Full assessments rarely done – but are players at risk?
In the 2014 soccer World Cup, concussion assessment protocols were not followed in more than 60 percent of plays in which players involved in head collisions. These potential injuries were not assessed by sideline health care personnel, according to a study published by JAMA on 27 June.
The consensus statement from the 2012 and 2016 International Conference on Concussion in Sport, adopted by Federation Internationale de Football Association (FIFA), indicates that players showing any feature of concussion should be immediately withdrawn from play and assessed by sideline health care personnel. Such recommendations and their enforcement may influence officiating, coaching, and play of millions of young players.
To evaluate compliance with the consensus statement, Michael D. Cusimano of St. Michael's Hospital, Toronto, and colleagues examined the incidence, characteristics, and assessment of head collision events during the 2014 FIFA World Cup. Trained reviewers identified head collisions through observation of video footage of all 64 matches of the tournament. Any event involving head contact in which a player did not continue playing immediately afterward was defined as a head collision event. Observable effects of the collision on the player (slow to get up, disoriented, obvious disequilibrium, unconsciousness, seizure-like movements, head clutching) were documented as potential signs of concussion.
During 64 games, 61 players had 81 head collisions in 72 separate events. Health care personnel assessed the player in 12 cases (15 percent); 45 players (56 percent) received assessment from another player, referee, or personnel on the field; and 21 players (26 percent) received no assessment. Of the 67 occasions in which players manifested two or more signs of concussion, 16 percent received no assessment and returned to play immediately. Among players with three or more concussion signs, 86 percent returned to play during the same game after an average assessment duration of 84 seconds.
The researchers note that the estimates from this study could be underestimated because video footage follows the play and some injuries could have been missed.
"Soccer players presenting signs of concussion following a head collision event deserve assessment from independent health care personnel to avoid delay of care or further injury. Assessment and management of soccer players suspected of concussion should be improved," the authors write.
While assessments were often not carried out, in this set of collisions there is no evidence that any serious injuries were missed. Soccer players may be slow to get up after a collision for a variety of reasons, including hoping that the referee will award a foul, or to get play stopped if the opposition has the ball (referees are rightly required to stop play where there is a potential head injury to allow for medical assessment). But head trauma is a concern in soccer as in other sports where contact takes place, and as well as collisions there are concerns about potential risks from repeated heading of the ball, something that is unique to soccer.
Sports injury rates are most commonly tracked through records of participants attending accident and emergency departments. One study published last year (Smith et al., 2016) received widespread attention when it was reported that in U.S. youth soccer, the annual rate of concussions and "closed head injuries" per 10,000 participants increased by 1,596 percent from 1990 to 2014. Researchers from Nationwide Children's Hospital and Ohio State University College of Medicine examined data between 1990 and 2014 that represents nearly 3 million children between the ages of 7 to 17 who ended up in the emergency room after playing soccer, with concussions or head injuries accounting for around 7% of total injuries. However, a comment on the article by Berz et al. suggested that this increase could be associated with both an increase in frequency of play over the study period, and much greater awareness of injury risk and thus a greater likelihood of attending clinics. They cite related research by Leininger et al. (2007) that “true injury rates may actually be decreasing.” The commenters argue that “there are many reasons to be optimistic about the brain health of our young athletes based on better recognition of concussions, enhanced emphasis on safety, and new research and prevention priorities.”
Head injury risk must of course be taken seriously, without discouraging the health benefits from sports participation and physical activity. As well as unintentional impacts and collisions, youth soccer in particular needs to monitor and investigate the effects of intentional impacts from heading the ball. Among the most recent research, Stewart et al. (2017) report in adult amateur soccer players that intentional (i.e., heading) and unintentional head impacts are each independently associated with moderate to very severe CNS (central nervous system) symptoms. U.S. soccer has banned heading among young children, while Dawn Comstock of Colorado School of Public Health and colleagues report in JAMA Pediatrics July 13 2015 that athlete-to-athlete contact that occurs during heading is a greater source of injuries than heading itself.
See the literature cited and further reading lists below for more information.
References
Michael D. Cusimano, Julia Casey, Ruiwei Jing, Anamika Mishra, Michael Solarski, Kristina Techar, Shudong Zhang. Assessment of Head Collision Events During the 2014 FIFA World Cup Tournament. JAMA, 2017; 317 (24): 2548 DOI: 10.1001/jama.2017.6204
R. Dawn Comstock, L.A. Pierpoint, J.A. Grubenhoff, S.K. Fields. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatrics, 2015, 69(9):830-837. doi:10.1001/jamapediatrics.2015.1062
Walter F. Stewart, Namhee Kim, C.S. Ifrah, R.B. Lipton, T.A. Bachrach, M.E. Zimmerman, M. Kim, M.L. Lipton. Symptoms from repeated intentional and unintentional head impact in soccer players. Neurology, 2017, 88(9), 901-908, doi: 10.1212/WNL.0000000000003657