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What Is a Concussion Protocol? Sport by Sport, There's No Single Solution

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What Is a Concussion Protocol? Sport by Sport, There's No Single Solution What is a concussion protocol? Sport by sport, there's no single solution Courtney Lawes undergoes an on-field assessment for concussion while playing for the British and Irish Lions during their tour of New Zealand in 2017. David Davies/PA Images via Getty Images Sep 16, 2019 • ESPN In recent years, the handling of concussions has become one of the recurring topics across the biggest sports across the globe. EDITOR'S PICKS • Love, rugby and a sport's crucial battle with concussion Be it contact sports which revolve around tackling -- such as American football, soccer or rugby -- to the combat sports of boxing and MMA all the way through to the supposedly genteel game of cricket, each has had to reckon with the difficulties of an injury you cannot see. So we asked reporters from across ESPN about the challenges their sports have faced and are still facing, and what protocols are in place in each. Does the sport you cover have an existing concussion protocol? And is there a mandatory period of time that an athlete with concussion has to sit out? Boxing (Nick Parkinson): It is up to the ringside doctor, referee and trainer in the corner to determine if a boxer is concussed, and if a fight needs to be stopped. A ringside doctor can step in at any time to tell the referee to stop a fight, and a referee can halt the contest if a boxer becomes unresponsive or unable to defend himself. A trainer can throw in the towel at any time. World governing bodies like the WBA state that "any boxer who has suffered an actual knockout shall be suspended for at least 60 days", and if the same boxer suffers a knockout in his next bout or within three months he will be suspended for six months (and refrain from sparring during that time). MMA (Marc Raimondi): Not exactly. MMA promotions don't have injury protocols and, for the most part, don't regulate themselves in that way. State, provincial and tribal athletic commissions regulate and sanction mixed martial arts events. When a fighter gets a head injury or another kind of injury in a bout, the ringside physicians will administer a medical suspension. The severity of the injury will determine the length of such suspension. Usually a fighter who is knocked out gets anywhere from a 30-day suspension to a six-month suspension. Where MMA (and boxing) runs into trouble is that many injuries, including concussions, happen during training, especially sparring. Then, it's up to the individual fighter's coach to determine what to do next. There are no hard and fast rules. When a fighter is concussed during a bout, the commission will impose a suspension and a "no contact" suspension, meaning the fighter in question should not be sparring until the length of time is up. But there's no real way to enforce that -- it's not like commission officials can come into a fighter's gym and see if he or she is training or not. MMA and its rule set are very decentralized in that way. NFL (Kevin Seifert): The NFL has an extensive concussion protocol, beginning with mandatory evaluations if any symptoms are noticed or reported. The league doesn't have a mandatory period of time for sitting out. Instead, every player who is diagnosed must follow a five-step process before they can be cleared to fully participate in practice or a game. Rugby (Tom Hamilton): Rugby has a global concussion protocol, called the head injury assessment (HIA). If a player is concussed mid-match, or if there is any suspicion of a concussion then they are permanently removed from play. If there is any ambiguity, then they use the HIA which assesses the player -- it takes 10 minutes and the player is not allowed to return in that time. If a player fails any of the cognitive tests (their score is measured against a pre-season baseline test when they were symptom-free) then they are removed from play. If a player is deemed to have suffered a concussion (they are also tested post-match) then they have to go through a mandatory six-step Return to Play protocol. The player has to pass each stage symptom-free to return to the field. If they fail any stage then they must start again. Cricket (Andrew Miller): It has protocols, plural -- a reflection of the differing speeds at which governing bodies around the world have woken up to the issue. The recent Ashes series between England and Australia is the first at international level to allow for concussion substitutes -- and that provision was required in the second Test at Lord's when Steven Smith was struck on the neck by a Jofra Archer bouncer and replaced mid- match by Marnus Labuschagne. However, Smith actually returned to complete his interrupted innings at Lord's, having passed the mandatory tests in the immediate wake of the incident before suffering delayed symptoms the following morning. That move attracted criticism, not least because he was clearly not his usual self at the crease, but also because Cricket Australia's own code calls for medical professionals to "adopt a conservative approach" when in doubt. Most protocols call for a "graded" return to action. The ECB's code is currently the most robust, requiring that "all symptoms need to be absent for 24 hours" at every stage of the recovery, which adds up to a minimum of six days' rest. The ICC code (which governs international cricket) rather vaguely states that the "typical recovery process will take about seven days to complete", although that did at least inform that decision to omit Smith from the subsequent third Test at Headingley. Soccer (Jeff Carlisle/James Tyler): Soccer's ruling body, FIFA, has a protocol but the problem is that it's unevenly and inconsistently applied around the world. The amount of adherence seems to vary from league to league. As for mandatory periods of rest time following a concussion, the bare minimum as defined by FIFA is six days of rest before someone "returns to play," though there is an additional guideline stating that players cannot return to full training and/or match play until any concussion issues have been resolved and they have been medically cleared. In MLS, for example, every player does baseline testing at the beginning of the season, and that is one of the main criteria used to determine how long a player must sit out. If a player doesn't reach their previous baseline, they are not allowed to return. Australian batsman Steve Smith was at the centre of a concussion controversy during the recent Ashes series against England. Stu Forster/Getty Images What measures is the sport you cover taking to educate athletes about concussion? Boxing (Parkinson): It varies, globally. In Britain, the British Boxing Board of Control regularly runs educational, or awareness, workshops for boxing trainers, boxers and those in the trade on matters such as concussion, and effects of punches in later life. Boxers also undergo regular medicals and brain scans. Boxers do not need reminding what a dangerous sport they are in, but recently boxing has mourned the deaths of two boxers due to punches to the head. Russian Maxim Dadashev and Argentine Hugo Alfredo Santillan died of injuries suffered in the ring in July. Also, in recent years, due to medical research there has been an increased understanding of the effects of blows to head in later life. Chronic traumatic encephalopathy (CTE), formerly known as "punch-drunk syndrome", has affected many famous boxers. Some brain injury experts are convinced that Ali's suffering post-boxing was a result of the poundings he took in the ring and argue that head trauma increases the risk of Parkinson's. Others suspected to have suffered in later life from the effects of blows to the head include the great Sugar Ray Robinson. MMA (Raimondi): The UFC has held several summits where they'll bring coaches and fighters to Las Vegas to the UFC Performance Institute and talk to them about a host of different things, including health and safety. They'll bring in speakers and experts to discuss different topics. So much in MMA is resting on coaches and the fighters themselves. The fighters are all independent contractors and the UFC has no real sway over the coaches, since they're not tied to the UFC in any meaningful way. The UFC Performance Institute, a $14 million facility which opened in Vegas in 2017, has been a huge boon for fighters. There is a full-time staff there of coaches, strength-and- conditioning trainers, doctors and physical therapists. They work with fighters on site and remotely. And they do pass on education to fighters about the dangers of concussions. Other, smaller MMA promotions don't have those kinds of resources and are not as active in that way. NFL (Seifert): The NFL and NFL Players Association holds training sessions to teach players to recognize symptoms. A portion of the training also makes clear that players are required to abide by instructions from team physicians and/or independent neurologists who may be evaluating them in the immediate aftermath, as well as those who monitor recovery. Rugby (Hamilton): World Rugby has a dedicated Concussion Management website which has concussion guidance, a guide to the HIA and resources to learn online. Their 'Recognise & Remove' campaign is also pushed out the world over. Players at the elite level are also briefed on the dangers while at amateur and school level, there are a series of charities -- like Headway, Heads Up and Return2Play -- and organisations that focus on concussion education, training and awareness.
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