The Fédération Internationale de Football Association (FIFA) has long had a policy that players who show signs or symptoms of a concussion should have a timely evaluation by a licensed clinician using established assessment tools and should not return to play if a concussion is diagnosed.1 After discussions about poor adherence to this policy in the 2014 World Cup, which were highlighted in JAMA,2 the FIFA Medical Committee made 3 changes to their concussion protocol (Box).3 In this analysis, the incidence, characteristics, and assessment of head collisions during the 2018 World Cup were reviewed to assess compliance with FIFA’s updated concussion protocol.

Box Section Ref ID

Box. Changes to Concussion Protocol After 2014 World Cup and Concussion Signs and Symptoms Changes to Concussion Protocol3 A referee may stop a match for 3 minutes to allow a team physician to complete an on-field assessment. A second team physician may access in-match video replays to assist with decision making. The injured player will be allowed to continue playing only after authorization by the team physician. Concussion Signs and Symptoms4,5 Disorientation

Clutching of head

Motor incoordination/balance disequilibrium

Slow to get up (characterized by >5 seconds spent in the recumbent position after contact)

Impact seizure

Blank or vacant look

Visible facial injury

Loss of consciousness/unresponsiveness

Methods

Four trained reviewers identified head collisions through review of video footage of all 64 games of the 2018 FIFA World Cup recorded on FuboTV. A similar methodology has been used previously to assess sports-associated head injuries.2,4 A head collision event (HCE) was defined as any event in which a player stopped playing immediately after head contact. Observable signs of potential concussion were documented for each HCE (Box).4,5

The 64 games were each watched by 2 of 3 independent reviewers (A.T.A., S.W.L, and F.M.). A fourth reviewer (K.X.F.) then studied supplementary video footage for each identified HCE to ensure reporting accuracy. The length of each assessment was recorded and players with 2 or more signs were categorized as potentially having a concussion.

This study was exempt from institutional board review, and the use of video recordings of a public broadcast made informed consent unnecessary. Differences in categorical variables were assessed using the χ2 test. All 2-sided P values less than .05 were considered significant. Data analysis was completed with SPSS version 25.0 (IBM).

Results

During 64 games, 95 players had 115 HCEs in 111 separate incidents (1.79 HCEs per match). Twelve players had 2 or more HCEs. A total of 25 players (21.7%) showed no or 1 sign of concussion, while 90 players (78.3%) showed 2 or more signs of concussion.

Of the 90 players with 2 or more signs of concussion, 33 (36.7%) were evaluated by health care personnel (median time of evaluation, 53 seconds; range, 13-253 seconds). Thirty-nine (43.3%) were evaluated by the referee (median time of evaluation, 14 seconds; range, 1-57 seconds). Eighteen players (20%) were evaluated by another player or never evaluated.

Of the 6 players that were ultimately removed from gameplay after an HCE, 3 were initially allowed to keep playing after evaluation (Table). A comparison with published data from the 2014 World Cup2 indicates no statistically significant difference in the proportion of players who did not receive appropriate assessment by health care personnel after showing 2 or more signs of concussion after an HCE (2018 tournament: 57 of 90 [63.3%]; 2014 tournament: 38 of 67 [56.7%]; P = .40).

Discussion

During the 2018 World Cup, FIFA’s own concussion protocol was not followed in at least 63.3% of HCEs that resulted in 2 or more signs of concussion, a rate slightly higher than but similar to that of the 2014 World Cup. When evaluation did occur, the average length of on-field assessment was less than 1 minute and not standardized. It appears that FIFA’s concussion policy changes (Box) did not lead to enhanced concussion management on the field, and its absence has thus rendered these policy changes ineffective.

There are a number of interventions that have shown promise in other professional leagues that warrant further examination in international football. These include use of standardized assessment tools and allowance for player substitutions during evaluation.6

This study had limitations. When comparing data between World Cups, it should be noted that this study had a different team of reviewers and that television coverage may have differed. Additionally, video observation is insufficient to diagnose a concussion, and some players may have been feigning injury. However, 2 or more signs of concussion were observed in most events (78.3%), and these signs have been used for concussion surveillance in a number of settings. Furthermore, health care personnel cannot reliably distinguish a concussion from gamesmanship without evaluating the player. Thus, all players should be evaluated when exhibiting signs of concussion.4,5

Conclusions

Concussion assessment protocols and their implementation by large sporting governing bodies may have widespread effects on officiating, coaching, and play of athletes around the world. Concussion assessment and management in international football continues to have significant room for improvement.

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Corresponding Author: Ajay Premkumar, MD, MPH, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021 (premkumara@hss.edu).

Accepted for Publication: September 7, 2018.

Published Online: November 12, 2018. doi:10.1001/jamaneurol.2018.3462

Author Contributions: Dr Premkumar had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Premkumar, Farley, Anastasio, Mirza, Gottschalk, Xerogeanes.

Acquisition, analysis, or interpretation of data: Premkumar, Farley, Anastasio, Lee, Mirza, Gottschalk.

Drafting of the manuscript: Premkumar, Farley, Anastasio, Mirza, Gottschalk.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Premkumar, Farley, Anastasio, Lee, Mirza.

Administrative, technical, or material support: Premkumar, Lee, Mirza, Gottschalk, Xerogeanes.

Supervision: Premkumar, Farley, Gottschalk.

Conflict of Interest Disclosures: None reported.