WHY WERE WE GETTING IT WRONG?

– Written by Louis Holtzhausen, Qatar, and Craig Roberts, United Kingdom

INTRODUCTION  

Concussion in sport has arguably become the hottest topic in sports medicine in decades. Seldom, if ever, has there been such media and public interest for a sports injury as there has for concussion in the past decade. It seems that this interest, often critical of sports federations’ attitudes and medical staff management of head injuries, is entirely justified. The medical world totally underestimated the importance of this seemingly innocent injury.  They had it so wrong that sports federations are facing and losing lawsuits against former athletes with degenerative neurological disorders, now ascribed to poor concussion management during their playing careers.  Furthermore, in football, former players with a history of repeated concussions have a higher prevalence of neurological and psychological maladies, including sleep disturbances, anxiety and depression¹.  Only as recently as 2001 did a group of concussion experts form the Concussion in Sports Group (CISG) to investigate best practice and produce regular consensus statements on the correct management of sport related concussion².

Despite clear guidelines from the CISG, concussions are still ignored, under-recognised, or undertreated across the entire scope of sport, right up to Football World Cup level, where blatant on-field mismanagement of concussion has occurred in front of world-wide audiences in recent tournaments.  The situation has become so serious that concussion is the only sports injury for which management has been legislated in all 50 states of the USA and other countries. In an industry renowned for cutting-edge management of injuries, why would the sports world and in particular the sports medicine fraternity allow such an embarrassing and seemingly negligent situation to develop? 

WHY DO WE GET IT WRONG?

The first reason for this oversight is that it is easy to hide or “miss” concussions. Most concussions occur without overt clinical signs. It presents with general symptoms, including headache, dizziness, pressure in the head and many more which are not recognizable from the outside, making recognition largely reliant on reporting of symptoms. Athletes are unlikely to offer information which will result in being removed from play, for reasons including career aspirations, financial drivers, a commitment to a sport, school, or team, pressure to meet expectations from family or coach, intrinsic competitiveness and a loyalty to teammates and the team culture³. It is therefore the team medical staff, referee, and other players’ responsibility to recognise high risk events or subtle manifestations, such as slow responses to instructions, forgetting plays, etc. A further consideration concerning concussed players is that the brain is injured, and in addition to all the biases mentioned, a player may be mentally incapacitated to make a rational decision. Even with clear evidence of concussion and a doctor’s intent to remove a concussed player from the field, the decision may be overturned by the coach or manager.  Many managers’ primary interest is having his or her perceived best players on the field. Even if a manager or coach is informed about concussion, the risk remains that the subtle presentation of concussion can make him/her turn a blind eye and risk player welfare.  It is no secret that there is a massive power differential between the coach and player, as well as between the coach and the medical staff. Team sports, like other warrior cultures, are necessarily hierarchical, with the manager in a very powerful leadership role.  This powerful vertical relationship is characterised by deference and total obedience to the manager.   A player will never willingly risk a coach’s disfavour. Similarly, the team medical staff are in a difficult conflict of interest situation. The relationship between a team physician and a football team is complex.  The physician has a doctor-patient relationship with the players as his/her patients, and with the employer, who is ultimately the team owner and employer of both the players and the doctor.  The doctor inevitably has a loyalty to the employer and the organisation, which may result in biased decisions favouring the will of the employer, represented in this case by the manager or coach. A UK study amongst elite football medics revealed that 40% felt pressure from the coaching staff to accelerate player return following concussion⁴, and in Italian club football 33% felt pressured by the coaching staff when making concussion  RTP decisions⁵.    Heat-of-the-moment concussion decisions can and do easily create a perfect storm where medical decisions are influenced by loyalty to the team, manager, or owner.  In situations such as this, team physicians have repeatedly been forced to allow oversight of concussion to happen because of fear of losing their jobs, or loyalty to the team/club who employ them⁶. Vague diagnostic criteria for concussion and risk of “getting it wrong” further complicates the decision. The fundamental medical ethics principles of beneficence (to do the right things) and non-maleficence (to do no harm) are often seriously compromised in the process.

WHAT ARE THE CONSEQUENCES OF CONCUSSION?

Most serious complications of concussion occur if a player continues playing after sustaining a concussion or returning to play before full recovery. The mainstays of safe treatment are therefore early recognition and removal from play, as well as graduated return to play (GRTP) as recommended by the CISG.

The consequences of concussion are threefold. Firstly, concussion may have severe short- and long-term medical complications. Secondly, concussion increases risk of any other injury significantly, and thirdly, concussion affects athletic performance negatively.  In addition to these three direct complications for the player, there are also ethical and medico legal consequences which need to be considered.

The first medical complication is the rare but potentially lethal second-impact syndrome (SIS).  This condition results in massive swelling of the brain, with often permanent neurological consequences or death. It is caused by loss of autoregulation of blood flow to the brain, as a result of a second blow to the head of an already concussed person⁷.  The second complication is a prolonged recovery from concussion, also called prolonged symptom complex, or post-concussion syndrome.  This complication is characterised by more than a month duration of debilitating concussion symptoms, including physical symptoms such as headaches or ringing in the ears, inability to concentrate or remember, mood disturbances such as anxiety or depression, balance disturbances, or sleep disturbances⁸.  

Chronic traumatic encephalopathy (CTE) is an early-onset neurodegenerative condition resulting in early onset dementia, Parkinson’s disease, or other neurodegenerative manifestations.  It is caused by a build-up of tau protein and beta-amyloid in the brain, caused by concussion⁹.  This condition was described by Martland in 1928 as the punch-drunk syndrome but has largely been ignored until CTE in former American Football players was described by Omalu in 2005 and 2006¹⁰. In addition to this dreaded condition, evidence is growing that athletes with a history of concussion are more at risk for mental health disturbances such as depression, anxiety, and sleep disturbances later in life¹.  It took a massive lawsuit by former American footballers against the National Football League (NFL) for the world to take notice of CTE. This event has created tremendous press and public interest and awareness, forcing organised sport over a broad spectrum to institute proper concussion prevention and care measures. Ironically, the correct decision to improve player welfare has only been made out of fear of litigation.

Concussion increases the risk of subsequent injuries by 50% or more for a year¹¹. This is probably due to subtle residual sensorimotor, balance or vestibulo-ocular sequelae of concussion. There is no doubt that such abnormalities will affect athletic performance as well.

WHAT HAS BEEN DONE IN FOOTBALL?

Football has recently introduced several initiatives to improve concussion care and decision-making at the elite level of the game. These include: 

1.     Education and awareness programs for administrators, coaches, medical staff, players, and referees. There are now also mandatory online education and exams for all doctors and medical staff wishing to obtain accreditation for FIFA regulated tournaments, commencing with the World Cup in Qatar 2022. Currently, in elite clubs in the UK a recent study amongst team doctors found that less than 50% of respondents delivered specific concussion education to the players every season and only 38% delivered an education session to the coaches⁴.

2.     Independent Medical Coordinators (MC) have been introduced pitch-side to oversee field of play medical teams. The MC is in direct contact with the medical staff of both teams.  Although the team doctor still has ultimate responsibility for the players’ welfare, it is the job of the MC to advise, alert, document and hopefully alleviate some of the inherent biases. 

3.     Experienced independent doctors acting as injury (“concussion”) spotters have been placed in the stands in selected tournaments to look specifically at injury mechanisms and signs that can then be passed to the MC via 2-way radio, to assist with their management of concussion and  injuries¹².

4.     Pitch-side video replays are now often available for both teams and FIFA staff. These provide simultaneous camera angles, and the ability to zoom in, slow down and view the game frame-by-frame. 

5.     Whenever a suspected incident of concussion occurs, the referee can stop the game for three minutes, allowing the team doctor to complete an on-pitch assessment to decide if the player has suspected concussion. While this is certainly a step in the right direction, physicians know that it takes much longer to do a proper concussion assessment. Furthermore, it is not optimal to do concussion assessments on the pitch with potential interference from players, officials, and spectators¹³.

6.     Extra permanent concussion substitutions are starting to be introduced if the team doctor suspects concussion, with or without offering the opposition an additional substitute, depending on the competition protocols. 

7.     FIFA has also started to offer a Concussion Assessment and Rehabilitation Service (CARS) for selected competitions.  This is a competition specific service afforded to teams should they require assistance in dealing with suspected concussions it is led by an independent expert in concussion to facilitate the correct management and safe return to play following concussion. 

8.     Online SCAT 5 and computerized neurocognitive baseline testing are offered to any competition requesting this, free of charge to assist in clinical decision making following concussive episodes. Elite football doctors in the UK reported that 98% of respondents are collecting baseline SCAT5 tests and 16% utilised a computerized neurocognitive assessment tool (ImPACT or Cogsport)⁴. However, a recent study of elite European football physicians found that 63% of respondents did not collect any baseline neurological or neuropsychological assessments¹⁴.

WHAT ARE THE REMAINING CHALLENGES IN IMPLEMENTING GOOD CONCUSSION CARE IN FOOTBALL?

The heat-of-the-moment conditions at field-side are often not conducive to adequate monitoring of the game, to witness incidents of concussion amongst other things. Doctors are often situated in the dugout (often literally dug out below the level of the pitch) which many think is the best seat in the house, but far from it: Most modern pitches have a significant camber and if you are below pitch level in a dugout, it is almost impossible to see what is happening on the far ends of the pitch. On top of that you usually have a manager pacing up and down in front of the dugout. To compound matters even further they are often joined by the assistant manager, defensive coach and a fourth official to observe key set pieces. As a team doctor, one often feels like a meerkat bobbing and pitching your head to try and get a glimpse of the high risk set piece play down the end of the pitch. This can also be used as an excuse: “I did not see the episode/mechanism... by the time I got to him he was awake and alert” - a convenient escape clause.  Perhaps football should take a leaf from other sports (rugby, NFL, AFL) where the medical team is able to roam along the sides of the pitch, enabling a much clearer view of mechanism and initial presentation, faster response time, and easier regular communication with a potentially affected player. 

When a player goes down with a suspected head injury the team doctor has a very short time (three minutes to be exact) to process all the information, assess the player, and hopefully make the correct decision. There are many points of bias and risks to make mistakes:  The doctor can’t go on the pitch without the referee stopping the game and summonsing the medics on the field. This may be appropriate for obvious musculoskeletal injuries, but an understanding and elevated index of suspicion is required to identify suspected concussion, especially when players tend not to be forthcoming with symptom reporting. Are the referees adequately equipped for this responsibility? Hopefully this will be partially alleviated by using spotters and the MC, although implementing such improvements would require a law change as to who can stop the game, or to allow medics to enter the field of play while the game is still live.

On the way to the player there is a lot for the team doctor to process: What was the mechanism? Are there any early signs of potential concussion (LOC, loss of head control, posturing, seizure etc.) given that players are often coached to hold their heads if injured in an attempt to force the referee to stop the game? If the medics are lucky, another member of the medical team may have had a better view or access to video replays and can relay this information via the radio. On arrival at the player there is even more to process: Is it safe? Is the player conscious? Take control of the head and neck (manual inline stabilisation), run through ABCDE.  Are there any associated injuries? Any signs of concussion – Maddocks and observable signs?  Can you clear the C-spine? This all then leads to a rapid decision if this is suspected concussion or not. Finally, you need to have a discussion with the manager about making an appropriate substitution or not. 

Once concussion is confirmed the appropriate graduated return to play protocols (GRTP) need to be followed (Table 1). These rely heavily on player reported symptoms (or lack thereof) for players to progress though the return to play stages. The player may be inclined to under report his/her symptoms to be ready for the next game. This is particularly valid in an enhanced care setting where players may possibly return on day 6 post injury. A recent study amongst Elite UK football medical staff revealed that only 27% felt that players rarely or never under reported symptoms⁴.

Despite recent advances in real-life concussion care in football, the practical execution of best practice in concussion care remains challenging.

TOWARDS A SUSTAINABLE SOLUTION

The generally poor performance in concussion care in football can be ascribed to a few factors.  We discussed the inherent power differential, conflict of interest, and risk of bias situation in football and other sports.  Furthermore, concussion is a relative newcomer in the list of injuries that need to be taken seriously. A general argument is that we have never paid so much attention to this injury, and nothing happened. Why now? This situation is compounded by the still prevailing (although dwindling) media praise for players remaining on the field despite being concussed – a trend long gone in many other sports, where the media now reports in the interest of player welfare. This attitude still prevails amongst many football managers, teammates, and fans.  Furthermore, appropriate concussion care is not popular, as it invariably means that a player will miss the next match if appropriate GRTP measures are followed.  One way to change this behaviour is by legislation which has proved to be effective. However, legislation does not necessarily change attitudes. To achieve attitude change requires a lot of patience and “preparing the soil” before enforcing new concussion rules. A team physician, or medical manager of a sport needs to understand the “culture” of the sport, the internal and external environment in which it is played, and the cultures and attitudes of all stakeholders. Understanding the context may guide one to the “low-hanging fruit”, or potential early adopters, with which to start the conversation of change, and gradually build understanding and trust in the new way of thinking.  The higher up in the hierarchy that this conversation can take place, the more powerful and influential it will probably be¹⁵.

Shared decision-making is a proven method to navigate medical decisions at an individual doctor–patient level. We recently proposed a customised shared decision-making solution to address the common field-side disagreements on concussed players. This plan involves clinicians’ use of Elwyn’s three talk model for shared decision-making at individual level¹⁶, but also at two additional levels of engagement – at organisational level and at coach/team management level.  This three-tiered approach at Organisational, Coach, and Athlete level has been coined the “OCAsion”  decision-making model (Table 2)¹⁷.

We propose a knowledge transfer and informed decision-making process starting at the highest decision-making body in the sport at international, national, regional, or even club or team level, which is ready to embrace concussion care.  The ideal outcome of this process is adoption of a concussion policy. With a policy in place, the same process is followed at team management level to agree on detailed concussion decision-making and care in the team. When there is agreement between team management and medical staff, players are educated and requested to sign informed consent to adhere to medical advice in the event of a concussion.  The timing of these processes is all important. It should be done well in advance of the start of a season and reinforced regularly¹⁷.

Despite the best efforts described here, a sustainable solution for concussion care is elusive. We are convinced that the missing link in concussion care will turn out to be the advent of objective diagnostic testing for concussion. Much progress has been made in this regard, including promising work on objective field-side vestibulo-ocular testing, salivary and blood markers, and functional neuroimaging. Introduction of these into mainstream concussion care will be game-changing.

CONCLUSION

The medical, contextual, ethical, and legal complexities in current day concussion care have created one of the biggest challenges the sports medicine fraternity has ever encountered. Many researchers, clinicians, neuroscientists, and others are working tirelessly towards better solutions. We have come a long way, but in the absence of objective diagnostic and prognostic measurement tools, concussion care relies heavily on education, changing attitudes and building relationships of trust between medical teams and other stakeholders in sport.  The difference in objectives of medical teams, managers and players are major stumbling blocks in this quest, where the managers’ and players’ outlook and biases will invariably tend to favour dismissal of suspected concussion. A paradigm shift towards player welfare as priority in the sport can make a huge difference. The example of World Rugby in this regard has been hugely successful.  Up to now there has been a reluctance not to damage or alter “The Beautiful Game”, but when it comes to concussion football is lagging behind many other sports. Unless football truly embraces and actions the premise of player welfare at all levels, the sport is at risk of severe damage to its reputation and legacy.

Louis Holtzhausen M.B.Ch.B., Ph.D., F.A.C.S.M.

Sports Medicine Physician

Deputy Chief of Sports Medicine

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Craig Roberts M.B.Ch.B., M.Phil. 

Club Doctor

Bournemouth Football Club

Bournemouth, UK

Contact: louis.holtzhausen@aspetar.com

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Header image by Aleksandr Osipov (Cropped)