Robert Glatter, MD, attending emergency medicine physician at Lenox Hill Hospital
The scene at the World Cup Final this past weekend wasn’t pretty--in fact it was downright brutal. As the world watched as Germany’s Christoph Kramer slammed his head into the shoulder of Argentina’s Ezequiel Garay, he appeared dazed, spinning head first into the ground and appeared to lose consciousness for a short period.
Amazingly, Kramer stayed in the game for an additional 15 minutes after this tremendous impact before he had to be helped off the field dazed, glassy eyed and clearly confused. Not a pretty scene.
Had this scene occurred in an American Football game in 2014--based on a newly heightened and appropriate concern for concussions--the player would have been immediately removed from play, not to return to the game.
From this as well as multiple other incidents---including Alvaro Pereira who overruled his team doctor 3 weeks ago after losing consciousness, as well as Javier Mascherano after a stunning blow to the head that left him staggering and confused but returned to the game-- its quite clear that FIFA’s protocols for concussion management need a major overhaul to adequately protect its players. In fact, FIFpro, the player’s union, has called for immediate changes regarding how players are assessed on the field and sideline for potential concussions.
AAN Call to Action
According to the American Academy of Neurology (AAN), largest group of neurologists in the US, safeguarding and protecting all athletes from the immediate and long term effects of concussion is a moral and ethical duty for all physicians.
The American Academy of Neurology (AAN), in a newly released position statement July 9 in the Journal Neurology, emphasized that physicians have a moral and ethical responsibility to protect and educate athletes from the potential long term effects of concussions in order to safeguard not only their long term physical health, but mental and cognitive health. The statement was released ahead of the AAN sports concussion conference held in Chicago, July 11-13.
"With nearly 4 million sports-related concussions in the U.S. each year, it is imperative doctors are educated and protect these athletes who may have sustained a concussion," said statement lead author Dr. Matthew Kirschen, a neurologist with The Children's Hospital of Philadelphia.
"Concussions can have devastating effects such as short-term impairments in athletes' cognitive and athletic performance. Repeat concussions have been linked to long-term impairments in brain function, such as problems with learning, memory and behavior," Kirschen explained.
The position statement makes it clear that if an athlete has suffered a concussion, doctors should not allow players, coaches or parents to influence return to play decisions. Physicians should only allow a player to resume play when they are medically stable and have gone through thorough exams and neurocognitive testing. It is also important that doctors inform athletes and their families about the risk of concussion associated with various sports.
The new statement also emphasizes the importance of increased use of specialized neurocognitive tests to develop a baseline evaluation of athletes, the creation of a national concussion registry with mandatory reporting, and the addition of concussion evaluation and management training to neurology residency programs.
The AAN emphasized that doctors who care for athletes who have suffered a concussion must have specialized training and experience to recognize and evaluate both the presence and severity of concussion.
The AAN also endorsed new and emerging sensor-based technologies that allow identification of the severity and number of brain impacts that could lead to long term brain injury. This technology could also help to understand how the risk of concussion relates to gender, age and ethnic background. This may help parents can make informed decisions about playing contact sports.
Meanwhile, a supporting editorial in The Lancet Neurology published today further emphasizes the concept that medical providers be aware that repeated concussions can lead to long term neurological compromise and decline including dementia, amyotrophic lateral sclerosis, chronic traumatic encephalopathy (CTE). And, most importantly, concussions are the most common form of sports-related traumatic brain injury (TBI).
The recent FIFA World Cup held in Brazil drew sharp criticism from not only medical professionals but also the public regarding management of head injuries and concussions. Spectacular collisions occurred multiple times throughout the competition, with players not being removed from matches. Even those without any formal medical training could see that some players did not appear stable to return to the competition.
One such case involved Uruguayan defender Álvaro Pereira during the 2014 FIFA World Cup who overruled team doctors’ advice to be substituted and replaced. He returned to play soon after sustaining a concerning head injury.
Research has now shown that while symptoms of concussion may be delayed, neurological damage can remain. This damage can be detected on specialized MRI scans using a technique known as diffusion tensor imaging (DTI).
A Call for Change
Lancet Neurology’s editors also believe that the decision for players to return to a game after sustaining a concerning head impact are the sole decision of a physician and “should surely be taken out of the hands of those with a vested interest in the player’s performance.”
One potential solution is to form a committee of independent and unaffiliated physicians selected by the governing body of a sport-- not employed by teams--to perform detailed exams and evaluations after concerning head impacts in conjunction with scalp mounted sensor technology characterizing the impacts themselves. The NFL currently has independent neurologists on the field at games working with team physicians.
“In my opinion, the NFL and the FIFA should have clinicians that are trained to evaluate and treat concussions,” explained Dr. Robert Duarte, neurologist at the North Shore-LIJ Sports Concussion Program in Manhasset, New York.
“This should be someone who has medical training, such as a physician, physician assistants or nurse practitioner. It is key that the team clinician should not hired by the specific team but by an independent committee of clinicians to avoid any biased decisions about an athlete’s degree of injury or possible recommendation on return to play,” added Duarte.
As the use of new wireless technology to measure the impact of head injuries emerges, Duarte feels that this technology may become important in the future.
“Scalp and helmet sensors are the wave of the future, although more information and experience needs to be completed. This may also prove to be costly but it would be money well spent,” said Duarte.
And when it comes to heading the ball in adult soccer, Duarte has mixed feelings.
“As a sports fan, I would not consider remove “heading” but would seriously consider the use of a helmet specifically designed for soccer players. These helmets may affect the “type” of heading but would not eliminate it.”
The current consensus regarding the practice of heading among experts in concussion management is that it should be prohibited in children under the age of 14 due to concern for cumulative damage from repetitive sub-concussive impacts. Dr. Robert Cantu, a neurosurgeon affiliated with the Sports Legacy Institute, is a strong proponent of this policy.
Rule changes may also help to increase safety for players. Current rules allow only 3 substitutions per game. If the rules would allow for temporary substitutions for suspected concussions, then teams and players would certainly benefit from a safer and more open environment. Additionally, when a player is on the sideline receiving medical treatment, the team is playing with one less player, making the contest uneven.
According to the Lancet’s editors, “Many sporting organizations now acknowledge the potentially serious consequences of mild TBI and have drawn up new protocols to protect athletes who sustain a head injury”. While the NFL has been forced to change its approach to concussion management as a result of litigation from former players, FIFA has not followed in the same footsteps as yet.
In fact, FIFPro, the soccer players’ union, has called for an investigation of concussion protocols and return-to-play standards following Pereira’s injury. Beyond the players’ concerns, obvious concerns raised by spectators watching the World Cup this past month have pushed FIFA to re-evaluate its management of concussions.
The AAN position statement also explains that schools and athletic organizations need to “consider the potential financial burden athletes and their families incur in order to obtain evaluation of a sports-related brain injury; such costs may prove prohibitive for disadvantaged families. These entities should also ensure that, at a minimum, a concussion evaluation is available to all athletes.”
The AAN position statement along with the Lancet editorial both provide fuel to empower doctors to put patients first--even when doing so draws disapproval from various stakeholders.
Although there will always be demands and pressures on physicians caring for athletes, it is important that doctors uphold their principles and obligations--as patients first and foremost--to protect their immediate as well as long term health.
Barbara Osborn, Media Relations Manager