Concussion - A reflective blog.
‘Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.’ (McCrory et al, 2013). It doesn’t sound great does it?! Concussion is a BRAIN INJURY. Yet for some reason, from my recent and limited experience in professional football, I believe it is not being treated as seriously as it should be.
I have decided to write this blog on the back of a number of incidents I have witnessed and been a part of with regards to concussive incidents.
Concussion can be caused either by a direct blow to the head, face or neck. It typically results in a rapid onset of short-lived impairment of neurological function, which resolves spontaneously (McCrory et al, 2013). Diagnosis of concussion is usually made via various domains such as clinical symptoms, physical signs, cognitive impairment, neurobehavioral features and sleep disturbance.
Pitchside, the medical team should always be suspicious of a concussion following a head injury and should look for signs such as being slow to get up, unsteadiness, loss of balance, blank or vacant look or confusion. Both the FA and IRFU have produced guidance recently on Concussion. The slogans for both include ‘If in doubt, sit them out’ and ‘Recognize and Remove’. Both guidelines are extremely clear in that any player who has or is suspected of having a concussion should be removed from play and they should not return until they have completed a Graduated Return To Play Protocol (GRTP).
These guides are extremely useful and can be found here:
For even further information on Concussion please have a read of the most recent Zurich consensus statement from 2013 (http://bjsm.bmj.com/content/47/5/250.full.pdf+html?sid=c1c9d91b-436e-459e-8b96-f6ae850a8117)
Also keep an eye out this year for the most recent research on Concussion following the 5th International Consensus Conference, which was held in Berlin at the end of 2016.
Concussion continues to be thrust in to the media, almost on a weekly basis recently. The Hollywood movie ‘Concussion’, which stars none other than Will Smith plays Dr Bennet Omalu, a forensic pathologist. Dr Omalu attempts to raise awareness of the risks of playing American football and ultimately being at risk of Chronic Traumatic Encephalopathy (CTE) and fights the NFL in making the sport safer by representing his research on CTE. His research is initially refuted, however after persistence, and an increasing number of former NFL players unexpectedly dying, the research is accepted and former players begin suing the NFL for covering up what they knew about the dangers of concussion.
Even more recently, there was an inquest into Northampton Saints medical management of George Norths head injury following a mid-air clash on the 3rd December 2016. North had a clear loss of consciousness (LOC), and despite the medical team having access to instant replays, the player was allowed to return to the field of play following a head injury assessment (HIA).
An inquest by The Concussion Management Review Group (CMRG) was undertaken a few days after the incident and they ultimately produced a document detailing their findings. They suggested that North should not have returned to the field of play and provided 9 recommendations following the enquiry. Details of which can be found here: http://www.premiershiprugby.com/news/concussion-management-review-group-report-northampton-saintsgeorge-north/
It is clear after reading these recommendations that mistakes were made in the management of Norths head injury. Recommendations such as checking wifi connectivity prior to matches, the pitchside video reviewer remaining in their allocated seat and reviewing footage prior to a HIA by the medical team display some obvious discrepancies in the management of this incident.
Now please understand if you’re reading this, that this blog is not to lambast the Saints medical team for their management of George North, as im sure they have an excellent medical team, who can recognize the mistakes that were made and will be doing they’re utmost to ensure it doesn’t happen again. And it is this point that I would like this blog to be known and to be useful. I want it to be used as a reflective piece where practitioners feel confident about recognizing their mistakes and learning from them. As it is mistakes where most valuable lessons are learned and I genuinely believe this.
I have recently finished reading ‘Black Box Thinking’ by Matthew Syed. The follow up to the bestselling book ‘Bounce’. In the book, Syed opens with a harrowing first chapter which describes an incident in which a healthy 37 year old mum of 2 was due to have a routine operation to help with sinus problems she had suffered with. Unfortunately the patient died following a lack of oxygen during intubation prior to surgery. The highly experienced anesthetists were unable to insert an airway in to the patient, and despite nurses recognizing this and offering the anesthetists the option to perform a tracheostomy, (which would have saved the patients life) the offer was ignored and the patient died following 13 hours in a coma. The lack of oxygen causing irreparable damage. The reason for this death? ‘It was one of those things. Accidents happen. The anesthetists did their very best. It was a one-off.’
This horrific incident is the fulcrum of the book as it discusses mistakes, but more importantly, reflecting on mistakes. Not just in healthcare but in high performance sport, business and technology. The book discusses the lack of reflective learning within healthcare and how other organizations and entrepreneurs use failure to their advantage by reflecting on their mistakes and sharing them. Syed uses Aviation as a classic example of how mistakes are not seen as a scapegoat exercise, but rather an opportunity to learn and to share so that other airlines and pilots reduce the risk of making the same mistakes. That is why every single plane has a blackbox which records what occurs in the moments and hours prior to crashes or near crashes. Airlines then have access to this information which can then be used to help prevent future tragedies.
Syed’s book gives a plethora of examples where people use their mistakes to their advantage, and those that don’t, continue to make the same mistakes again and again and again. The book is an exceptional read and I would implore anybody interested in improving themselves in any dimension, to read it. If you haven’t read his first book, Bounce, then this is also an essential read!
It is Syed’s book that encouraged me to write this blog, as I want to discuss a couple of incidents that I have seen and been a part of over the last couple of months. I have done this as I believe I have made a mistakes, and have learned from them, and I believe others have made mistakes, and I want those people to learn from them also. I also want you, the reader, to learn from the mistakes of some of the incidents I am going to discuss so that you and your medical team can reflect and hopefully reduce the risk of making similar errors.
A bit of background info on myself, I have recently moved from u18/u21s football, to 1st team football and I am currently the Head Physiotherapist at St Johnstone FC who play in the Scottish Premier League. With all the examples below, I have gained players permission to share these incidents on this blog.
FYI, I am not using these incidents to place blame on anybody. I am simply showing how frequent these incidents are occurring and how I feel medical teams need more help from organisations such as the FA, and SFA to promote better management of concussions in professional football, before something disastrous happens.
Incident 1. 19/11/16
This incident occurred in my 4th game at Saints. You can see that the defender and goalkeeper take a massive hit. The defender clearly takes the brunt of the impact, however as I run on to the pitch, it is the goalkeeper who appears to be more of a concern. Players are beginning to role him on his side whilst the defender begins to sit up. Prior to each game myself, the assistant physio and doctor discuss our Emergency Action Plan. This is a 10 minute meeting discussing and planning for incidents such as cardiac arrest, concussion, major trauma and stretcher/spinal board extrication. Unfortunately, one thing we did not discuss was the scenario whereby 2 of our own players are involved in a collision. In this scenario our assistant physio stayed on the bench maintaining radio contact for coaches, whilst the doctor assisted me with assessing the goalkeeper. My initial contact with the player is to get in to the MILS position (manual in line stabilization),to protect the players neck. Whilst maintaining MILS I went through a pre-planned C-spine assessment consisting of:
Maintain MILS
Ask player if they have neck pain
If negative, ask if they have any neurological symptoms such as numbness, parasethesia, burning or tingling in their upper limbs or neck.
If negative, palpate C-Spine spinous and transverse processes assessing for tenderness.
If negative, ask player if they are able to rotate their neck left and right 45°.
If negative, confirm with Doctor and C-Spine can be cleared.
This is a modified version of the Canadian C-Spine rules (Stiell, 2008). The players C-Spine was cleared and we began to assess other injuries. Following this we asked the player Maddocks questions which consisted of:
What venue are we at today?
Which half is it?
Who scored last?
Who did we play last week?
What score was that match?
The player passed his Maddocks questions by answering all questions correctly and myself and the Doc were happy that the player was not concussed and that he could continue to play.
Unfortunately, whilst this assessment ensued, the defender was knelt on the floor being encouraged by a couple of his team mates to get up to help defend the corner. The player does this and does not receive any assessment by myself or the Doc.
20 minutes after the incident, at half time, I asked the defender if he was ok. His response? ‘I don’t remember anything that happened in that half’.
ALARM BELLS!
At half time, I further questioned the player and continued with Maddocks questions. The player was unable to answer these correctly and myself and the Doc agreed that the player was concussed and that he needed to be removed from play. The management team accepted this and the player was removed from play at half time.
For the remainder of the game, the player was closely monitored and was given advice and education regarding concussion. A family relative of the player was staying with him for the weekend and we educated them on concussion and signs to watch out for and what action to take if he deteriorates.
The player made a full recovery following the incident and followed the GRTP as recommended by the FA and returned to complete the next match 2 weeks later.
So there it is. My mistake and I have tried since to learn from it. I have reflected on it formally by writing it down as per CSP guidance and have reflected on it informally by discussing it with some of my peers including the FMA and a professional mentor. I should have ensured the player was assessed at the time of the injury despite spending so much time with another player. I should have had somebody in the stands watching replays to tell me to go back and review the player, as its clear in the video that he took the majority of the impact.
Since the incident, we have trialled our assistant physio sitting behind the dugout to enable a better, clearer view of incidents. I have made the ‘2 injured players down’ an agenda for our EAP and changed our management for this to ensure that every injured player is seen before the match resumes. I have began speaking to our media team to see if it is possible to enable live replays of incidents similar to that used in Rugby. I am trying to learn from my mistake to reduce the risk of it happening again, and I want you the reader to put things in place at your club, if you haven’t already, to help you, your team and your players.
Incident 2. 3/12/16 (The next match)
In this incident, our central midfielder and opposition midfielder have a mid-air head to head collision. Both players go down, but as you can see, when the opposition player hits the ground, he displays the classic ‘Fencing response’ which occurs when there is a force applied sufficiently to the brain stem. Theres plenty of youtube videos showing NFL players displaying this classic sign, and it is a clear indication that the player has a concussion and should be removed from play (https://youtu.be/ZlXjwAlOflA). You'll then see that the opposition player remains motionless for 5 seconds prior to being rolled on his side by team mates. Upon assessing my player, he has a small graze above his eye, has no neck pain, recalls the incident immediately, displays no signs of concussion and completes his Maddocks questioning. After further checks with our Doc and a couple of functional pitchside tests, the player returns to the match and is monitored closely.
Meanwhile the opposition player who has clearly had a LOC and displayed the fencing response is being treated by the opposition medical team. It appears to me that they do everything required. They protect the players C-Spine, they appear to perform neuro and MSK testing, and they take their time assessing the patient. Following their assessment, they clearly indicate to the bench and management that the player should be removed from play. The classic hand-rolling signal. When I returned to the dug out I could see the opposition Doc and Physio remonstrating that the player should not return to the field of play. I couldn’t hear what was said, but they had made the decision that the player should not return to the pitch. Unfortunately, 2 minutes later and with no restraint from the management or 4th official, the player returned to the field of play and continued to play for a further 24 minutes before being substituted.
I genuinely believe that the opposition medical team did every thing in there power. They assessed the player safely, they made their decision and they told the management that the player needed to be substituted. The only thing they could have done, would have been to physically restrain the player from re-entering the field of play, but I cant imagine this would have gone down too well with the player or management. So what should be done? Should the 4th official be able to refuse to let a player return to the field of play if the doctor states that he is not allowed because of a concussion? This is the rule set out by UEFA in all European matches including the Champions League and Europa League. So why isn’t this the case in domestic competitions? This ruling came in to place following the World Cup in 2014 when Uruguays Alvara Pereira was hit in the head and despite a LOC and team doctors stating the player should be removed, the player was allowed to return to the match, once again, against the recommendation of qualified Doctors. So, now that UEFA has recognized this, and put a ruling in place, why hasn’t the FA and SFA done the same? This is the change I want this blog to make.
Incident 3 – 17/12/16 (The third concussion incident in 29 days)
Final video and reflection! Our defender goes down with a clear head injury. The referee recognizes this and despite no foul, the referee stops play a couple of seconds later. I thought that the idea of stopping play despite no foul, would be to allow the injured player to receive treatment. However, for some reason, the referee asks the player if he would like treatment, to which the player refuses. At the point I am stood by the side of the pitch in line with the player and I ask the linesman to ask the referee if the player is ok as it looked like he took quite a knock to the had and might not be able to give an informed decision on wether he needs treatment or not. After 20 seconds or so, the player attempts to stand up, however he then isn’t able to stand and goes to the ground again. At this point, I raise my concerns to the linesman to tell him to tell the referee to let myself and the Doc on to assess the player as it is clear that the player is suffering with a head injury. The referee ignores this request, again asking the player if he's ok before determining that he is ok and does not allow myself or the Doc to assess the player at any point despite a clear head injury and possible concussion.
In this scenario, surely it would be beneficial to all to allow the medical staff on to assess the injured player. If the referee has stopped the match because of a head injury, why would he then not allow medical staff on to the pitch to decide whether the player is fit to continue? Why is the referee allowing the player to make the decision on his head injury? Having spoken to a couple of people including referees about this, the common response is along the lines of ‘well players may start taking advantage of this rule when they’re in a winning situation’. Surely though, if a player has to receive treatment following a head injury when play is stopped, and the player has to be removed from the pitch momentarily, then there is no advantage as the players team is momentarily down to 10 men?
I’m not asking for referees or governing bodies to create a rule whereby medical staff should be allowed to enter the field of play for every single injury even if a player refuses it. I’m simply suggesting that if a player goes down with a head injury, and play stops because of the head injury, then surely it would be advantageous for all to allow the Medical team to make the decision on whether a player is concussed or not and take that decision out of the players hands?
I have raised this issue with the Scottish FA referees association recently and am currently awaiting their response.
Three separate incidents. All, I feel, with separate learning opportunities for everybody. I genuinely hope that medical teams from all sports all plan EAP’s prior to matches and always plan for the worst case scenario. I hope the FA, SFA and referees associations take note of some of these incidents and also learn from them and put things in place to help reduce the risk of them from happening again.
Thank you very much for reading, I hope you found some value from it and if you have any comments or thoughts then please share them. Also, if you have made errors or mistakes, then please share these as well. I see so much on Twitter promoting best practice exercises and best practice treatments, but wouldn’t it be great if we could also share worst practices? Not for people to be held accountable and hung out to dry, but to learn from others experiences and to progress Sports Physiotherapy even more!
Cheers!
Tony
E-Mail: tonytompos@googlemail.com
Twitter: @TonyTomposPT
