Dr, Anthony Lovat, founder and Chairman of OPRO observed, “Harrow was the first OPRO school and has therefore always held a unique place in our history, so we are excited to be involved in this project. We pride ourselves at being pioneering leaders in the field of mouthguard technology and consequently are delighted to team up with Prevent who are at the forefront of iMG technology. Together we can make a positive difference to player safety and welfare.”

 

Making iMG technology accessible to coaches and medical staff at all levels of the sport is the logical progression for Prevent, supported by OPRO. Harrow School, known globally for its leadership in education is pioneering the use of Prevent’s technology at the school-age level, showcasing its commitment to adopting cutting-edge technology for the benefit of its student athletes.

 

MDr Sam Barke, Harrow’s sports doctor and Head of Sports Medicine at Return2Play said “The iMGs have already proven to be a valuable additional tool in our armoury to safely manage head injuries. At Harrow we follow a ‘performance through welfare’ philosophy and while identifying HAEs has been our main aim, the data has also proven to be valuable in monitoring the cumulative HAEs that players experience during training and matches. This allows us to consider adapting individual players’ training loads and game time to protect them from injury and maximise match performance.”

 

About Harrow:

Harrow School was founded in 1572 under a Royal Charter granted by Queen Elizabeth I. It is located in a leafy 300-acre estate, encompassing much of Harrow on the Hill in north-west London. As stewards of many cherished traditions, today’s Harrovians follow in the footsteps of The Giants of Old, united by strength of character, lasting friendships and the desire to be of good influence.

 

For additional information visit https://www.harrowschool.org.uk/welcome-to-harrow/welcome

 

About Prevent & OPRO:

Prevent Biometrics®, a Cleveland Clinic spin-off, was established in 2015 in Minneapolis, Minnesota, USA. Prevent has been working with World Rugby, the leader in advancing the understanding of head impacts across the sport and is committed to reducing the head forces experienced by players at all levels of the game. Prevent’s data is being used by rugby stakeholders in making recommendations to further inform rugby’s injury-prevention strategies as the sport continues its research-led drive to protect players at all levels of the game.

 

OPRO was founded more than 25 years ago in 1997 by Dr. Anthony Lovat BDS., OPRO is the world’s most technically advanced mouthguard company and a leading pioneer in oral protection. From its state-of-the-art manufacturing facility in Hertfordshire (UK), OPRO is dedicated to creating the ultimate in dental protection by using innovation and technology for the good of athletes at all levels of sport. Over the years, OPRO has been privileged to supply gum shields to some of the world’s leading athletes and are proud to be the official sports mouthguard supplier to many international teams and associations. To name just a handful, OPRO are proud to supply England Rugby, Wales Rugby, New Zealand Rugby, GB Taekwondo, the UFC, USA Wrestling, the GAA and England Hockey with premium-level mouth protection.

 

For additional information visit PreventBiometrics.com and https://www.opro.com/

 

About Return2Play:

Return2Play, part of Meliora Medical Group, is the leading provider of sports medicine services to UK schools. . Their specialist Head Injury & Concussion Care Service provides 7-day-a-week, unlimited access to our team of highly experienced clinicians who are experts in their field. Their doctor-led medical team comprises over 60 professionals who are on hand to ensure that every individual receives prompt attention and guidance throughout their recovery journey. They follow the most current protocols and best practices to promote a safe return to sport. In the 2022-23 school year, they undertook over 10,000 appointments. Their innovative online injury management system allows schools & clubs to document injuries, automatically communicate to parents and coaches, and track a player’s recovery.

For additional information visit https://www.return2play.org.uk/

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First UK Government concussion guidance released

By Harry Black,

Return2Play welcomes the release of the Government’s “UK Concussion Guidelines for Non-Elite (Grassroots) Sport”  published today. The guidance recognises the need for greater awareness about the risk of head injury and a need for improved management. These include the need for medical review followed by a gradual, personalised return to normal life and sport with minimum “stand-down periods”.  These are things we have championed since the launch of our Head Injury & Concussion Care service in 2016. We are proud to have been at the forefront of delivering expert care and to have helped our partner schools & clubs achieve what is now being recommended long before this announcement.

Following the new Government guidance, it is likely that we will see a change in sporting Governing Body return to sport protocols following a concussion or suspected concussion. These new protocols may be in place for September 2023.

While the timeframe to return to unrestricted sporting activity (eg matches) is unlikely to change, it is possible that we will now be looking to introduce low-risk light physical activity much earlier in the symptom free person. Latest research has showed this is likely to aid recovery and, of course, has benefits to wider physical and mental wellbeing.

It is important to note that the changes outlined in this announcement will still need to be adopted by governing bodies. We will be keeping a close eye on emerging guidance from government and sporting governing bodies. If current guidance does change as expected, we will update our partner schools and clubs and will have resources available to explain the changes and how medical assessments will fit into the new timeframes.

You can read the full report here

Return2Play launch partnership with National League Rugby

By Harry Black,

National League Rugby and Return2Play (part of Meliora Medical Group) are delighted to announce a partnership that will see all of National League Rugby clubs offered discounted access to Return2Play’s medical services.

Return2Play are the UK’s leading sports medicine provider for youth and grassroots sport. They work to create a safer environment for rugby clubs to operate in by ensuring players with head injuries and concussions receive gold-standard medical care from some of the UK’s leading sports medicine doctors.

Whilst their main focus is around their ‘Head Injury & Concussion Care’ and ‘Match-Day & Tournament Doctor’ services, they also provide Sports Doctor and Physiotherapy services. Their team of over 40 doctors, many of whom also work in elite sport, have unrivalled experience in the management of head injuries and concussion and are seen as the UK’s leading experts in the area, undertaking over 4000 appointments in the 2021/22 season alone.

Return2Play operate across the whole of the UK with clients including rugby academies, some of the UK’s leading schools and rugby clubs including National League Rugby members Barnes RFC, Esher RFC and Rosslyn Park FC. Their services can help every player at a club, from 1XV through to minis.

Dr Sam Barke, Head of Sports Medicine, at Return2Play said: “The health impact of head injuries is of ever-increasing concern across all sports, but particularly rugby. It is crucially important that all players get the absolute best medical care and advice in the event of a head injury, and that’s what we provide at Return2Play. By doing so, we protect not only the player but also our sport. We’re delighted to be partnering with National League Rugby to offer their clubs access to our Head Injury & Concussion Care service along with the rest of our range of medical services.”

Mike Brennand, National League Rugby’s commercial officer, said: “National League Rugby are pleased to be working with Return2Play and we believe this proactive approach to injury management will be very useful to all our clubs.”

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Sunday Times Interview with Dr Sam Barke

By Harry Black,

“My biggest fear is that there are still schools and clubs where cases are being underreported and not managed safely.”

Following a series of high profile examples of concussion being wrongly managed in professional rugby, The Sunday Times’ David Walsh talks to Return2Play’s Head of Sports Medicine, Dr Sam Barke, about the example set by the elite game and how this affects the management of concussions at the grassroots level.

 

Read the full article here.

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NextGenXV & Return2Play Interview

By Harry Black,

Watch former England Rugby International and current Return2Play team member Peter Richards, alongside Head of Business Development Andrew Marshall, talk to NextGenXV about some of the benefits of Return2Play’s Head Injury & Concussion Care service.

 

The full clip (15 mins) can be found on our Youtube Channel.

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Dr Sam Barke on BBC Newsround

By Harry Black,

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

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Return2Play’s Dr Sam Barke features in The Times

By Harry Black,

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.

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The dangers of rugby – how applicable are they to the school game?

By Harry Black,

 

Dr Sam Barke

Head of Sports Medicine

Meliora Medical Group, Return2Play

 

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.

 

 

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