conor little b00047775 cctplr document january 2015

The Current Understanding of Concussion in Soccer and Similar Contact

Sports

Conor Little B00047775

Department of Business

School of Business & Humanities

Institute of Technology, Blanchardstown

Dublin 15

Minimum word count for this assignment: 5,000 Words

Maximum word count for this assignment: 7500 Words

Actual Word Count: 5,971 Words

Sports Management & Coaching

Contemporary Coaching Theory & Practice

Gary Bernie

16th January 2015

http://www.itb.ie/homepage.asp

The Current Understanding of Concussion in Soccer and Similar Contact Sports

Table of Contents

1. Introduction to Concussion...............................................................................................................1

2. Research Findings..............................................................................................................................3

2.1 Concussion Rates in Soccer..........................................................................................................3

2.2 Mechanisms and Variables of Concussion...................................................................................5

2.3 Knowledge of Concussion and Symptoms in Soccer....................................................................7

2.4 How to Reduce On-Field Concussions..........................................................................................9

3. Conclusion.......................................................................................................................................13

3.1 Discussion..................................................................................................................................13

3.2 Recommendations for Further Research...................................................................................15

3.3 Limitations of Study:..................................................................................................................16

References...........................................................................................................................................17

Appendices:............................................................................................................................................ I

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Table of Appendices

Appendix A – Cantu Concussion Grading Scale...................................................................................I

Appendix B - AAN Practice Parameter Grading System for Concussion..............................................I

Appendix C – Nelson Grading System for Concussion.......................................................................II

Appendix D – Roberts Grading System for Concussion......................................................................II

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1. Introduction to Concussion

Concussions and Traumatic Brain Injuries (TBIs) have long been identified as an area of serious

concern when treating patients due to potential short and long term effects. Concussion derives

from the Latin word, concussus, which means to shake violently. The term concussion was first used

by physician Petri de Marchetti in 1665, as he defined the condition as being “transient with a short

duration of alienation of the mind, with privation of sense and motion.” The current and most widely

accepted definition is from the American Academy of Neurology (1997) and they define concussion

as; “Any trauma-induced alteration in mental status that may or may not include a loss of

consciousness.”

The WHO (World Health Organisation) estimated that as many as 89% of mild traumatic brain

injuries go unidentified, making exact numbers very difficult to reproduce and that the estimated

cost to the economy of TBIs is upwards of $12 billion a year, which includes the cost of hospital

admittance and time lost from work (WHO, 2013). Concussion and TBIs are known to be the cause of

both short term cognitive defects and long term neurological problems, which is more prevalent in

cases of multiple injuries.

Sport is the second most common aspect from which TBIs occur with a reported 1.6 – 3.8 million

reported sports related concussions annually (Conidi, 2012). This number is more likely higher with

the majority of concussions suffered not reported by the athletes due to the inability to identify the

symptoms of TBIs. The Centre for Disease Control and Prevention (2013) state 3.8 million sports and

recreational TBIs occur each year in the USA, but these only include athletes who lose consciousness

and only 10% requiring hospitalisation. Since the loss of consciousness is only seen in approximately

10% of all concussions, the real number is believed to be ten-fold.

Due to inability to identify sporting concussions, second and third concussions are more likely to

occur causing slow neurological recovery and future, persistent cognitive and behavioural

deterioration (Jotwani, 2010). This deteriorating disease, known as Chronic Traumatic

Encephalopathy (CTE) is caused by sustaining multiple concussions and can currently only be

established post mortem. This was first identified by Martland (1928) and has reported symptoms

such as dementia, confusion, depression and loss of motor skills. In at least 17% of cases of multiple

concussions, the individual develops CTE (Roberts, 1990).

Recent media interest in concussion and traumatic brain injuries is currently at an all-time high, since

the release of Steve James’ documentary ‘Head Games’ in 2012, which was based on the interview

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with the parents of American football player Owen Thomas, who took his own life following

sustaining major brain damage during his college football career. Concussion(s), often referred to as

the ‘silent injury’ the very mild symptoms which can follow and be missed, are a concern for many

sporting bodies worldwide but primarily those involving a high quantity of athlete to athlete contact

(King, 2014).

Football, or soccer, is considered the world’s most popular sport with 207 member associations and

265 million registered participants worldwide, in addition to five million referees and officials,

meaning that up to about 4% of the world’s population are involved in the sport (FIFA, 2006).

As part of the sporting consortium that developed the SCAT 3 test (Sport Concussion Assessment

Tool), FIFA to this date have failed to implement this at grass root or elite level soccer around the

world. While many forward thinking sports have adapted the recent findings about concussion and

concussion assessment into their rulings, soccer has not changed in a similar way. With still no side-

line assessments or knowledge being delivered to coaches regarding the potential long term risk to

athletes and their state of mind, the question is asked, “Where is soccer in relation to concussion

prevention and assessment compared to other contact sports?”

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2. Research Findings

2.1 Concussion Rates in Soccer

Competing in contact sports potentially exposes each athlete to a 19% chance of experiencing a

concussive episode per season (American Academy of Neurology, 2012). With the rate of concussion

within sport growing at a rapid rate (4.2 fold since 1998) in high school athletes (Lincoln, 2011), an

international consensus among all sports should be developed to lower this estimate and increase

knowledge of the injury throughout the sporting world.

While soccer was never viewed as a high risk sport for TBIs, it is reported that as high as 22% of all

soccer injuries are concussions, higher than other sports perceived as more violent such as ice

hockey or American football (Covassin, 2003). This figure may not directly represent figures of all

concussions received in the outline sports as numerous cases of concussion are unidentified and

undiagnosed, leading to uncertain numbers. Delaney (2001) diagnosed that only 29.2% of concussed

university soccer players were actually aware they had suffered a concussion due to the inability to

identify its symptoms.

With a 4.2 fold increase in high school sporting concussions per athletic exposure between 1998-

2008, the trends, “showed an overall increase of 16.5% in concussion rate annually over the past

decade in both boys’ and girls’ sports, with a substantial increase in rate beginning in 2005” (Lincoln

et Al., 2011). The question is what has occurred in since 1998 to warrant this drastic increase?

The increasing injury rates in soccer and comparably high concussion rates in American football and

hockey is accepted by most academics in generalised context. With studies showing a higher

percentage of soccer players receiving one or more concussions in a season than American football

(46.2% and 34.1% respectively), soccer has to be viewed in the same context as these higher contact,

helmet protected sports (Delaney et Al., 2001).

Lincoln (2011) delved further into sporting concussion rates and analysed how gender differences

play a key role in concussion injuries, with girls and women at a higher risk than their male

counterparts. Lincoln showed that rate of concussion per 1000 athletic exposures was almost double

in female as in males in high school athletes. This finding by Lincoln compliments that of Delaney et

al. (2007) who stated adolescent girls had an adjusted relative risk of 1.97 compared to their male

counterparts. This higher risk is associated with a difference in the mechanisms of concussion, as

discussed further in section 2.2.

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Dick (2009) also proposed that the differences in concussion rates between the genders could be

hormonal as well as biomechanical, with females more willing to come forward with their symptoms

than male athletes. Western cultures are established as being more protective of their female

athletes and, thus, treating their head injuries more seriously and delaying their return to play

(Gessel et Al., 2007). On the contrary, males do not wish to report concussion or concussion

symptoms at fear of being withdrawn from competition (Delaney, 2001). Not identifying the

symptoms of concussion to medical staff may result in the athlete sustaining multiple concussions.

Delaney’s 2001 study among university soccer players showed that of the players who suffered

concussion in a season, 33.3% of them received three concussions.

There is conflicting evidence surrounding which age bracket is most effected by concussion, due to

structural differences, youth athletes are at more risk due to anatomical deficiencies. (Why?)

Nevertheless, concussion rates in collegiate athletes have been seen to be higher than in high school

athletes but concussions represented a higher percentage of all injuries in high school athletes

(Gessel et Al., 2007). Delaney et Al. (2007) indicated that 47.8% of the adolescent players studied

had experienced concussion-like symptoms. With the rate of concussion on the increase and with

literature, including Delaney et Al. (2001), suggesting that an increase in age and standard of play is

directly proportional to injury increases, a gap in literature is clearly identified.

With many academics arguing over positions most at risk, most, including Delaney (2001), agree that

the goalkeeper is the highest risk position to sustain at least one concussion in a season due to high

velocity shots, increased time spent on the ground around other players and the technique of diving

onto the ground. This correlates to Boden et Al. (1998), who suggested goalkeepers were at highest

risk. Further studies conducted by Delaney et Al. (2007), however, show that at an adolescent age,

defenders were the most susceptible to suffer multiple concussions in a season. This may be due to

the amount of opportunities to head the ball or an increase in physicality when defending.

While carrying out case studies, the CDC (1994) also identified an increased risk of brain injuries to

goalkeepers due to proximity to goalposts. They identified 27 injuries involving goalkeepers and

falling goalposts across a four year period, 18 of which were fatal. Correct installation and

management of goalposts is a must for all clubs/teams and minimum safety guidelines as provided

by the manufacturer should be followed and adhered to. Incorrect use of equipment or non-

conformance to internationally approved guidelines can be seen as a major cause of concussion in

young athletes and correct equipment management will be further discussed in section 2.4. The

evidence therefore shows positions on the field strongly impact the likelihood of sustaining a

concussion or TBI and therefore must be noted in the preventative measures.

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2.2 Mechanisms and Variables of Concussion

With soccer being a multi-directional field sport involving little required protection, collisions,

lacerations and trauma are common. Identifying the ‘mechanisms’ of concussion in soccer is a big

first step to outlining preventative measures.

A number of studies (Delaney, 2006, Dick, 2007, Agel, 2007, etc.) have all issued compelling

arguments surrounding how these brain traumas are caused during general play in soccer. The

Journal of Athletic Training published a review of men and women’s soccer stating that 80.6% of

head injuries and TBIs occurred from player to player contact. The majority of academics accept

concussion mainly result from head to head contact between opposing players or players from the

same team, with elbow to head the second most seen. This is due to the arms and elbows rising high

to enable a player to increase vertical momentum and, ultimately, jump higher.

These concussive injuries occur predominantly within the penalty area and across the midfield line

(Kirkendell, 2001). This would leave us to suggest that the players involved in these areas are of

goalkeepers and midfielders. The midfield rate of injury is high as it is in direct proportion to the

number of aerial battles contested there.

An area of major debate across youth level soccer, worldwide, is the rate of injury occurring from

‘heading’ the ball. With little recent research carried out it is widely accepted that heading and

heading rates, an average of six to seven headers per game as found by Jordan et Al., (1996).

However, as expressed by Levy et al., (2012), these numbers do not include similar occurrences that

happen during practice or training. This overall number remains unidentified in literature and should

be found for correct comparison.

Long and short term neurocognitive impairment in soccer players relating from incidences of

heading the ball have been long identified by academics. Matser et Al. (2001) declared a dose-

response relationship between the number of headers in a season (which was estimated at around

800) and the degree of impairment by testing attention and visual/verbal memory. This finding

indicates the direct relationship between contact between the head and ball in the form of heading

and neurocognitive defects. (Levy et Al., 2012)

While these defects are accepted by a number of academics, Kirkendall et Al. (2001), suggested

these studies to be flawed, methodologically, as it did not note or control key factors such as aging,

alcohol consumption or previous head injuries, all of which effect long term cognitive responses. The

repetitive nature of heading may have a cumulative effect on neurological or cognitive impairment,

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but it remains to be determined (Levy et Al., 2012). However, it has been identified that in elite

players, using computer based neuropsychological testing, no evidence of cognitive impairment

associated with heading exposure with heading and concussions weakly linked through the cases of

intense aerial battles (Straume-Naesheim et Al., 2005), which is in stark contrast to Matser et Al.,

(2001). Straume-Naesheim’s findings are concurrent with Boden et Al. (1998) who found, out of 29

soccer related concussions, zero were caused by heading the ball.

The gender difference, as referenced in Section 2.1, is also of importance when discussing

concussion and TBI mechanisms. Dick’s research of literature (2009) showed that females suffer a

higher percentage of head to ball/surface contacts that result in concussion than their male

equivalents. With this difference in mechanism, further research is needed to identify if this leads to

a difference in the outcomes of TBIs.

While head-to-head contact can be seen while competing to win a fair ball, it is increasingly being

seen in a violent light, with more players being removed from the game due to headbutting others.

This has recently been picked up by FIFA and national bodies with them now issuing three game

suspensions and financial penalties at elite level (Volker, 2012).This intentional act to cause harm

occurs on a weekly basis at amateur level and is very difficult to eradicate if not stopped at a young

age.

Athletes themselves should be made aware in an educational environment of the variables which

can increase the relative risk of sustaining a TBI. Variable tables for soccer were established by

Delaney in 2001 and revised in relation to concussion prevention in 2007. He notes how years of

experience and chronological age can decrease your risk of concussion (0.92 & 0.99 respectively),

but how playing a summer outdoor season can increase your risk by 4.71 times and an 11.12 odds

ratio increase if a previously recognised concussion from soccer had been sustained (Delaney et Al.,

2001). He added in his 2007 study how not wearing headgear protection increases relative risk by

2.65 times. While these can be viewed as numbers on a page, Delaney has made it clear these are

the factors which increase the risk of sustaining a possible life threatening injury. While Delaney lists

previous concussions as a considerable risk, through their computerised neuropsychological testing,

Straume-Naesheim et Al. (2005) identified no relationship between cognitive impairment and

number of previous concussions.

With the knowledge of these mechanisms of injury, International Ruling Bodies such as FIFA, and

National Governing Bodies like the FAI, have begun to change rulings and equipment to enhance

player safety, but are they moving quickly enough?

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2.3 Knowledge of Concussion and Symptoms in Soccer

As previously stated, a lack of knowledge and information within coaching structures, athletes and

governing bodies is of major concern to athlete safety regarding TBIs. If concussion is not identified,

the athlete will return to play prematurely, possibly resulting in double-impact syndrome or a

second, more fatal, concussion. (Delaney et al., 2001)

Delaney also concurred with several other studies (Broglio, 2010), (Shenouda, 2012), (King, 2014)

that the players showed a lack of knowledge and the inability to recognise concussion. Delaney

reported that of all who suffered concussion in a season, only 14.9% of the athletes realised the

symptoms they experienced represented concussion.

Shenouda et Al. (2012), showed that an educational programme for coaches, athletes and others

involved in sport has a positive effect on the correct diagnosis for concussions and therefore the

return to play decision is not made too soon, or without correct knowledge of the injury. This lack of

knowledge or inability to identify concussion symptom is scattered throughout literature. This is

very evident as up until the late 1990’s; loss of consciousness was used as the primary indicator of

concussion, although loss of consciousness is only seen in 10% of all cases (Guskiewicz et al, 2000).

With medical staff within soccer mainly using athlete reported symptoms (Broglio et Al., 2010), the

naivety of athletes to symptoms of concussion is of particular worry and is evident throughout

research. Over half of concussed athletes fail to report their concussion due to the fact they did not

feel it was serious enough to report (63%). (McCrea et Al., 2004) The findings gathered by McCrea et

al., were reconfirmed by Broglio et al., in 2010 as they conducted a survey for Italian soccer and also

found the main reason for not reporting concussion was it was not viewed as a serious enough

injury, with 62.1% not reporting the injury also.

The lack of understanding of the severity of concussion and grasp of its minor and major symptoms

is a major factor in the high rate of unidentified and unreported concussions. With LOC considered

the hallmark of concussion up until recently and with diagnoses relying on self-reporting from

athletes, many were missed. With other, less pronounced, symptoms overlooked such as the

physical factors i.e. lack of balance, sensitivity to light and/or noise, drowsiness and also

psychological factors like personality change, memory problems, poor concentration and

inappropriate emotions (CDC, 2013).

Cantu’s grading scale (2001) suggests the best indicators for the severity of a concussion to be depth

and duration of unconsciousness but mainly the duration of PTA (Post Traumatic Amnesia). In light

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of this, The Journal of Athletic Training (2004) created a Graded Symptom Checklist, which should be

completed by a medical professional over a period of time i.e. from the time of injury to 72 hours

post injury and symptom severity is graded from 1 to 6, with six being the most severe.

A change in legislation or rulings by government or National Governing Bodies (NGBs) is an effective

way of increasing the general knowledge of TBIs in sport and preventing athletes from returning to

play prematurely. This naiveté amongst coaches, athletes and others involved in sport can be

altered, as seen currently in Washington State, USA. The introduction of the Lystedt Law, 2009,

requires coaches, parents and youth athletes to be educated about concussion prior to practice or

competition. The knowledge of those involved was monitored by Shenouda et Al. (2012), and

findings exhibited a good general knowledge throughout those involved at youth soccer in

Washington State, but gaps in the knowledge, and lack of practical awareness for preventing

concussion still exists. However, a lack of a pre legislative baseline or control to assess whether or

not an increase in knowledge can be seen as a result was a clear limitation to their study. With many

states passing or in the process of passing similar laws in an effort to reduce concussion in

adolescent athletes, a more educated coaching and volunteer force will be seen throughout the

USA.

If this law can increase the knowledge of coaches, athletes and parents alike, a similar, worldwide

ruling can be rolled out by FIFA or each country’s NGB. This knowledge will help identify more

concussion and thus stopping the possibility of premature return to play.

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2.4 How to Reduce On-Field Concussions

With major advancements in technology to prevent and identify concussion and TBIs, these medical

technologies can be adapted to integrate into a sporting programme or competition. Methods of

preventing and assessing sustained concussion are implemented in certain sports globally but not in

others. While sports and activities are funded in different ways, this is shown in their advancement

towards the prevention of concussion. While certain organisations, like the Rugby Football Union

(RFU), the National Football League (NFL) and the National Hockey League (NHL) are constantly

conducting or being involved by academics into the latest research surrounding injuries and long

term defect prevention (Levy et Al., 2012). However, other major Governing Bodies such as FIFA are

not making a similar effort.

This section is to identify the preventive methods, as identified by academics and FIFA’s willingness

to adapt to protect their players in relation to other sporting bodies. With evidence based and

accepted assessment methods such as the SCAT3, the Child-SCAT3 and the King-Devick Test, a

minimum of one should be conducted in the event a potential concussion occurring on the field of

play. The King-Devick test is an ocular motor, visual and cognitive test with the ability to monitor

brain function. This test can, not only indicate signs of a sustained concussion but also can assist in

the detection of other neurological aliments such as Parkinson disease, hypoxia and multiple

sclerosis. The reasons for the deviations in concussion management are a lack of concussion

knowledge and confusion about the many available public guidelines related to concussion (King et

Al., 2014).

While this is acceptable for initial concussion identification, a full clinical examination involving

cognitive, balance, optic and muscle tests against baseline scores should be conducted by fully

qualified medical staff (Broglio & Guskiewicz, 2009). This full clinical testing is impossible to provide

for all levels as Broglio identifies but he developed a system of best practice to help reduce guideline

confusion. These clinical assessments will allow medical staff to grade the severity of the TBI using

the Cantu Grading Scale. The scale, consisting of three grades, with grade three being the most

severe with signs of loss of consciousness of greater than 5 minutes and/or amnesia greater than 24

hours will help professionals in the return to play decision for the athlete (Cantu, 2001). With eight

recognised and peer reviewed concussion grading scales, this is where the confusion as identified by

King. An example of these grading scales, as adapted by Cantu (2001) can be seen in the Appendices

from A-D.

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While these assessment methods within the sport can identify concussion, medium and serious

cases of head injury are clinically treated including hospitalisation. For this, the NHS has updated

their NICE guidelines for head injury (2014). With the majority of hospital attenders not requiring

specialised treatment, 5% will go on to have acute intracranial complications (NICE, 2014).

The wearing of protective headgear is a popular TBI prevention measure used in many different

sports, but has recently come to the forefront in soccer, especially at a youth level. With FIFA

allowing the use of headgear, Delaney et Al. (2007), discovered that the wearing of protective

headgear can decrease the chances of suffering injuries to the head and face by up to 30%. He

suggested that the headgear be worn by goalkeepers, due to the high risk of sustaining multiple

concussions and by youth athletes due to their weaker necks and thinner, developing skulls.

However, a review of literature by Navarro (2012) identified major limitations in Delaney’s (2007)

study. The validity of the self-reporting players’ symptoms and reinforcement of lack of education

and lack of reporting of concussion like symptoms in athletes raises major concerns. Rodolfo states

the decrease in relative risk when wearing headgear must be investigated further in a non-

retrospective survey but he currently views it as ineffective as a prevention tool.

Injury Prevention protocols were outlined by McCroy et Al. (2013) as part of the International

Conference on Concussion in Sport. They agreed that head gear would reduce head and facial

injuries but argued the possibility of ‘Risk Compensation’. This is where, “the use of protective

equipment results in behavioural change such as the adoption of more dangerous playing

techniques, which can result in a paradoxical increase in injury rates” (McCroy et Al., 2013). This

outlook is similar to that of Lincoln et Al. (2011) who discovered that helmeted sports still see a

much higher rate of concussion due to their high collision nature and aggressive plays. The

implementation of headgear and mouth guards in soccer would have to follow strict guidelines on

having aggressiveness to enhance competition, but no violence. These violent acts, such as a

premeditated headbutt to cause harm have no place in any game, but lack of rules, laws and

inadequate punishment systems mean it is still very common (Volker, 2012).

Whereas the introduction of headgear may alter how the game of soccer is played, certain steps

have already been taken to reduce the chances of concussion and long term neurological damage.

Changes to the game have been made including the introduction of the plastic coated football, as

opposed to the much heavier leather balls, that varied and gathered weight in wet and muddy

conditions, increasing the weight by almost 20%, straining neck muscles. (Matthews, 1972)

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As seen in Section 2.2, the art of heading the ball is a controversial one in terms of potential long

term cognitive defects and uncalculated number of headers that occur between training and

competition. This is exemplified when working with youth level athletes. When working with young

players, coaching is required to ensure the heading technique is carried out correctly. With children

being inexperienced at heading and having an immature skull and neck anatomy, they are at higher

risk of concussion. (Kirkendall, 2001). Qualified and experienced coaches should be teaching correct

technique to reduce risks of concussion.

Correct equipment and equipment management should be implemented to help prevent these

concussion in children. This is as simple as using the correct size and pressure ball for different age

groups. Smaller sized balls with a lower mass for younger players working up to the 70cm, 410g size

five ball, used by players aged fourteen and up (Kirkendall, 2001).

The accurate identification of concussion through side-line assessment is of paramount importance

to the prevention of Second-Impact Syndrome. Second-Impact Syndrome (SIS) was first described

and identified by Saunders and Harbaugh (1984). This involves a second traumatic injury to the brain

before the prior concussion has time to heal. SIS causes cerebral swelling, brain herniation and death

can occur within minutes (Bey & Ostick, 2009).

Where very few cases of SIS causing death have been reported worldwide, in 2011, a young Antrim

rugby player. After receiving an untreated and unidentified concussion, continued to play on and

suffered another head trauma in the final minutes of the game, causing loss of consciousness and

death. The death was officially recorded as cerebral oedema and subdural haemorrhage associated

with second-impact syndrome (The Guardian, 2013).

Andy Bull, the journalist who wrote this article, asked why all coaches, referees and schools do not

have a copy of the SCAT3 in their pocket. With the use of this concussion assessment form, this boy

would never have been, allowed return to play. Correct and consistent side line procedures must be

put in place across the board to see a reduction in players returning to play too soon (Broglio, 2009)

(Bey & Ostick, 2009).

Following return to play protocols is a key part of recovery and the prevention of incidences of SIS.

Cantu (2001) outlined processes and identifiers on how and when to return an athlete to play. He

very clearly states the athlete must be completely free of all post-concussion symptoms and PTA

(Post-Traumatic Amnesia) symptoms at rest and exertion.

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While the worldwide implementation of rule changes or requirement for medical staff at every game

may be hard to conduct initially, a simple educational programme, as seen in Washington State,

could be distributed to coaches and athletes alike. Broglio et Al. (2010) questioned the knowledge of

the athletes themselves as it was noted they did not report their head injuries as they did not see it

serious enough to do so. ”The most significant finding was a clear need to educate athletes about

concussive signs and symptoms. It is evident that the high levels of unreported concussions extend

beyond American Football and into other sports and cultures” (Broglio et Al., 2010). This matches

the statement from the International Consensus on Concussion in Sport (2009) who supports the

baseline testing of all athletes at high risk for concussion. This baseline test score would be used as a

control score when a suspected concussion or TBI has occurred. While this practice is popular in

American Colleges and High Schools for contact sport, it is yet to be applied on a more international

basis.

This initial assessment is of paramount importance. With competition continuing and time restraints

on medical staff, concussion evaluations are often rushed or not completed at all. The introduction

of a ‘Concussion Bin’ in Australian rugby in 2011 on an eight-month trial period was branded a

massive success by Dr Warren McDonald, the Australian international team’s doctor. This followed

the AFL’s (Australian Football League) move to introduce the ability to bring a substitute on for up to

twenty minutes if a player was considered concussed, thus removing time constraints from medical

staff to return the player to play. This falls in line with the International Consensus of academics

(2013), who outlined a six step model of recovery, beginning with no activity to promote rest to full

contact practice to restore confidence and assess functional movements and skills.

While rugby union throughout the Southern Hemisphere is seen as a very advanced sport,

scientifically, the inherent scrutiny that the NFL (National Football League) finds themselves under

has led to a complete overhaul in rules, regulations and the appointment of a new scientific advisory

committee in 2010 (Ellenbogen, 2010). Similar to the public outcry to abolish American Football back

in 1905 following the deaths of 18 players and 149 seriously injured, current anti-football protests

are rife around the United States of America. The establishment of the NFL Head, Neck and Spine

Committee (HNS) in 2009 finally enabled an independent committee to report to the NFL on best

practices and publish journal studies to assist the prevention and/or assessment of TBIs in all contact

sports. The main focus of the HNS was its broad sports research, advocacy and educational mission

to teach elite players and to trickle the information down though the levels and ages (Ellensbogen,

2010).

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3. Conclusion

3.1 Discussion

With a plethora of current research regarding the spectrum of TBI or concussion, and the preventive

measures which have been examined and tested, soccer is in a very weak place. While further

investigations into brain injuries and its complexity is needed, current evidence based studies have

acquired enough verification to identify concussion incidents at a minimum. While an estimated 2.1

million adolescent soccer players suffer at least one concussion every year, over half of these will go

unreported and untreated (Broglio et Al., 2010), this figure should spark major concern with

coaches, parents and players alike.

Through this review of research it is very clear that due to the internal nature of concussion, self-

reporting is common practise. While this can be strictly viewed and analysed, the ability for athletes

to forget certain things or to tell untruths is uncontrollable by those conducting the study. Other

aspects of concussions must be identified first, using technology to remove human error. This was

excellently conducted by Straume-Naesheim et Al. (2005) using computer based neuropsychological

testing, removing the need to survey their sample.

The inherent nature of certain sports must be investigated also, with many coaches and players still

holding the view that going out to hurt another person is acceptable because it is sport. This

encouragement of violence over competitive aggressiveness is inherently wrong and should be met

by proper punishment from the hierarchy of sport. This may be seen in soccer and other sports

considering the requirement of head and mouth gear for adolescents as a ‘Risk Compensation’ is

seen (McCroy et Al., 2009). The increase in education lends itself to athletes, parents and coaches

learning of the seriousness of concussion and not treating it like nothing has happened because of

the lack of symptoms.

With contradictory findings surround the issue of heading the ball a definitive study must be

conducted to develop a scientific stance on heading, with many organisations worldwide looking to

ban it from the sport, especially at youth level. With heading recently becoming a very important

part of attacking and defending, not allowing new, young talent to practice the art of heading will

remove a very key element of soccer today.

Navarro’s findings (2012) show no conclusive method of preventing concussion and he suggest there

to be major flaws to the Delaney et Al. (2007) study regarding head and mouth protection, a more

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comprehensive study must be conducted to see if investment into headgear should continue or are

other aspects of the game to be altered to reduce the increasing risk of concussion.

While certain Western societies have begun to make strides in concussion prevention and

assessment, such as that of American high schools and universities with mandatory baseline testing

conducted on at risk athletes, Eurasia is much further behind. Electronic Cardiographs and heart

monitoring have only become a requirement for professional teams in Europe since the 2012/2013

season. With a serious aspect like heart conditions taking so long to be implemented into Europe’s

largest sport, how long with it take UEFA to identify the ‘silent injury’ as a major threat on player

safety?

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3.2 Recommendations for Further Research

With a number of grading systems and scales, different return to play protocols and different

definitions for concussion, this poorly understood subject is an area of major confusion for the public

and sports people alike. While there has been International Consensus’ surrounding concussion and

its treatment and assessment, many sporting organisations, who do not or cannot seek the evidence

themselves, are left in the dark. The International Consensus must identify a universal grading

system to be used by all and outline very clear return to play processes. Cantu himself states that,

while there is no universal agreement on grading or return to play protocol, there is a unanimous

agreement that players suffering from concussion and PTA symptoms at rest and exertion should not

return to play (Cantu, 2001).

With clear reviews regarding the success of game and rules changes to assist the diagnoses of

concussion in Australian rugby union and Australian Rules football, other contact sports should

consider something similar to the ‘Concussion Bin’. Where the RFU have implemented the ability to

use ‘Blood Subs’ to replace players who have sustained lacerations due to the danger it causes

themselves and others during the game, a similar effort can be made to protect players from the

dangers of concussion, or SIS. A pilot review of the ‘Concussion Bin’ should be run in sport

worldwide on a trial basis to test its suitability to contact sports, such as soccer. With no loss to the

game, it would provide valuable and comparable information on the number of concussions

sustained but more importantly, enable medical professionals to diagnose and slow the return of

players to the field of play.

While the clinical guidelines are set in stone throughout the medical profession, they can be only put

in place when head injuries are identified. With sport being the second largest contributing factor of

head injuries, the initial assessment is as, or more important as the after care. Consist updating of

assessment and monitoring protocol.

On a medical and care front, further knowledge into the likelihood of long term cognitive defects

should be identified with conflicting arguments regarding number of concussions leading to an

increased probability of neuropsychological repercussions. Having this information will allow

professionals on making complete removal of players from sport if long term defects are a

possibility.

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3.3 Limitations of Study:

With a lack of access to all relevant studies and theories surrounding that of concussion in sport, a

complete picture of the concussion environment could not be painted and a therefore limitation of

the study can be drawn. New articles and journals requiring sign up and/or yearly membership is

preventing coaches and parents from accessing the findings. This is another cause of the lack of

information in coaching circles from various sporting backgrounds. With a minority of agencies

providing the information need by coaches (WHO, CDC, NICE etc.), major gaps in concussion

education can be seen.

With a limited knowledge of important authors and findings when beginning this review, important

findings dating back through time may have been missed. However, due to the nature of concussion,

evidence has been seen to overlap numerous times, with academics adding on to already stated and

accepted claims.

B00047775 17


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Appendices:

Appendix A – Cantu Concussion Grading Scale

Appendix B - AAN Practice Parameter Grading System for Concussion

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Appendix C – Nelson Grading System for Concussion

Appendix D – Roberts Grading System for Concussion

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conor little b00047775 cctplr document january 2015

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