U.S. Soccer Chief Medical Officer and Medical Committee Member Speak About Recognize to Recover Program

U.S. Soccer held a Conference Call with media on Dec. 2, 2015 to announce its new Recognize to Recover Initiative, a dedicated program aimed at improving player health and safety. Answering questions for U.S. Soccer were U.S. Soccer Chief Medical Officer, Dr. George Chiampas and U.S. Soccer Medical Advisory Board and Director of Athletic Medicine, Princeton University, Dr. Margot Putukian. Former U.S. Men's National Team player and Athlete Ambassador, Taylor Twellman also joined the call to speak of his support for the Recognize to Recover program. 

Dr. George Chiampas, U.S. Soccer Chief Medical Officer

Opening comments:
“For us at U.S. Soccer and for the players who play the sport, we feel that today is a significant advancement for U.S. Soccer and an opportunity for us to connect with all the youth players and all the players that touch our game. Obviously, the health and safety of our players is extremely important to U.S. Soccer, and as our sport grows significantly year over year, it is important as ever to make sure that our players at all skill levels and all genders are safe as they learn and play the sport each of us loves.

“It's important to realize that for decades, U.S. Soccer has taken significant steps with our National Team players to advance the health and safety of our players. In the last 18 months, U.S. Soccer hired a Chief Medical Officer, which in the National Governing Body (NGB) situation across the United States is somewhat of a rare thing but it's a significant step with regards to investing in our player safety and establishing safe play processes and protocols that take into account their safety. Over the past 18 months, there's been significant movement, dialogue and collaboration. We've co-hosted with MLS a medical symposium, as well as hosted a medical symposium at the NSCAA, the world's largest coaching conference so that we can introduce best practices and protocols to our coaches knowing that those will be implemented across all sports, all players, again guiding safety as our top priority.

“Additionally, we worked with the NCAA in its first ever sports specific medical summit, which was soccer. Those collaborations lead to greater dialogue and greater interest in our sport in the United States which will lead to research opportunities, collaboration and looking at our sport in a way that’s never been done in the United States. We introduced some rule changes, including modifying substitution rules to allow players who may have suffered a concussion during games to be evaluated without penalty, and prohibit heading the ball for children 10 and under and limit the amount of heading in practice for ages 11-13. These rules, like the substitution rule, are significant and allow parents and players and coaches to realize that any player who potentially has suffered a concussion or is dealing with potential concussion symptoms has that assessment and is evaluated prior to returning to play. It is important also to understand that heading, in and of itself, does not cause concussion. Again, heading in and of itself has not shown to cause concussions.

“What we are sharing with you today is the latest in our ongoing effort and design to cement player health and safety at the forefront of our sport and intensify focus and awareness on all aspects of player safety to protect our athletes and grow our sport. Recognize to Recover, or R2R, is our national safety program which we are announcing today. It's the first of its kind player health and safety program in soccer in the United States and we're excited to announce it. It aims to reduce injuries in soccer players of all ages and promote safe play, as well as educate players, coaches, parents, and referees. We feel that by elevating player health and safety above the game and bringing all of our health and safety efforts into this one powerful program, we believe that R2R will be a leader in this area and allow deeper understanding of player health and safety and the role parents, players, coaches, and officials play in protecting our youth athletes and our pro-athletes across the country.

“It's a comprehensive program with best practices. There are some areas of initial focus. We've developed our first ever soccer specific heat guidelines in the United States. We intend to implement that and disseminate that through R2R. There are protocols on concussions and head injuries, highlighting how to identify players who have signs and symptoms and the process for players to return to play. R2R will emphasize the basics, proper techniques, good sportsmanship, safe play, and identifying signs and symptoms of injuries. We will do that through educating our coaches, allowing our coaches who have this expertise to disseminate those best practices to coaches across the United States. As part of R2R we are sharing guidelines with our membership regarding head injuries and potential head injuries. These are intended to give direction when dealing with head injuries during soccer participation. While some guidelines are mandatory, others are recommendations or informational in nature. We feel that these guidelines coming from U.S. Soccer in this capacity and in this platform will impact our membership organizations and state associations across the United States, allowing consistent and best practices in quality of care for our athletes.

“Finally, we intend for R2R to become visible on and off the field in the coming months. We are committed to our membership and we are committed to highlighting Recognize to Recover as a culture within our sport. This is only the beginning. We'll have more to come in the weeks and months ahead and realize that our work is beginning. This is a step in that direction.”

Dr. Margot Putukian, U.S. Soccer Medical Advisory Board; Director of Athletic Medicine, Princeton University

Opening comments:
“It’s surely a pleasure for me to be here, and as a former college player and coach and current team physician in sports medicine, I really applaud the Recognize to Recover program. I've been involved with U.S. Soccer for a long time. I think what this program does is really comprehensive, it pulls together and incorporates all of the sports and health and safety initiatives that U.S. Soccer has had over the years for its National Teams and brings it all together and tries to bring it to the youth players. It's very inclusive of all the partners and including the athletes themselves, the coaches, the referees and the medical staff, it's very proactive in terms of supporting prevention efforts which are really important for not only concussion but also injury and illness. I've been really pleased and privileged to be a part of the U.S. Soccer sports medicine advisory committee, and one of the things that we addressed maybe 18 months ago was really looking at the issue of concussion and head injury in soccer, and reviewing the literature and trying to determine where there are areas where we can make a difference and decreasing this injury, especially in our youth players.

“Unfortunately there's not much data for the youth player as it relates to head injury, but certainly what we were able to determine is that aerial challenges account for a fair a number of these injuries, about 50-60 percent, and often times heading is a component. That's part of the reason our committee determined that trying to limit the heading at the younger ages makes sense and allows for development of other components of the game and skill development and technique in terms of those types of guidelines. I certainly support the changes that have been put forth, understanding that we need a lot more research as it relates to determining what forces occur during the sport of soccer. Overall it's a really safe sport that already enjoys a very low injury profile currently, but I think these efforts are really only going to make us stronger and make it a better sport.”

Taylor Twellman, former U.S. Men’s National Team player and Athlete Ambassador

Opening Comments:
“I feel honored and privileged first and foremost to be a part of this. On a personal level, I thought at age 25 that everyone would remember me as a player, but I now know my purpose in life has turned into an advocate of player safety. As a former player, and more importantly as an advocate of player safety regarding traumatic brain injury, I am very pleased that U.S. Soccer is taking a leadership role in putting this first and foremost. The most important thing that needs to be said is that this program is evolving. As data comes out so does this program evolve. I think that's the most important thing for all of us to realize, is that this program will evolve, it will change, it will only improve and I feel very privileged to be a part of it.”

On whether heading the ball directly leads to concussions:
Chiampas: “What we're trying to say is that purposeful heading has not shown to this day scientifically to lead directly to concussions. Now, with that being said, we're following the research. As the research comes out we have the adaptability within U.S. Soccer to adjust as needed. The changes that we made are based on expert opinion at this point. What we do know is   the majority of concussions that do occur are in areas of foul play and areas where players collide. Again, we're learning more and more; however, this decision and this direction was made on highlighting player safety in our sport, especially in our youth levels, and providing an opportunity where if there's a suspected head injury that player has an opportunity to be evaluated and assessed.”

On whether girls suffer more concussions than boys, and if so should there be different rules for each:
Putukian: “It’s interesting the data as it relates to boys and girls or men and women for soccer, and there is certainly an increase incidence of reported injuries in girls and women compared to men. But the reasons for that we're not exactly sure of. It may be related to the fact that girls and women are more likely to report their injuries. It may also have something to do with the neck girth and mass of men and boys compared to women and girls. There are a lot of different factors at play in terms of the differences there.  But most of the research as it relates to the incidents of concussion show they are related to the aerial challenge more so than the ball. Very few  - you never say never - can occur with these mechanisms [of directly heading the ball]; the most common mechanisms are an elbow to the head, or a head to the head, or a head to post, or a head to the ground that occurs in the process of just going up for a challenge.”

Chiampas: “Recognize to Recover allows us to look at ways to protect our players, and so if we know that core strengthening or neck strengthening is a critical component in player safety then we have the opportunity to incorporate that in coaching education at a broad high level and then disseminate that down so that we make sure that it's touched upon across all players in the United States.”

On how U.S. Soccer arrived at the age-specific limitations on heading given there is little data on youth players:
Putukian:  “It's a great question. There is a paucity of data, but at the same time we are trying to use common sense. We recognized when we met as a committee that with young kids a lot of times they don't see the ball that often and most of the time it’s not up in the air. There's also motor development that occurs in the 11, 12, 13-year age group in terms of whether or not athletes have that strength [as it relates to aerial challenges]. So it was a matter of trying to look at common sense, knowing that the aerial challenges happen to be one of the culprits, and then saying that translates to looking at ways to limit or set parameters on heading. In other contact sports like American football, you can do that by saying we're going to limit the number of contact practices. For the sport of soccer we're trying to find ways to draw analogies to say ‘how can we pull out the high risk behaviors in the sport as it relates to concussion?’, and that's where that aerial challenge and specifically heading came into play.”

On whether it’s fair to describe this is as a “better safe than sorry” approach:
Putukian: “I think that’s a fair way to describe it. We are saying how can we maintain the integrity of the game based on what literature we have currently, but then at the same time potentially decrease those aerial challenges where we know injuries can and do occur. This is a big, bold step for soccer in the United State and the decision to make these changes for the safety of our players is of the utmost importance. As research becomes available you can never ignore research. So we have that adaptability to adjust as it comes forward.”

On how these new rules will be enforced in the places where they are mandated:
Chiampas: “We want to establish guidelines, and we want to establish safety as the key pillar here. Yesterday we conducted a webinar with our member organizations yesterday to outline these new rules. Our goal here in U.S. Soccer is to be able to work with our member organizations through these rules to be able to support them and be able to answer questions for them. We've been able to support them in areas that they were looking to go from a safety perspective, and that guidance has already been significant.”

On what parents or coaches should do if they see rules that are being violated:
Chiampas: “We hope that common sense prevails. We hope that as a group, everyone that touches the game we all take responsibility. We need athletes to be responsible for not only themselves but for their teammates. If they see one of their teammates potentially injured, they need to step up and look out for them. We need parents to have that same keen sense of awareness. We need coaches to advocate for athlete safety and we need referees to do the same thing. So for now we're looking at common sense, and we will be encouraging that and working with our member organizations again highlighting player safety and wellness as our top priority.”

On what parents, coaches and volunteers can do to help implement these guidelines:
Putukian: “I think that part of it is just being educated, and there's going to be a lot of information available on ussoccer.com as it relates to health and safety initiatives and health and safety issues that we want our parents to be very well aware of. We want them to look and make sure that they have an emergency action plan for their program. We want them to try to if at all possible take into account the guidelines as it relates to key issues, like understanding the common signs and symptoms of concussions and making sure if their son or daughter experiences any of those symptoms that they don't continue to practice or play but that they are evaluated by a healthcare provider. I think those are the key components that I can see from a parent's perspective.”

Chiampas: “I think what's critically important is to realize that we want our kids to exercise, we want our kids to have the ability to be a part of a team, to be able to be fit because we know the benefits as medical providers of what that all means physically, mentally, and from a leadership perspective. At the same time, U.S. Soccer wants to implement all safety measures that we can. From a parent's perspective, I think the key thing is awareness. There's a lot of misinformation in the community in the United States, and what U.S. Soccer is moving forward with Recognize to Recover is creating a platform where parents can go to get answers. Specifically in the area of a concussion for example, what are the expectations? What are the signs and symptoms? What should I be looking for in my child? Then if that injury occurs, providing them resources and especially a return to play process that allows that player to return safely, not prematurely, allows them to recover and then gradually return them back into the game that they love to play. So awareness is a key thing.”

On whether the use of head gear was considered in the discussion about rule changes:
Putukian: “There's a lot of concern as it relates to the media hype around some of these products without having good research to tell us that number one, if they're effective, and number two that they are not harmful. You don't want players to have a false sense of security with a product that might not only not prevent them from concussion, but might actually make things worse. There is some data that suggests that that acceleration forces that you see with head gear may be increased, especially with girls. We did take into account all of those different components. I think the other part of this is that is getting lost is that the focus for a lot of the programming is really on a best practices for concussion management recognition and treatment. Those really are part of what we want to be the focus.”

Chiampas: “With the Recognize to Recover program, we'll share that type of information with parents because we want our parents to have the most up-to-date information. Currently across sports like football and hockey, head gear is not shown to prevent a concussion and it's important that our media outlets and individuals like Taylor keep messaging that information so that there's not a false sense of security. They may prevent skull fractures and those types of injuries, but we have to be responsible in our messaging and Recognize to Recover hopefully will create a space for parents as well to receive that type of information.”

On whether other Federations around the world are utilizing these types of rules regarding heading and concussions:
Chiampas: “That’s a good question. Realize that U.S. Soccer works collaboratively and is a part of the medical conferences and committees in our sport. We're extremely engaged. Recently you may have seen the [English] FA announced their concussion guidelines. We work closely with MLS as well as FIFA, and there's dialogue amongst all of us.”

On whether the recent litigation had any impact on the implementation of these new procedures and initiatives:
Chiampas: “What I can tell you is that U.S. Soccer for years has implemented processes and protocols for the safety of all its National Team players. The fact that a chief medical officer was hired 18 months ago was another significant step. These guidelines that were created about six or eight months ago were the first of its kind in soccer. What U.S. Soccer is committed to is overall safety of the kids that play the sport of soccer. So this is something that's been continuous for years past, and now Recognize to Recover is becoming a platform where we feel we can disseminate that messaging all the way down to the youth players.”

On the role of referees in the concussion protocol process:
Chiampas: “Obviously the referees have a significant role here. First, there's going to be an educational process where our referee program is going to be engaged and involved here, making sure that our referees are educated on the types of injuries can occur in the game of soccer. The rules that we've created also are there to support the referees. For example, the substitution rule is a rule where that if there's a suspected concussion the player is to be removed from play, and the only way they can return to play that same day is if there is a healthcare provider on site that is able to assess that player. So that in and of itself is a significant step forward and supports referees in that capacity.”

On where the new rules apply that require that a health care provider be on site for games:
Chiampas: “We've placed language in where it's mandatory in the Development Academy as well as our Youth National Team games, and we've additionally mandated and required it for our large tournaments in member organizations. Mind you, that's a big safety push because it encompasses all types of injuries. It encompasses head injuries, falling, safety and emergency action plans, cardiac issues, and overall making sure that our players are safe and in an environment that takes that into account.”