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What is football's concussion protocol? Symptoms, rules & health risks to head injuries

7:46 PM GMT+4 17/04/2019
Loris Karius Liverpool Champions League final
Concern is growing in the medical world over player wellbeing but while the FA has taken measures to improve matters, FIFA has not truly followed

Awareness is growing over the seriousness of head injuries in football, with players, medical staff and managers particularly wary of the dangers of concussions.

When it was once commonplace to see players battle on after head collisions, with the long-term consequences of doing so now better understood and fully in the public eye, there is a trend away from this.

However, there are many commentators who believe that football has to evolve further in its diagnoses and treatment of such problems.

But what is a concussion, what causes it and how can it be treated? Crucially, what are current protocols to do with the injury and where do experts believe they fall short? Goal takes a look…

What is a concussion?

According to the NHS, a concussion is a “temporary injury to the brain caused by a bump, blow or jolt to the head”.

In a footballing context, this is likely to be caused by a collision, such as a clash of heads, a flailing elbow or perhaps a particularly heavy and unfortunate fall.

It occurs when the brain is caused to slide back and forth forcefully against the inner walls of the skull. The brain is generally protected from everyday collisions by cerebrospinal fluid inside the head but a sudden acceleration can cause a brain injury, resulting in the symptoms of a concussion.

What are the symptoms of a concussion?

There are a number of different symptoms that typify such an injury, although they are not always apparent immediately. Typically they appear within a few minutes but it can be days afterwards before they are apparent.

The NHS website reports that the symptoms can include:

  • a headache that doesn't go away or isn't relieved with painkillers
  • dizziness
  • feeling sick or vomiting
  • feeling stunned, dazed or confused
  • memory loss – you may not remember what happened before or after the injury
  • clumsiness or trouble with balance
  • unusual behaviour – you may become irritated easily or have sudden mood swings
  • changes in your vision – such as blurred vision, double vision or "seeing stars"
  • being knocked out or struggling to stay awake

Critically, it is possible to have concussion and not be aware of it.

Additionally, the British Journal of Sports Medicine (BJSM) adds: “Making an accurate diagnosis is both important and challenging because of concussion’s varied and sometimes subtle presentation. Symptoms overlap with other musculoskeletal, psychological and neurological diagnoses and a lack of definitive investigations or diagnostic markers raises challenges.”

Although Liverpool were mocked for claiming goalkeeper Lorus Karius had suffered a concussion in the wake of his two grave mistakes in the Champions League final of 2018-19, such errors are consistent with the indicators listed above.

What are the health risks of concussions?

Most people fully recover after suffering a concussion but at its worst, it can lead to death due to bleeding in the brain. This is why people who suffer significant head trauma should have their condition monitored closely in the hours and days after injury.

Additionally, and this is particularly pertinent to the debate in a footballing context, second impact syndrome can also be fatal. This is when a second concussion is suffered before the effects of a first have been resolved, which can result in rapid and usually fatal brain swelling.

As such, it is critical that sportsmen do not return to playing if they are experiencing signs of a first injury.

Moreover, there is growing research into the cumulative effects of multiple brain injuries, with a suggestion that people who suffer several traumatic instances are at risk of lasting or progressive impairment that can limit their lives. These issues could come in the form of psychiatric disorders and loss of long-term memory, while three or more concussions leads to a fivefold increased chance of developing Alzheimer’s, according to a 2007 study in the journal Neurosurgery.

Chronic traumatic encephalopathy or CTE is a similar issue to Alzheimer’s and was first discovered in boxers who were said to be ‘punch drunk’. It is thought it can be the result of multiple less severe blows to the head, with the repeated heading of a football coming into this category.

FIFA argues: “The current evidence for a correlation between heading frequency and neurocognitive deficits is weak and probably biased by inaccurate reports of heading frequency.”

Nevertheless, CTE can lead to cognitive and physical handicaps, speech and memory problems, slowed mental processing, tremor, depression and inappropriate behaviour.

Generally speaking, the short-term health risks to concussions are not as serious, though headaches, dizziness and thinking difficulties can be experienced weeks and even months after the initial injury.

What is the concussion protocol in football?

FIFA instructs via its medical diploma portal that “the primary focus of the initial on-pitch assessment of a player who has sustained a head trauma during training or match play is to screen the player for concussion or a more severe head or cervical spine injury”.

The initial diagnoses is conducted by taking account of symptoms reported by the player, visible signs and any clinical suspicion by medical staff.

If a player suffers what are deemed as “mandatory signs of concussion” (i.e. loss of consciousness, lying motionless for more than five seconds, confusion/disorientation amnesia, vacant look, incoordination, tonic posturing, impact seizure or ataxia), they must be removed from the field of play.

While some sports organisations, e.g. the NFL, demand a player is removed once they’ve shown a mandatory sign, this is not the case in FIFA-sanctioned competition.

However, the FA has instructed its members that if there is a loss of consciousness on the field of play, a player must be removed and not allowed to return. Video replays can be used to clarify events, if available.

If there is any suspicion at all of a concussion, players are supposed to leave the pitch and not return. Furthermore, if they are deemed fit to go home, they are not allowed to drive or be left alone in case of a deterioration of their condition.

Meanwhile, FIFA has guidelines which are vague and based “on the medical freedom of the team doctor”, according to the chairman of FIFA’s medical committee Michel D’Hooghe, who was speaking following a controversial incident at World Cup 2018 when Nordin Amrabat started a match against Portugal five days after suffering a concussion against Iran.

“FIFA has no authority over this – we produce the guidelines but it is the team doctors who make the decision,” he subsequently added.

FIFA does, however, have Return to Play (RTP) criteria that advise that six days is the minimum required to overcome the problem, but this is by no means set in stone and there is no punishment for flouting these rules as Morocco did in Russia.

Herve Renard, coach of the North Africans, said after that incident: “He’s a warrior, he wanted to play. I’m not a doctor. Medical reports are read by competent people. I’m not competent in medical matters. They take their own responsibilities and so does the player.”

Indeed, the player had admitted: “From the first minute, until I woke up in the hospital, five or six hours, gone. Totally gone. When you think about it, it is a little bit scary.”

What can be improved to treat concussions in football?

Clearly, there are shortcomings in the laws to protect players from concussions, although there is little indication that change will be swift.

Indeed, in the wake of the Amrabat incident, D’Hooghe argued it is vital to give team medics the freedom to make the call as they are aware of the medical histories and behaviours of their players.

“Otherwise, you would have to work with absolutely neutral doctors, and that is also not the ideal situation. On the one hand, we do our best to give the best possible advice. On the other hand, we want to respect the fact that the doctor of the team has the sole responsibility for his players,” he said.

This is a stance that FifPro is not happy with.

“It’s important that FIFA takes a leadership role to enforce the world’s gold standard in concussion management,” the player’s union argued at the time.

“While team doctors have a critical role to play, it cannot be the case that they are left to make mistakes of this nature, putting the player at risk, without any consequences. FIFA has the responsibility … to intervene in order to ensure the players are protected.”

The Amrabat incident was by no means isolated; Ragnar Sigurdsson for Iceland and Blaise Matuidi for France in the semi-finals against Belgium were also treated in a less-than-exemplary manner.

Could safety equipment, like the helmet worn by Arsenal goalkeeper Petr Cech, be a solution?

FIFA suggests not.

“Despite the claims of many manufacturers, mouthguards and headgear do not prevent concussion. Mouthguards have, however, been shown to significantly reduce the risk of dental injuries and facial and skull fractures,” it reports, though it also notes that they are useful when a player returns to the game following a skull fracture, as the Czech Republic international did.

SyncThink’s EYE-SYNC could be one solution. It is a device that uses virtual reality to conduct an eye movement assessment on a person who may have suffered a concussive blow, taking just 60 seconds to accurately diagnose any issue.

Crucially, it also offers an objective measure as to a player’s wellbeing, whereas currently everything is done in a subjective manner.

“I’ve spoken to 30 or so athletes that have used this technology on the sideline in an NFL game or a soccer game, and they all spoke very highly of it,” Taylor Twellman, a former USA international and an analyst for ESPN, who had his career cut short due to repeated concussive blows, explained to Goal.

“When you look at the sport of soccer, which exponentially can change and give us data, it can only move the meter on how to really rehabilitate head injuries.

“Ultimately, that’s where the conversation needs to go. Often, we talk about prevention but concussions aren’t going anywhere. It’s what are you going to do when you get one. How do you treat it?

“I honestly believe that this EYE-SYNC technology is going to help us get to that point a little bit faster than the way we are going right now.”

Twellman believes that greater flexibility must be given to coaches over head injuries, too.

“For me the biggest issue in football is that you only have three subs,” he said. “Until FIFA really addresses it and actually is proactive about the situation you are going to have to find a way to help all these medical professionals find answers.”

The BJM agrees: “In sports that do not have a replacement policy (eg, football/soccer), there may be additional challenges contributing to increased pressure on athletes to under-report symptoms.”

It argues that medics are under severe time constraints and says: “Sports in which the laws do not facilitate the recommended 10 min off-field assessment should look to policymakers to make law changes rather than expecting clinicians to compromise the concussion evaluation and, possibly, athlete safety.”

With FIFA worryingly slow to advance their protocols, Twellman is concerned for the health of players around the globe.

“It’s going to take someone dying on the field for FIFA to actually do something,” he says. “Quite honestly, I’m not sure they’d even do something on that.

“The protocol is one thing. But the paper it’s written on is worth more than the protocol if you do nothing about that protocol.

“That is the biggest discussion that goes on in the world of soccer. If you’re finding instances all the time on the protocol not being followed – especially in the World Cup tournament – then what’s the point?”

All these issues stem back to an archaic attitude towards the severity of concussions and until that changes, players will continue to receive less than gold-standard treatment.