From Russia with concern: concussions in the FIFA World Cup 2018

Aaron Gray, M.D. University of Missouri — a.k.a. @MizzouSportsDoc

Have you been watching the World Cup as I have?  These games in the group stage are being broadcast in North America during working hours, and I have them streaming in the background at my desk while I am seeing patients in clinic.  As I sit and do charting, I can catch some of the action…..

Dr. Mark Fulcher and colleague at World Cup Stadium Samara, Russia

Or are you like my friend Mark Fulcher, Medical Director of New Zealand Football, who is in on site in Russia right now, touring the various venues?  Or for that matter, you may be one of the team docs or physios caring for one of the 32 teams’ players?

Wherever you are, or however much interest you may have in football/soccer/World Cup, if you are in the world of sports medicine you likely are aware of the concussion incident which occurred a week ago when Morocco was playing Iran in its first game of the tournament: the player Noureddine Amrabat was visibly posturing after he went to the ground; was slapped in the face subsequently by attending medical personnel; and then, five days later, allowed himself back into Morocco’s next game (you read that right: the player cleared himself for ‘return to play’).

I reached out to my American Medical Society for Sports Medicine colleague Aaron Gray M.D. for some commentary on this incident.  Besides being an experienced sports medicine clinician in the world of football/soccer and an Associate Professor of Orthopaedics/Family Medicine at the University of Missouri, Dr. Gray is an insightful social media commentator who is a ‘must follow’ on Twitter at @MizzouSportsDoc  I can’t tell you how many times I have become aware of an incident at a high profile sporting event because of Twitter comments from Dr. Gray.  For instance, it was Dr. Gray who provided some of the most cogent commentary I saw on the previous World Cup’s struggles:  the 2014 FIFA World Cup you may remember had its own share of high-profile, mismanaged concussions.

Dr. Gray rightly argues that it is not enough for us who are on the sidelines to literally and figuratively ‘roll our eyes’ at what happened with Amrabat.

I specifically asked Dr. Gray to provide three specific thoughts on this current controversy, and where all concerned parties can move from here.

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  • FIFA should use the Video Assisted Referee (VAR) system to immediately communicate with team medical staffs when a player shows clear signs of a concussion. In Amrabat’s injury, the video replay clearly shows signs of a concussion, but this would be near impossible to see in real-time from across the pitch. (video can be found here)  He appears to be unconscious immediately after his head to head collision with the opposing player since he does not protect his face as it contacts the ground.  He also displays the classic “fencing” posture by raising his extended arms after he ends up on his back.  A neutral trained sports medicine professional viewing VAR could radio to the physio and team physician so they would know this information before they even make it across the field to assess the injured player.
  • The international sports medicine community must work to translate and disseminate current knowledge and best practices for our colleagues from parts of the world with fewer opportunities for continuing sports medicine education. The initial evaluation/management of Amrabat’s concussion (quickly standing him up, slapping his face, spraying water on him)  is not in line with international best practices of sideline evaluation put forward in the 5th Consensus Statement on Concussion in SportMany team physicians, physios, and ATCs from around the globe are not able to regularly travel to attend sports medicine conferences to learn from experts on concussion evaluation and management.  These education disparities can lead to widely varied medical sideline practices which become magnified on the global stage of World Cup. Research needs to evaluate concussion knowledge/practice gaps of international soccer sports medicine staffs and identify best methods for knowledge dissemination to these providers.
  • Keeping an athlete out of a competition is one of the most difficult decisions a sports medicine provider has to make, but it is our duty. We are called to protect the player’s health above all else. I cannot imagine the pressure that a World Cup sports medicine staff feels to clear a player to return to the pitch. Participating in the World Cup for your country is the pinnacle of most careers and a dream come true for a professional soccer player. It is a moment that most athletes have trained their entire life to try to achieve. Athletes will do anything they can to return to the pitch, and rightfully so, but at times sports medicine providers have to save athletes from themselves. For some injuries, shared decision making exists between a physician and an athlete to discuss risks and benefits of returning to competition following an injury. But with certain injuries, such as a concussion, an athlete’s decision making capability may be compromised or the risk to the athlete is too high.  In situations like these, the team physician must make the extremely tough decision to protect the athlete even against their strongest protest.

The 6 “R’s” of New Zealand football return-to-play concussion policy: an up-to-date model for management of this injury

 

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Thanks Dr. Gray for those thoughts.   And for readers who are looking for more on the subject of concussion in sport, don’t forget the resources that exist at our journal website, where we publish so much of the most current research in this area.  Our March 2018 issue, for instance, has 10 review or original research studies on the subject of sport-related concussions.

Finally, I wanted to share some resources that are freely accessible and which model the most up-to-date and evidence-based policies for management of sport-related concussions from around the world.  New Zealand and South Africa are both leaders in this area, and I would direct interested readers to this site courtesy of NZ Football and this site from the South African Rugby Union initiative known as BokSmart–a different football code, but the principles apply generally.

P.S.  Thanks too to another high-profile and insightful commentator on the scene, Chris Nowinski, who has guested on one of our CJSM podcasts. With quality video clips from the World Cup difficult to access at times (I think because of media rights), I find his posted Twitter clip of the Amrabat incident one of the best.

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Five Questions with CASEM President Tatiana Jevremovic, M.D.

Tatiana Jevremovic, M.D. — current president of the Canadian Academy of Sport and Exercise Medicine (CASEM)

The Canadian Academey of Sport and Exercise Medicine (CASEM) hosts its annual symposium in Halifax, Nova Scotia, in just a couple of days:  from June 6 to 9 sports medicine clinicians from around Canada and the globe will be attending what looks to be another excellent conference which CASEM is hosting.

This past year Tatiana Jevremovic, M.D. has been serving as the CASEM president.  We thought it would be a good time to catch up with her before the clock runs out on her presidency at the end of this month.

In the midst of all her many, many commitments, she graciously found the time to do this interview.  We were delighted with the results, and we know you will be as well.

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1. CJSM: Where else to begin but by asking you about your year as President of the CASEM. You complete your term at the end of June, after the annual meeting which takes place in Halifax this year. What were your major challenges as president this year?  What were your high points?

TJ: There have been a few high points during my presidency year. We hired a communication advisor that has started elevating CASEM’s profile on social media through infographics and soon-to-be-completed new podcasts. We have met and introduced CASEM to the Public Health Agency of Canada as well as other organizations such as ParticipACTION, and are exploring future collaborations on projects of mutual interest such as concussion and health enhancing physical activity.. We continue to strengthen our professional relationships with friends and stakeholders such at Sport Information Resource Centre (SIRC), Canadian Medical Association (CMA), Royal College of Physicians and Surgeons of Canada (RCPSC), College of Family Physicians of Canada (CFPC), Canadian Concussion Collaborative affiliated organizations (CCC), and others.

It has been an extremely exciting year, and my biggest challenge has been accepting that this role is only for 1 year. I will miss it terribly, but am comforted in knowing that my successor, Dr. Paul Watson, will do a great job. I will also continue to promote the Academy and all of its success in my new role as past president.

2. CJSM: You currently work as an Associate Professor in the Dept. of Family Medicine at Western Ontario and at the Fowler Kennedy Sport Medicine Clinic in London, ON. Can you tell us a little about your background in sports medicine and what you do with your professional time when you are not attending to CASEM Presidential duties? Read more of this post

FIFA World Cup 2018 — Will There be Concussion Miscues Again?

FIFA World Cup apperances 1930 – 2018 Picture courtesy of Dufo, from Wikimedia Commons

Ah, the long, lazy days of summer have arrived….or have they?

With a caveat that I must be mindful that fellow colleagues in different parts of the world may be experiencing different workloads right about now, I have been feeling of late both a sense of lassitude and a sense of professional, shall we say, anxiety.

My children’s school year has wrapped up — they certainly are in the mode of being lazy.  The multiple school sports I cover as a pediatric sports medicine physician have largely wrapped their respective seasons too.  There is a bit of a lull in my clinics.

On the other hand, in the larger sporting world, the schedule is most definitely heating up.  I find this to be one of the most interesting times of the year for sport.  In the USA, we are in the midst of the NBA and NHL basketball and hockey finals, and MLB baseball offers multiple games daily.  To our north, the CFL has just started its season.  In Europe, the tennis stars Rafael Nadal, Garbine Muguruza and others are experiencing the joys of Roland Garros.  Golf’s U.S. Open is just around the corner.

And, of course, in less than two weeks, the FIFA World Cup kicks off in Russia. The quadrennial event — alongside the Olympics probably the biggest global sporting event on the planet — opens on June 14 and will continue for a month, until the championship game on July 15.

Like many of my colleagues, I am a fan of sport as well as a physician.  I care about who plays, and find myself cheering on certain teams and certain players [Vamos El Tri!]

Like many of my colleagues as well, however, I am also eyeing this World Cup as a doctor, and I approach the event with concerns over how concussions will be handled in 2018. Read more of this post

CJSM Podcast 24 — A conversation with Christina Master, M.D. about vision/vestibular dysfunction in children post-concussion

Christina L. Master, M.D. speaking on her work on vision and vestibular dysfunction at recent AMSSM 2018 conference.

“Invest a little time; get a lot of information.”

So says the guest for our newest podcast — Christina L. Master, M.D., pediatric sports medicine specialist at the Children’s Hospital of Philadelphia, and Professor of Clinical Pediatrics at the Perelman School of Medicine, University of Pennsylvania–in reference to the physical examination for sports-related concussions (SRCs)

If you attended her lecture at AMSSM 2018 I am sure you were as suitably impressed as I was:  Dr. Master is a masterful speaker, and she gave a memorable presentation on the importance of a focused oculomotor exam in the evaluation of pediatric SRCs.

She exhorted the clinicians in the audience to consider a move away from a primarily symptom-based evaluation of their pediatric patients, to one which is more oriented toward looking for physical signs of visual and vestibular dysfunction — in as little as two minutes, a physical exam can provide the clinician with vitally important information.

Not coincidentally, we had just published one of her more recent publications on this very subject in our March 2018 issue: Vision & Vestibular Dysfunction Predict Prolonged Recovery in Children. We thought it would be the perfect time then to have Dr. Master as our podcast guest; the trick was to track her down in all the comings and goings of AMSSM 2018.  We succeeded.

In the podcast, she discusses her research on physical exam findings of vision and vestibular dysfunction which aid in the diagnosis, prognosis, and management of pediatric sport-related concussion.

Take a listen to our conversation: as ever you can find our podcasts on our main webpage or, better yet, subscribe to them on iTunes Read the study itself…..AND…..I’d encourage you to take the CME module covering Dr. Master’s work.

“Invest a little time; get a lot of information.” So true.  Both in the examination room with our patients, and here with us at CJSM.

 

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