Addressing the challenge of concussion in rugby is like a skirmish with the marauding All Blacks. Hazards emerge from every angle and each advancing metre is hard fought.
Leading the line is Dr Simon Kemp, chief medical officer at English rugby’s governing body the RFU and a former physician to the England squad.
With his involvement, the game has made significant progress in improving its handling of concussion in recent years, but the battle is far from won.
“Concussion is just about the most difficult sports injury to diagnose and recognise because it can present in so many different ways,” he says.
“It can lead to two or three seconds of unconsciousness with no signs or symptoms afterwards – or can present with somebody who develops a headache over the course of four to 24 hours, for example.”
Custodians of the game are working on several fronts to better prevent, manage and understand concussion at every level, from schools and grassroots to the top tier.
Like football, American football and boxing, rugby must also answer difficult questions about its long-term impact on the brain.
This follows revelations about links between football and NFL to CTE, the progressive degenerative brain disease caused by repetitive brain trauma and associated with dementia.
Long term study
Kemp (pictured above) says: “Sport in general needs to answer the question of whether there is an association between playing sports and neurocognitive decline.
“It’s a difficult question to answer because, as we age, we all see neurocognitive decline, which is one of the reasons for the limited amount of evidence around to date. We acknowledge that there may be an association [between rugby and CTE] but the reality is that the available evidence is limited and conflicting.
“Unlike some other sports, we do actually have a long-term study underway, involving 205 ex-rugby players, most of whom were England internationals. Rugby has been pretty upfront about this issue.”
The RFU is working on the study with the London School of Hygiene & Tropical Medicine and researchers from Queen Mary University of London, The Institute of Occupational Medicine, University College London and Oxford University.
It is backed by £450,000 in funding from The Drake Foundation, which supports sports concussion research. Results are expected to be published next year.
At the last count in 2015/16, concussion accounted for 25 per cent of all match injuries in the English professional game, up from 17 per cent the year before.
But the sport is not necessarily becoming more dangerous – heights and weights of players have remained stable since 2002, after an initial surge when the game turned professional in 1996.
Rather, Kemp puts rising concussion rates down to greater recognition of the condition.
“In the professional game, reported concussions have been going up dramatically over the last five years but all other contact injuries have remained stable. We think the rise is because we are much better at recognising it.”
This surge in reported concussions corresponds with the establishment of World Rugby’s Head Injury Assessment (HIA) tool, which underpins concussion management in the elite game.
It consists of a three-step process of assessment for any player suspected of sustaining a concussion.
The first stage involves 11 immediate and permanent removal criteria relating to factors such as consciousness, balance or behavioural changes.
“The player absolutely does not go back onto the pitch if any of these criteria are met,” says Kemp.
An off-field screening tool, pitch-side video review system and evaluation by an attending doctor are also involved at stage one.
Stages two and three cover tests and assessments for early signs of concussion, within three hours of the match, and delayed signs, after the player has had two night’s sleep.
The protocol was introduced in 2012 – a year in which an estimated 56 per cent of players later deemed to be concussed stayed on the field.
The latest available stats, from 2015/16, put that figure at nine per cent, with the fourth version of HIA now in play. As often happens at the intersection between much-loved sports and newly installed regulations, the HIA protocol has attracted some criticism.
And, despite its continual improvement via updated versions, it cannot protect against every concussive incident in every match.
Lessons to learn
Last year Northampton winger George North was allowed to return to the pitch at Leicester, despite having appeared to lose consciousness.
A review found there was enough evidence from footage of the incident, together with North’s history of concussion, to have kept him on the field.
It accepted that Northampton’s medical team acted in the best interests of the player, however, since it had not seen all the available video footage due to Wi-Fi problems.
Rugby’s response was swift. The Concussion Management Review Group drew up
nine recommendations, which were implemented by Premiership Rugby.
They included ensuring a pitch-side video reviewer remains in their allocated seat and has backup to make sure video feeds are monitored continually.
Various Wi-Fi protocols and a stipulation that medical rooms should have hard-wire video feeds were among other measures.
Former World Rugby medical adviser Dr Barry O’Driscoll said at the time that the episode showed: “The protocols are totally unfit for purpose. Time and again they are putting brain damaged players back on the field.”
O’Driscoll quit his role at World Rugby in 2012 in protest at the way concussion was being handled.
In the absence of a proven and objective, single pitch-side test for concussion, Kemp insists the HIA system is performing well in terms of protecting players.
Official data backs this up; in 2015/16, 98.5 per cent of head injury events in the Premiership were managed according to the protocol.
“HIA has evolved since 2012 and it really is pretty sophisticated now. The tools that we
have to identify concussion are of real value, but they are, of course, subjective.”
Should an accurate, objective pitch-side test emerge, Kemp envisages it being embedded into HIA protocols, rather than replacing them. Such a test might be based on saliva samples, if trials taking place this season in the Premiership and Championship are successful.
The study, being carried out in collaboration with the RFU, Premiership Rugby and the Rugby Players’ Association, will run throughout the 2017/18 season and is the biggest of its kind in the history of UK sport.
Birmingham University, led by neurosurgeon Professor Tony Belli, has spent the last nine years working towards a test that measures biomarkers present in the saliva and urine of players.
If validated, it could be carried out on a hand-held device, which is currently under development.
Professor Belli says: “If these biomarkers are found to be reliable, we can continue our work with industrial partners with the hope of having a device available within the next two years that will instantaneously diagnose concussion on the pitch-side with the same accuracy as in the laboratory – a major step forward for both sport and medicine.”
While rugby works towards a fast, watertight pitch-side concussion test, what other interventions might minimise the risk of brain injuries in the game? NFL or amateur boxing-style head guards are often suggested, perhaps by those uninitiated with the medical implications of contact sports.
These, says Kemp, would be pointless in relation to head injuries.
“Rugby headgear can protect against head lacerations and cauliflower ears but there aren’t any helmets in sport that have been shown to protect against concussion.
“They can prevent skull fracture, but not the rotational, acceleration and deceleration injuries that are associated with concussion.”
One safety measure which has been adopted by the professional game recently is an increase in the sanctions players receive for tackles made over shoulder level.
In January 2017, the minimum on-field sanction for a reckless (high) tackle was upgraded to a yellow card with a maximum of red, while the minimum on-field sanction for an accidental (high) tackle is now a penalty.
“We are already starting to see more penalties and yellow cards as a result, so referees are definitely implementing it.”
Time will tell whether this heightened threat of an early bath or time in the sin-bin leads to a reduction in concussion rates.
A longer-established part of rugby’s concussion prevention strategy is the
training course delivered to all players and backroom staff at every club in English rugby’s top two divisions.
The club doctor at each of the 24 clubs runs an hour-long concussion session, with mandatory attendance for every member of the playing, coaching and support staff.
Around 1,300 people have now been through the course since its launch in 2014.
“It has transformed the way players understand concussion. They are really well informed about what it looks like, what it feels like and why they need to come off.
“The course also talks them through what the potential consequences are.
“In the short term, if they stay on the field, they have an increased risk of further injury, their performance goes down and their symptoms are likely to last longer. We also talk about the potential long-term consequences.
“We don’t know exactly what they might be, which is why it is so important to get across to players why they need to be removed in order to recover and return safely.”
At amateur and age group levels of rugby, concussion education is not mandatory, but plays a crucial role in protecting players.
The RFU runs online courses and offers a wealth of resources to school and community teams through its Headcase initiative.
They include advice, assessment tools and changing room posters with the slogan “DON’T BE A HEADCASE, STOP! CHECK FOR CONCUSSION”.
Tens of thousands of people have undergone training via the scheme since it was launched in January 2013.
The grassroots campaign advises anyone involved in the game to; ‘Recognise, Remove, Recover, Return’ and Kemp says the message is hitting home.
“Evidence suggests that the simpler your message, the more likely it is to be remembered. We’ve been working hard around the Headcase resource to achieve this, including through the commissioning of a video animation which has gone down particularly well with teenage players.
“The message is getting through but it needs to reach millions of people and it hasn’t got to everybody yet. We also need to consider what is rugby’s responsibility and what is that of the departments of education and health.
“Our principle responsibility is to get the message to coaches, players and parents.
We can help in terms of getting the message out to GPs, emergency doctors and teachers but we do need support from government departments, which, in fact, we have very good relationships with.
“Also, concussion advice to teachers needs to be consistent across sport, which is why we’re working with other sports and our advice is aligned with soccer’s for example.”
Schools must adapt
An important element of the RFU’s work with schools is providing guidance on what happens after a concussion.
“If a pupil sustained a concussion on a Saturday and still had a headache on the Monday, they shouldn’t be back into a full school programme.
“We have been working with schools to help them understand that they may need to make some academic adjustments as the pupil recovers from the injury.
“This is a big task but schools are increasingly receptive. Some independent schools with big rugby programmes have even developed an approach to player recovery that looks very similar to that of professional clubs.”
In concussion prevention and management, the amateur and schools-levels of rugby take their lead from the professionals.
“Concussion is the same injury in professional, community and age group rugby. But the way it is managed varies because of the different resources you have. The principals are the same however and are consistent with the science [of concussion].
“How concussion is managed at the professional end drives how it is managed at the community end.
“So it is incredibly important in the professional game that we recognise and remove players with suspected concussion and do not leave them on the pitch. By doing so, we send a message to the community and age group levels.”
Further protection for young people comes via a lower threshold for leaving the pitch, and a slower return to play.
“Schools rugby doesn’t have video evidence, but does have the coaches, parents, teachers and other players all alert to the possibility of concussion and players coming off.”
Young players also experience a gradual increase in the level of contact permitted in their game as they get older. Full contact rugby is not played until players turn 15, a strategy which also protects players from head injuries, says Kemp.
Exercise may protect young people
New measures could further protect young players, meanwhile. Recent research from the University of Bath found that a 20-minute exercise programme for young rugby players to improve their strength and balance could help to reduce concussion injuries.
A study, involving 14 to 18-year-olds across 40 schools, found 59 per cent fewer concussions in schools that completed the exercises three times a week, compared to those that didn’t.
The exercises focused on increasing neck muscle strength, balance and movement. The RFU is rolling out the programme in schools in England this season.
Other researchers suggest the game should go even further to prevent concussion in school rugby.
A Newcastle University study, published in July in the British Journal of Sports Medicine, re-examined existing evidence on the rates and risks of injuries in sport.
It cited “strong evidence” from Canada that removing the “body check” from youth ice-hockey, where a player deliberately makes contact with an opposing player to separate them from the ice-puck, led to a 67 per cent reduction in concussion risk.
The report drew parallels with rugby and urged a ban on tackling in the youth game; although another recent study in the same journal suggested concussion risk in youth rugby is no higher than in other sports.
Kemp urges balance when considering the risks and rewards of young people playing rugby.
“You have to look at both the sport’s benefits and negative elements. The reality is, at a time when our children are becoming increasingly sedentary and heavy, the place for physical activity in sport is increasingly valued.
“One of the important points about rugby is that it’s a game for all shapes and sizes. The shorter or less mobile child who might not get a look in in soccer, may have a place on the rugby team.”
Yet, despite rugby’s obvious health benefits, is there a danger that officious head teachers might still be tempted to avoid any rugby-related risks completely?
In the US, where American football is still reeling from revelations about links to early-onset dementia, non-contact, ‘flag football’ is reportedly replacing the pigskin in some schools.
Non-contact forms of rugby are already in existence here, but Kemp sees no signs of a drop in appetite for proper rugby among young people.
“Clearly as we become more aware of injury risks, it might change how schools review individual sports, but at the moment the uptake of rugby in schools is significantly growing,” he says.
Inspiring a brighter future for residents
A neuro-rehab provider which opened its first facility in Worcester shortly before the first lockdown has succeeded against the odds – and now has plans to expand in 2021, as NR Times reports.
Inspire Neurocare provides support for people with a variety of neurological conditions, offering rehabilitation, respite and palliative care.
The firm opened its first specialist care centre in Worcester in February 2020, and this will be followed by further facilities in Basingstoke and Southampton in 2021/22. Inspire prides itself on a novel model of care that has “no limitations on the possibility of recovery,” all led by director of clinical excellence Michelle Kudhail.
A key element of the centre’s approach is the team’s commitment to understanding that every patient, and the circumstances that led them there, is different.
Whether this means enabling people to leave high dependency hospital units and develop their independence in a modern, home-from-home environment, or providing long-term support or end-of-life care, the service is designed to work around the needs of each patient.
Michelle’s background means she is the ideal person to head up the Inspire team, having worked as a neuro physiotherapist in the NHS until 2010, before moving into the private sector.
She takes an holistic approach to patient care, which has led to the creation of a team of life skills
facilitators and therapists at the provider, who develop their care around the needs of everyone.
“The life skills facilitators support and assist the residents to do as much as they can for themselves,” she explains.
“As the name suggests, their role is more than a carer; it is to facilitate the residents in all aspects of their care, whether that’s helping them get their breakfast, choosing what they are going to wear, or taking their medication.
“Their skills are broad because we want them to be involved in all aspects of the residents’ care; and because we want to provide what they need at the time that they need it.
“Roles such as this also enable us to evaluate the outcome of any action. If a resident has been given pain medication, a facilitator can assess whether it’s been effective, rather than a nurse giving the medication and then not seeing them until the next round.
“We also know from a therapy perspective that some patients don’t respond well to having therapy at a fixed time on a particular day; they simply might not feel like doing it. Our facilitators mean we can best provide interventions for the resident when they want them.”
Alongside this role, the facility also employs a wellbeing and lifestyle coach, focussing on the health and emotional needs of both residents and their relatives, particularly during a time when COVID has caused a lot of uncertainty.
Michelle says: “We wanted somebody that had relevant experience in working with residents, particularly with neurological conditions but also with a well-rounded experience so that they would not just focus on one aspect.
“The idea is to have somebody who can offer support in all areas, whether it be psychological, emotional or physical.”
Staff are overseen by experienced rehabilitation consultant Dr Damon Hoad, who shares his clinical oversight with the interdisciplinary team and supports patients on their journeys.
The rest of the clinical team have a wealth of experience within neuro services in and around the region.
The design of the Worcester facility draws on Michelle’s years of experience, and she had the opportunity to use her skills to help develop the purpose-built home.
She says: “We’ve had a lot of involvement all the way through from knocking down the pub that was there, to seeing it grow. Having the opportunity to be involved from the ground up was fantastic.
“Within the build itself we try to consider the needs of younger people, and so the inside of the home is very much a contemporary design and a lot of research has gone into its development to ensure it has the correct, up to date, equipment.”
Adding to the sense of autonomy staff are keen to foster, is the independent living flat, which staff are able to support via environmental controls.
With soundproofed rooms, residents can enjoy listening to music or watching films without disturbing others.
In common with all care facilities, the impact of COVID means that a lot of thought has had to go into the long-term plans for the property. The recently-built visitation suite – known as the ‘family and friends lounge’ – allows visitors to meet their loved ones in a safe and COVID-compliant way.
The suite includes separate access for visitors from outside, and features a large transparent Perspex screen separating each side of the suite, while an intercom enables contact-free communication.
As well as creating an infection barrier, the screen also assists when it comes to residents who may struggle to understand that they are unable to hug their relatives, while still allowing them to communicate and see each other up close.
After each visit, the room is cleaned and decontaminated in preparation for the next visit.
As Michelle explains, human contact is essential for emotional wellbeing, adding: “We’ve tried to create an environment that is as safe as possible, because we know how important visits are to the residents but, more particularly, to their relatives.
“Supporting the residents through this time is vital. We have residents that are used to going out and doing things in the community and we have had to adjust by being creative in the ways in which they can still access things that they enjoy and still communicate with their families.”
And while the pandemic has certainly delivered some challenges, Michelle and the Inspire team have been able to look at some positive outcomes.
She explains: “One of the positives for us is that it gave the team and the residents the opportunity to really get to know each other.
“We could also develop the life skills facilitator role to its truest form, because everybody was very much working together dealing with the crisis, supporting each other and supporting the residents.
“It was a testing time but it actually it brought the team together, bearing in mind the facility opened literally as everything was going into lockdown.”
The creation of the COVID-secure visitation suite is just one example of the creativity with which all at Inspire approach care, Michelle says.
By looking to build collaborations with other organisations, Michelle also hopes to share her hard-won knowledge, potentially becoming involved in research and training in the future.
Despite the upheaval of its first few months, the Inspire team has already achieved some successful patient outcomes.
One such success story is the case of Adrian, who came to the centre for specialist neuro-rehab following a car accident in which he suffered a severe brain injury. In the months that followed, Adrian’s journey enabled him to walk out of the service and return home to his wife and children.
(See Adrian’s story below – and read more here).
While the coming months may bring more challenges, as COVID lingers and vaccinations are rolled out, the Inspire team seemingly has the skills, approach and dedication to rise to whatever the future holds.
‘My brain trauma caused my head to turn 180 degrees’
Sarah Coughlin experienced the horror of her head facing backwards after sustaining a brain injury. Here she shares her recovery journey with NR Times.
“I was wondering why my windscreen had black lines across it – until I realised I was looking out of my back window.”
Sarah Coughlin recalls the horrific moment she realised her head had turned 180 degrees to face backwards, due to brain trauma she had suffered after sustaining a head injury.
In the immediate aftermath of the injury, Sarah recalls little seemed wrong aside from a persistent headache.
But five days later, when she woke up late and rushed out to her car, the extent of what had happened became all too clear.
“I could feel this searing pain through my shoulders and my back,” says Sarah, as she realised her head had turned around to look out of her rear windscreen.
“It was quite difficult to turn my head back around and keep there but after a while I managed it, though the pain did not go away.
“I thought I had just slept funny and once I had properly woken up the sore neck would probably calm down. But when I got to work I still felt awful.”
This began the long process of diagnosis, which took years to achieve.
“I went to A&E every week for three months because the pain wouldn’t go away and I was still getting neck spasms,” she remembers.
“I was told it could have been a slipped disc, a muscle injury or having slept awkwardly. It changed each time.
“I was in agony constantly, but I still wasn’t diagnosed for at least another two years.”
At first only Sarah’s neck and walking were affected, but over the course of a year she developed spasms, optical neuralgia, pressure on the occipital nerve which runs through the neck up into the scalp, causing tremors, fits, paralysis and fatigue.
Eventually, she was diagnosed with dystonia – a condition which causes involuntary muscle spasms and was the cause of her head rotating.
Doctors also told her she had a Functional Neurological Disorder (FND), a variety of medically unexplained neurological symptoms which appear to be caused by problems in the nervous system.
After her injury in 2014 and its consequences, Sarah could no longer drive, do her job as a teaching assistant – a role she loved – or take part in the same social activities as before.
She also lost touch with many of her friends and hardly left the house as she was scared of people staring at her and judging her for the way she walked and moved.
The 37-year-old, from Fazakerley, Liverpool, says: “I used to be quite fiercely independent – so to go from doing so much to not being able to do anything was the hardest transition.
“I felt a real sense of loss for the life I had when I was first diagnosed.”
In 2017, Sarah discovered The Brain Charity, a national charity based in Liverpool which provides practical help, counselling and social activities for people with all forms of neurological condition.
She made new friends by joining the charity’s craft club and received help getting carers allowance for her partner John and with finding a new home as she could not use stairs safely anymore.
One night in Autumn 2019, John woke up to find she had turned blue and stopped breathing as a spasm had caused Sarah’s neck to contort, closing her throat and airways.
The only solution was a specialist bed which cost £10,000, which was achieved through fundraising and grant funding. She managed to raise the money last year, and now has a bed which uses deep massage cyclo-therapy to improve circulation and reduce her symptoms.
Sarah is now a passionate supporter of The Brain Injury Charity for the assistance it has given, and is keen to encourage people to donate. The charity’s resources are currently under unprecedented pressure as a result of the COVID-19 pandemic, with a 70 per cent increase in referrals met with a huge decrease in fundraising.
“There’s lots of things I can’t do anymore but The Brain Charity has freed me from staring at four walls,” says Sarah.
“They helped me achieve goals that without them I wouldn’t have been able to do.
“It seems obvious, but the more money people donate, the more people the charity can give the vital support I found so important.
“I want other people to have that place that is safe and secure, in an environment with people who have had similar experiences.
“The Brain Charity has given me such incredible support and I’m so grateful for it.”
‘I’d never imagined using Zoom as part of my physio placement’
Every aspect of neurophysiotherapy has had to adapt with the onset of COVID-19, including how students prepare for a career in the profession. Here, student Tabitha Pridham discusses her experience of a pandemic placement.
Prior to the COVID-19 pandemic, the concept of physiotherapists routinely holding sessions with clients remotely was quite unlikely.
While used to some degree in a small number of practices nationally, telerehab, as it has now become widely known, was not on the agenda of many.
But due to its seismic rise during the past few months, with physios realising the potential of digital and virtual means to see clients when meeting in person isn’t possible, it seems telerehab is here to stay.
While it was never part of the studies of aspiring physiotherapists, they are now having to adapt to something that will most likely be part of their future careers.
“The very nature of physiotherapy is that it is hands on, so it seemed really strange to me at first that we would be using Zoom to do online physiotherapy,” says Tabitha Pridham, a third year student at Keele University.
“But I have seen how useful it can be, particularly for those patients who are very advanced in their recovery and maybe can take part in a few classes a week remotely. I think it can be valuable in addition to face to face treatment.
“I do believe it will carry on into the future, particularly in private practice, so have accepted that telerehab will be something I will be using in the longer term.”
For Tabitha, currently on a placement with neurological physio specialist PhysioFunction, telerehab is not the only big change from her expectations pre-pandemic.
“The use of PPE is something I have had to adapt to,” she admits.
“Every time you see a patient in person, you have to change gloves and thoroughly wash down equipment, to be compliant with the very high hygiene standards.
“This can be time consuming, and when you have back to back appointments I’ve found it can be quite stressful to ensure you’re doing everything you need to do in addition to your work with patients, but that’s something I’m learning as I go.
“Wearing a mask and visor isn’t always ideal for communication, but that’s something else I am finding gets better with time and use. Although it can be quite a juggle when you’re trying to treat a patient with one hand, and trying to stop your visor falling off with the other!”
Tabitha is based in the clinic four days a week, but has to work from home one day a week due to the need for a regular COVID-19 test, to ensure the safety of clients and colleagues alike.
“I have my COVID test every Monday, so I carry out consultations by Zoom that day, and providing my test comes back negative, I see patients in person Tuesday to Friday,” she says.
“I find the mix of telerehab and practical experience is really useful, especially as we are going to be using Zoom and the likes in the long term.”
Having had a previous placement cut short in April due to the pandemic, Tabitha is grateful she is able to get such experience, which accounts for vital clinical hours training for her degree course.
“Some of my year group were taken off their placements and have had to do everything virtually, so I’m lucky that I have been able to continue in a clinic,” she says.
“I’m still getting the same training, as aside from the PPE and new rules around social distancing, clients get the treatment they always have done so the practical work is the same.”
Tabitha is set to graduate in summer 2021 and has the experience of her studies, supported by three years of placements, to help her build a career in physiotherapy.
“In some ways this has been a really weird time to be working in physio, but in others it has been a very good time. This kind of experience prepares you for anything and everything, and the use of telerehab has shown me what it will be like in the future,” she adds.
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