Objective To investigate the awareness of English football team doctors of the ‘Consensus in Sport’ (CIS) guidelines for the assessment and management of concussion, and to identify adherence to these internationally accepted recommendations.
Method A questionnaire was sent to Club Medical Officers of all the 92 English Football league teams.
Results The majority (55.6%) of teams in the English Football Association (FA) do not routinely follow the CIS guidelines. Only 21% of teams routinely record an approved preseason cognitive score and only 42% complete a recommended postconcussion assessment. One-third are still using outdated fixed periods of abstinence following a concussion.
Conclusions FA players are not being treated according to the guidelines recommended by International sporting organisations. The endorsement of the CIS guidelines by the English FA would ensure that all medical teams have a sound and safe protocol for managing concussed players and making return to play decisions.
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Concussion is inevitable in many sports, especially in high-speed and contact sports such as boxing, American Football, rugby union, football (soccer) and martial arts.1 It has been estimated that there are between 200 000 and 300 000 concussions in sports in the USA annually.2 In rugby union concussion was shown to be the third most common match injury with each injury resulting, on average, in 14 days lost playing time.3 Traditionally, clinicians were faced with having to manage concussion in players in the absence of any clear guidelines. Indeed, until recently, neurology textbooks did not even recognise concussion as a medical condition.4 The first International Conference on Concussion in Sport was held in Vienna in 2001. This was convened by the International Ice Hockey Federation, the Federation Internationale de Football Association Medical Assessment and Research Centre and the International Olympic Committee Medical Commission. The aim of the conference was to establish some guidelines to improve the safety and health of athletes suffering from a concussive injury in ice hockey, soccer and other sports.5 A small group of experts (Concussion in Sports Group, CISG) were tasked with producing this. These Consensus in Sport (CIS) guidelines have subsequently been further developed at the second conference in Prague in 2004 and then at the third conference in Zurich in 2008.6 ,7
In professional football in the UK, it is a legal requirement for the managers of professional football teams to ensure, as is reasonably practical, the health and safety of their players.8 In the Premiership, Club Medical Officers must complete an AREA (Advanced Resuscitation and Emergency Aid) course on the acute management of head injury, but are given very little formal advice on how to assess recovery and return to play.
In 2007, following a high-profile player suffering a loss of consciousness (LOC) in a cup final, the Football Association (FA) clarified its recommendations for Club Medical Officers. It stated that fixed periods of rest following a concussion should not be used in professional football. The Club Medical Officer or a neurological specialist should determine when a player is fit to return to sport. It advised that a player should not return to playing until symptom free and sign free.9 However, there is no guidance on how to recognise or assess the signs or symptoms. Many Club Medical Officers who make these decisions are general practitioners and currently they are not required to demonstrate any expertise in concussion management. It is therefore entirely possible that concussed players are being managed by doctors who are unaware of best practice.
The primary aims of this study were to investigate the awareness of English football team doctors of the CIS guidelines, and assess whether teams are following these recommendations and thereby adhering to best practice. A secondary aim was to determine whether practices differ between the leagues and to gauge the opinions of Club Medical Officers about the available assessment methods.
Concussion in sport recommendation
The aim of the CISG was to recommend a management protocol to improve the health and safety of athletes who have suffered a concussion. The definition of concussion was standardised. It was no longer required for a direct impact to the head or a LOC to occur to constitute a concussion.5 Club Medical Officers were encouraged to be vigilant for seemingly innocuous events and to be aware of potential concussions. A simple injury where a player is knocked to the ground, sustaining an impact that is transmitted to the head causing a dazed sensation, is enough to represent a concussion.
In 2004, the CISG recommended the following as a gold standard:6
All players to have a baseline cognitive assessment score.
All players to have a baseline concussion symptom score.
All players deemed to have suffered a concussion should follow a graduated return to play and should not return to play until wholly asymptomatic.
These recommendations were subsequently re-inforced in Zurich in 2007.7
The assessment method is not specified, but the Sports Concussion Assessment Tool (SCAT), subsequently updated to the SCAT27 is recommended. The SCAT/SCAT2 is a paper-based concussion assessment tool. Whereas ImPact and CogSport are computerised. The CIS guidelines recommend the use of the SCAT2, as it is affordable and available to all, but note that computerised assessment tools are preferable. In the current study if a club used SCAT2 or a computerised assessment tool, then they were deemed to be following the guidelines.
Other assessments include the Standardised Assessment of Concussion, Digital Symbol Substitution Test and Trail-Making Test. The advantage of using the SCAT system is that it includes a cognitive assessment and symptom score.
In the event of a head injury on the pitch, the attending doctor should complete a brief Pocket SCAT assessment consisting of three stages; (1) the identification of any symptoms of concussion, (2) the modified Maddocks questions and (3) a balance assessment. If any stages are positive the player should be withdrawn from play for further assessment (full SCAT). This involves a symptom score, orientation, balance and cognitive assessments. It incorporates a table for documenting baseline, postinjury and recovery scores, as well as a personalised head injury advice slip to be given to the player. Return to play is based on individual assessment and resolution of symptoms rather than a fixed period of abstinence.
A 10-part questionnaire was developed to identify what assessments teams currently use and which methods they consider to be valuable when treating concussed players (appendix 1). The questionnaire was piloted with Club Medical Officers from three different leagues. After filling it in they were questioned on how relevant the questions were to them and whether they had any difficulties in answering the questions. The changes made were to confirm who was filling out the form, for example, Club Medical Officer or Physiotherapist, the addition of a question for comments and a revision of the Likert Scale from 5 to 4 points. A four-part Likert scale was used to improve the commitment of responders to answer each question. Part of survey also allowed responders to voice their own opinions of current head injury management. The study was approved by the Queen Mary, University of London, Research Ethics Committee.
The English Football League is made up of 92 clubs, separated into four leagues, the Premier League, the Championship, Leagues 1 and 2. Clubs in higher leagues (Premier League, Championship) generally have greater resources and medical budgets than clubs in the lower leagues. For example, in 2009 the top club had an annual revenue of £270 million, compared with a total of £500 million for all the 72 clubs in the divisions below.10
The questionnaire was posted to all 92 of the clubs in the English FA leagues at the start of the 2009/2010 season in August 2009. The names of Club Medical Officers were used where they could be found from club websites. Alternatively, the letters were addressed to ‘Club Medical Officers’. A second questionnaire was sent to non-responders in October 2009. Table 1 shows the distribution of responses from each division.
Not all questions in each survey were answered. In these cases, the rest of the data completed were still used for the study. The data were analysed using the computer-based software SPSS (V.18.0). χ2 test was used to investigate differences between variables. Fisher's exact test was used where the cell count was less than five in greater than 25% of cells. Statistical significance was accepted at the 95% confidence level.
The response rate was 39.1%. Questionnaires were returned in similar numbers from each of the leagues. Many responders did not complete the questions for the reserve team, so this provided much less data for analysis.
Awareness of the CIS guidelines
Among all responders, over a quarter (27.8%) had not heard of the 2008 Zurich Consensus Statement (table 2). This was similar at all levels, although slightly higher in League 2. The premiership teams were not significantly more aware compared with the lower-league teams (χ2 value 0.185, p=0.667).
There was an ordinal relationship between the level of the league and the completion of more preseason cognitive assessments. Fourty-four percent of the Premiership teams carried out a preseason cognitive assessment on all their players (table 3). The Premiership teams completed significantly more preseason assessments compared with the lower leagues (χ2 value 6.977, p=0.008, Fisher's exact test 0.17). The most commonly used assessment was the SCAT. Thirty-three percent of the Premiership teams routinely used ImPACT computerised assessment. Only one other team, in League 2, used another computerised assessment (CogSport). One Premiership team used its own confidential system; other clubs used paper and pencil tests. Only 11.1% of all teams routinely completed a CIS recognised preseason symptom score.
Following a concussion, most teams used a combination of assessments. The CIS recommends using a symptom score and cognitive assessment, which can be compared with recorded preseason values. The SCAT or ImPACT would be Gold Standard tests as they incorporate both elements. Over half of Premiership and Championship teams complete one of these assessments postconcussion. There was a trend towards more premiership and championship clubs completing these assessments than clubs in the lower leagues (χ2 value 3.399, p=0.065, Fisher's exact test 0.091). Only 48% of the teams who were aware of the Zurich consensus routinely used a postconcussion SCAT.
Postconcussion-assessment methods and assessments deemed important by clubs are shown in tables 4 and 5. Postconcussion, all players in the Premiership and League 2 would be reviewed by the Club Medical Officer. This was deemed to be an essential part of the postconcussion assessment by most teams (91.7%). Despite many teams using a preseason cognitive assessment, few used this as part of their postconcussion evaluation. The SCAT was not regarded as an essential part of the assessment by Premiership teams and was only considered of value by less than a 10th of clubs in remaining leagues. Few teams routinely used a neurologist as a part of their assessment or felt that their input was necessary. Only one team (in the Premiership) felt that computerised cognitive assessment was a mandatory part of a full appraisal.
Return to play decisions
As previously stated, one of the key concepts of the CIS statement is the individual treatment of players. It recommends a stepwise return to play with a review of symptoms every 24 h. The earliest a player could safely return to play would be 6 days. It categorically states that teams should not enforce a fixed period of time away from competitive football postconcussion. This is consistent with FA advice. Fourty-four percent of teams regularly enforced a rest period that did not meet the CIS guidelines and could potentially be unsafe. The lower league sides tended to institute fixed rest periods (χ2 value 6.218, p=0.013) (figure 1). Additionally, one team in the Premiership enforced a 2-week time-out. The length of rest periods varied from 3 to 28 days (figure 2).
This study found that a quarter of teams surveyed had not heard of the 2008 Zurich Consensus Statement. This represents a deficiency in the knowledge of medical teams treating elite players. This gap was significantly widened further down the leagues. Although the majority of teams knew of the CIS guidelines, less than half of them actually followed the practice to evaluate players and make return to play decisions. Most teams relied on the Club Medical Officer's subjective judgement or symptoms reported by players. Both of these methods are susceptible to external pressures, such as demands from the manager, or a player's desire to return concealing his symptoms of concussion. The guidelines provide an objective approach and a player would be protected from returning to play too early, by waiting for his SCAT score to return to baseline. In addition to preventing premature return to play, the guidelines could reduce overcautious lengthy abstinences. This questionnaire established that at least one premiership side and some lower league teams enforced unfounded and probably excessive set rest periods. A recent study has supported the CIS guidelines for an individually planned return to play. It found no measurable impairment in playing performance and no increase in injury rates, in concussed players returning to play according to the CIS guidelines.11 Although there is no definitive or conclusive evidence that it might be harmful for a player to return to sports while still symptomatic of a concussion, it is in contrast to an internationally recognised standard of care to continue with this practice.
The English FA has not enforced the introduction of the CIS guidelines. This potentially gives coaches the licence to demand the return of players when they need them, rather than when their recovery is complete. It is widely accepted that medical teams are under constant pressure to return players to fitness as soon as possible. Some survey respondents remarked that they felt rushed into making decisions on the pitch side and pressured into approving concussed players to return to play. One feared that ‘set rating scales’ would allow coaches to misinterpret data and return players too soon. However, the CIS does not prescribe scaling systems or fixed time periods, it relies on a doctor to supervise an individualised return to play, thus strengthening the position of the medical team.
Two responders to the questionnaire commented that concussion happened so rarely that it did not warrant spending time and money completing assessments. Concussion accounts for 2–11% of all football injuries.12 ,13 The incidence in elite football is 1.4–1.7 per 1000 h played.13 ,14 If a player trains for 3 h a day, 3 days a week, for 10 months of the year and plays 50 games in a season, this equates to 1.4–1.7 every 2.3 years. It you were to expand this to a squad of 25 players, one could anticipate a concussion almost every month. Therefore, concussion must be accepted as a significant occurrence in competitive football. Appropriate medical management is achievable with relatively small time and financial commitments. The SCAT system has no copyright restriction and is free to download, copy and use. It takes approximately 20 min to complete and it is within the reach of any professional team to complete for all players. The CIS recommendations are not exclusive to the SCAT and allow teams a degree of autonomy in the choice of assessment they use. One-third of the Premiership already uses ImPACT. At least one team in the Premiership uses its own concussion assessment programme, which it considers to be superior to the SCAT.
It is in the interests of clubs and their players for the FA to endorse the CIS guidelines followed by the majority of world sporting organisations. It should recommend that all professional teams use the SCAT (unless they have their own protocol which complies with the CIS guidelines). This would allow a standardised, cost-effective and time efficient tool for preconcussion and postconcussion assessments. It could be recorded and kept in all players’ medical records.
There were several limitations associated with this study. Achieving a good response rate with postal questionnaires is an inherent problem.15 However, alternative methodologies to gain the opinions of such a big group over a large geographical area are generally prohibitive from both a practical and financial perspective. The response rate in the current study was similar to previous similar surveys.16 Additionally, the small number of clubs involved limits the amount of statistical analysis that can be undertaken and the results are therefore mainly restricted to descriptive statistics. Despite these limitations, the survey provides an indication that the management of concussion in professional football in the UK needs a consistent approach that could be achieved by adopting the CIS guidelines. Finally, the SCAT2 had not been published when this study started and this has superseded the original SCAT.
The majority of teams who completed this survey from the top four leagues in English football do not routinely follow the CIS guidelines on the management of concussion. This included recommendations on preseason testing, postconcussion management and return to play. The survey provides an indication that the management of concussion in professional football in the UK needs a consistent approach that could be achieved by adopting the CIS guidelines.
What this study adds
This survey of Professional football clubs in the UK indicated that a quarter of the clubs were not aware of the guidelines and there was a wide range of practice covering preassessment and postassessment and return to play strategies with many clubs still enforcing fixed rest periods following concussion.
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Competing interests None.
Ethics approval Queen Mary University REC.
Provenance and peer review Not commissioned; externally peer reviewed.
▸ References to this paper are available online at http://bjsm.bmjgroup.com
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