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…..

Drs. Mark Fulcher & Celeste Geertsema 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 5^th Consensus Statement on Concussion in Sport.  Many 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.