As part of our continuing effort to service and educate our membership, each Thursday the U.S. Soccer Communications Center will send out an informative article from one of its departments. Once a week, we will post an article/paper/essay that will hopefully enhance your enjoyment and knowledge of the game of soccer - on and off the field.
This week, an article by members of F-MARC (FIFA Medical Assessment and Research Center) examines their first findings from an in-depth study of head injuries and soccer. This article was first posted on www.fifa.com.
F-MARC PRESENTS ITS FIRST FINDINGS
Recent media articles have focused on the issue of head and brain injuries, and on possible long-term changes to cerebral functions after repetitive injuries. F-MARC (FIFA Medical Assessment and Research Center) has looked into this issue and presents its first findings.
As little scientific literature is available concerning head injuries, F-MARC based its results mainly on surveys conducted at FIFA competitions, starting with the 1998 World Cup and including events for both male and female players, as well as for different age groups. A total of 10,155 playing hours in 398 matches were taken into account.
The statistical data and findings were presented at the first International Conference on Concussion in Sport, held in Vienna in November 2001. This event was organised by FIFA together with the International Ice Hockey Federation (IIHF) and International Olympic Committee (IOC). The lowest occurrence of injury was registered during the 1999 Women's World Cup, with 39 injuries per 1000 playing hours, whilst the highest rates occurred during the FIFA World Youth Championship 2001 (143) and the FIFA Futsal World Championship in 2000 (190).
Head injuries during soccer matches (127 in total) accounted for approximately 15% of all injuries during FIFA tournaments, but as few as 14 concussions (1.4 per 1000 playing hours) were registered. What is more, these concussions were all due to contact with another player and not because of heading the ball.
Major concerns continue to be voiced over potential brain damage due to concussion. However, injuries that result in the structural damage to the brain tissue are extremely rare and usually occur only after severe head-to-head or elbow-to-head collisions in the facial or parietal region.
More common are mild head injuries, which result in what we commonly refer to as concussion. The Concussion in Sports Group (CISG) developed a definition for the state of concussion. The traditional stance, which takes loss of consciousness as the primary measure of injury severity, has been replaced by a renewed interest in the role of amnesia (loss of memory) and its manifestation as part of the measurement of injury severity.
Signs and symptoms of acute concussion
If any of the following symptoms are spotted they may indicate a head injury or concussion, and the physician or coach should take appropriate steps. Note that a player does not need to lose consciousness to have suffered a concussion.
a. Cognitive features: Unaware of period / opposition / score of game / time, date and place, confusion, amnesia, loss of consciousness
b. Typical symptoms: Headache, dizziness, nausea, unsteadiness/loss of balance, feeling "dinged", stunned or "dazed", "having my bell rung", seeing stars or flashing lights, ringing in the ears, double vision. Other symptoms such as sleepiness, sleep disturbance and a subjective feeling of slowness and fatigue in the wake of an impact may indicate that a concussion has occurred or has not been resolved.
c. Physical signs (may be observed when examining a player): Loss of consciousness / impaired conscious state, poor coordination or balance, concussive convulsion / impact seizure, gait unsteadiness / loss of balance, slow to answer questions or follow directions, easily distracted, poor concentration, displaying unusual or inappropriate behaviour (e.g. running in the wrong direction), significantly decreased playing ability.
The team physician, or responsible paramedical personnel, should perform an on-site examination of players with suspected concussion, including simple neuropsychological tests (e.g. attention and memory functions tests). Abbreviated testing procedures performed on the sidelines are not meant to replace comprehensive neuropsychological testing.
Neuropsychological testing is one of the cornerstones of concussion evaluation and contributes significantly to both the understanding of the injury as well as the management of the individual player. To maximise the clinical utility of such neuropsychological assessments, a baseline test is recommended (the "performance" and capabilities of the fully fit athlete are assessed later on to uncover potential discrepancies).
Neuroimaging, such MRI and CT scans are commonly performed at specialised hospitals. Another diagnostic tool is the analysis of biochemical serum markers, such as S100B, occurring after brain injury. Genetic studies have also proved to be beneficial to the understanding of traumatic brain injuries.
"When in doubt, sit them out!"
There are no clear rules or guidelines as yet to indicate when to return to play, since the team physician or person responsible has to deal with each case of suspected concussion on an individual basis. However, if a player shows any symptoms or signs of concussion as previously described, the following recommendations are made:
- The player should not be allowed to return to play in the current game or practice session.
- The player should not be left alone; regular monitoring for deterioration is essential.
- The player should be medically examined following injury.
- Return to play must follow a medially supervised stepwise process.
A player should never return to play while showing symptoms: "When in doubt, sit them out!"
Return to play following a concussion follows a stepwise process:
- No activity, complete rest. Once asymptomatic, proceed to level (2).
- Light aerobic exercise such as walking or stationary cycling.
- Sport specific training (e.g. skating in hockey, running in soccer).
- Non-contact training drills.
- Full contact training after medical clearance.
- Game participation.
The player should only continue to the next level if symptom-free at the current level. If any post concussion symptoms recur, the player should drop back to the previous level and try to progress again after 24 hours.
Prevention and education
Fair play and strict enforcement of the Laws of the Game are the key factors in reducing and preventing concussion. In particular, elbowing opponents must be severely sanctioned as these kinds of blow cause the most serious injuries.
There are relatively few methods by which concussive brain injury may be minimised in soccer. Helmets have been discussed as a means of protecting the head and theoretically reducing the risk of brain injury. However, no helmets designed for soccer players have proven to be of any advantage in reducing the occurrence of such head injuries. Some researchers even believe that the use of protective equipment such as helmets may have a negative impact on playing behaviour and may actually increase the risk of head and brain injury.
Concussion in sport may have partially serious neurological, mental and psychosocial consequences and may totally change the life and career of the athlete. This fact makes it necessary that rules be strictly adhered to and that special training be given to match officials. The management of athletes with head injuries and the decision as to when to allow them to return to play remains largely a matter of medical discretion. Cases are evaluated on an individual basis.
Sports doctors and other medical attendants of the players have a special relationship with their athletes ("position of being a guarantor"). Coaches may also belong to this category and may be considered responsible for the well-being of players and their fitness.
Consequently, a person who holds the position of guarantor has superior knowledge of the consequences of an injury like concussion. If this person omits to take a player out of the match, he or she may be committing an offence by failing to lend the necessary assistance based on their aforementioned superior knowledge. That person will therefore have to accept the consequences should they be found liable for their actions.
Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathological and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:
- Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an 'impulsive' force transmitted to the head.
- Concussion typically results in the rapid onset of short-lived impairments to neurological functions that resolve themselves spontaneously.
- Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
- Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.
- 5.Concussion is typically associated with grossly normal structural neuroimaging studies.
PROF. DR. JIRI DVORAK, PROF. DR. TONI GRAF-BAUMANN and DR. ASTRID JUNGE are members of F-MARC and they work in the Schulthess clinic in Zurich. PROF. DR. KAREN JOHNSTON is a neurosurgeon at the McGill University in Montreal (Canada). Dvorak and Graf-Baumann are also members of the FIFA Sports Medical Committee.