Recovering from concussion: how should a leading football team support its players?

This is the second article in a series of reports from the Sports Tomorrow Congress. You can read the first piece, examining the effectiveness of cognitive training, here.

Concussion is one of the most serious issues facing sport. Read the chilling testimony underpinning legal cases launched by former rugby union players. Take a look at studies highlighting former footballers’ susceptibility to neurodegenerative disease. The case for inertia is non-existent.

So what are teams actually doing to support players suffering from concussion? In a session at the recent Sports Tomorrow Congress, Edwin Goedhart, the Dutch Football Association’s Chief Medical Officer, took attendees inside the recovery programme used by the country’s national teams. The presentation provided an insightful illustration of how a leading sports organisation is dealing with one of the most complex challenges facing football.

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“We don’t know exactly what it is.”

If it’s refreshing to hear an expert admit the boundaries of a profession’s understanding, Goedhart’s admission that concussion is a subject of which much is still not known is faintly chilling.

This is a man that has worked for the Dutch Football Association (KNVB) for over 10 years, helping to oversee the establishment of a ‘concussion clinic’ dedicated to treating elite and recreational athletes (competing in sports ranging from football to cycling).

But he doesn’t pull any punches in laying bare the scale of the challenge facing football. For a start, he dispels the myth that a blow to the head is the only way in which a concussion is sustained, listing knocks to the face and neck - which have the potential to spark violent jarring or shaking that disturbs the brain’s functioning - as being among the causes of sport-related concussions.

It’s a hint at the complexity of the condition. Goedhart and his team will be on the lookout for an array of symptoms players might show during a game, ranging from blurred vision to imbalance. The image below shows a snapshot of some of the 30-odd red flags they will be searching for:

It makes identifying the seriousness of a case a tricky business. In a Nations League match between the Netherlands and Poland, Teun Koopmeiners seemed to be the least affected of two players involved in a mid-air collision - sitting rather than lying prostrate after the fall - but the Dutch doctor revealed that the Atalanta midfielder actually came off worse, displaying blurred vision and disturbed balance.

Indeed, loss of consciousness - which, until recently, seemed to be the only criteria commentary teams saw fit to judge a potential concussion - is present in only 15 % of cases, according to Goedhart.

Players who do suffer a concussion are enrolled in the KNVB’s ‘Gradual Return to Play Protocol’, a recovery programme comprised of six stages. The process, which only starts once an individual has been symptom-free for 24 hours, gradually takes the participants from light aerobic exercise to full contact practice, with players returning to the previous step in the cycle if they display any symptoms of concussion.

Within the concussion clinic, which has been running for over five years, variables such as information processing are rigorously scrutinised, with Goedhart highlighting this cognitive capability as the most important yardstick of a player’s recovery.

The image below illustrates the extent to which reaction speed slows in the aftermath of a concussion, with the player highlighted taking over a month to recover the responsiveness exhibited in baseline tests taken by all Dutch national teams.

Whilst long recoveries are not frequent - 15% of cases take longer than 7-10 days to resolve - Goedhart and his team have identified common denominators of a lengthy spell on the sidelines, including age (with teenagers possibly at most risk of experiencing persistent symptoms), playing whilst recovering and whether an individual has a history of mental health conditions.

The former Ajax medical officer also stresses that “it is almost impossible to be free of complaints” two weeks after an individual sustains a concussion, even if the recovery process has been successfully completed. The KNVB programme takes this into account, allowing complaints (as long as they return to pre-exercise levels within 2-3 hours) to increase by no more than 2 points on a 10-point scorecard.

The approach reflects the sensitivity required when helping players recover from concussions. As football, along with other sports, grapples with the significance of this medical challenge, it’s also a model which will give real food for thought.

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