Concussion in sport

When it comes to concussion in sport, misguided notions of bravery have clashed with medical evidence. But the science is winning, says Craig Moore

Bert Trautmann’s heroics for Manchester City during the 1956 FA Cup Final have acquired legendary, almost mythical, status in football folklore.

Despite sustaining concussion and a broken neck during a collision with an opposing player, Trautmann continued to play as goalkeeper for the final 15 minutes of the game and helped his team to win the Cup. The fact that he had dislocated five vertebrae and risked further catastrophic, potentially fatal, injury by continuing to play was not identified until several days later. Trautmann was a German living and working in austere post-war Britain, adding to the mystique surrounding the story.

Bravery and selfless commitment to a cause are human qualities that we understandably admire. This admiration has, though, contributed significantly to a failure to identify the dangers of head injuries in sufficient time. Together with an ignorance of the significant risks associated with brain trauma, it has also created an inertia within certain sports, including football, which persisted for over 50 years following the Trautmann Cup Final.

For most of that period, a culture of passive acceptance of concussive injuries and their consequences existed amongst players, managers, coaches, medical staff , owners and governing bodies alike.

Increased awareness

As recently as November 2013, the Tottenham Hotspur goalkeeper, Hugo Lloris, was allowed to continue playing after sustaining a head injury following a collision with an opposing striker. Lloris

appeared to lose consciousness – although the club subsequently disputed this. He was attended by the club doctor and club physiotherapist on the pitch.

As Lloris was being led to the touchline he resisted and said that he wanted to carry on. Tottenham’s coach at the time, Andre Villas Boas, directed Lloris to return to his goal and to continue. The

Everton striker with whom he had collided had to be replaced as a result of the injury to his knee, which he sustained when it made contact with the head of Lloris.

Lloris was lauded as a hero but controversy soon ensued over the decision to allow him to continue to play, demonstrating at least an increased awareness of the risks associated with concussion. Although Tottenham claimed that tests carried out after the match showed that he had been fit to continue playing, FIFA’s chief medical officer was insistent that Lloris should have been withdrawn. Robust statements, critical of the decision to allow a player to continue playing after losing consciousness were also issued by the head injury charity, Headway, among others.

Setting out new rules

New guidelines and rules were introduced by the FA for the 2014/15 season for the management of concussion and head injuries in football. They followed a review by its medical committee, which was undertaken in 2013.

The key features of the guide include a requirement for all players to undergo pre-season baseline cognitive training to detect any risk that may exist through previous injury. The guide has also

radically changed pitch-side medical assistance. Always erring on the side of caution, players must be removed from the field of play and not be allowed to return, even if there is only a suspected

period of loss of consciousness. Where there is no doctor, players must be sent to A&E immediately, and never left alone or allowed to drive home.

In addition, neuropsychological testing should be carried out every 48 hours after the injury until return to play, and show a gradual return to baseline. Clinical assessment should be made

daily, with a minimum return to play period of six days.

Where there has been a head injury, but no loss of consciousness, an on-field or touchline assessment will take place using the Pocket Concussion Recognition Tool which should be a

standard item of any pitch-side medical kit.

FA Premier League Rules were also amended for the 2014/15 season to establish that the decision of the team doctor is final when assessing whether a player who has sustained a head injury

is, or is not, fit to continue playing or training.

Those developments drew on the recommendations that were made in Zurich at the fourth International Conference on Concussion in Sport in 2012, and published in 2013. A panel

of neurological experts defined concussion as “a complex pathophysiological process affecting the brain, induced by biomechanical forces.”

Difficulties

The chronic and long-term effects of concussion are still not fully understood. Repeated insults (like heading a football) are believed to be a major risk factor, and an early return to play has been

implicated in poorer outcomes.

The foremost difficulty is how to diagnose a concussive injury.

Indeed, criticism has been made of the definition of concussion as a brain injury within the Zurich guidelines. Its detractors are of the view that concussive syndrome does not have to involve the

brain. This, they argue, has led to a lack of diagnostic specificity,management strategies that are not evidence-based, and rehabilitation goals that are not realistically attainable.

The difficulty surrounding diagnosis of a concussive head injury is underlined by the fact that symptoms can vary, are mostly nonspecific, and may evolve over the course of a number of days. As yet, there is no single objective test that is capable of being carried out, and a diagnosis relies heavily upon a clinical assessment.

There are also problematic ethical issues bound up in all of this. Firstly, there is a patient’s right to choose or refuse treatment. When a player is removed from the field of play, often against his will, the effects of a suspected concussion are unlikely to be fully known.

The giving of informed consent to treatment is another difficulty in the context of someone who has suffered concussion. Thirdly, and from the doctor’s standpoint, there is a potential conflict of interest between serving the best interests of the injured player, but also the club paying his or her wages. The latter issue can be partly addressed by the presence of an independent doctor.

The delayed reaction in this country to a recognition of the risks of head trauma in sport can be contrasted with the position in the USA where recurrent insults have for some time been associated

with a progressive deterioration in brain function. Perhaps, not surprisingly, litigation (or the threat of it) has acted as a catalyst for a greater understanding of the risks.

The power of litigation

A lawsuit brought in 2011 involving more than 4,500 former NFL players alleged that the governing body of the sport knew, or ought to have known, that players who sustain repetitive head injuries are at risk of suffering a constellation of neurological and psychological conditions, including personality changes and the early onset of Alzheimer’s disease.

Chronic traumatic encephalopathy (CTE), a progressive degenerative disease of the brain found commonly in boxers, is arguably the most damaging long-term effect of brain injury and was diagnosed in a number of cases. Symptoms of CTE include memory loss and mood swings.

The likely traumatic effect of repeated, fast-moving and violent helmet-to-helmet insults is not difficult to imagine. A number of former NFL players committed suicide, including Ray Easterling, the former Atlanta Falcons player in whose name the lawsuit was filed.

The claims against the NFL were subject to a lengthy mediation process which culminated in a $765 million (£490 million) settlement, but which Easterling and other former players did not live to see.

In 2015, the United States Soccer Federation unveiled a series of safety initiatives directed at head injuries in the sport at youth level. The principal measure is a policy that sets strict limits on youth players heading the ball. It will prohibit players aged 10 and below from heading the ball at all, and reduce the number of headers that those aged between 11 and 13 will be able to make during practice. The new guidelines resolve a proposed classaction lawsuit filed against the governing Federation, and others (including FIFA), in 2014. The claims alleged negligence in treating and monitoring head injuries, but no financial compensation was sought, only rule changes.

The proposed changes that have just been announced by US Soccer also include amendments to substitution rules to improve protection for players who suffer suspected concussive injuries.

Current international rules allow for three substitutions per game during senior level games. There is no provision for temporary substitutions to enable a player with a suspected head injury to be properly examined and, if judged by a doctor to be fit to do so, to then return to the game in place of the temporary substitute. In the absence of an independent doctor, temporary substitutions for a suspected head injury would reduce the pressure on managers and medical staff when making a decision at a critical stage of a game and which may affect its outcome.

Both codes of rugby have embraced the Zurich Guidelines. During the recent Rugby Union world cup, players suspected of concussion were temporarily withdrawn to undergo cognitive, balance and memory testing. By common consent, Dan Biggarwas the outstanding Welsh player in the competition. His clear reluctance to be withdrawn during the closing stages of Wales’ quarter-final match against South Africa, following a blow to the head, demonstrates that even temporary substitutions will not always be consensual.

At elite level, where an independent medical practitioner is in attendance, his or her clinical judgment should prevail.

When there’s no doctor

Most sport, however, does not have that luxury, especially games played at amateur level where there will invariably be no qualified medical practitioner present. The default position set out in the FA guidelines should apply in those circumstances: even if there is a suspicion of concussion, supervised attendance at an accident and emergency department is required.

If nothing else, the assimilation of the Zurich guidelines into the rules and regulations of major sports governing bodies means that a standard has been set against which any alleged failure to

comply is capable of being measured. The test will be whether that standard will be put into practice, or whether it will take litigation arising out of a concussive injury to focus minds.

As far as scientific developments are concerned, it is anticipated that an objective diagnostic tool for assessing head injuries will become available in the foreseeable future. A research study

currently being conducted at Sheffield Hallam University is seeking to identify the changes that occur to the structure of the eye during a concussive episode. Retinal scanners, which are already in routine use, provide information about nerve fibres, blood vessels and the eye’s ability to discern colour.

It is anticipated that a portable retina scanner would be used to examine an injured player’s eye following a suspected concussion. The data collected would then be compared with healthy readings, facilitating an independent and speedy clinical assessment by the touchline.

If and when such a tool becomes available, the initial difficulties in diagnosis will hopefully be reduced, if not removed altogether.

The efficacy of strategies for managing head injuries, and whether rehabilitation goals are attainable, are likely to remain controversial subjects.

There must also be a significant cultural shift in our perception of players who insist on playing after sustaining a head injury.

Heroism is an epithet that is entirely apt in other fields of endeavour. But with respect to the late, great Bill Shankly, he was wrong. Football is not a matter of life and death, let alone more important than that.

Instead, we should applaud players like Trautmann and Lloriss for leaving the pitch, not for staying on it.

Craig Moore is a barrister with Parklane Plowden

This article is a bridged version originally produced by Parklane Plowden