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Dealing with concussion

The popularity of the anecdote is revealing.

A striker falls heavily after a clash of heads. The physio checks his state of health. The player does not know where he is, or indeed who he is. This is relayed back to the manager, who thinks quickly before saying: "Brilliant. Tell him he’s Pele and get him back on."

The quip has been attributed to many great names, Brian Clough and Bill Shankly among them, but was actually delivered by Partick Thistle manager John Lambie about Colin McGlashan during a Scottish Premier League game in the 1994-95 season.

A traumatic history

Concussion is an occupational hazard of playing football. It has even provided backdrop to some of English football's most heroic stories. Bolton centre-forward Nat Lofthouse was forever known as the "Lion of Vienna" after being knocked out while scoring for England against Austria in May 1952.

The 1957 FA Cup final saw Manchester United’s Busby Babes denied the double when keeper Ray Wood was poleaxed by Aston Villa’s Peter McParland. There were no substitutes in those days, so Wood, unable to stand unassisted for several minutes after the incident, later returned to play as a passenger on the wing. Particularly striking from TV footage is the image of Wood's team-mates and trainer Tom Curry swiftly lifting off his goalkeeping jersey so centre-half Jackie Blanchflower could wear it instead; the emphasis was on the game continuing. When United pushed for an equaliser late on, Wood even returned to playing in goal. Such was the spirit of the age.

Hitting the headlines

Fifty-six years on, Wood's stricken Wembley demeanour was echoed at Goodison Park in November when Tottenham goalkeeper Hugo Lloris' head came into heavy contact with Everton striker Romelu Lukaku's knee. Such was the impact that Lukaku limped from the field, but Lloris -- stunned, unsteady and looking confused -- was allowed to continue after a lengthy dispute with team doctors in which the Frenchman kept trying evade their grasp while demanding to continue.

Mystery remains over who made the final decision for him to play the further nine minutes of added time, in which he made a crucial save to preserve the 0-0 scoreline.

Firstly, manager Andre Villas-Boas admitted it was his call, but later suggested it had been on the advice of two Tottenham doctors. His description of Lloris as showing "great character" seemed flippant, and what was widely suspected to be his decision was heavily criticised by many, including FIFA chief medical officer Jiri Dvorak.

"The fact the other player needed ice on his knee means it's obvious the blow was extensive," said Dvorak. "It's a 99 percent probability that losing consciousness in such an event will result in concussion. When he has been knocked unconscious, the player himself may not see the reality."

Context of concussion

A $765 million NFL concussion compensation payout settled in August has raised worldwide awareness of the long-term dangers of a condition that presents danger to any sportsman. Last week, 10 former NHL players launched a civil action against the ice hockey league, alleging the league knowingly concealed the long-term effects of brain trauma.

Rugby Union's concussion protocols were altered after the deciding test match between Australia and the British $amp; Irish Lions in July was marred by legendary Wallaby forward George Smith returning to the field in a punch-drunk state after colliding with Welshman Richard Hibbard. Smith’s "snake dance" crystallised a serious concern in rugby circles. Suspicions abound that football is yet to take the issue remotely as seriously.

Professional Footballers' Association chief Gordon Taylor led the charge in the immediate aftermath of l’affaire Lloris, and continues to be outspoken. “We should be quite unequivocal," he tells ESPN. “They have to be pulled from the field of play and not be allowed to return for at least five days, with a clear responsibility on the medical officers at the club.”

“Professional sports need better guidance," says Luke Griggs of brain injury charity Headway. “While criticism was laid at AVB, there's the element that there wasn't enough guidance. It's down to the authorities to provide direction.”

The sufferer

At home in Boston, Taylor Twellman, these days an ESPN TV analyst, was getting his Sunday fix of the English Premier League but could hardly bear to watch as Lloris returned to the action.

Five weeks before he had flicked off his TV set in anger when Lukaku, while scoring for Everton at West Ham, was knocked unconscious after colliding with Joey O’Brien as he headed in. Lukaku later admitted he had asked his team doctor who had scored the winner. He had no idea the goal had been scored by him.

Twellman could not believe what he was seeing at Upton Park. “I felt sick to my stomach, I didn't want to watch him play on. Your life's in danger, and until people realise it's not a career thing ... you just don't want to live your life the way that post-concussed athletes have to live. It's barbaric. We are not in the Roman Colosseum any more.”

He has paid a crippling price for playing on with a concussion suffered playing for New England Revolution against Los Angeles Galaxy in 2008.

“The goalkeeper made a bad decision and punched my head but I still scored the goal,” he recalls. “I played six days later and for the next eight weeks -- and then my career was over.”

He had suffered concussions before, but this time was different. Its aftereffects have still not gone away. “I deal with symptoms daily, for the last five years,” Twellman says. “My life has changed drastically. I have had a headache for five years, have not worked out for four years. I can barely go to a cinema theatre. I've only just started reading books again.”

The greatest risk to a concussion victim is further concussion; it can lead to serious brain trauma, and have serious consequences in later life. “It's lucky that Lloris didn't get another one, or Lukaku,” says Twellman. “And I'm not talking about playing. I am talking about lives here. Science has shown us that it's not the first one. It's what they call ‘second impact syndrome.’

“If the immediate decision is to take them away from the game, then you give them a better chance of recovery.” The survivor

In contrast to the days of Wood and Lofthouse, head injuries are treated seriously in football. Any head injury leads to a referee calling a break in play, but a show-must go-on attitude still pervades. Blood injuries mean a player must leave the field while being patched up, but that does not always happen when players lose consciousness.

David Preece is a 37-year-old goalkeeper with non-league Lincoln City, where he is also player-coach. He has been concussed nine times in his career, the first when playing for Aberdeen against Celtic in 1999, a day he calls “Blankety Blank Day.”

“I had no recollection of what had happened whatsoever, amnesia, memory loss,” he says. “At the time, apart from having to ask people what the score was, everything was functioning perfectly well. My speech wasn't slurred, I wasn't groggy or anything like that.

“In another instance, Aberdeen against Livingston, I took a bang to the side of my head, and looking back I could see that something wasn't right. There was a blurry frame around what I was seeing, but apart from that, you watch the tape and see that I am moving all right.”

Preece’s instinct as a footballer has been always been to play on.

“You think 'Why should I come off?' It's really easy for people to sit on the sidelines and say that’s the way it should be and err on the side of safety, but sport isn't like that, it isn't civilised all the time. It's not tiddlywinks, it's not chess -- it's physical sport."

Still, he does have fears about the future. “I did a bit more research; there could be long-term damage there,” he says. “There's been lots of links to loss of emotion and depression, and memory loss as well. Not once, though, have I ever thought I would stop playing because of this.” The consequences of concussion

Twellman thinks rather differently than Preece. He utterly regrets playing on after his concussion in Foxborough. “If I was more educated on the risks of what happened, I might have sat out for a year. I would have stopped doing the things I was doing to try and feel better,” he says.

Vincent Gouttebarge, medical advisor to FIFPro, the international professional players‘ association, spells out the dangers of long-term exposure to concussion.

“Repeated brain injury may lead to a different type of brain condition, neurological, cognitive problems, and you may have affected motor systems,” he says. “You may have a lower level of attention, some concentration difficulties. You may have some problems performing activity in daily life.”

Gouttebarge fears club doctors are encouraged by coaches to declare players fit too readily. “The player wants to stay, the coach wants him to keep playing. The physician has to look at it from a health perspective, but the pressure can be great on him,” he says.

Club concerns

Seven days after Goodison, Lloris was absent from Spurs’ home match with Newcastle, this time on doctor’s orders. Spurs had spent the week under serious fire. The same day, Manchester United’s Phil Jones’ head smashed into that of Arsenal goalie Wojciech Szczesny, only for the pair to carry on playing after a lengthy delay for treatment. Minutes later, Nemanja Vidic was unable to continue after crashing his head into his own ‘keeper, David De Gea. Vidic was still missing when United played at Cardiff last Sunday.

"I listen to the doctor. If he says to me he has to come off, he comes off,” said Arsenal manager Arsene Wenger post-match at Old Trafford. "No matter if we have seven men on the field, I do it. You have only one life and you have 60 games per year."

Manchester United, when approached by ESPN, would not comment on the Vidic case, but sent back a list of Premier League guidelines pertaining to concussion. “As it is often not possible to be certain during a game situation, the player should be substituted if there is any doubt regarding potential for a diagnosis of concussion,” they state.

Following the Lloris incident, Everton manager Roberto Martinez, who had allowed to Lukaku to continue at West Ham, said such a decision should not be in manager's hands.

"I don't think it should be a manager's decision whether you take a player off or not," he told a news conference. "If there is a strong view from the medical side that when a player gets concussed he should come off, I think we should look into it and make it a rule. It should be part of the game and a law."

Concussion is, quite obviously, not a problem confined to the Premier League. November 2012 saw Real Madrid’s Cristiano Ronaldo elbowed in the face by Levante’s David Navarro. At half-time, Ronaldo, who had a cut over his eye, complained of feeling dizzy and was withdrawn by coach Jose Mourinho. Within six days, he was back in action and patched up, but did not score for the next three matches, a performance level well below his prolific norm.

In September 2011 Maarten Stekelenburg, Holland's World Cup final 'keeper, was kicked in the head by Internazionale's Lucio while playing for Roma. Having spent the night in a Milan hotel, he was given two days' rest. Though reports at the time suggested he had evaded a serious injury, he was sent to a neurosurgeon and missed Roma's next three games. Stekelenburg had sat up after the incident but then immediately appeared to lose consciousness, and his head dropped back to the ground.

Next steps

That recent series of high-profile concussion cases in England precipitated calls for a further tightening of the regulations, and the issue was discussed at a meeting between the PFA and Premier League a fortnight ago.

“The next steps are to establish that, without any ambiguity, they should be taken off the pitch and not allowed to play again within five days, and only then with the express approval of fully qualified medical practitioners,” says Gordon Taylor.

Gouttebarge believes clubs should be taken to task for unduly risking their players. “The national body should take some sanction when the club doesn't concur with international guidelines,” he says of the Lloris incident. “In this case, the player was not ready to return to play -- and this was opposite to international guidelines.”

“FIFA could do a lot of good,” says Taylor of the world governing body. “They are seen as being political and about the money, but issues of health and safety are where they should be at the front of change.”

A suggestion supported by Luke Griggs at Headway, Twellman and Gouttebarge, is that those medical professionals deciding on a potentially concussed player’s ability to continue should be independent, and not affiliated with either competing club. A similar policy is employed by the NFL.

Taylor is open to such an idea. “I'd say that club doctors would be happy to have a second opinion available, as that would help take the pressure off them,” he says.

Twellman suggests a further rule change to prevent concussed players from playing on. “FIFA needs to step in,” he says. “That's where the referee steps in and says you can't play. You should have an extra sub for head injuries, and have a mandatory 14-day absence to stop people cheating that rule.”

ESPN approached FIFA with those suggestions. “Such an option would be very difficult to put in practice globally,” a spokesman said, responding to the idea of independent doctors on site. “FIFA would favour investing more in education of all parties involved in order to ensure that existing recommendations are fully implemented.”

On Twellman’s idea of a mandatory absence period, FIFA points to the development of recommendations devised during a series of concussion conferences with bodies from other sports, including the NFL, NHL and the International Olympic Committee.

“Any athlete with a suspected concussion should be removed from play, medically assessed and monitored for deterioration. Athletes should not be returned to play the same day of injury. And when returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, with stages of progression. At this stage, there has been no discussion on an additional substitution or a 14-day mandatory absence.

“FIFA also conducted research studies which allowed us to convince the International Football Association Board to adapt the Laws of the Game to punish incidents which cause concussion such as an elbow to the head with a red card. This has led to a significant decrease of concussions. If we compare the 2002 FIFA World Cup to the 2010 FIFA World Cup, we helped to cut the frequency of concussions and head injuries by half.”

There is an admission, though, that the Lloris affair revealed that not all are following their recommendations. “Generally speaking, doctors, especially in top leagues and competitions, are aware and appear to follow these recommendations,” the spokesman said. “What the Lloris case shows is that education is still needed among coaches and managers.”

Tottenham Hotspur were unwilling to enter into a wider debate about concussion with ESPN. Those within the club were unhappy with the coverage the Lloris incident received and feel Spurs were unfairly targeted. An Everton representative said that, at this time, they felt unable to take part in a discussion.

The Premier League doctors group meets regularly during the season to help shape medical policies and rules. A source suggested to ESPN that concussion is expected to be discussed at that body’s next meeting.

ESPN approached both Italy’s Lega Calcio and Spain’s Liga De Futbol Profesional, but neither body made themselves available for comment on concussion. Living with concussion

Twellman is happy to be the public face for the cause very close to his heart, not least because of what happened to Junior Seau, the former New England Patriots player who was his neighbour in Boston.

The pair were frequent dining partners and, while Twellman was trying to recover from his own condition, they had a conversation with chilling portents. “I told him I didn't think I felt good, and he just said he’d had a headache since he was 15,” Twellman says.

Last year, at the age of 43, Seau took his own life with a shotgun. His brain tissue was donated by his family to the U.S. National Institute of Neurological Disorders and Strokes, and revealed signs of chronic traumatic encephalopathy, a degenerative disease suffered by victims of multiple concussions. It used to be known as dementia pugilistica because of its association with boxing.

It is now beginning to be associated with many other sports. Gordon Taylor suggests that concussion compensation cases are likely to come to football, especially in cases where clubs have been proved to be “reckless.”

When he dies, Twellman plans to donate his brain to Boston University’s medical centre. “I just want parents to understand the risks,” he says. “I want them to know it's not just a hockey problem or an NFL problem -- it's a sports problem, an education problem.”