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Tackling football’s inconvenient truth



Football’s alleged culture of bungs and backhanders was thrown under the floodlights in September – culminating in the sacking
 of England manager Sam Allardyce.

In the same month as the Telegraph’s exposé of under the table deals, came another revelation to unsettle the custodians of the game.

The University of Stirling delivered the first piece of evidence to suggest heading footballs may be damaging to young people’s brains. With only 19 youth players tested, the study was relatively small.

Its findings, however, could have significant repercussions.
A machine fired balls to replicate corner 
kicks, with players heading them numerous times.

Brain function was tested before and after, with small but significant changes 
noted over the subsequent 24 hours among players who headed the ball at least 20 times.

“If I were a parent of a kid with an exam on a Wednesday, I would suggest they miss football training on the Tuesday,” warned co-author and neuropathologist Dr Willie Stewart.

The news was no surprise to Dawn Astle, whose father Jeff (pictured), the former West Brom and England striker, died of ‘industrial disease’ caused by heading footballs.

Having been diagnosed with early onset dementia, a coroner’s report revealed the true impact his career as a prolific scorer of headed goals had on his brain.

Dawn (pictured at a recent brain injury event) says: “If John Terry saw what my dad went through, not even remembering he had been a footballer, and choking to death, he would never head a football again. I honestly believe that.”

Jeff Astle was the first known case of chronic traumatic encephalopathy (CTE) – traditionally known as boxer’s brain – in a footballer. CTE is a progressive degenerative brain disease in individuals with a history of repetitive brain trauma, including symptomatic concussions and asymptomatic subconcussive hits to the head.

The trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau.These changes can begin months, years or decades after the last brain trauma.

They are associated with memory loss, confusion, impaired judgement, impulse control problems, aggression, depression and progressive dementia.

Following her father’s death in 2002 at age 59, Dawn launched the Jeff Astle Foundation to encourage research into the dangers of heading footballs.

Concussion in football campaigner Dawn Astle at the UKBIF eventHer battle has been marked by indifference, silence and mostly empty promises from footballing authorities.

“The coroner ruled that being a footballer killed my dad. In any other industry that would have had earthquake-like repercussions.

“Think of asbestos in factories, for example. But not football. They tried to sweep his death under the carpet. It was the last thing they wanted the coroner to say. The FA wasn’t interested and initially didn’t acknowledge what had happened to dad.”

The FA and PFA did promise a 10-year investigation in 2002 into the risks of heading a ball but this ultimately amounted to nothing.The 20 to 30 young people involved dropped out of the game and the investigation was discontinued.

Dawn discovered this years later from a journalist, much to her surprise.“We were stunned. It was a disgrace, especially from the PFA whose job is to represent players.”

Parallels are clear between Dawn’s campaign, and the struggles of Bennet Omalu, a forensic pathologist who discovered links between American football and CTE.

For Dawn’s cold shoulder from the FA and friends, read the opposition of legions of lawyers, doctors and brand protectors in the lucrative NFL club.

Although his fight for change goes on, the game did eventually donate US$12m to support CTE research.

For Dawn too, there are signs that the footballing world is finally listening.This winter she will attend an FA symposium at which the risks of CTE in football will be discussed with medical experts.

In the longer term, she hopes for robust, in-depth research to be undertaken.“Firstly we need a longitudinal study into the impact of heading footballs and it must be independent. If you look at the NFL, they initially did their own study and said there was nothing happening.

“It later transpired that they did know the risks. A lot of people say CTE in football is a generational thing and that it won’t happen nowadays because the balls are lighter.

“But that’s a red herring because they travel at a greater speed now. We don’t know whether a big heavy leather ball soaked in water would make a difference.

“Personally I don’t think it would because new balls still result in a blow to the head causing the brain to move in the skull.

“Another thing that could be done relatively cheaply is to look back at our former players and simply ask, have a disproportionate amount of them been diagnosed with dementia?” 

The evidence Dawn has accumulated from emails and letters from concerned families, suggests the answer would be yes – but unequivocal proof is needed.

“One lady’s dad played in the 50s and 60s at a local level. He never smoked or drank and was very strong and active. He collapsed when he was 52 and died days later of a brain bleed.

“He would always suffer headaches which o en kept him in bed for a few days. He was a centre half and often said heading the ball left him with headaches.“Another footballer’s daughter told me that her dad was one of three brothers who were all professional footballers. All three ended up with a brain disease. Also, my dad was the number nine for West Brom. The number nine before him died from Alzheimer’s and the same thing happened to the number nine before him.

“If you look at the 1966 World Cup winning team, Martin Peters, Nobby Stiles and Ray Wilson have all been diagnosed with Alzheimer’s.”If the scale of CTE problems in ex-footballers is to be properly investigated, more brain samples must be donated by families and loved ones of the deceased.

“It’s brutal to see a dad, brother or husband going through these problems. It can be a very distressing time but some are willing to agree to it. Not one person has mentioned anything about suing for compensation. They just want to find out the truth.“It’s the not knowing that drives you mad. Once that person has been buried or cremated it’s too late and they will never know.”

Dawn hopes her upcoming date at FA towers will be a catalyst for change. She would also like to see more measures to protect grassroots players from brain injuries.

“Grassroots football does not have a doctor on the sideline. Kids would carry on playing even if their leg was hanging off so if there is a head collision the choice of whether they come off or stay on, should not be with the parents. It should be in black and white in guidance from the football authorities.”

Investigating CTE in future

Dr Michael Grey, a motor neuroscience expert at Birmingham University, envisages future research into CTE and football as being cross-sectional, ideally following groups of players throughout their careers.

Grey is also hopeful that new research aimed at developing new tests for concussion will lead to greater player safety in future.

“Researchers around the world are looking at blood and urine tests and I think we are going to make some headway soon.

“One thing we’re working on is a breathalyser which could potentially detect concussion.

“Concussion causes brain chemicals known as metabolites, to change. If they get into the blood, as we believe they do, they should then transmit into the lungs and into the breath.

“So we should be able to detect them. We are working on this now but its use in the game could be a few years down the line.”

In terms of better protecting grassroots footballers from concussion, Grey says: “We need better tests that are inexpensive and can be rolled out to every football club across the world.

“We need a physiological test. Tests which rely on the compliance of the person involved don’t always work because players often just want to get back onto the pitch.“In some cases they don’t even realise there is a problem. There are no pain centres in the brain so it is difficult to detect.”

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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.

Michelle Kudhail, director of clinical excellence at Inspire Neurocare.

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.

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Case management

‘I’d never imagined using Zoom as part of my physio placement’



Tabitha Pridham is a third year student at Keele University. 

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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Case management

‘The challenges have been many, but we’ve found ways to overcome them’



"The demand for digital technology going forward should mean that we can develop a better working practice"

The COVID-19 pandemic has forced huge changes within case management and the traditional ways in which clients have been supported. In our continuing series of Q&A features with case managers across the country, Martin Gascoigne of Neuro Case Management UK (NCMUK) shares his experiences.

Can you summarise how the past few months have been for you.

The past few months for NCMUK have been extremely challenging. This is due to the Government initially ring fencing all of the PPE supplies for NHS staff which made it very difficult for us to procure the necessary equipment. Also, due to our Paediatric Clients Parents furloughing, we have experienced different challenges with the type and level of care that they felt they would like us to provide whilst still working in accordance with National Minimum Standards.

How did you adapt to the restrictions of lockdown? Were you able to do this quickly or did it take a bit of time?

We managed to adapt to all of the new guidelines effective immediately as we were informed by the Government that failure to conform with these would mean that we were no longer able to deliver the care needed. NCMUK therefore reassigned staff to new roles to deal with the new daily/weekly challenges set, identifying new sources of equipment provision, medication and standards of care.

What have been the main challenges – were you able to overcome them?

The main challenges we found were that of procuring PPE at a clinical level. Unfortunately we could not identify or purchase any in the UK and so in order to overcome this it was necessary for us to establish a regular supplier overseas who was able to both meet our needs and the needs of our clients.

Has the use of telerehab been of benefit to you?

NCMUK has indeed benefited from digital technology including Zoom and Facetime. During this period of lockdown, telephone calls and digital contact was the only way the case managers/directors could maintain a high level of communication with our suppliers, clients and families.
At this time we also relied on a digital marketing organisation which made sure that our company stayed at number one on page one with Google. This meant that we could maintain our on line presence and as a result of this we would benefit from new referrals which continued to keep us busy.

How have your clients responded? Was it difficult for them to adapt to?

Our clients did find it difficult just understanding the pandemic initially, as we all did, with the obvious additional worries that they would be infected by our carers. This concern, however, was alleviated as the NCMUK team provided all care in a fully barriered manner using face masks, aprons, gloves and hand wash following the Government guidelines set.

Do you feel the lack of face-to-face contact with clients or/and colleagues has been damaging?

Our carers have been continuing to attend their home visits following the correct guidelines throughout the pandemic. This meant that they continued to have face to face contact. New links have been established via digital marketing and Zoom calls but this has been a positive addition to our communication network and as we already undertake telephone reviews with our staff, there was no change to our relationship with our colleagues.

How central do you think the use of telerehab will be for you going forward?

The demand for digital technology going forward should mean that we can develop a better working practice combining the face to face home visits and the human side of our meetings/assessments alongside digital meetings. This has the benefit of reducing the carbon emissions of our team, whose level of travel is reduced.

How do you think the future of case management has been shaped by the pandemic?

The NCMUK team will have the opportunity now to work more from home, allowing them to complete basic administrative tasks within their own environment, thus reducing emissions due to unnecessary travel.
It will also mean that when completing some assessments, these can be carried out via Zoom/Facetime meaning that more out of reach areas throughout the England/Wales can be contacted more easily. It has been necessary for us to think of alternative methods of communication moving forward and these will probably be maintained in the future as they have been a success.

Will you be doing anything differently within your business going forward, compared to your working practices pre-pandemic?

The pandemic has changed our business considerably as we are all now working more from home with the benefit of our staff reducing their overall carbon footprint. This will continue and streamline the industry as there will be more work undertaken on a virtual basis as staff are able to complete the basis administrative tasks within their own home environment in lieu of travelling to the office. It will also allow NCMUK to have clients referred to us who live in more inaccessible areas of the England/Wales which should provide more people access to more services.

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