Éanna Falvey – a wide-ranging Q&A with World Rugby’s chief medical officer

Dr Éanna Falvey became chief medical officer of World Rugby, the game’s global governing body, in January. The appointment follows his extensive experience as team doctor for Munster, Ireland and the British & Irish Lions.

Falvey didn’t play rugby, having grown up in GAA and hurling country in East Cork, but was an international amateur boxer. He has worked at elite level across a wide range of sports.

He has a private sports medicine practice in Cork and lectures to Masters students, predominantly physiotherapists, at University College Cork.

In an interview published in our September 2020 edition, he spoke to Rugby World about everything from Covid to concussion. The interview took place before the recent second wave of coronavirus cases and shutting down of spectator access to our sport, with the disturbing financial ramifications that is set to bring. But Falvey’s answers remain highly instructive…

Rugby World How do you see your job at World Rugby?

Éanna Falvey To make the game as safe as possible for players. But not just to focus on the negative side of injury but also on the positives. Rugby brings an awful lot to the table: team participation, a sense of community, the benefits of physical activity.

I’ve been lucky to take over from Dr Martin Raftery, who has done a phenomenal job in revolutionising some of the medical standards. Rugby was one of the first sports to implement an off-field assessment for concussion.

Previously we had about 26 seconds to assess a (potential) concussion; getting somebody off the pitch and having initially five minutes and then ten to make that assessment significantly improved how well we could make a decision about a player.

At the 2011 World Cup, more than half the players who had a concussion stayed on the pitch and that’s down at below 8% now.

RW Can the concussion process be improved?

EF We want to do better and spend an awful lot of time researching the area. We’ve got five published papers in press looking at how to improve the HIA (head injury assessment) process. How we can improve the tool, the baseline measures that doctors take, how well doctors apply their clinical judgment in making a diagnosis.

We’ve based our tool on the SCAT test (Sports Concussion Assessment Tool). But over the years we’ve trialled adding visual tests with the RFU, a reaction time test in Super Rugby, the full SCAT in the Pro14. Dr Gordon Fuller, an independent epidemiological expert, is writing up those papers at the moment. The better the baseline, the better the outcome.

For example, your baseline might include “I regularly get neck pain”. In a match, if you’re having an HIA and the doctor asks “Are you having any neck pain?” and you say yes, it might not count towards whether you’ve got a concussion if it was regular pain.

But rather than say “Okay, you’ve got neck pain”, we’ve asked doctors to say “Why have you got neck pain? Is this something we need to look into?” That’s not when we’re looking into a concussion but in a pre-season setting. We are delving more into the baseline.

We’re taking a 360-degree approach to how we manage concussion. And many other areas: injury rates post competition, preventable injuries such as soft-tissue injuries, hamstring injuries, tendon injuries, seeing if we can improve the risk factors.

RW Is there a problem with players being able to memorise answers for an HIA?

EF Until last year we were using a five-word list. So almost every player will tell you elbow, apple, carpet, saddle, bubble. The first five words on the list. Generally, when people did it on paper, they would have read the first list; there are six lists but they read the first one.

Now all our concussion assessments are done on an online tool that scrambles the words, and each list is ten words, which is much harder. So we’ve significantly strengthened the test.

RW How important has the High Tackle Sanction Framework been in reducing concussion?

EF We’ve just published an article in the British Journal of Sports Medicine about the Rugby World Cup (2019), which saw a significant decrease in the amount of concussions. Because the numbers are small, it’s difficult to know whether this will be borne out in time.

The World Cup is a fixed environment in which we can implement measures easily with teams. Unfortunately, when something spreads around the world, the implementation isn’t always as en pointe as it might be at the World Cup. So we’re gathering the data as we speak.

We had a player welfare meeting in March in Paris. We showed that if a tackle is above the shoulder, the player being tackled is far more likely to have an HIA, but the player tackling is four times more likely to have an assessment as well. That’s why we’re zoning in on high tackles.

RW French community rugby has trialled a ban on tackling above the waist and injuries have reduced. Could that ever come into professional rugby?

EF It’s too early to say. We’re looking for a sweet spot of between the hips and the shoulders; that would be the safe tackle zone for us. If we bring a tackler to below the waist, that potentially raises problems where the ball-carrier knows what is going to happen; the tackler is dropping immediately. That could have a negative outcome. Contact between the thigh and the knee to the head is a concussion risk as well.

When you go above the sweet zone, it goes to four times the risk. But when you go below the sweet zone you’re at two-and-a-half times the risk. So it’s that in-between spot we’re after.

RW What are the main challenges for players returning to action after a long break?

EF The positions on the field have varying demands. Forwards require a good deal of strength training and conditioning, in addition to aerobic fitness. You’d imagine players would have done quite a bit of aerobic fitness (during the summer lockdown) because they could do that on their own. But many players didn’t have access to gym equipment and would have been unable to do the strength training they need.

So one of the most difficult things has been ensuring that players get an adequate lead-in back into professional rugby. A minimum of four weeks of sports-specific conditioning is required before getting back into activity.

And the more the better because there is precedent there. The NFL (in 2011) had a shortened pre-season after a dispute over collective bargaining. As a result they had a significant spike in soft-tissue injuries, like Achilles ruptures. So that’s something that S&C coaches around the world will be trying to prevent.

RW How about the impact of Covid-19?

EF When this all started, many of us felt we might get back to sport when Covid was suppressed or there was a vaccine. But we’re very much in the ‘dance’ phase, which is getting back into communal activity when there’s still community disease out there. We’re getting back to sport whilst living with Covid.

We must try to ensure we don’t get infections among players. But that will probably happen. There are probably going to be cases where a player goes to a coffee shop or supermarket, or a family member is exposed at home, and that player will bring it into the team.

Our primary concern is player welfare. At the moment we don’t necessarily know what Covid infection means for an athlete. So we’ve linked up with the IOC, who are heading a study of what happens to athletes after infection and how to return to activity as safely as possible.

RW Taking your example of a player who goes to a coffee shop and becomes infected. Will that be picked up by testing or just by observation?

EF That depends on the strategy employed by the union, the competition and the club. First and foremost, it will depend on what the public health and government authorities recommend. Below that unions and clubs decide what their players should do. But it all links back to public health policy. So if your country says if one person has been infected, everyone needs to do a PCR test (polymerase chain reaction) straightaway, then that’s what you’ll do.

You have two kinds of presentations. First, someone who is asymptomatic but is picked up in a PCR test by your club. How many people has that person been in contact with? If a team had done a full contact training session that day, at least half of the team might have been in direct contact with that player. So that type of contact is something we’re looking at trying to nail down with clubs and unions.

The second type is the person who hasn’t tested positive but feels unwell. In those situations, we would have measures in place to prevent them ever getting to the club. In other words, players are doing symptom testing at home every day before they come to the club.

RW If a player gets infected, will that lead to his team cancelling matches?

EF It may do. Symptoms don’t tend to develop until day four after you’re exposed. So if a player becomes unwell on a Wednesday and tests positive, they would probably have done a training session the day before, which means team-mates would have been in close contact, and those close contacts would need to be isolated and tested as well. So it may well be that if it happened on a Wednesday, the game that weekend would be postponed.

Teams will need to have a plan in place; they will have been in contact with their public health authority and agreed measures so that if the team picks up somebody with an infection they know how to respond. That’s going to vary around the world, depending on the disease prevalence in the community.

What is really heartening is that in the German Bundesliga and in the Premier League, despite there being cases there haven’t been any games cancelled (post resumption). As a sport we’ve been able to watch what football has done and to take our lead from that.

Related: Leicester v Castres cancelled due to Covid

RW People say the skin-to-skin contact in rugby is very high. Is the infection risk much higher than in other sports?

EF Skin to skin doesn’t mean anything. Covid-19 is transferred via me breathing your air – it’s respiratory droplets from your air that I breathe. It isn’t spread by sweat, or by me touching you, unless I touch part of your body that you’ve breathed on and then I touch my face with my hand. There is an element of there being a contact exposure to this but it’s much smaller than me breathing your air.

We’ve differentiated between me tackling you round the ankles and me tackling you face to face and us breathing each other’s air. The skin-to-skin contact is the same but in reality they’re entirely different.

We also know from Japan that the risk of contacting Covid-19 indoors is 19 times greater than it is outdoors. China documented 303 super-spreader clusters and only one of those 303 clusters was outdoors. So almost no one gets infected outdoors. The reason being that air blows away your breath and the exposure is low.

Where you are face to face with somebody for a set period, that changes your risk from being outdoors to indoors. We’ve done a lot of work on proximity. Even though there’s an offside line, (rugby) players are in proximity quite regularly. But we know that outdoors that risk of contact diseases is very, very low. So what we’re interested in is situations where the proximity makes the outdoor contact become indoor contact.

RW What about the scrum?

EF Even in a scrum, players are facing downwards so their breath goes down into the ground. And with wind those droplets are dispersed away very quickly. So a scrum isn’t anywhere near the risk that you would think. The highest risk in the scrum is when the teams are facing each other getting ready to engage, rather than when they’re actually scrummaging.

Which do you think is a higher risk – basketball, soccer or rugby? The answer is basketball because it’s indoors. It’s not one sport versus another, but what we’re trying to do is tease out the reality of the situation because for every one good chunk of information we get about Covid, we get five ones that are utterly useless.

So people are being told to exercise outside. And then you want teams to do as much of the work as they can separated and keep contact sessions to a minimum. Do them towards the end of the session with a day’s break afterwards. So it sounds unusual but you’re at a much higher risk of catching Covid-19 sitting for half an hour in a coffee shop than you are moving around outdoors and being involved in a team sport.

RW Do you have three key bits of advice for grass-roots clubs returning to action?

EF Yes, we had a fantastic meeting with a professor at Cambridge called David Spiegelhalter who’s done a lot of work around risk. His advice is that in a sports setting, the most dangerous place is a changing room. Because it’s indoors, players are having fun and shouting, and they’re in close proximity.

Related: When will rugby return in the UK and Ireland?

So number one: keep your changing room and showers closed in the short to medium term. Players should arrive ready to play and then go home and shower afterwards.

The second thing is that basic hygiene measures remain really important. Players should sanitise their hands before and after a session; when there’s a break in play they should sanitise; and they should not spit, not clear their nose, not remove their gumshield and pop it back in again. These types of measures that seem inconsequential will make a difference.

And number three would be that when a club is coming back into training, keep socially distanced for two weeks. Easing back into it gently is a good way to reintroduce people to the environment. Just like you would for pre-season training, you don’t come back and train hard the first day, you give yourself a week or two to get up to the speed of it.

RW The breakdown and tackle laws are being applied much more stringently now. How does the process for imposing new laws or directives work at World Rugby?

EF I can speak about the breakdown because I was at the initial meeting in Paris. There were elite coaches, active and retired players, medical and game administrators. There were two reasons for approaching this: the injury risk associated with certain behaviours at the breakdown, and the impact that was having on the game.

A player being struck in the side of the knee by a side entry was something that as a medical group we were very anxious to avoid. The other issue was where a jackler is contacted in the head by another player’s head or shoulder. Both issues were covered in the rules but weren’t necessarily being applied sufficiently.

What became obvious in the meeting was that the tools for managing this were there, but the language around it was a little more opaque than it should be. Richie Gray led the group, in conjunction with referees, because they’re the people who have the thankless job of trying to implement it. They tried to make it as reproducible and as simple as possible.

So our explanation from a medical perspective was these are the particular areas we’re concerned about, we would like them addressed. But also how you address them is one thing but the implementation of how you address them is probably more important.

RW Teams in the Gallagher Premiership have been playing matches four days apart. And there is a busy international programme this autumn. Does the heavy schedule concern you?

EF People are being forced to make decisions they wouldn’t normally make because of the strange circumstances we find ourselves in. There are obviously negatives to playing that many games close together. But having larger squads, such as those present in the Premiership, allows you to rotate players and look after them properly.

Of all the countries in the world, the RFU probably has the best track record for publishing information on injury rates and showing how well they look after their athletes.

In 20 years working in professional rugby I haven’t come across anybody who doesn’t give player welfare the regard they should. But even if a team or a coach wanted to disregard that, you don’t get the return on players in terms of performance if they’re exhausted.

The best coaches I’ve worked with, like Joe Schmidt, will say the next best guy at 100% is better than the best guy at 80%. So if a player has played three games on the bounce, they’re not going to be in good shape to play a fourth game on the bounce. That’s why in the Six Nations you’ve built in down weeks.

RW Rugby might be able to create a global calendar. Are you in favour of this?

EF 100%. From a player welfare perspective, anything we can do to align it to have similarity between the hemispheres would be a huge bonus.

If we refer back to the previous question, player welfare informs the quality of the games we see; so if you’re adding players who are exhausted, injured or not being looked after properly, you have a lesser product. Unless you build in the player welfare aspect to this, eventually you lose anyway. Players always want to play but they need built-in rest periods.

RW You’ve worked in lots of sports at elite level. How do you think rugby compares to other sports in terms of player welfare?

EF I’m loathe to look at sport versus sport as the context is different. Take Australian Rules football; I worked at Geelong, who played a 22-week season over 23 or 24 weeks. Players might play ten or 11 weeks at a go. This is a two-hour game where the on-ballers would cover between 17 and 22km in a game. So they had monstrous demands. They have acclimatised to that, they have trained up for that level.

Rugby players have become better conditioned since the advent of professionalism. The demands of the game are a lot higher, the ball in play time has gone up. So we need to up our game to match that.

Player welfare fits into the demands of the game. It also fits into an important juxtaposition with the spectacle of the game. Over ten years a lot of measures were implemented to make the game faster and more attractive. One downside to that is an increase in contacts and tackles. For me, watching from a player welfare perspective, I don’t want more tackles in the game, I want less. So we’re constantly moving between player welfare and spectacle.

We’ve been encouraged to see that the voice of the players is becoming stronger. In the last 12 months the International Rugby Players have employed Dr Sharron Flahive, who was the Waratahs doctor for 20 years and is a serious campaigner. We’ve been working closely with them to see what we can do better and how we can do it.

RW Eddie Jones is among many to have called for a reduction in the number of substitutes. Would that put a greater onus on endurance and so lighter players, making the game safer?

EF We’re undertaking a study to look at the impact of substitutions. So what does it mean when you bring on a full front row after 55 minutes, in terms of injury rate or the pace of the game? We’re looking at data from professional rugby in New Zealand, England, Wales, South Africa and Australia to answer these questions.

It may well be that if you have fewer substitutions, those players who stay on the pitch may become more injured later in the game. Does a person who comes on and is fresh cause injuries to other players? We don’t really know the answer to that and we’re looking. I can see both sides of the argument but these areas need to be based on facts rather than emotion.

RW Felipe Contepomi (a doctor and former Puma coaching at Leinster) said recently he thinks we aren’t catching everyone who cheats through doping. Do you agree?

EF I don’t think there are a lot of doping infringements at international level. I’ve worked in professional rugby since 2003. I never saw a player sweat when having a test. I’d argue that if players are considering cutting corners it would be to recover from injury and in countries with a well-developed medical programme I don’t think they need to resort to that. They realise that the benefits they will get are far, far outweighed by the risk of being caught.

There’s good testing in and out of competition. I think some of the questions would be around whether or not it happens in the community game and that’s far harder to police. We have schoolboys and junior level testing done quite a lot in some countries and not in others, and that’s probably an area that can be looked at.

RW What will Tackle Ready, World Rugby’s tackle education programme, do for the game?

EF The basics underpin everything we do in sport. One thing we’ve encountered in our work on concussion and tackle technique is an assumption that elite players know how to do these things properly, and it’s not always the case. Having the basics right is really what underpins the level of skill we see from New Zealand teams, from Australian teams as well.

We often focus on elite level because that will influence what people watching on TV will do. But this is the other way round. It’s an ambitious project that works from the bottom up – the grass roots. Start from the base and make sure that everybody learns to do things safely and correctly and then that travels with them through their career.

RW Finally, what has been your favourite moment in rugby?

EF 2006, in the Millennium Stadium. Munster were playing Biarritz in the Heineken Cup final. Trevor Halstead went over for a try and there was a noise in the stadium that wasn’t even cheering, I’ve never heard anything like it. It felt like the roof was going to come off. I’m from Munster and was working with Munster (as doctor, sitting with the subs); we’d had so many years of nearly getting there and that try brought an outpouring of emotion.

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