Concussions: The “Injury of 2018”

Concussions remain a dominant subject in the sport medicine literature and media at large — Photo: PET Scan Brain, Wikimedia

As 2018 winds down, the Clinical Journal of Sport Medicine, like so many of its sister media, finds itself in a reflective mood.

Time magazine, for instance, has just named its “Person of the Year”: a group of journalists the magazine notes has been ‘targeted’ for the work they do pursuing the truth.  Time calls them The Guardians. It is an interesting selection:  a media outlet honoring other professionals in its own line of work.

I thought it time that CJSM do its own version of “Person of the Year,” but with a sport medicine twist — Injury of the Year.

I’m naming “Concussion” the Injury of the Year.  In 2019, I’ll have my ‘act together’ and put out a Twitter poll in late November for reader contributions; but in 2018, I’ll have to play judge and jury, given that it’s nearly mid-December. Thanks for indulging me!

Like LeBron James of the NBA, who could probably be named MVP in any year he has played in the league, concussion is a sports injury which could probably earn this distinction in any year over the last decade or more.

In truth, 2018 was a red banner year for the injury, so to speak.  As an example, nearly our entire March 2018 issue was devoted to original research on various aspects of the subject, including a systematic review on the long-term consequences of traumatic brain injury in professional football players.  Continuing this line of reasoning, I would draw your attention to another noteworthy systematic review just published in our last issue of 2018 (November).   This one looks at the utility of blood biomarkers in the assessment of sports-related concussions (spoiler alert:  we have a long way to go in developing these for ‘prime time’).

The dominant theme of our 2018 podcasts was, again, concussion.  Read more of this post

CJSM Podcast: Dr. David Howell looks at pediatric concussions

One of the top young guns in the world of pediatric sports medicine research is David Howell, PhD, ATC of Children’s Hospital Colorado, and the University of Colorado School of Medicine.  Dr. Howell has graced the pages of the CJSM blog before and, even more notably, the pages of the journal itself many times.  He has been one of CJSM’s more prolific authors over the last few years.

When we recently published several of his articles within a span of months, I knew it was time to reach out and get him on the podcast.

Listeners will not be disappointed — Dr. Howell is as erudite and lucid a speaker as he is a writer.  Together in this, our newest podcast, he and I discuss “Breaking research developments in pediatric and adolescent concussions.”  We were able to focus on three of his most recent studies published in CJSM:

Dr. Howell’s work continues to fill a significant research gap noted by the Berlin consensus statement on concussion group — the relative lack of evidence for how to diagnose and manage concussions in the under 13 year old crowd.  Not surprisingly, several of these new CJSM studies have received a lot of buzz, most especially the first study in that litany (on Concussion symptom profiles).  As someone who sees concussions in this age group on a nearly daily basis, I have found the results of this published research to be, already, of significant practical use.  The Altmetrics on the paper underscore the importance of the work.

This newest podcast can be found with all of our podcasts here on the CJSM website and here on iTunes  And don’t forget you can subscribe to our podcasts on iTunes so you never miss one.

Thank you, again, Dr. Howell for the continued work you do in the field of sport medicine at large, and in the area of pediatric sport-related concussion in particular.

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.


  • 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



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.

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

%d bloggers like this: