MLS' concussion protocol still a work in progress

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Soccer has a long way to go in the process of properly evaluating concussions in real time. MLS is addressing that with advancements in 2017. Is it enough?

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It’s the 13th minute of the Nov. 30 Major League Soccer playoff game between Montreal and Toronto, and Hernan Bernardello and Jozy Altidore leap into an aerial duel. The 6-foot-1 frame of the U.S. international towers above the Argentine midfielder, with Altidore’s shoulder and arm making contact with Bernardello’s head. Bernardello,falls toward the ground, fails to put out an arm to protect himself, and hits the surface head-first.

The referee stops play. Altidore complains he was fouled just as the Montreal team doctor sprints onto the pitch. The urgency is striking, but within the context of a soccer game, it still feels normal. It seems a foregone conclusion that Bernardello will not kick another ball that night.

Yet he is back on the pitch within minutes. The commentators and viewers are all surprised, assuming the player cleared the concussion protocol. Unfortunately, he hadn’t. He wasn’t tested for a concussion at all.

That Bernardello left the game at halftime amid head injury concerns highlighted the need for a consistent way to identify and diagnose head injuries in soccer - the need for a real concussion protocol.

There isn’t one yet.

“In medicine, you can rarely follow a protocol. This is why we have a well-trained physician at every game.”

- Dr. Bert R. Mandelbaum

Much of American soccer’s approach to head injuries is shaped by the U.S. Soccer Federation’s guidelines, which are built on the idea that if a suspected concussion occurs, the player must be removed from the game and assessed on the sideline. During that assessment, the player undergoes the Sports Concussion Assessment Tool (3rd edition), also known as SCAT3 - a list of steps to follow if a concussion is suspected.

The questions, designed to measure cognitive ability, include testing the player’s memory, concentration, balance and coordination. If the physician decides the player is concussed, the player is not allowed to return to the game. Afterward, the player is monitored and only allowed to participate in training once he has been symptom-free for 24 hours. Subsequently, the player follows a stepwise, supervised program which starts with “light aerobic activity” and ends with “full-contact practice.”

At each step, the player is monitored to confirm that no concussion-related sequela (such as irritability, seizures, vomiting, etc.) are observed. Once the player is medically cleared, he can play in competitive games. These steps are outlined in both the SCAT3 as well as U.S. Soccer’s ‘Recognize to Recover’ program.

While the guidelines for head-injury management are clearly defined post-concussion, the actual on-field assessment of concussions is not.

How are concussions assessed?

Unlike the NFL’s poor handling of the early research, MLS deputy commissioner Mark Abbott believes the league has “committed to this issue since the league’s inception.” The members of MLS’ 12-person Concussion Committee range from well-known neuropsychologist Dr. Ruben Echemendia to former player Taylor Twellman, who had his career curtailed due to complications related to concussive head injuries.

With similarly qualified and connected people making up the committee, MLS feels it has placed the right people in charge. So what is that panel’s recommended protocol? Does it even have one? These questions do not presently have clear-cut answers.

Nick Turchiaro-USA TODAY Sports

Nick Turchiaro-USA TODAY Sports

According to documentation provided by MLS, “Any player suspected of having sustained a concussion is removed from play immediately and evaluated by team medical staff.” Both these steps involve a significant amount of subjectivity, or as Dr. Bert R. Mandelbaum, assistant medical director of MLS, put it, that’s where “medical judgement comes in.”

“In medicine, you can rarely follow a protocol,” Dr. Mandelbaum said. “This is why we have a well-trained physician at every game.”

While that is true, a standardized set of guidelines would help medical personnel make correct decisions, especially since they are placed in high-pressure situations with limited time to make a diagnosis. In the Bernardello incident, for example, the incident occurs at 12:06 on the game clock, the trainer begins his assessment at 12:41 and the player comes back onto the pitch at 15:10. Subtracting a few seconds between the end of the initial assessment and Bernardello being given the all-clear to play, it leaves the medical personnel around two minutes to ascertain whether Bernardello was concussed.

According to an Impact spokesman, Montreal’s team doctor did not see Bernardello’s head hit the ground in live time. When the team’s medical staff reached the field, Bernardello complained of shoulder pain and was treated accordingly. It was only at halftime, when a Toronto FC doctor told Impact personnel about the nature of the hit and fall – and Montreal’s doctors saw the video replay – that Impact began treating Bernardello for a possible head injury. Bernardello was subsequently substituted before the second half kickoff.

Bernardello played on because the team doctor didn’t see his fall. And because no head injury was suspected, no SCAT3 was performed. The player was back on the field within minutes, but ultimately, when the doctors saw the footage, they decided he shouldn’t have been on the field at all. He should have had to work through the protocol.

The full SCAT3 is time-intensive and would take 10-15 minutes to complete. And, unlike sports such like hockey, basketball and football – all of which allow constant substitutions – in soccer, if a player is being tested on the sidelines, it leaves their team short-handed. Those circumstances make it more difficult for medical staff to sufficiently complete the entire SCAT3.

There are absolutes, of course – conditions that are supposed to end a player’s game, no matter what. “Loss of consciousness, ataxia, seizure and severe headache are the cardinal signs of concussion,” Mandelbaum said. “If those signs are there, 100 percent of the time, the player is taken off.”

But how often are those obvious signs there? Not enough to make that standard a reasonable guideline.

“I’m always anxious about the latent occurrence of symptoms and signs related to a suspected concussion. Those can appear after 10 minutes once the player has been allowed to return to play.”

- Dr. Vincent Gouttebarge

A 2010 study examining high school sports-related concussions found that over 95 percent of concussions did not involve loss of consciousness. Setting aside the obvious caveat of comparing high school sports to professional soccer, you can at least see the disconnect. Similarly, only about 10-20 percent of traumatic brain injury patients exhibit seizures. The MLS concussion protocol is looking for obvious signs as definitive proof of concussions when, by that standard, a majority of concussions are going to go undiagnosed.

Bernardello’s was not an isolated incident, either. In October 2015, Sporting Kansas City goalkeeper Tim Melia was allowed to play for 14 minutes before being substituted after an accidental head injury. Those 14 minutes could have resulted in a subsequent concussion for Melia, and the potential brain damage due to successive concussions could have had severe consequences.

While it was not deemed to be the case at the time, did Bernardello lose consciousness? Was there enough evidence for a medical professional to diagnose a concussion, if they were given the correct tools to do so?

Dr. Vincent Gouttebarge, Chief Medical Officer of FIFPro, told FourFourTwo via email what he saw on the play: “One might have suspected a concussion here: clear blow on head transmitted through shoulder/neck when the player has his eyes exclusively on the ball, being then not prepared to the upcoming contact. In addition to that, the head of Bernardello seems to hit the ground as it might be an immediate post-traumatic neurological impairment due to the initial blow.”

Dr. Gouttebarge continued: “I’m always anxious about the latent occurrence of symptoms and signs related to a suspected concussion. Those can appear after 10 minutes once the player has been allowed to return to play.”

For MLS’ part, Mandelbaum and Abbott believe that given the dynamic nature of the situation, the medical personnel made the “best decision they could at the time.” And without the assistance of video technology, Abbott’s assessment is probably correct. Abbott did confirm that, at halftime, “additional information was taken into consideration,” and Bernardello was substituted.

As one study suggests, sport concussions are being underreported due to external pressures, making it all the more important to develop an objective standard. In this case, there’s no reason to think MLS’ personnel acted in anything but the player’s best interests. When it comes to head injuries, however, that’s not enough. MLS needs to provide physicians with a checklist to normalize concussion diagnoses, and, most critically, all decisions should error on the side of caution.

Giving perspective and taking action

At the recently completed league meetings in Los Angeles, MLS’ concussion committee agreed to the idea of “spotters” who will aid medical personnel. An individual who is “trained in diagnosing and recognizing concussions” will be able to “immediately communicate to the doctor on sideline” if they observe a head injury, explained Abbott, adding that there would be a spotter “for every game watching video feeds.” This would be a welcome addition to helping diagnose concussions in the case of brief loss of consciousness, which could be otherwise missed.

Certainly, in the case of the Bernardello incident, spotters would have been critical to identifying the head injury in a timely manner. In a way, Toronto’s medical team became the de facto spotters, wisely informing the Impact of a possible problem. MLS will benefit from the change if that kind of feedback loop is in place at every game.

Amid all this talk of procedure and protocol, it’s important to remember why erring on the side of caution is so important. A concussion is a change in the normal function of the brain in response to an impact injury to the head. There is scientific evidence linking concussive injury to chronic traumatic encephalopathy (commonly known as CTE) – the condition that put head-injury awareness in the NFL spotlight, one that’s linked with an increased rate for suicide, depression, gambling behaviors and addiction. CTE hypotheses posit a buildup of inappropriate forms of proteins observed in other neurodegenerative disorders, such as Alzheimer’s disease and Frontotemporal dementia.

Put plainly, concussions are injuries to your brain, ones that impair function and have been linked to serious, negative long-term health results.

Interestingly, the scientific literature itself is redefining the concept of concussions constantly. In fact, there has been discussion that the word “concussion” should be done away with entirely, and renamed as ‘Mild Traumatic Brain Injury (mTBI).

Given the potential risks to player health, the correct diagnosis of concussions is paramount to player safety, as well as propagating the correct message to coaches, athletes and supporters alike. This is not just an MLS problem – it’s one that extends to FIFA, at large. When it comes to player health, each league can and should take responsibility for its own actions.

The next steps

In addition to video replay, Gouttebarge would like to see additional changes made to the game:

1. The consistent application of the guidelines, i.e. SCAT3;

2. Better education for medical staffs and coaches; and,

3. The presence of an independent clinical physician, if management of concussion is still not at a high level.

Gouttebarge has also previously indicated that he would like to see the introduction of temporary substitutes into the game for head injuries. This would allow teams to play 11-on-11, while simultaneously allowing full application of the SCAT3 for possibly concussed individuals.

Still, there are other questions which MLS and soccer leagues around the world need to address about their protocols. Are medical staffs being given enough time to make responsible decisions? Is the full SCAT3 required for every suspected concussion diagnosis? If not the full SCAT3, which section of the SCAT3 takes precedence?

Currently, these questions do not have clear-cut answers. And given the importance of player health, that needs to change.

The league seems committed to navigating a very tricky problem in a professional and appropriate way, which is essential given the potential long-term complications of brain injuries. Mandelbaum agrees: “Players, coaches, referees need to be educated about (concussions).”

In fact, Abbott and Mandelbaum are excited about a new updated MLS concussion protocol to be implemented “before the start of the season.” The details are not yet public, but Mandelbaum hints that a centralized protocol will be realized. “We are truly a single entity,” he explains.

The challenge for the league, however, is answering the most basic question: When it comes to diagnosing on-field brain injuries, what exactly is the concussion protocol?

Right now, the only discernible answer to that is, ‘it depends.’

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Nipun Chopra studies neuroscience at The Indiana University School of Medicine. He also writes about and reports on soccer. You can follow Nipun on Twitter @NipunChopra7.