How effective is FIFA's concussion protocol?
Published 08 October 2014 By: Jake Cohen
The football community has become increasingly aware of the dangers of head injuries in recent years, but this summer’s World Cup has thrust the issue to the forefront, most notably with German defensive midfielder’s Cristoph Kramer’s concussion during the final against Argentina.1 This article endeavours to discuss FIFA’s shortcomings with regards to implementing appropriate concussion protocols.
Even before Kramer’s injury, however, Alvaro Pereira suffered a concussion while competing for Uruguay in a group stage match against England. After a collision with Raheem Sterling in the 61st minute, Pereira was lying unconscious on the ground. Following the match, Pereira stated “after the hit, I only recall that I was unconscious for an instant. It was like the lights went out.”2 By the 63rd minute, Pereira had already been looked at by Uruguay team doctors, was given the all-clear, and was back on the pitch.
Recognising that a two-minute examination and evaluation for a player with a suspected concussion by a doctor who answers to the Uruguayan FA is insufficient to ensure player safety, FIFPro, the international players union, called on FIFA to “to conduct a thorough investigation into its own competition concussion protocol which failed to protect” Pereira.3
FIFPro's recommendations for an effective concussion policy
FIFPro’s chief medical officer outlined six priorities for what the union believes is required for an effective concussion policy:
- The development of a monitoring system to assure and control the application of the Zurich 2012 concussion guidelines;
- The systematic completion of a standardised and valid side-line examination (cognitive and physical) on any player suspected to have suffered concussion;
- The presence of an independent medical professional on the side line during matches to assess a player with suspected concussion;
- The possibility of replacing (temporarily substitute) any player undergoing the side-line examination;
- Enforcement mechanism to ensure proper application when procedures are not followed to protect the health and safety of the players;
- The introduction of a baseline reference, pre-competition examination (cognitive and physical), which allows important comparisons to be made with any eventual side-line examinations undertaken as a consequence of a suspected concussion.4
By any metric, these seem like reasonable requests, if we assume that every stakeholder in football is concerned with ensuring player safety. However, many of the priorities listed by FIFPro are not currently part of FIFA’s concussion protocols, and in fact, FIFA appeared to have egregiously disregarded the well-established consensus protocols for assessing concussions in sport.
By focusing on FIFPro’s proposed changes and relying on statements made by FIFA officials, medical experts, and Taylor Twellman, a former player whose career was cut short by the effects of numerous concussions he suffered on the pitch (and who is currently a noted advocate for awareness and research of traumatic brain injuries), this article will show that not only are FIFPro’s proposed changes feasible, but also that they are necessary to better ensure player safety.
Sport Concussion Recognition Tool
FIFA makes available and puts its name on a pamphlet called the Sport Concussion Recognition Tool (SCRT) to “help identify concussion in children, youth, and adults."5 The pocket pamphlet is primarily to assist laypeople in recognising when an athlete has suffered a head injury and should be immediately seen by a trained medical professional. The pamphlet was developed by the Concussion in Sport group, which is wholly independent of FIFA, and is comprised of neurologists, other doctors trained in diagnosing and treating head injuries, and domestic and international sporting federations.6 It reflects a consensus approach to diagnosing and treating head injuries in sport, and relies on the consensus statement on concussions in sport created at the International Conference on Concussion in Sport held in Zurich in November 2012, and subsequently published in the British Journal of Sports Medicine in April 2013.7
On the timetable for recovery, the consensus statement explicitly states:
“The majority (80–90%) of concussions resolve in a short (7–10 day) period, although the recovery time frame may be longer in children and adolescents.”8 Further, “persistent symptoms (>10 days) are generally reported in 10–15% of concussions.”9
Curiously, however, FIFA’s chief medical officer Jiri Dvorak, advocates a six-day timeframe:
“After a mild head injury it is recommended that players gradually increase their activity levels, ideally making a return to full participation in football six days after sustaining the injury.”10
Christoph Kramer FIFA World Cup case
On football’s biggest stage, the 2014 World Cup final, Christoph Kramer, Germany’s defensive midfielder, suffered a concussion after an inadvertent collision with Argentine defender Ezequiel Garay.11 After a very brief examination by the German team doctors, Kramer was sent back out, and played for about ten minutes before slumping to the ground and having to be helped off the pitch.
Following the match, Kramer said, “I can’t really remember much of the game.”12 “I don’t know anything at all about the first half. I thought later that I left the game immediately after the tackle. I have no idea how I got to the changing rooms. I don’t know anything else. In my head, the game starts from the second half.”13
The referee, Nicola Rizzoli, saw that Kramer was clearly disoriented and unaware of his surroundings. He described his interaction with Kramer, explaining: “shortly after the blow, Kramer came to me asking: 'Ref, is this the final?’” “I thought he was joking and made him repeat the question and then he said: ‘I need to know if this is really the final.’ When I said: ‘Yes,’ he concluded: ‘Thanks, it was important to know that.’”14
The SCRT specifically states that any athlete with even a suspected concussion should be immediately removed from play and attended to by a medical professional.15
Further, the SCRT states that a concussion should be suspected if a player exhibits one or more of the following symptoms:
- Loss of consciousness or responsiveness;
- Lying motionless on the ground and/or slow to get up;
- Unsteady on feet, balance problems, falling over, or lack of coordination;
- Grabbing or clutching one’s head;
- Dazed, blank, or vacant facial expression;
- Confused and/or unaware of his or her surroundings.16
Based on statements made by both Kramer and Rizzoli, it seems clear that Kramer exhibited multiple symptoms of a concussion, and his head injury should have been deemed a suspected concussion.
Sport Concussion Assessment Tool
The team doctors should have used the Sport Concussion Assessment Tool (SCAT3) to test Kramer. The SCAT3 provides significantly more intensive baseline testing than the SCRT and is: “intended for use by medical professionals only.”17
As part of the SCAT3, there are five basic questions about the match that should be asked, including: “which half is it now?” and “what venue are we at today?”18 Failure to answer any of these questions correctly suggests a concussion, and from Kramer’s statements, it is clear that he would not have known the answers.
Ensuring that a player who suffers a concussion does not return to the pitch is of paramount importance, and can actually mean the difference between life and death in severe cases.
Second impact syndrome is often fatal and occurs when an athlete returns to play while suffering post-concussive symptoms and suffers a second head injury.19 According to a paper published in the Western Journal of Emergency Medicine: “while rare, [second impact syndrome] is devastating in that young, healthy patients may die within a few minutes.”20
As discussed earlier, Uruguay’s Alvaro Pereira lost consciousness after a collision with England’s Raheem Sterling and was allowed to play on despite Jiri Dvorak stating just weeks earlier, when Hugo Lloris suffered his concussion, that: “it’s a 99 percent probability that losing consciousness in such an event will result in concussion.”21
Disturbingly, Dvorak defended the decision to allow Kramer to resume playing, despite heavily criticising Tottenham Hotspur for allowing goalkeeper Hugo Lloris to resume play after being struck in the head by Romelu Lukaku in a Premier League match last season, calling the decision: “dangerous and irresponsible.”22
“[Lloris] should have been substituted,” said Dvorak. “The fact the other player needed ice on his knee means it's obvious the blow was extensive. When he has been knocked unconscious, the player himself may not see the reality. We have a slogan: if there is any doubt, keep the player out.”23
When you compare Dvorak’s reaction to how the Tottenham Hotspur and the Premier League handled Hugo Lloris’ injury with how he reacted to how Germany and FIFA handled Christoph Kramer’s injury, there is a strange disconnect.
“Take the example of Christoph Kramer. When the incident happened, of course the audience saw it on the television, but the referee and doctors could not see it when they ran to the player, who assured them he was all right.”24
These were two very similar situations, yet two very different reactions from Dvorak, and the author wonders if the fact that Kramer was playing in a FIFA-run competition (as opposed to a Premier League-run competition) is the reason why FIFA’s chief medical officer chose to issue dramatically different opinions on the same issue just weeks apart.
Taylor Twellman is a former United States international and was named as Major League Soccer’s (MLS) most valuable player in 2005 (he also won the golden boot that season). Multiple clubs in Europe made transfer bids for the United States international over the course of Twellman’s career, but MLS consistently refused to sell one of its top stars.
Three years later, Twellman suffered a severe concussion and the fifth in his career. Despite suffering severe effects (headaches, nausea, fatigue, difficulty reading a book or watching a movie), he attempted to continue playing until 2010, when he made the decision to retire.
After the lingering affects of his injuries forced him to end his playing career early, Twellman founded a non-profit organisation called ThinkTaylor, which aims to: “create social change in the world of Traumatic Brain Injuries, by generating increased awareness, recognition and education.”25 His organisation does whatever it can to help those who are suffering from traumatic brain injuries, whether it be as a support group, helping people find doctors, and as Twellman puts it, being: “a mechanism for which to advocate change.”
Twellman is also a broadcaster and football analyst for ESPN, and generously shared his insights for this article.
“FIFA is turning a blind eye” to the concussion problem, shared Twellman. “FIFA doesn’t need to go from zero to one hundred, but they’re not even going from zero to ten.”
FIFPro’s proposals examined
In the following section, each of FIFPro’s proposals will be discussed, with a particular focus on how each proposal would better ensure player safety and the logistical feasibility of implementing the proposals.
The development of a monitoring system to assure and control the application of the Zurich 2012 concussion guidelines, and an enforcement mechanism to ensure proper application when procedures are not followed to protect the health and safety of the players.
The infrastructure for a monitoring system and enforcement mechanism is likely already in place, as evidenced by FIFA’s Transfer Matching System (TMS),26 which FIFA president Sepp Blatter described as a: “relatively simple online system, but it will have a tremendous impact on the international transfer of players.”27
Blatter highlighted the benefits of a streamlined online database, noting: “the most important thing is that it increases the transparency of individual transactions and helps us to tackle issues such as the fight against money laundering and the protection of minors in transfers.”28
The TMS also “aims to enforce adherence to the transfer regulations through a specific sanction system”.29
A similar system to monitor concussion protocols, where each league would be required to not only submit its concussion protocols, but also a detailed report whenever a player suffers a head injury would likely lead to better accountability and transparency, as well has have a positive effect on player safety.
The presence of an independent medical professional on the sideline during competition with the training required to assess a player with a suspected concussion.
Following Alvaro Pereira’s injury (and the Uruguay team doctors sending him back out on to the pitch) The Lancet Neurology, a leading medical journal, published an editorial, stating: “the decision on whether Pereira should leave the field for assessment was left in the hands of the Uruguayan team doctor and team officials, but such decisions should surely be taken out of the hands of those with a vested interest in the player's performance.”30
Twellman astutely notes that a medical professional, by definition, can be a dentist or a chiropractor, i.e. someone not qualified to diagnose and treat head injuries. As such, Twellman strongly believes that the protocols need to mandate that the independent doctor is properly trained in traumatic brain injuries.
With regards to ensuring that side line doctors have proper training, there is the logistical issue of providing the necessary training to these, but Twellman is adamant that: “FIFA has the means to get this together.”
Given the importance of ensuring player safety, Twellman argues that it wouldn’t be very difficult to ensure that the side line doctors receive the proper training and points out that the implementation would be similar to that of the fourth official.
The systematic completion of a standardised and valid sideline examination (cognitive and physical) on any player suspected to have suffered concussion
At the September 2014 Soccerex conference in Manchester, FIFA Medical Commission Chairman, Michel D’Hooghe (who is also the head of sports medicine at Bruges Hospital)31, said that he would propose to FIFA and UEFA that matches be stopped for three minutes if a player is suspected to have a concussion. 32
D’Hooghe’s proposal will also include a provision where: “the referee will only allow the player to continue playing with the green light of the team doctor, and nobody else.”33
UEFA’s executive committee approved D’Hooghe’s proposal just a few weeks later, and the three-minute assessment period for suspected concussions took immediate effect for UEFA competitions (i.e. Champions League, Europa League, Euros).34
While allowing three minutes for assessment appears better than zero minutes, the consensus among both the medical and sporting community is that three minutes is insufficient. The International Rugby Board, for example, recently revised its own concussion protocols to allow up to ten minutes for assessment, after five minutes was deemed insufficient by an independent study that was peer-reviewed and published in the British Journal of Sports Medicine.35
In addition, the National Football League’s concussion assessment takes a minimum of eight minutes to complete.36
While attempting to defend FIFA against what he described as “inappropriate” criticism resulting from how it handled head injuries at the World Cup, Jiri Dvorak stated: “the German team doctors are very experienced and Kramer didn’t report any symptoms or signs, so he was allowed to play on. Then over the next ten minutes he realised that symptoms were occurring – it’s not unusual that there is a delay – and he himself called the doctors for attention.”37
Setting aside the fact that accounts from both Kramer and the referee show that the player was visibly displaying overt symptoms of a concussion, it seems clear that FIFA recognises that concussion symptoms can often be delayed for ten minutes. What isn’t clear, however, is why it only recommended three minutes for assessment.
The possibility to replace (temporarily substitute) any player undergoing the side line examination
While there is a strong case to be made that this could be abused (as a player could feign a head injury late in the match to allow a fresh player to take his place) safeguards can be implemented to reduce this possibility.
For example, the temporary substitution could count towards the allotted three substitutions. In addition, if a manager has already used his three substitutions, the player who is suspected of having a concussion (and is therefore substituted) could be forced to sit out the following week.
This would not only help prevent the rule from being abused, but it would also help ensure that the player has time to recover if, in fact, he is diagnosed with a head injury.
Said Twellman: “I am not sure what to make of the substitution dilemma, because I understand both sides,” he said. “I just know I would love to see advancement on substitutions because it would eliminate any anxiety from coaches or players who feel like making a safe substitution might be letting their team down.”38
In comparison to some of these other proposals, which have thorny logistical issues, temporary substitutes while a player suspected of a concussion is being assessed on the side line would appear very easy to implement, and could take immediate effect with a simple approval and statement from FIFA.
The introduction of a baseline reference, pre-competition examination (cognitive and physical) which allows important comparisons to be made with any eventual side line examinations performed as a consequence of a suspected concussion.
FIFPro has advocated for improved pre-competition medical assessments for a number of potential health concerns, and this proposal is in line with FIFPro’s platform.39
The consensus statement from the 2012 Zurich conference considered this issue and found that: “a baseline assessment is advised wherever possible.”40
Further, the consensus statement issued a recommendation that: “all athletes should have a clinical neurological assessment (including assessment of their cognitive function) as part of their overall management. This will normally be performed by the treating physician often in conjunction with computerised neuropsychological screening tools.”
However, there are issues with baseline testing for the purposes of concussion assessment, specifically the fact that players can easily manipulate the test results by deliberately scoring low on the baseline examination. As former Scotland international rugby player Roy Lamont explained:
“Players can view the baseline test as an obstacle in their way for getting back playing."41
“So who is at fault here? It is clearly the player's responsibility to take the test seriously. However, in a job where every game is a chance to win your next contract and keep paying the mortgage, it is easy to understand a player's desire to get back playing.”
“The bravado culture… is another driving force. There is nothing more heroic and sacrificial than to declare yourself available for selection in spite of injury and coaches will often commend such behaviour. If the player is not informed of the long-term health implications, he doesn't know what he is gambling.”
“The evidence suggests it is a gamble of epic proportions, concussion is linked to a host of neurological problems including increased risk of early-onset dementia.”
“Concussion mismanagement is best remedied by education. If a player chooses to cheat the protocol or decides not to report their concussion after being educated of all the possible health risks, then at the very least it is an informed decision.”42
Looking ahead to the future
When asked why he thought FIFA hasn’t implemented some of these proposals, Twellman presents a harsh reality:
“Why hasn’t FIFA done this? Because the moment you address it, what does it do? There’s litigation and liabilities.” Indeed, positive changes to the concussion protocols could be construed as an admission that the current protocols are ineffective.
Twellman argues that litigation is not the main problem, nor is it going to solve the problem. Rather, ligation “opens up a can of worms” that FIFA does not want to deal with.
“The moment FIFA addresses the fact that they have a concussion issue and they need to address it, and then they do address it [by implementing some of these proposals], now all of a sudden, you open yourself up to questions like: 'well, what about heading a soccer ball?'”
“Litigation is part of it, but it’s the next step that’s [very worrisome to] FIFA. That is, [addressing] heading the soccer ball and the substitution rules – you’re changing the essence of the game.”
The impact on concussion litigation in the National Football League has had dramatic effects on not only the league, with several rule changes in recent years, but American football as a whole.
Participation in American football at the youth level has decreased nearly ten percent between 2010 and 2012, and over twenty percent at the high school level.43 This is the largest two-year decline ever recorded, and the chief medical officer of Pop Warner, the largest youth football organisation in the United States, cited concerns about head injuries as the leading cause for this decline.44
A lawsuit against FIFA has already been filed in United States federal court by a number of parents of current youth footballers and some current former youth footballers. The lawsuit alleges that FIFA and the relevant domestic and regional bodies that govern football have failed to fulfil their duties with regards to ensuring player safety and exclusively focuses on youth football (as opposed to professional football).
The plaintiffs are not seeking monetary damages. Rather, they have filed for injunctive relief and have asked the court to compel FIFA to implement stricter regulations and protocols with regards to head injuries in youth football.
Specifically, the plaintiffs have asked the Court to order FIFA to:
- mandate the enactment and enforcement of proper concussion-management practises and return-to-play guidelines;
- mandate substitution rules that allow for evaluation without penalty, and
- mandate limits on heading by players under 17.45
Major League Soccer, US Soccer, and youth players
Major League Soccer, the league in which Twellman spent his entire professional career, has committed to being a leader in safeguarding against head injuries.
The league hired Dr. Ruben Echemendia, a clinical neuropsychologist with a wealth of experience implementing concussion protocols in professional sports leagues. Echemendia had previously been in charge of implementing the concussion protocols for the National Hockey League.46
Each MLS club has a neuropsychologist who specialises in identifying and treating concussions.47
While Twellman still sees situations being handled incorrectly, he believes that MLS and US Soccer are addressing the issue, but still has a long way to go before instituting the necessary changes to properly ensure player safety when it comes to head injuries.
“I hope MLS and US Soccer are at the forefront, because that’s my roots and my home country, and I want to be a part of that, but we still haven’t addressed the issue at the youth level.”
“Playing sports at a young age is so important, and you can learn so many social skills.”
Twellman points out that in many sports, there are safety limits on what a young athlete can do. For example, in Little League baseball, a twelve-year-old pitcher is not allowed to throw more than eighty-five pitches in a game, and if he or she throws more than sixty-six pitches, then the player must rest his or her arm for four days.48
Twellman raises the point that there is nothing preventing a youth coach from having his nine-year-old players head the ball one thousand times a week.
While Twellman makes clear that he is not advocating banning or restricting heading the football at the professional level, he is also clear on his position that there needs to be different regulations for different age levels, as it has been proven that children are more susceptible to head injuries than adults. The consensus statement at the Zurich conference recognised this, and advocated for specialised protocols for children who have suffered head injuries.49
The Premier League’s new rules to address head injuries
The Premier League introduced new concussion protocols are better at addressing and treating head injuries on the pitch. The new rules, which came into effect at the start of the 2014-15 season, were largely a response to the criticism the league faced after Tottenham Hotspur goalkeeper Hugo Lloris was knocked unconscious after being inadvertently kneed in the head by Everton’s Romelu Lukaku last season. Lukaku, who suffered a bruised knee, left the match, while Lloris, who suffered a concussion, stayed on.
The new protocols include a number of important changes, including placing the decision on whether a player who is suspected of sustaining a concussion may return to the pitch in the hands of the team doctor, rather than the player or manager.50
In addition, there is now a third “tunnel doctor,” who will use video replays to help the team doctors determine if a player suffered an injury and if the player displayed any symptoms of a suspected concussion.51
However, as the doctor is paid by the home club, therefore it could be argued that the doctor won’t be truly independent. Twellman has raised concerns over the issue of an independent doctor: “my biggest concern right when I saw the announcement was there not being a neutral doctor making the decisions, because you still have the conflict of interest when a doctor being paid by a team makes personnel decisions.”52
“You know there will still be pressure on doctors to keep the best players in [the match].”53
Indeed, Chelsea goalkeeper Thibaut Courtois recently suffered a head injury during the 5 October match against Arsenal after a collision with Alexis Sanchez. Courtois lay motionless on the ground in the immediate aftermath of the injury, but after a cursory evaluation by Chelsea’s medical staff that lasted no more than seventy seconds, Courtois was permitted to play on.54 Fourteen minutes later, he was taken off the pitch.55
Said Twellman, “The problem is this: the EPL yesterday -- how is Courtois' incident any different than Lloris? It's not. Both happened on the field, both were blatantly obvious yet this year, with 'new' concussion protocol, the same mistakes were made. Less than a minute of assessment and Courtois was back on the field.”56
Following a hospital visit, Chelsea announced that Courtois had been given the “all-clear,” following a series of precautionary tests, and cleared him to join the Belgium national team for international fixtures.57 While Courtois was not diagnosed with a concussion, he presented clear symptoms of a suspected concussion, and should have been taken off the pitch immediately.
While Twellman will continue to advocate very strongly for football to change how it addresses head injuries, it does not appear as though FIFA is willing to enact meaningful changes to its concussion protocols anytime soon. When asked what it will take for FIFA to start taking head injuries seriously, Twellman bluntly stated: “the tipping point will be that someone of my generation will die at a young age.”
“The way FIFA is acting, that’s ultimately the way it’s going to go. I hope it doesn’t get there, and I hope they open up to [better concussion protocols], but I’m not sure they will.”
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- Tags: Concussion | England | FIFA | FIFA's International Transfer Matching System (TMS) | FIFPro | Football | Germany | Governance | Major League Soccer | Premier League | Regulation | United Kingdom (UK) | United States of America (USA)
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Jake is a Consultant Mills & Reeve and an attorney working on both sides of the pond.
He has worked in the sports team at Mills & Reeve, and also writes about legal, economic, and financial issues in European sport for the Wall Street Journal, ESPN, and other publications. He has been cited as an authority by media outlets all over the world.
At one time, he was a serviceable fly-half.