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Dr Alex Maxwell

Head of School Medicine

Meliora Medical Group

 
Across the UK, schools are increasingly finding themselves on the front line of children’s health – often without the clinical support they need.

Supporting pupils’ physical and emotional well-being is no longer a ‘nice to have’ alongside education – it’s a necessity for engagement, learning, and long-term development. Many schools have invested in strong pastoral, psychological, and medical provision. Yet, for others, a combination of constrained resources, a lack of prioritisation, and rapidly evolving pupil needs has left their health and well-being provision suboptimal and, in some cases, no longer fit for purpose.

The health profile of pupils is changing. Mental health conditions such as anxiety, obsessive-compulsive disorder, and depression are rising¹. Pupils diagnosed with neurodivergent conditions like attention-deficit hyperactivity disorder or autistic spectrum disorder or who experience learning skills challenges are more common². At the same time, lifestyle-related concerns, including childhood obesity, poor sleep, physical inactivity, and a suboptimal diet, continue to grow³.  Expectations from parents and the role and responsibilities teachers play in children’s lives are also increasing, areas that must be monitored and governed. Children’s digital lives also play a significant role, with new and complex health impacts: social media-driven distress, body image concerns, sleep disruption, and screen-related concentration difficulties⁴.
 
The reality is that many pupils present with concerns that do not fit neatly into one category. They are often experiencing a complex blend of medical, psychological, social, and behavioural challenges. This requires careful coordination, clinical insight, and collaboration with external agencies – but that support is not always readily available.

In the last few months, I supported children in many difficult situations: from a teenager with deteriorating mental health and safeguarding concerns to a child with growth and development issues exacerbated by bullying. None of these cases had a clear pathway – but all required a timely, joined-up response. Navigating these complexities whilst ensuring the integral voice of the child isn’t lost is not easy and something I strive to do as a school doctor.

These situations will be familiar to school nurses, school doctors, pastoral staff, and teachers. They are often the first to recognise when something is wrong. However, in many schools, the ability to act on that recognition is limited. Access to a school doctor is rare – but shouldn’t be. GPs are very overburdened and understandably not able to prioritise a school-age population and give the input schools require in a timely manner. External services are increasingly stretched: mental health teams face impossibly long waits; safeguarding thresholds have risen under caseload pressure. As a result, schools are being asked to manage more but without the resources, training, or systems to do so.
 
This raises a fundamental question: ‘What should school-based medical care look like in 2025 and beyond?’
 
This article marks the beginning of a new series, ‘Whole Child, Whole School’, which explores how schools – with a focus on the independent sector – can move toward more integrated, proactive, and lifestyle-informed provision for pupil health and well-being.

Independent schools are often well-positioned to trial new or enhanced approaches. With greater resources, on-site health staff, more flexible infrastructure, and growing leadership support for health and well-being, they have the capacity to test models that offer earlier intervention, reduce strain on families and the NHS, and improve continuity of care. In my own work, I’ve seen how embedding school doctors alongside nurses and school pastoral and health and well-being staff can support decision-making, reduce safeguarding risk, streamline referrals, and give much-needed reassurance to families and staff alike. This integration results in an overwhelmingly positive impact on the pupils’ experience, health, and educational outcomes.

These challenges are by no means unique to the independent sector. State sector colleagues are facing the same challenges – often under greater pressure and with fewer resources. Many are pioneering excellent work, developing innovative pastoral systems and strong referral pathways. NHS-led initiatives like Mental Health Support Teams⁵ have created new models of collaboration. I applaud these efforts and believe we should learn from and share best practices across all settings.
 

This series draws on examples from the independent sector because it’s where I currently practise and can speak with the most clarity. These are not blueprints, but case studies — offered in the spirit of collaboration, with the goal of supporting all schools to better meet the needs of the children they serve. I am actively building my experience within the state sector, and hope that any insights gained can benefit every pupil, regardless of background. I welcome all and any input from colleagues in this field and beyond!

We also have much to learn internationally. In Finland⁶, pupils receive regular health assessments by school nurses and doctors, supported by psychologists and social workers. In the United States, School-Based Health Centers⁷ deliver a wide range of care on-site, including mental health. In Australia, school-based GP clinics are being trialled to improve access and early support for adolescents.

Here in the UK, there are green shoots. Mental Health Support Teams are expanding amongst other plans in the NHS ‘Long Term Plan’ to improve mental health provision for children. Some independent schools are developing more comprehensive clinical teams that reflect the complexity of pupil needs. Although there are a number of incredible institutions supporting child health, like the Royal College of Paediatrics and Child Health or the Boarding School’s Association, there is no national framework for a modern and multi-disciplinary school-based healthcare system – no shared definition of what “good” looks like and too few examples of truly integrated, lifestyle-oriented care embedded in the fabric of school life.

We need to change that. I know that my team and I are doing so alongside the incredible and dedicated professionals out there in this space.
 
Over the coming articles, we’ll examine:

• ‘A week in the life of a school doctor’: You could call this my diary – how I work within a school setting – responding to common presentations, supporting staff, and contributing to both individual care and whole-school well-being
• ‘A term in one clinic: the real health landscape in schools’: An evidence-informed look at the most common physical, emotional and behavioural issues seen in schools – and what they reveal about system gaps and emerging trends.
• ‘Lifestyle Medicine in schools: more than a lesson plan’: How schools can embed the principles and pillars of Lifestyle Medicine into the daily rhythm of school life, supported by clinical insight.
• ‘Screens, sleep and social pressure: responding to the digital realities of school children’: An exploration of how the digital world is shaping children’s well-being – from social media and screen time to cyberbullying and how schools and clinicians can respond more effectively.
• ‘Safeguarding: the good, the bad, and the ugly’: an honest and challenging look at the current state of safeguarding in schools and beyond.
• ‘School Medicine: a recommended model for the independent sector’: an exploration of what best-practice school medicine should be.

 
This is not a call for schools to take on more alone. It is a call for integrating medical expertise into schools and closer collaboration between education and health – for a joined-up approach that matches the complexity of the needs we now see in schools every day.

The evidence is clear: children who are physically and emotionally healthy attend more, learn better, and experience greater long-term outcomes⁸. When health improves, education does too.

Although this first series focuses on the independent sector, I hope to follow it with a companion series focusing more on the state sector – where the challenges may differ in some ways, but children are still children, and the stakes are just as high.

Let’s think boldly, work together, and design school-based medical care that truly meets the needs of the whole child.
 
Resources and references:

1. NHS Digital (2023). Mental Health of Children and Young People in England, 2023 – Wave 4; Vizard, T., Sadler, K., Ford, T., et al. (2022). Mental Health of Children and Young People in England, 2022. NHS Digital.
2. Green, H., McGinnity, Á., Meltzer, H., et al. (2020). Mental health of children and young people in Great Britain, 2020. Office for National Statistics.
3. Public Health England (2019). Health matters: getting every adult active every day; Office for Health Improvement and Disparities (OHID) (2022). Childhood obesity: applying All Our Health.
4. Royal College of Psychiatrists (2020). Technology use and the mental health of children and young people.
5. NHS England (2019). Mental Health Support Teams in schools and colleges: Trailblazer Programme.
6. Koskinen, S. et al. (2014). School health services in Finland: A national overview. Finnish Institute for Health and Welfare.
7. Love, H. E., Soleimanpour, S., Schlitt, J., et al. (2019). Twenty years of school-based health care growth and expansion. Journal of Adolescent Health.
8. Basch, C. E. (2011). Healthier students are better learners: A missing link in school reforms to close the achievement gap. Journal of School Health, 81(10), 593–598.

Co-authored Article

Adolescence is a crucial stage of physical and psychological development. For young athletes, maintaining overall wellbeing is essential to sustaining performance, preventing injuries, and fostering long-term success. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This holistic perspective is particularly relevant in adolescent sports, where the pressure to perform can sometimes overshadow the need for rest, recovery, and mental resilience.

The Reality of Injuries in Adolescent Sports
Competitive sports demand physical exertion and dedication, pushing young athletes to their limits. Injuries are common due to repetitive strain, physical contact, and, at times, mismanagement of training loads. While injuries can be setbacks, they also offer an opportunity for young athletes to reflect, adapt, and grow. A well-structured recovery plan not only restores physical strength but also helps in addressing mental and emotional challenges associated with being sidelined. This multi-dimensional approach with layered social support can often help an athlete return feeling refreshed and lead to greater levels of performance.

Understanding the Recovery Process: A Dual Approach

Athletes face a unique challenge when they experience an injury. The recovery process goes beyond just physical healing; it also involves significant psychosocial hurdles. These two dimensions are deeply intertwined and must be addressed together for optimal rehabilitation and long-term wellbeing.

Physiological Stages:

1. Injury: The body’s immediate response involves inflammation, characterised by swelling and pain.
2. Repair: During this stage, the injury may need surgery or specialised treatment before starting to rebuild and regenerate. Athletes rely on proper nutrition, rest, and physical therapy to optimise this process.
3. Re-modelling: As new tissue and muscle forms, it must be strengthened to regain full function. This stage involves progressive rehab exercises to stress the area and restore mobility, strength, and stability.
4. Return to Train/Play: The final stage involves a gradual return to sport-specific activities, ensuring the athlete is fully recovered and prepared for competition without re-injury risk.

Psychosocial Stages:

1. Reaction to Injury: Initially, athletes may express emotion, often negative such as anger or frustration, questioning the injuries severity and impact on their ability to perform. This stage is key to managing expectations until a diagnosis has been given.
2. Reaction to Rehab: As athletes shift their focus to recovery, they can begin to scrutinise the rehab process due to its longevity or lack of immediate progress. They may struggle with motivation towards the demands of rehab and seek extra or avoid social support from coaches, teammates, family, and friends.
3. Reaction to Play: As they begin their return to performance, athletes might be cautious or anxious through fear of re-injury and lack of confidence. They may also experience heightened excitement with the ability to do what they enjoy again. Reflecting on lessons learned and providing mental skills training can help address these anxieties.

The Role of Social Support in Recovery

Adolescents are particularly sensitive to social influences, making communication and encouragement from coaches, medical professionals, and family essential in their recovery journey. A multi-dimensional support system helps young athletes navigate setbacks and maintain a positive outlook on their rehabilitation process.

Practical Examples of Social Support:

• Coaches: Regular check-ins with injured athletes, modifying training plans to keep them engaged, and reinforcing their value to the team even when they cannot compete.
• Teammates: Encouraging inclusion in team activities, offering moral support, and celebrating small milestones in recovery to help maintain a sense of belonging.
• Family: Providing emotional reassurance, ensuring adherence to rehabilitation programs, and emphasising long-term health over immediate performance.
• Medical Professionals: Clearly communicating progress, setting realistic expectations, and using positive reinforcement to help athletes stay motivated.

By creating an environment where young athletes feel supported physically and emotionally, they are more likely to remain committed to their recovery and return to their sport with confidence and resilience.

Moving Forward: A Holistic Approach to Adolescent Athlete Wellbeing

Recognising the deep connection between wellbeing and injury recovery is vital for adolescent athletes. A structured, holistic approach that incorporates both physical rehabilitation and psychological resilience ensures they return to their sport stronger and more self-aware. By prioritising their overall health and providing the right support, we empower young athletes to recover fully and thrive both on and off the field.

About Alex Davis OLY

Alex Davis is a seasoned Rugby 7s technical & tactical coach with a distinguished career on and off the pitch.  As a former Olympian and Captain of the national team, Alex has amassed a wealth of experience and achievements.

Beyond his athletic prowess, Alex has become a passionate mental health advocate and public voice for speaking up in the face of adversity. Sharing these personal and sporting experiences has allowed him to recognise the power of connection, leading to charity ambassador roles and guest speaking opportunities. This commitment to supporting athletes overall wellbeing is evident in his values of togetherness, growth, and kindness. With a focus on resilience, compassion, and humility, he aims to empower individuals to reach their whole person potential and live authentic, purpose-driven lives.

While actively playing at the highest level, he completed a certificate in Elite Athlete Wellbeing. This commitment to further self development has equipped him with the tools to foster a supportive and nurturing environment for athletes.

Throughout his career, Alex has led the design and implementation of numerous high performance team cultures. This ability to inspire and motivate others has enabled him to help athletes flourish and work towards their whole person potential. Working with individuals, he focuses on a collaborative approach to deeply understand the person. This foundation paired with robust bespoke practices allows people he works with to become researchers of their own experience.

He is driven to support athletes in achieving their goals while prioritising their wellbeing. His expertise and passion for making a difference are an invaluable combination for those seeking to excel in their respective sports and lead fulfilling lives.

About SPI Coaching 

Sport Performance Intelligence (SPI) is a holistic high performance sports coaching company, designed to support aspiring athletes. We are all experts in our sporting fields, having coached at professional, International or Olympic levels or attained a Doctorate in our specific focus area. We work closely together, to construct bespoke, flexible and progressive performance plans for athletes, to ensure we all support them in their pursuit of excellence.

We have a passion for sport and an understanding of what it takes to reach the highest levels. We all have a drive to support athletes, offering access to world class holistic sports coaching, which is normally only available within a professional club environment.

Specific team roles:

• Performance Psychologist
  Guidance and support for individuals on their psychological performance, improving confidence, motivation, focus, intensity and developing mechanisms for the management of anxiety prior to and during pressured situations, helping you deal with challenge, build resilience and develop belief.
• Performance Nutritionist
  Athletes are given strategies and personal diet plans based on their training, physical development and performance level. This may include the use of supplements, on occasion, to ensure you are getting the right nutrition for your required output and development.
• Strength and Conditioning
  Athletes are given sport specific programmes to develop keys aspects of their physical performance, in accordance with performance level, physical development and the specific stage of your periodisation plan.
• Tactical Performance Analyst
  Personal tactical analyst using our SPI sport specific elite coaches. On review of performances, the coach will develop an improvement pathway, discussing and improving tactical knowledge and decision making under pressure.
• Technical Performance Analyst
  Personal technical skills analysis delivered by our sport specific elite coaches, based on a review of competitive performances and skill related practices.
• Well-being and Performance Lifestyle Coach
  Personal assistance to improve and maintain a high level of mental well-being.
• For Coaches
  Our group of elite specialist coaches offer coaching guidance for sports coaches on how to coach appropriately at all ages and all levels, from grassroots to international level. They offer ways to ensure coaches attain the highest performance levels and ensure longevity of athletes in their sport.

Dr Sam Barke

Head of Sports Medicine

Return2Play & Meliora Medical Group

Skiing and snowboarding offer children the opportunity to partake in winter activities that enhance physical fitness, balance, and self-confidence. However, without adequate preparation, these sports can result in injuries.

Proper preparation not only enhances the enjoyment of the experience on the mountain but also significantly improves overall fitness levels. While it is not necessary for children to be capable of completing a triathlon or marathon, maintaining a fundamental level of strength and fitness is crucial to minimise the risk of injury and maximise their time on the slopes. Parents, school sports coaches, and medical professionals play a pivotal role in mitigating these risks.

With many school ski trips approaching, we have put together some ways to prepare children effectively to minimise injuries and ensure a safe and enjoyable experience on the slopes.

Strategies to Minimise Injury Risks

1. Build Physical Fitness Beforehand

Skiing and snowboarding require strength, flexibility, and endurance. Fatigue is a common cause of injury in the once-a-year skier, as evidenced by the fact that many ski injuries occur after 3 p.m. Therefore, depending on your base level of fitness you should aim to start your preparation at least 6 weeks ahead of your ski trip.

• Focus on Core Strength: Exercises like planks, side planks and sit-ups help stabilise the body during skiing or snowboarding. Adding in med ball slams and Swiss ball pikes target the deep abdominals as well as the whole body and have the added advantage of raising the heart rate.
• Improve Balance and Flexibility: Activities such as yoga or using a balance board help children control speed and direction and keep them steady on uneven terrain and can enhance range of motion in joints which allows for smoother movements when skiing.
• Leg Strength: Squats, lunges and RDL’s prepare the muscles most used in skiing and snowboarding (Quads, Gluteal and Hamstrings).
• Cardiovascular fitness plays a huge role in skiing too. High-altitude exercise can quickly wear out even the fittest of athletes if they’re not used to it. So, incorporating cardio routines into the pre-ski season workouts would be beneficial. This could be anything from running or cycling to using an elliptical trainer or stair climber.

2. Ensure Proper Equipment

Using well-fitted, high-quality equipment is one of the most effective ways to reduce injuries:

• Helmets: Mandatory for all children. Ensure the helmet fits snugly and meets safety standards for snow sports.
• Boots and Bindings: Ski boots and snowboard bindings must be properly adjusted for the child’s height, weight, and skill level to prevent unnecessary strain on joints.
• Protective Gear: Snowboarders can benefit from wrist guards, while padded clothing can reduce the impact of falls for both skiers and snowboarders.
• Clothing: Waterproof, insulated layers keep children warm and dry. Don’t forget gloves, goggles, and face coverings for extra protection. Hand and toe warmers can be a welcomed accessory for those colder days.

3. Provide Professional Instruction
No matter the child’s skill level, lessons from certified instructors are invaluable. Instructors not only teach proper technique for stopping, turning, and safely falling, all of which reduce the risk of injury, but they can be a great guide showing the children the hidden gems of their own resorts. Beginners especially benefit from controlled practice before heading to larger slopes.

4. Teach Safety Awareness
All Children need to understand and respect the rules of the slopes including the codes of conduct for all resorts:

• Trail Etiquette: Teach children to yield to downhill skiers, avoid stopping in narrow paths, and look uphill before merging onto a trail.
• Hazard Awareness: Encourage children to stay within marked boundaries and avoid icy, overly steep, or crowded areas.
• Knowing Limits: Emphasise that pushing beyond their skill level increases the likelihood of accidents.
• Codes of Conduct: FIS Code of Conduct

5. Warm-Up and Mobility
Cold muscles are more prone to injury. Before hitting the slopes, have children do a light warm-up, such as jogging on the spot or jumping jacks, followed by dynamic stretches targeting the legs, back, and arms.

6. Monitor Fatigue and Hydration
Tired or dehydrated children are more likely to make mistakes that lead to injuries.

• Schedule frequent breaks to rest and hydrate.
• Encourage healthy snacks to maintain energy levels.
• Watch for signs of fatigue, such as slower reaction times or a lack of focus, and call it a day before exhaustion sets in.

Returning to Skiing Following an Injury

Returning to skiing after an injury requires careful planning, patience, and the right mindset to ensure recovery is complete and further damage is avoided. Whether the injury was minor or significant, taking the right steps can make the difference between a safe return to the slopes and a potential setback. If you have a niggling injury, now is the time to get it dealt with, rather than two weeks before you are about to travel.

1. Get the Advice of a Medical Professional
Before resuming skiing, get clearance from a doctor, physiotherapist, or sports injury specialist. They can evaluate the child’s recovery and provide specific guidelines based on the injury, such as:

• Whether strength and range of motion have fully returned.
• Any limitations to avoid, like certain movements or intensities.
• The need for additional rehabilitation exercises.

2. Prioritise Full Recovery
Returning too soon can risk re-injury or worsen the initial condition. Signs that a child may not be ready to ski include:

• Persistent pain or discomfort during daily activities or light exercise.
• Limited mobility in the injured area.
• Fatigue or weakness in the muscles supporting the injury.

3. Ease Back onto the Slopes
A phased approach to skiing helps children rebuild confidence and skill gradually:

• Start Small: Begin with easy, gentle slopes. Avoid challenging terrains or high speeds until fully comfortable. If returning to race training aim for drills on a gentle piste before moving onto stubbies and then finally full gates.
• Short Sessions: Keep initial skiing sessions brief to avoid fatigue. Gradually increase duration as endurance improves.
• Practice Technique: Focus on proper form and technique to minimize strain and avoid compensatory movements that might lead to new injuries.

Returning to Skiing Following a Concussion

Return2Play has specific guidance about returning to the slopes following a concussion. This can be found here: www.return2play.org.uk/wp-content/uploads/2025/01/R2P-Skiing-following-a-concussion-2025

Dr. Alex Maxwell, our Head of School Medicine at Meliora Medical Group and President of the British Society of Lifestyle Medicine, has been interviewed about how this evidence-based field enhances clinical care by promoting a holistic approach to individual health.

Lifestyle Medicine is an evidence-based discipline that recognises the importance of addressing the socioeconomic determinants of health, provides practitioners with proven techniques to support sustainable lifestyle changes, and focuses on six key pillars: mental wellbeing, avoiding harmful substances, healthy relationships, nutrition, sleep, and physical activity. With global movements and societies, it seeks to integrate these principles into healthcare practice.

Read the full article here (the interview can be found on pages 70–73).

For more information or if you are interested in the services offered by Return2Play, please click the button below.
Talk to us

Dr Sam Barke

Head of Sports Medicine

Return2Play & Meliora Medical Group

As we step into 2025, it’s the perfect time for reflection and planning. For schools, that means setting goals for the year ahead, particularly when it comes to the welfare of youth athletes. While the excitement of new sports seasons, tournaments, and achievements is often the focus, it’s crucial that pupil-athletes’ well-being doesn’t get lost in the shuffle.  After all, a well looked after athlete performs better.

At this time of year, the pressure on young athletes can be high. Whether it’s the desire to impress coaches, secure their place in a team, or simply excel in their chosen sport, the stakes can sometimes feel overwhelming. But it’s essential to remember that the path to success isn’t just about performance — it’s about creating a balanced, supportive environment that promotes both physical and mental health.

So, how can schools maximise youth athlete welfare in 2025? Here are a few strategies to ensure that pupil-athletes thrive, not just on the field, but off it too.

1. “I’m fine, I don’t need rest” — The Importance of Recovery

We’ve all heard it before: a pupil pushes through pain, exhaustion, or fatigue because they’re determined to perform at their best. This mindset, while perhaps admirable, can also be detrimental to long-term health. In the rush to compete and achieve, recovery often gets overlooked. But the truth is, proper rest is essential to an athlete’s development.

Recovery should be integrated into a pupil’s routine, not just as an afterthought. Schools should promote strategies that include regular rest days, proper sleep, hydration, and nutrition, alongside physical recovery practices. When athletes prioritise recovery, they can avoid burnout, injury, and mental fatigue — which are just as important as winning the next match.

2. Understanding the Mental Health Side of Sports

Physical health isn’t the only aspect of welfare that needs attention — mental health is just as crucial. There’s often a silent pressure on young athletes to constantly perform, and for some, this can lead to stress and anxiety.

Schools can maximise youth athlete welfare by ensuring they’re aware of the mental health challenges athletes face. This could involve providing access to school doctors, counsellors or mental health resources, implementing workshops on stress management, or training teachers and coaches to spot the signs of mental distress.

More importantly, creating an environment where it’s okay to talk about mental health and seek support can go a long way. Pupils should feel that their well-being matters just as much as their ability to score goals or break records. By addressing mental health head-on, schools can create more resilient athletes who feel supported both in and out of competition.

3. Balancing Academics with Athletics

It’s not uncommon for young athletes to feel torn between their studies and their sport. With the pressure to succeed academically and the desire to excel in athletics, the demands can be overwhelming. Schools need to take a holistic approach that supports academic and athletic achievements without sacrificing either one.

Encouraging time management skills, looking at flexible scheduling for training sessions, and ensuring that pupils don’t face academic penalties for participating in sports are all ways schools can balance academics and athletics. After all, the best athletes aren’t just those who excel in their sport — they’re also the ones who can manage their academic responsibilities and develop life skills that will benefit them in the future.

4. Educating Coaches and Staff on Injury Prevention

Injury prevention is a crucial element of youth athlete welfare that’s often overlooked. Coaches, teachers, and school staff need to be well-versed in the signs of injuries and know how to react appropriately when an athlete is hurt. This is particularly important with regards to head injuries and concussion where there is clear guidance on how these should be managed to protect players’ welfare (see What is Concussion?).

Beyond that, schools should invest in educating coaches about proper techniques, warm-up and cool-down routines, and safe practices. Athletes are more likely to stay injury-free if they are taught the right way to perform exercises, stretch, and train. Schools could also consider having regular workshops or seminars on injury prevention for both athletes and coaches.

A critical factor in preventing injury is not allowing pupils to push their bodies beyond their limits. Schools and coaches should ensure that the training loads are appropriate for the age and experience of the athlete, with ample time for recovery between sessions.

If a pupil is injured, it’s important that recovery is given the same priority as performance. Clear protocols for injury assessment, treatment, and recovery should be in place to ensure that athletes receive appropriate care and don’t return to play too soon.
 
5. Inclusivity and Well-Being for All Athletes

It’s important to remember that youth athlete welfare isn’t just about those who are top performers or elite athletes. Schools should work to create an inclusive environment where every pupil has the opportunity to participate, feel valued, and develop their skills. This is especially important for pupils who might not naturally excel in sports but who still benefit from physical activity.

Schools can maximise athlete welfare by creating a culture of inclusion, offering a variety of sports and activities, and ensuring that all pupils have access to the resources they need to be healthy and active. Promoting physical literacy and encouraging lifelong participation in sports will help pupils develop a positive relationship with physical activity, no matter their skill level.
 
The Takeaway: Setting Goals for Sustainable Success
The new year offers schools an opportunity to set fresh goals for their athletes — goals that go beyond winning trophies or breaking records. By prioritising athlete welfare in all its forms — physical, mental, and emotional — schools can help ensure that their athletes thrive for years to come. Collaboration with a school healthcare provider, including sports medicine specialists, can help achieve this.

Success is not defined solely by what happens on the field, but by how well pupils are supported in their journey as athletes and individuals. With a balanced, supportive approach, we can create the best environment for young athletes to grow, both in sport and in life.

Dr Mike Forsythe

Deputy Head of Sports Medicine

Return2Play & Meliora Medical Group

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’s 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 12,500 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 for review with our most senior doctors 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.

There are various options available following a case review. These include review in the Complex Case Clinic, particularly in cases where the underlying cause of ongoing symptoms is unclear, or referral for specialist concussion physio, where issues affecting recovery can be proactively addressed. Our team takes a holistic approach in identifying the specific cause – or causes – of ongoing symptoms, and tailor their management plan accordingly. Commonly patients will have input from both the Complex Case team, and our specialist physios.

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 benefited from input from our specialist concussion physio. 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 require further input?

12% of the patients diagnosed with a concussion in the last year were referred for Case Review. 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 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 provide relevant information regarding the risks of repeated injuries A referral to the Complex Case Clinic can be made 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.

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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
 

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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.

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

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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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“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.

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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