Concussion assessment protocols were not followed in more than 60% of plays in which players sustained head collisions in the 2014 soccer World Cup, a new study shows.
This finding is “concerning,” lead author, Michael D. Cusimano, MD, PhD, from St. Michael’s Hospital, Toronto, Ontario, Canada, told Medscape Medical News.
“Assessment of any condition, including concussion, with subsequent diagnosis is the cornerstone of management, including secondary prevention,” he explained. “The fact that these players are not being assessed when sustaining collisions that are suspicious for inducing concussion means that diagnoses are not being made, which means, by definition, that treatment and prevention are delayed.”
“These delays could have consequences, such as returning a brain-injured player to the risk of secondary injury and second impact syndrome, which can have disabling or fatal consequences,” Dr Cusimano said.
The study was published June 27 in JAMA.
The consensus statement from the 2012 and 2016 International Conference on Concussion in Sport, adopted by Federation Internationale de Football Association (FIFA) states that players showing any feature of concussion should be immediately withdrawn from play and assessed by sideline healthcare personnel.
To assess compliance with this recommendation, Dr Cusimano and colleagues examined the incidence, characteristics, and assessment of head collisions during the 2014 FIFA World Cup.
Trained reviewers identified head collisions through observation of video footage of all 64 matches of the tournament. A head collision was defined as any event involving head contact in which a player did not continue playing immediately afterward. Observable effects of the collision on the player, such as slowness getting up, disorientation, obvious disequilibrium, unconsciousness, seizure-like movements, and head clutching, were viewed as potential signs of concussion.
During the 64 games, 61 players had 81 head collisions in 72 separate events. Healthcare personnel assessed the player in 12 cases (15%). Forty-five players (56%) were assessed by another player, referee, or personnel on the field. Twenty-one players (26%) received no assessment.
Of the 67 occasions in which players manifested two or more concussion signs, 16% received no assessment and returned to play immediately. Among players with three or more concussion signs, 86% returned to play during the same game after being assessed for an average of only 84 seconds.
“An organization like FIFA faces a great challenge but also a great opportunity to reshape the face of concussion by behaving in an exemplary fashion which implements all the recommendations contained in the consensus statement before the next World Cup in a year,” Dr Cusimano said.
“This is a good study that shows that FIFA could do better and it gives them an opportunity to make improvements,” Joseph Herrera, DO, system chair, Department of Rehabilitation Medicine, Mount Sinai Health System, New York, who wasn’t involved in the study, told Medscape Medical News.
FIFA did not respond to a request for comment.
Happening at All Levels of Sport
Dr Cusimano believes a lack of adherence to concussion protocols is occurring “at all levels of soccer and in other sports. Furthermore, our concern is that these practices (ie, the lack of adherence to recommendations) mute efforts at prevention and treatment of concussion caused by all mechanisms, not just those incurred during sports,” he said.
Michael Makdissi, MBBS, from the Melbourne Brain Centre in Australia, has studied the reliability and validity of video analysis for the assessment of clinical signs of concussion and reviewed the current study for Medscape Medical News.
“From a technical point of view,” he said, “it is important to understand that not all signs observable on video are equivalent. For example, our research demonstrated that ‘slow to get up’ is a common sign but has a low specificity when compared to a clinical diagnosis of concussion. Similarly, ‘clutching of the head’ has a low sensitivity and moderate specificity.”
This new study does suggest that “soccer has some challenges in the area of on-field recognition of concussion,” Dr Makdissi said. “I don’t think that ‘greater awareness’ of the guidelines is necessary (especially at the professional/elite level). But they do need to look at pragmatic ways to help improve the identification of concussion on the field (this will probably mean a combination of technology and possible rule changes).”
“At lower levels of sport, everyone has a role (players, coaches, trainers, referees, et cetera) to help identify suspected concussion, remove the player from the game (or training) and have them appropriately assessed,” Dr Makdissi said.
Dr Herrera noted that although concussion protocols are now in place, “we know that there is going to be a growing process as far as how we improve our monitoring to make sure that our athletes are well taken care of. With the increasing concern about concussions, what we have seen over the last few years now is that not only are medical staff more aware of concussion but so are coaches and players, which is fantastic.”
The authors, Dr Herrera, and Dr Makdissi have disclosed no relevant financial relationships.
JAMA. 2017;317:2548-2549. Abstract
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