How effective is FIFA's concussion protocol?

The football community has become increasingly aware of the dangers of head injuries in recent years, but this summer’s World Cup has thrust the issue to the forefront, most notably with German defensive midfielder’s Cristoph Kramer’s concussion during the final against Argentina.¹ This article endeavours to discuss FIFA’s shortcomings with regards to implementing appropriate concussion protocols.

Even before Kramer’s injury, however, Alvaro Pereira suffered a concussion while competing for Uruguay in a group stage match against England. After a collision with Raheem Sterling in the 61^st minute, Pereira was lying unconscious on the ground. Following the match, Pereira stated “after the hit, I only recall that I was unconscious for an instant. It was like the lights went out.”² By the 63^rd minute, Pereira had already been looked at by Uruguay team doctors, was given the all-clear, and was back on the pitch.

Recognising that a two-minute examination and evaluation for a player with a suspected concussion by a doctor who answers to the Uruguayan FA is insufficient to ensure player safety, FIFPro, the international players union, called on FIFA to “to conduct a thorough investigation into its own competition concussion protocol which failed to protect” Pereira.³

FIFPro's recommendations for an effective concussion policy

FIFPro’s chief medical officer outlined six priorities for what the union believes is required for an effective concussion policy:

• The development of a monitoring system to assure and control the application of the Zurich 2012 concussion guidelines;
• The systematic completion of a standardised and valid side-line examination (cognitive and physical) on any player suspected to have suffered concussion;
• The presence of an independent medical professional on the side line during matches to assess a player with suspected concussion;
• The possibility of replacing (temporarily substitute) any player undergoing the side-line examination;
• Enforcement mechanism to ensure proper application when procedures are not followed to protect the health and safety of the players;
• The introduction of a baseline reference, pre-competition examination (cognitive and physical), which allows important comparisons to be made with any eventual side-line examinations undertaken as a consequence of a suspected concussion.⁴

By any metric, these seem like reasonable requests, if we assume that every stakeholder in football is concerned with ensuring player safety. However, many of the priorities listed by FIFPro are not currently part of FIFA’s concussion protocols, and in fact, FIFA appeared to have egregiously disregarded the well-established consensus protocols for assessing concussions in sport.

By focusing on FIFPro’s proposed changes and relying on statements made by FIFA officials, medical experts, and Taylor Twellman, a former player whose career was cut short by the effects of numerous concussions he suffered on the pitch (and who is currently a noted advocate for awareness and research of traumatic brain injuries), this article will show that not only are FIFPro’s proposed changes feasible, but also that they are necessary to better ensure player safety. 

Sport Concussion Recognition Tool

FIFA makes available and puts its name on a pamphlet called the Sport Concussion Recognition Tool (SCRT) to “help identify concussion in children, youth, and adults."⁵ The pocket pamphlet is primarily to assist laypeople in recognising when an athlete has suffered a head injury and should be immediately seen by a trained medical professional. The pamphlet was developed by the Concussion in Sport group, which is wholly independent of FIFA, and is comprised of neurologists, other doctors trained in diagnosing and treating head injuries, and domestic and international sporting federations.⁶ It reflects a consensus approach to diagnosing and treating head injuries in sport, and relies on the consensus statement on concussions in sport created at the International Conference on Concussion in Sport held in Zurich in November 2012, and subsequently published in the British Journal of Sports Medicine in April 2013.⁷

On the timetable for recovery, the consensus statement explicitly states:

“The majority (80–90%) of concussions resolve in a short (7–10 day) period, although the recovery time frame may be longer in children and adolescents.”⁸ Further, “persistent symptoms (>10 days) are generally reported in 10–15% of concussions.”⁹

Curiously, however, FIFA’s chief medical officer Jiri Dvorak, advocates a six-day timeframe:

“After a mild head injury it is recommended that players gradually increase their activity levels, ideally making a return to full participation in football six days after sustaining the injury.”¹⁰

Christoph Kramer FIFA World Cup case

On football’s biggest stage, the 2014 World Cup final, Christoph Kramer, Germany’s defensive midfielder, suffered a concussion after an inadvertent collision with Argentine defender Ezequiel Garay.¹¹ After a very brief examination by the German team doctors, Kramer was sent back out, and played for about ten minutes before slumping to the ground and having to be helped off the pitch.

Following the match, Kramer said, “I can’t really remember much of the game.”¹² “I don’t know anything at all about the first half. I thought later that I left the game immediately after the tackle. I have no idea how I got to the changing rooms. I don’t know anything else. In my head, the game starts from the second half.”¹³

The referee, Nicola Rizzoli, saw that Kramer was clearly disoriented and unaware of his surroundings. He described his interaction with Kramer, explaining: “shortly after the blow, Kramer came to me asking: 'Ref, is this the final?’” “I thought he was joking and made him repeat the question and then he said: ‘I need to know if this is really the final.’ When I said: ‘Yes,’ he concluded: ‘Thanks, it was important to know that.’”¹⁴

The SCRT specifically states that any athlete with even a suspected concussion should be immediately removed from play and attended to by a medical professional.¹⁵

Further, the SCRT states that a concussion should be suspected if a player exhibits one or more of the following symptoms:

• Loss of consciousness or responsiveness;
• Lying motionless on the ground and/or slow to get up;
• Unsteady on feet, balance problems, falling over, or lack of coordination;
• Grabbing or clutching one’s head;
• Dazed, blank, or vacant facial expression;
• Confused and/or unaware of his or her surroundings.¹⁶

Based on statements made by both Kramer and Rizzoli, it seems clear that Kramer exhibited multiple symptoms of a concussion, and his head injury should have been deemed a suspected concussion.

Sport Concussion Assessment Tool

The team doctors should have used the Sport Concussion Assessment Tool (SCAT3) to test Kramer. The SCAT3 provides significantly more intensive baseline testing than the SCRT and is: “intended for use by medical professionals only.”¹⁷

As part of the SCAT3, there are five basic questions about the match that should be asked, including: “which half is it now?” and “what venue are we at today?”¹⁸ Failure to answer any of these questions correctly suggests a concussion, and from Kramer’s statements, it is clear that he would not have known the answers.

Ensuring that a player who suffers a concussion does not return to the pitch is of paramount importance, and can actually mean the difference between life and death in severe cases.

Second impact syndrome is often fatal and occurs when an athlete returns to play while suffering post-concussive symptoms and suffers a second head injury.¹⁹ According to a paper published in the Western Journal of Emergency Medicine: “while rare, [second impact syndrome] is devastating in that young, healthy patients may die within a few minutes.”²⁰

As discussed earlier, Uruguay’s Alvaro Pereira lost consciousness after a collision with England’s Raheem Sterling and was allowed to play on despite Jiri Dvorak stating just weeks earlier, when Hugo Lloris suffered his concussion, that: “it’s a 99 percent probability that losing consciousness in such an event will result in concussion.”21

Disturbingly, Dvorak defended the decision to allow Kramer to resume playing, despite heavily criticising Tottenham Hotspur for allowing goalkeeper Hugo Lloris to resume play after being struck in the head by Romelu Lukaku in a Premier League match last season, calling the decision: “dangerous and irresponsible.”²²

“[Lloris] should have been substituted,” said Dvorak. “The fact the other player needed ice on his knee means it's obvious the blow was extensive. When he has been knocked unconscious, the player himself may not see the reality. We have a slogan: if there is any doubt, keep the player out.”²³

When you compare Dvorak’s reaction to how the Tottenham Hotspur and the Premier League handled Hugo Lloris’ injury with how he reacted to how Germany and FIFA handled Christoph Kramer’s injury, there is a strange disconnect.

“Take the example of Christoph Kramer. When the incident happened, of course the audience saw it on the television, but the referee and doctors could not see it when they ran to the player, who assured them he was all right.”²⁴

These were two very similar situations, yet two very different reactions from Dvorak, and the author wonders if the fact that Kramer was playing in a FIFA-run competition (as opposed to a Premier League-run competition) is the reason why FIFA’s chief medical officer chose to issue dramatically different opinions on the same issue just weeks apart.