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The Coaching Knife: What is really meant by concussion, with Dr Sam Barke

 

In this episode, we speak to Sam Barke, sports doctor – Head of sports medicine at Meliora Medical Group and Return2Play. Focusing on the myths surrounding concussion, we are going to cut to the root on how you play in the zone.

Sam is a school doctor at several major private schools and is match day doctor at Harlequins. Return2Play’s philosophy is that by managing risk we can ensure the huge benefits of rugby can continue to be enjoyed.

You can contact him at sam.barke@melioramedicalgroup.co.uk and visit their website: www.Return2Play.org.uk


Transcript

The Coaching Knife with Sam Barke

Speaker: Dan 

Hello and welcome to the Coaching Knife where we cut to the root of the matter. In this episode we speak to Sam Barke, sports doctor and head of sports medicine at Meliora Medical Group and return to play. Focusing on the myths surrounding concussion, we’re going to cut to the root on how we deal with head injuries. Sam, are you ready for the knife?

Speaker: Sam Barke 

Very ready. Thank you Dan.

Speaker: Dan 

Good. Great, how can you tell if someone has concussion?

Speaker: Sam Barke 

Pretty easily once you accept that the risks of missing a concussion are too high and that there’s no perfect test. But if someone has hit their head or their head is shaking around, and then they behave differently or feel differently, then you can be reasonably confident that their brain is unhappy and that they’ve sustained a concussion.

Speaker: Dan 

So how can you tell when you’re looking? You’re an expert?

Speaker: Sam Barke 

Well, I claim that I have no extra special skills compared to anyone else in the population, I just perhaps have a lower threshold and more confidence in making decisions than other people, and often people are very surprised at how quickly I make a decision particularly in the schoolboy game, that someone might have a concussion, because it really should be as simple as what I just said. Has been an incident that’s caused concern? And then is that player displaying any signs or any symptoms that that match with that concern?

Speaker: Dan 

So generally, the most obvious is when somebody smashes their head into somebody else. I mean, I don’t think anyone would argue that there is reason to take that as a situation. Can you give me some other examples where often people miss them?

Speaker: Sam Barke 

So concussion is really a whiplash injury rather than a direct blow injury. So if you hold someone’s head still and smack it, it would almost be impossible for them to have a concussion because there’s no acceleration, deceleration or rotational forces going through their brain. So the most common thing that people don’t realize is that you don’t need to hit your head to have a concussion and actually, in children, a whiplash type injury, so a non-direct blow is much more common, because they’re weaker neck muscles and bigger heads compared to their bodies. So if people are only ever looking for a direct blow to the head, then they’re probably missing quite a lot of concussions.

Speaker: Dan 

So give me some examples of where we should be watching out. It sounds like we should be watching the game so sharply that we actually don’t watch rugby, which is watch for whiplash. I mean, that might be the conclusion that we come to.

Speaker: Sam Barke 

I think that the first thing to say is that it would almost be impossible to see everything because sometimes these injuries are subtle, and sometimes you don’t realize something’s happened until after the game and if a player is honest about how they’ve been and tell you that they don’t feel well. So you know, because there’s no perfect test, because you can’t see everything and you can’t see everything, there’s something on the bottom of the rack or whatever, you can’t always see, we’re always going to have to accept that we may miss some of the incidents. But vigilance is absolutely key. And that’s where knowing your players is important. If people aren’t performing the way they should, or doing the things they should, then you should have a high suspicion that something might have happened. But yeah, looking at those heavy blows, obviously and perhaps the ones that are more likely missed are the sort of the close contact, close quarters battles where you have repeated, sort of lower level blows off again and again and again and keeping an eye on players and seeing how they behave after that is very important.

Speaker: Dan 

So getting a concussion happen after say two or three of these things. So the first one you might miss, but the second one exacerbates it?

Speaker: Sam Barke 

We think so. And that’s I suppose another thing to say on this is that the evidence is still emerging, the science is rapidly evolving in this area and lots and lots of research being done particularly on this sort of less, the lower level forces that they’re involved in. We started to talk a lot about what we call sub-concussions. So smaller incidents that don’t necessarily immediately produce symptoms that we think have an accumulative load in causing problems over time, whether thats short term in terms of people starting display symptoms after the second, third, fourth hit whatever it might be, or whether the problem is more long term that is still emerging, that science. But yes, we do think that there can be an incident of a bit of a straw that broke the camel’s back type situation where you’ve had lots of heavy hits and people will say, Well, I didn’t notice anything significant, but they certainly had a really heavy game and then there are signs and symptoms that display after. So yes, we’re starting to believe it doesn’t have to be just that big of a one off hit that causes problems, but it can be a cumulative load of what seemed to be relatively minor hits.

Speaker: Dan 

So you said after heavy games. So often, I’ve been involved with teams where we’ve had a very heavy game and the players come off and they’re absolutely shattered. Strikes me that you’d want to check on all the players for concussion, not just say, just wander around, because these people are obviously on their knees after making maybe eight, nine tackles on average each, perhaps at the end of the game, when they’re tired, they’re more susceptible to these things.

Speaker: Sam Barke 

And this is where real life practice is in conflict with this simplicity that I tried to describe at the beginning because the big issue that we faced with diagnosing concussion in the absence of a specific test is that the signs and symptoms we look out for, a lot of those are very what we call nonspecific, they can be caused by loads of things. The obvious things like being knocked out, you know, very clear that the concussion has happened, but actually very, very rare, particularly in children and adolescents, and being spaced out and days. They’re all things we associate. But yeah, having a headache, feeling dizzy, feeling a bit sick. And when I went out and tried to play game of rugby now I can be pretty certain I’d feel like that afterwards, irrelevant of whether I took any big hits.

I think that the biggest thing that perhaps we failed to do, over the last few years is really engaged with the players and by players, I don’t mean adult professional players who should be bearing age but children, there’s always a bit of protecting them from the knowledge of some of these areas. But they should be aware of the signs and tips to look out for and when to put their hand up and say actually, I don’t feel great, this isn’t right for me, because that’s the big thing, is this right for you? If someone says to me, I feel like that after every game, you know, that’s how I feel after playing a rugby, I feel tired, I feel a bit sick, I have a headache for a bit but once I’ve had some more water, I feel better and that’s consistent with how they feel, that’s very different than someone saying, after that particular match, I felt horrendous, I had a really bad headache, I felt sick or whatever it might be.

So engaging with the players, letting them know that they should raise their hands if they don’t feel where things were different so they got concerns, and not that is a they’re in a blanket, you’ve got concussion because of course there are consequences but that means that they seek the right medical attention and empowering those players to make their calls. I think it’s really important.

Speaker: Dan 

Okay, so there’s two things which jump out of that. Well, the first one is that some 12-year-olds will be almost seeking attention to say they’ve got concussion because that gives them a bit a bit of light on what they’re doing. How do you help yourself and them make more informed decisions without them not understanding what they’re trying to say? Because I’m not saying that they’re trying to lie or they’re trying to do this, but they may find it difficult to understand what’s going on. So as an adult, how do we help them and ourselves through that in a sensible way?

Speaker: Sam Barke 

I think by being open and explaining what we mean by concussion, and what the consequences are. So, when we talk about concussion, we’re talking about a brain injury, that’s clearly important. The brain is obviously very, very important. And I think, kids understanding that crying wolf, you know, trying to get out of things by using that is just not a good idea. And also enforcing other consequences of that because it shouldn’t be a punishment. But if you’re really following guidance around managing concussions to the letter, those kids shouldn’t be running around the playground, it’s not just you’re off rugby, because you don’t want to be in the west in the cold and you don’t like the contact element, there are other consequences to saying that. You will always have situations where injury like this, where there is not a specific test that people can abuse that. We’ve seen that in professional sport right, with HIA incidents where there’s been abused and undoubtedly, we have kids that come through my clinics where they are putting it on. And I always talk you know, you get gut instinct sometimes about those type of cases and I always talk about the importance of honesty and why this sort of crying wolf isn’t a good idea and the consequences of it, but always say look, if you’re saying, I believe you. It’s not my job as a doctor to call you liar, just explaining the consequences and the reason why it’s important. But I always say that the risks of going too far or the way of presuming everyone’s putting it on and therefore putting people back to play when they might have concussion, far, far outweigh the negatives of keeping a kid off sport when they don’t need to be. So at the moment, in the absence of that special test, we will always err on the side of caution and have to believe what a kid is saying.

Speaker: Dan 

So after you’ve decided with the player that they have shown symptoms of concussion, that doesn’t mean that you sign them off, someone else, not when you the coach don’t sign them off, what should they do next which gives a sensible way of approaching this rather than sort of panicking and rushing off to A&E? Which maybe we should.

Speaker: Sam Barke 

Yeah, so that’s why I suppose where it becomes really difficult in terms of access to medical care. So if you believe a player might have had a concussion, you have a suspicion, so that’s what we say coaches should have a suspicion of a concussion, they’re not making a diagnosis, then that player should be removed from play, obviously removed from potential harm’s way because the bigger risks from concussion don’t come from initial injury necessarily, they come from taking further knocks to the head. So removing them from danger, they should not be returned to play until they have been seen by a medical professional and even then, should they be returned to play the same day actually in amateur sport. But they should they should be assessed by a medical professional, whether that be a physio school nurse or a doctor, but someone that hopefully has done some education and training around the injury and understands it, which perhaps is a whole separate thread of the difficulties of that and the lack of knowledge in the medical community and the difficulty that can cause. So yes, you should be seeking medical care to assess the injury and to make a diagnosis.

Having said that, an acknowledgment of what I just said about the lack of knowledge among medics or they’re hopefully improving, the RFU guidance is very clear that if a coach believes there are clear signs and symptoms of concussion, that player should be managed as a concussion, irrelevant of what a medic says because unfortunately, there are situations where it is very obvious there’s been a concussion, and someone goes to their GP or goes to A&E and they’re given outdated advice about the measure of that injury. So, for example, oh just have a couple of days off, and then it’ll be fine to get back, which obviously is very difficult for non-medics to deal with. You’re a school coach and well, the doctor said I can play, why aren’t you letting me play? But an acknowledgment that the RFU guidance is now very clear that the coach should still be managing that as a concussion.

Speaker: Dan 

So we’re going to move on to managing the concussion. Something you’ve said which I think is very important for us to just delve into is that when you’ve been diagnosed with concussion, you are not just off rugby, you’re off running around as well.

Speaker: Sam Barke 

Yeah, exactly. So I think understanding what’s going on inside the brain is important, but also, I think it helps explain it anyway. So when we’ve had a concussion, that brain is shaken around, that a rapid fire unravel the nerves, almost an electrical storm, and then there’s leaking of certain chemicals out of the nerves. This is a very basic level, I hope there’s no neuropathologist listening, they’re going to pick me up on it. But what in effect is you get a plummeting of the energy levels in the brain, because all those nerves need to be reset so then the brain needs lots of energy to try and do that and get those nerves working again. And while that process is going on, we have symptoms that suggested that the brain isn’t working very well.

Now, if we were to carry on as normal and by that I mean sort of immediately normal life, rushing around like all of us do, and kids do at school, just not without playing sport, but then if we add in sport to that, where our energy starts to go to our muscles, rather than to our brain, we know that that slows the curve of recovery, and means the brain is vulnerable for a lot longer. So yes, it’s not just about staying away from rugby, it’s about staying away really from exercise, or exercise for finesses sake because we want all the energy gains the brain to fix it rather than to other places.

Now, where we get into some confusion there is well at what point can you start progressing into exercise? And there’s lots and lots of emerging research, some suggesting that actually, you’re better starting some exercise earlier, but staying away from contact for a lot longer than we do currently, and vice versa and that’s where at the moment, we’re in this slightly sort of area where knowledge is continuing progressing and obviously, we need to stay as safe as possible, we don’t want to suddenly go rogue with one bit of research comes out and we change the way we do things. But undoubtedly things will evolve with time in terms of the way we manage the injury.

Speaker: Dan 

Are some players more susceptible to concussion and others?

Speaker: Sam Barke 

Almost certainly, but it depends what we mean by concussion. So concussion really is when there has been a brain injury that displays symptoms. So that’s where it starts to get a bit complicated and where probably that sub-concussive picture comes into play, because I could apply exactly the same force to my head and your head or someone up at harder than my head or somebody with both our heads in exactly the same way, and it will be done allow in exactly the same way and we would therefore presume that the same forces have gone through our brain and that would have caused the same damage to us. But we could have wildly different symptoms. In fact one of us might not have symptoms at all but we know the same forces have gone through our brains and therefore presumably, the same damage has happened. So rather than saying people are more susceptible to concussions, perhaps it’s better to say some people are more susceptible to symptoms. And I think people like you, coaches that have been around kids and rugby a long time know that there are some kids that and adults that seem to have a very low threshold after knocks to have symptoms. And there’s some, you thin how? You know, the warrior types that we usually go wow, but now we go, maybe actually they’re putting themselves through a lot of harm, because we just never knew they were getting injured.

So there are people that there are more symptoms, and actually in some ways now with looking at that going, well, actually maybe these are the people that we’re able to keep you safe because at least we know when something’s happened to them, and therefore we can treat them appropriately. But those players where we have no idea, they’re going on and on and on and kept taking more and more knocks to the head and we just never know about it, we’re never allowing them to have the rest and keeping them away from further injury while their brain still recovering. And that’s probably where that sub-concussive picture is coming into play. You know, some of the players that we’re looking at now in terms of the legal case against the RV, the Steve Thompson’s, the Alex Spotters, you know, actually didn’t have that many clear concussive episodes across their careers, but took a hell of a lot of hits to the heads over their careers day in day out in that era of professionalism. And actually, perhaps, that’s the big problem is that their brain had such a high threshold to have symptoms that no one ever knew what was going on and now they’ve run into long term problems. Again, all very much still emerging area, but definitely there are some people that seem to have symptoms come on very easily and some people that don’t.

Speaker: Dan 

There’s potentially a danger that we think that concussion only happens in rugby. Where does rugby sort of sit in the concussion League?

Speaker: Sam Barke 

Pretty high up. As you know, I’m a massive, massive rugby fun, rugby man and I think that we need to acknowledge that that concussion isn’t only rugby’s problem, and it’s not even a sporting injury. Concussion happens everywhere. Some old research showed that kids going through A&E with head injuries are more likely to sustain those outside of sport than in sports. There’s lots of confounding factors in there that that perhaps the ones happened in sport didn’t present to A&E but this injury happens all over the place all the time and the data that we see through returns play, we’ve seen almost 4000 concussion appointments so far this year since September, and consistently over the years, we’ve seen about 20% of our injuries being non-sporting concussions. Our data of course is skewed because we work with mainly big Rugby School so you’re going to see the rugby injuries come through. But even in those rugby schools, you see plenty coming through from football, from hockey from all sorts. We saw last year, concussions across 18 different sports. So pretty much every sport you play can carry a risk of concussion, because if normal life carries a risk of concussion, a sport will carry a risk of concussion. But it would be foolish to suggest rugby doesn’t carry a higher risk than other sports. It’s a contact sport, it’s going to carry those risks and it would be almost impossible to eliminate those risks entirely but we of course have to make sensible steps to reduce it as much as possible but also to put the measures in place to make sure when we think the injuries have happened, that we’re reducing risk by providing good care, because that’s the big thing with concussions, as I’ve said earlier is that, of course we don’t want it to happen but the risks are significantly mitigated by managing the injury well, whereas if we don’t manage it, well, a lot worse harm can be caused.

Speaker: Dan 

So in conclusion, in a sense, is that we should all become more aware about concussion not just because we are involved in rugby.

Speaker: Sam Barke 

Absolutely, yeah. I’ve been saying for a while it’s a public health issue, it’s not a rugby issue. And there are most do that there’s now a government group, and they are actually focused on sport more but I think what will come out of it and certainly not focused on rugby alone, but will come out and is that actually just general better knowledge is required, certainly in the medical world, but just across the population in general because I’ve seen cases lots where kids have had very clear concussions outside of sport, and even in schools where they have a very good sort of rugby policy on concussion that kids be allowed to carry on because no one’s really linked the two but the injury that isn’t treated differently because it didn’t happen on a rugby field, it still needs to. You don’t treat a broken arm that happened in rugby different to a broken arm that happened in the playground. It’s the same concussion.

Speaker: Dan 

Well, that’s a great analogy to finish off. Okay, so Sam is a sports doctor at a number of rugby player schools. He is match doctor at Harlequins. He returned to play philosophy is by managing risk we can ensure the huge benefits of rugby can continue to be enjoyed. You can contact him at Sam.barke. That’s bark with an E @melioramedicalgroup.co.uk. The link will be in the shownotes and visit their website at return2play.org.uk

We’re going to finish off with some quickfire questions. Number one Sam your favorite question? How old are you?

Speaker: Sam Barke 

I’m 36.

Speaker: Dan  

  1. You don’t look a day over 38. Right. What book is besides your bedside?

Speaker: Sam Barke 

Well, nothing is the honest answer. There’s a book on my desk that I’ve been meaning to open for the last three months which is the mental impact of sports injury which actually has big crossovers with concussion because there’s definite anxiety response to that but it hasn’t been opened yet.

Speaker: Dan 

It’s okay. Which coach or teacher are you loving at the moment?

Speaker: Sam Barke 

To be honest, I have huge, huge respect for pretty much every manager in charge of rugby or director of sport at the schools we work with. I think they do an incredible job and when you sit behind the scenes as you are being is when you realize just how much work goes into it and their passion for supporting kids not just in sport, but in terms of developing into good young adults so, everyone,

Speaker: Dan 

Everyone, good. Right. Which sport subject or team would you love to be coaching at the moment?

Speaker: Sam Barke 

I would be a useless coach Dan. I wouldn’t want to and they wouldn’t want me to.

Speaker: Dan 

Probably doing yourself a disservice. Who’s inspired you the most then?

Speaker: Sam Barke 

I think in terms of the head injury and concussion side of things, Peter Robinson, who’s son Ben Robinson sadly died in 2012 in tragic circumstances, who I just think has tirelessly and just tirelessly campaigned for a better awareness around concussion and seems to be making good progress. So a lot of respect for him.

Speaker: Dan 

And though it’s not that long ago, what would you tell your 20-year-old self to do more of?

Speaker: Sam Barke 

Do what you enjoy, follow the path you wants to follow. I haven’t followed a standard medical career path. I’ve merged passion, sports and medicine and it seems to work quite well.

Speaker: Dan 

Great. Excellent. Sam, thanks very much for your time, really enjoyed that and thanks very much for listening to the Coaching Knife.

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