Are concussion guidelines good for elite sport

On the 3rd of November 2013 Tottenham played out a scoreless draw against Everton. From the result you may think it was an uneventful game. However, a collision between Tottenham’s goalkeeper Hugo Lloris and Everton’s striker Romelu Lukaku sparked widespread criticism of Tottenham’s medical staff.

Late in the game Hugo Lloris was knocked unconscious when he collided with the knee of Romelu Lukaku. He laid motionless on the turf for some time before being helped to his feet by the team doctor.1

What happened next is contentious. However, according to Tottenham’s manager the medical stuff gave Hugo Lloris the all-clear and he remained on the pitch to play out the game.1

Afterwards, FIFA, the player’s union and the Professional Footballer’s Association (PFA) called for the decision to be taken out of the hands of medical staff and for any player that sustains a concussion during the game to come off indefinitely.1

Since the Zurich guidelines were released on concussion in 2012 many sporting codes around the world including the Australian Football League (AFL) and the National Rugby League (NRL) have adopted the policy that players suffering from concussion can not play or train for 24 hours and should be immediately withdrawn from the game.2,3

In many situations in life it is easier, and many argue safer, to take the decision making out of the hands of an individual and allow a policy based on clinical evidence to dictate the situation. However, when it comes to concussion in sport I believe that the Football Association (FA) has made the correct move by leaving the decision with the team doctor.

My rationale behind this argument is first based on the fact that diagnostic specificity and management strategies are currently not evidence based and secondly, the actions of clubs in sporting codes where the Zurich guidelines have been enforced have placed players at greater risk.

The difficulty in diagnosis stems from the ambiguous definition given to the current concussion syndrome. McCrory et al. defined concussion as being a brain injury.4 However, the Zurich symposium require the shaking of a patient’s head to be followed by the presence of at least 1 of 22 symptoms. While, some symptoms on the the Likert scale are specific to head trauma, many aren’t such as: ‘don’t feel right’, fatigue, sadness and irritability.5 The intention of the Likert scale was to produce a highly sensitive test that identifies everyone suffering from concussion. However, in the process they have produced a test that is non-specific.

With the recommended treatment of concussion being rest and surveillance, many would argue that over treatment is a worthwhile consequence of a non-specific test. I agree that at sporting events where there are no medical professionals to make a clinical evaluation of a head injury such non-specific scales are useful to highlight a potential head trauma and hopefully prompt individuals to seek prompt medical help. However, I would argue that at events supervised by trained medical professionals the implementation of the Zurich guidelines and use of non-specific concussion tests could be detrimental to an athlete’s health.

If a medical professional is on the scene of a head trauma they should be able to use a concussion test as a tool to guide their clinical judgement but not as a requirement that relates to a management algorithm that must be followed. This will avoid conditions that share similar signs and symptoms such as whiplash and inner ear pathology being diagnosed and managed as concussion.

Furthermore, the Zurich guidelines rely on self reporting and it is known that athletes are notoriously poor at reporting symptoms,6 especially if the consequences might mean missing the rest of the game and potentially future games. Knowing this, a trained team doctor is surely the most qualified person to make a decision on the current status of an individual, not a list of non-specific questions.7

While a discussion surrounding the Zurich Guidelines is important for the concussion debate, I feel the heart of this debate is actually non-medical but ethical.

In the case of Hugo Lloris’, the incident highlights how the employer’s primary interest of winning may conflict with that of the team doctor, whose primary obligation is the patient. The reason a short critique of the Zurich guidelines was needed first, is because many sporting codes have adopted their concussion guidelines in the hope that it would resolve any conflicts of interest.

However, I believe guidelines drafted up by governing bodies have only muddied the doctor-patient-team triad. In the last few years I can remember seeing a number of AFL and NRL players staggering around after large hits but still remaining on the pitch. This brings into question a number of issues. Are players not being assessed on the pitch straight away by trained medical doctors? Are clubs preferring to use trainers to make a concussion assessment? Do medical staff feel pressurised to give players a couple of minutes to recover before they are assessed? And finally, do medical staff have a higher threshold to diagnosing concussion?

What seems to be clear is that the Zurich Guidelines have only increased the lack of diagnostic specificity surrounding concussion. In recent years this has further been framed by sensational media reports regarding chronic traumatic encephalopathy (CTE), class action litigation and conflicting information from researchers.

In my opinion third party policies have created tension to what use to be a clinical decision between a doctor and his patient. There will always be a conflict of interest but I feel the FA’s policy of leaving the clinical decision up to the doctor is a sign of confidence in the medical profession. I also believe the FA’s policy of having a third neutral doctor at every Premier league game is a better solution than navigating their clinical decision all together.

In my personal opinion if Hugo Lloris had of been an outfield player he would have come off the pitch immediately allowing the medical staff to take their time to assess him before maybe returning to the game. However, being a goalkeeper the medical staff didn’t have this luxury. Furthermore, if the medical staff did decide he was fine to continue and that Lloris didn’t suffer from concussion it is worrying to think that he missed a number of the training sessions and games after the accident due to ongoing concussion like symptoms.

In conclusion, I believe nonspecific guidelines, medical pseudoscience, legal wrangling, and media scrutiny have lead to medical hypocrisy. Until more robust inclusion criteria for concussion has been critically researched, I believe that club doctors should be trusted and made accountable for the treatment of their athletes.

References

  1. Paul Doyle. Andre Villas-Boas blasts ‘incompetent critics’ in Hugo Lloris concussion row. The Guardian. 2013 7 Nov. http://www.theguardian.com/football/2013/nov/06/hugo-lloris-available-tottenham-concussionPartridge B. Dazed and Confused: Sports Medicine, conflicts of Interest, and Concussion Management. Bioethical Inquiry. 2014;11:65-74
  2. Australian Football League (AFL). 2013 The Management of Concussion in Australian Football: With Specific Provision for Children 5-17 Years. Melbourne: AFL Research Board and AFL Medical Offices’ Association. http://www.aflcommunityclub.com.au/fileadmin/user_upload/Coach_AFL/Injury_Management/1211_AFL_Concussion_Management_2013_LowRes_1_.pdf
  3. National Rugby League (NRL). 2012. The management of concusion in rugby league. http://www.nrl.com/About/ReferenceCentre/ManagementofConcussioninRugbyLeague/tabid/10798/Default.aspx
  4. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvoøák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. Consensus Statement on concussion in Sport – the 4rd International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine. 2013;47(5):250-258
  5. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvoøák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. SCAT3. British Journal of Sports Medicine. 2013c;47(5):259–262.
  6. Dziemianowicz MS, Kirschen MP, Pukenas BA, et al. Sports-related concussion testing. Curr Neurol Neurosci Rep. 2012;12:547–559.
  7. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health. 2013;52:330–335.e3.
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