(Reuters Health) - Concussions are still often missed or ignored in World Cup soccer games despite rule changes designed to sideline players with head injuries, a new study suggests.

After reviewing videos from this year’s World Cup games, researchers concluded that more than 63 percent of players who showed two or more concussion symptoms did not get evaluated by a licensed healthcare professional - which was slightly more than in the 2014 tournament - according to the results in JAMA Neurology.

“We examined adherence to updated and improved concussion protocols which were established after the 2014 World Cup,” said the study’s lead author, Dr. Ajay Premkumar, of the Hospital for Special Surgery in New York City. “It appears that in spite of these changes, concussion management on the field in regard to rates and length of medical evaluation for potential concussion during this summer’s tournament were grossly unchanged from 2014.”

That’s a problem for several reasons, Premkumar said by email. First, there’s the danger to players if concussions are not caught in a timely manner. “Playing with a concussion increases the athlete’s risk for more severe traumatic brain injury or ‘Second Impact Syndrome,’ which can have devastating complications,” he said. “There is also significant literature which supports increased symptom severity and a longer recovery time for those who continue to play after a concussion compared to those removed from gameplay.”

Second impact syndrome, which almost exclusively affects younger athletes, occurs when a brain that has already been injured and hasn’t yet healed is concussed a second time. That second concussion can result in disability or even death.

A second concern from Premkumar and colleagues is that younger players watching World Cup soccer - known outside the U.S. as football - may get the wrong message about concussions. “Concussion assessment protocols and their implementation by large sporting governing bodies may have widespread effects on officiating, coaching and play of countless athletes at all levels and ages around the world,” Premkumar said.

To see whether rules added in 2014 by the medical committee of the Federation Internationale de Football Association (FIFA) had improved concussion identification and management, Premkumar and colleagues reviewed video footage from all 64 games of the 2018 World Cup.

“A head collision event was defined as any event in which a player stopped playing immediately after head contact,” Premkumar explained. “Observable signs and symptoms of potential concussion were disorientation, clutching of head, motor incoordination/balance disequilibrium, slow to get up (characterized by more than five seconds in the recumbent position after contact), impact seizure, blank or vacant look, visible facial injury, loss of consciousness or unresponsiveness.”

Of the 90 players deemed to have two or more signs of concussion, 33 were evaluated by healthcare personnel for anywhere from 13 to 253 seconds, 39 were evaluated by the referee for less than a minute and 18 were evaluated by another player or not at all.

Among six players initially removed from a game after a head collision, three were ultimately allowed to keep playing after evaluation.

Overall, FIFA’s concussion protocol was not followed in at least 63.3 percent of the head collisions that resulted in two or more signs of concussion. That compares with 56.7 percent in the 2014 tournament.

“Overall this study highlights the need to recognize and remove players with suspected head injury from the field or pitch for clinical evaluation and possible removal from the game,” said Micky Collins, clinical and executive director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center and Anthony Kontos, research director of the UPMC program.

The new findings warrant changes in the way FIFA deals with head injuries, said the Pittsburgh experts, who were not involved in the study.

“The implementation of a temporary head injury substitution - that would not count against a team’s normal allotted number of substitutions per game and allow for an off-pitch evaluation - along with head injury spotters and video review for potential head injuries could improve current recognition and removal of potentially injured players,” the two noted.

“We know that it is important to identify and remove players with suspected concussions, because if they continue to play following a concussion they have an increased risk for another head injury or orthopedic injury, experience reduced performance levels, and will substantially lengthen their recovery time.”

SOURCE: bit.ly/2QADqNr JAMA Neurology, online November 12, 2018.