A Shout From Across the Pond: the “Lloris Affair”

CJSM is an international sports medicine journal.  We are the official journal of two American sports medicine societies (American Medical Society of Sports Medicine and the American Osteopathic Association of Sports Medicine); as well as the Canadian Academy of Sports and Exercise Medicine and the Australasian College of Sports Physicians.  I regularly liaise with our Executive Editor, Chris Hughes, who lives in London, our publisher in Philadelphia USA, and our managing editor in Calgary, Alberta.

A small sampling of the twitter conversation
Our Executive Editor was engaged in
This weekend regarding the Lloris injury

Lots of science and lots of sports to keep track of, all over the globe.   And so it was that this weekend, residing in Columbus, Ohio, I remained blissfully unaware of the events surrounding the injury to Hugo Lloris until I noticed that the @cjsmonline twitter feed exploded with shouts of disbelief, as our executive Editor and others were busy deconstructing what they had just seen.

In short order, Chris let some other ‘tweeters’  know they could reach out to @cjsmonline, and one enterprising individual forwarded me a thoughtful piece on the situation:  voila!  The genesis of today’s guest blog.

@Daniel_Broman (Dr. Broman) is a Core Medical Trainee in London, and is currently based at Barts Health NHS Trust. He is keen to follow a career in Sport & Exercise Medicine and will be applying for specialist training in the coming months.

He shared these thoughts about the incident:

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Concussion in Football – The Lack of Consistency in Management and The Need for Guidelines

 By Daniel Broman

The topic of concussion in sport has been placed in the media spotlight again recently, especially in the UK, with articles about the proposed new rules for Pitch-side Concussion Assessment (PSCA) in Rugby Union matches (“Rugby and Concussion:  Are Big Hits Bringing Big Headaches?” and “Rugby Union, Concussion and the Ultimate Need for Responsibility of Care”) and with several incidents in Premier League football, including the cases of:

• Romelu Lukaku vs. West Ham United (21^st September 2013), where the player completed the final 3 minutes of the match and post-match admitted that “I did not even know I had scored, I was out of it and the first thing I asked the doctor was “who scored?” and he said “you did”.”

• Mathieu Flamini vs. Norwich City (19^th October 2013) with the player taken off at the time. Arsene Wenger stated a few days later that “There is a five-day (concussion) rule that we will respect, not to take any chance. It was a concussion and the doctor advised us not to play him.”

• Robert Snodgrass vs. Manchester United (29^th October 2013) where the player was also taken off the field of play and taken to hospital. Chris Hughton stated “I think that (going to hospital) is very much a precaution”.

Clearly all incidents and cases are different and of varying severity, however the lack of consistency in their management is still concerning. Over the weekend, another particular incident, prompted several discussions both on social media and in the media, with ‘Match of The Day 2’ stating there needs to be “uniformity on a rule”.

Hugo Lloris

Nearing the end of the Everton vs. Tottenham Premier League match on 3^rd November 2013, there was a collision between Romelu Lukaku and Hugo Lloris (the Tottenham goalkeeper) with the latter suffering a head injury. He clearly suffered a temporary loss of consciousness, lasting seconds, and in the post-match media conference his manager, Andre Villas-Boas stated that “The medical department were giving me signs that the player couldn’t carry on because he couldn’t remember where he was”. To me, this means he fails the ‘Maddocks’ questions which were designed and have been validated to detect concussion. Villas-Boas later admitted that the player “still doesn’t recall everything about the incident” and said his decision to keep the player on the pitch was influenced by the fact that “Hugo seemed assertive and determined to continue and showed great character and personality. We decided to keep him on based on that. The call always belongs to me. Brad (Friedel) was ready to come in but the person Hugo is, there were enough signs for him to continue.”

From watching the incident, seeing the medical teams’ actions in trying to substitute the player from the action and subsequently hearing the manager’s comments, it is quite clear that the player was concussed and yet he still remained on the field of play, severely risking his health and welfare. The medical advice here is simple, Hugo Lloris should not have continued in the game if his manager’s comments after the game are true. A player who suffers a head injury, loses consciousness and has any cognitive deficit or disorientation should be taken off the field of play. The Zurich Consensus Statement of Concussion in Sport is quite clear on this and the people who created this document are far more qualified than me to produce a comprehensive report on the topic. Professor Jiri Dvorak, FIFA Chief Medical Officer has since been quoted as saying “It’s a 99% probability that losing consciousness in such an event will result in concussion.”

This incident made me consider the science involved with concussion, but also raised questions in my mind as to the legal implications and ethics involved in sports medicine.

• Does a player who is concussed (as defined by head injury with temporary loss of consciousness and failing ‘Maddocks’ questions) have the capacity to make an informed decision to continue to play?
• Where does the medical team’s role end? Are we just an advisory service to the club/management?
• Is it fair for a manager to have the final decision on removing a player from the game or should in these cases should it be taken out of his/her hands, with the medical team giving a decision to a referee/independent official?
• What are the long term implications involved when a manager/coach overrules a medical decision and how does this impact on the on-going relationship within the multi-disciplinary team at a club?
• What are the implications on a doctor (who has a duty of care and registration with the General Medical Council) if a manager overrules his/her decision? Could they face professional/probity investigations if that athlete later suffered complications from a head injury?
• If a player remains on the field of play after a head injury, what are the insurance and legal implications for the club (employee), in not potentially safeguarding the athlete (employer) through UK employment law?
• Should video replays be made available for a medical team on the touchline, to allow them to better judge the extent of an injury?

I will not attempt to answer the questions above but would be extremely interested in the readers’ opinions on any of these.

In football, the majority of head injuries are caused by aerial duels and heading. People who follow and love football would undoubtedly agree that there is a great amount of skill involved in jumping for and heading a ball. Many goals come from this talent and the ability to do this well can separate a good from a very good footballer. Nobody wants this to be removed from the game but if a head injury does occur, it must be managed safely and an athlete’s welfare must always be the first priority. The 2013-14 Premier League Handbook outlines the thinnest definition of a head injury policy, stating “Any Player, whether engaged in a league match, any other match or in training, who having sustained a head injury leaves the field of play, shall not be allowed to resume playing or training (as the case may be) until he has been examined by a medical practitioner and declared fit to do so.” This statement includes no definition as to what constitutes a “medical practitioner” nor does is clarify what constitutes an examination”.

I have been extremely impressed over the last few weeks with the Mail on Sunday’s campaign, headed by journalist, Sam Peters, where they have tried to implement change in the management of concussion in rugby, with the campaign asking for rugby’s ruling bodies to:

1) Commission independent, scientific research into the incidence of concussion in rugby and the effect of repeated head trauma, including any links to serious neurological conditions.

2) Compel coaches and players at all levels of the game to undergo training in concussion awareness and treatment.

3) Introduce compulsory medical examinations by independent doctors for any player suffering more than one concussion within a three-month period.

4) Oblige all clubs and encourage all rugby-playing schools to display concussion information posters in clubhouses and changing rooms.

5) Enforce penalties for any failure to implement the above.

I feel football needs a similar campaign and clear guidelines/protocols in place for head injuries which occur during matches. I am certainly not here to criticise anyone involved and I am aware that there are huge pressures involved in elite sport, however a player’s health should always come first. I feel it is essential that all involved fully understand the potential consequences and if they don’t, then we as medical professionals need to educate players, management, coaching staff and the referees so they have an informed decision. It is also essential that the media are aware of the recent advances in our understanding of concussion to ensure the general public understand the risks involved because the problem is not only in professional sport, but is a potential risk for the thousands of “Sunday-League” footballers who enjoy the sport on a weekly basis.

The question comes as to how the sports medicine community can act best to safeguard athletes’ welfare. The IRB and RFU in rugby have recently tried to make positive changes and I propose that the football ruling bodies, such as FIFA and the FA in England, set up a commission to produce a protocol to ensure uniformity in the assessment and management of concussion in football to guarantee best practice in this widely debated topic.

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Thanks Daniel for those thoughts.  The debate over this incident, on line and in print:  today’s NY Times , The Daily Mail and  The Guardian have weighed in with their opinions.

Do you want to share yours?  The perfect place is in the Comments section of this blog post, or tweet us @cjsmonline, @Daniel_Broman, @SportsDoc_Chris.  And thanks for sharing!

p.s. clever commentary on this same event can be seen here: http://www.sportscapp.com/2013/11/03/new-easy-way-to-ignore-concussions/