Concussions in Soccer: Phase 2 - Recovery & Return

The darkside of the beautiful game...

The darkside of the beautiful game...

Introduction

Storelli presents "Concussions in Soccer " a series focused on the recognitionrecovery,and return phases in managing a concussion. As head injuries, head protection and header protocols have never been hotter topics in the world of soccer, our medical advisor Dr. Raymond Rocco Monto offers a number of head injury facts and best practices to help us make the Beautiful Game as safe as we can.

Continuing from our first installment, Phase 2 addresses Recovery and Return. Here we share insights and best practices for managing a concussion and overcoming the dark side of the Beautiful Game. Read-on and be sure to share this report with friends, family and coaches so that world of soccer can be more informed and better prepared to tackle 'Concussions in Soccer.'

Phase 2: Concussion Recovery

What Do I Do After I Get a Concussion?

The first thing you need to do is GET YOURSELF OUT OF THE GAME! Removal is the mantra here because your brain is most susceptible to dangerous re-injury immediately after the first trauma. Lab studies show that the brain neurons depolarize and need 1-10 days to recover in mild cases. More severe injuries lead to symptoms that can take weeks to resolve. All players should have a baseline screening (like an ImPact test) so that they can be assessed after for brain injury after a concussion during the season. Although there are many effective concussion recovery protocols, all share five basic steps:

Source: Elbin RJ, Sufrinko A, Schatz P, French J, Henry L, Burkhart S, Collins MW, Kontos AP:  Removal of Play After Concussion and Recovery, Pediatrics. 2016, e20160910; doi: 10.1542/peds.2016-0910

Source: Elbin RJ, Sufrinko A, Schatz P, French J, Henry L, Burkhart S, Collins MW, Kontos AP:  Removal of Play After Concussion and Recovery, Pediatrics. 2016, e20160910; doi: 10.1542/peds.2016-0910

 

1. Rest  After a concussion you need to rest until ALL your symptoms have resolved for at least 24 hours. This period can be as brief as a day or two, or as long as a month depending on the severity of injury. You should discuss the recovery protocol with your doctor and training staff and inform your family, coach, and team of your status.

2. Mild Concussion — You can now start short 5-10 minute periods of walking, swimming, or stationary biking. These exercises are started to raise your hear rate. Symptoms are closely monitored to check for relapse. Any more symptoms? If the answer is yes, then sorry, but back to step #1 you go. If you are doing OK, you continue on. This second stage of recovery usually lasts for several days or until you feel that you’re ready to progress.

3. Moderate Exercise — Your next milestone begins with the gradual extension of the exercise periods to 10-30 minutes and can add light non-contact soccer drills. You’ll need close supervision at this point to monitor you for subtle residual effects of your brain injury. Repeat cognitive testing is often done at this time to gauge your progress.

4. Heavy Exercise — This is where you put the pedal to the metal and get going. Still no contact, but you are training, hitting the weight room. You are not out of the woods yet, but your symptoms should be resolved at this point. You should be sleeping normally and feel energetic. If not, you stay here until you do. Remember that repeat head injuries are far more dangerous than the first time and take far longer to recover from. It’s just not worth rushing back- no matter what the reason.

5. Contact  Ok, so you made it this far and you haven’t had any more symptoms. Now we’re talking. You can now start training with your team in contact drills and small sided scrimmages. Still feeling good? Luck you, a final concussion screen test and visual check await. If you pass them with flying colors, you are finally recovered and can return to return to play.

Phase 3: Return & Prevention

How Do I Prevent Concussions?

So you did everything right. You recognized you had a concussion. You went through the five stages of recovery and are now symptom free and ready to return to play. What now? How can you prevent another scary injury? Look, we all know you’re not going to stop playing. I get that. So what can you do to protect yourself going forward?. The first and most obvious thing is to be completely honest with yourself and your teammates about your previous head injuries and DO NOT return until you have completed ALL of the recovery steps. The easiest way to prevent re-injury it to allow full recovery.

Next, make sure you work on getting your neck and upper torso muscles strong since they can help prevent or at least absorb a great deal of contact forces during collisions and jousting with other players. In the gym this includes seated rows, pull down behind the head, triceps, bench press, and core work.
 

Source: #1 Hanlon EM, Bir CA. Real-time head acceleration measurement in girls’ youth soccer. Med Sci Sports Exerc. 2012; 44:1102–1108. doi:10.1249/MSS.0b013e3182444d7d / #2: Temoun M, Sadeghi H, Nabaei A, Ksaeian A: The Relationship Between Biomechanical-Antrhopometrical Parameters and the Force Exerted on the Head When Heading Free Kicks in Soccer, Arch Trauma Res, 2012; 1(1):44-48. doi:10.5812/atr.5307.

Source: #1 Hanlon EM, Bir CA. Real-time head acceleration measurement in girls’ youth soccer. Med Sci Sports Exerc. 2012; 44:1102–1108. doi:10.1249/MSS.0b013e3182444d7d / #2: Temoun M, Sadeghi H, Nabaei A, Ksaeian A: The Relationship Between Biomechanical-Antrhopometrical Parameters and the Force Exerted on the Head When Heading Free Kicks in Soccer, Arch Trauma Res, 2012; 1(1):44-48. doi:10.5812/atr.5307.

Is soccer headgear worth it? The question of headgear and its potential to lower the risk of concussions is controversial. Initial impact testing of prototype soccer headgear in the 1990’s was disappointing, but the recent introduction of more durable, military-grade shock absorptive materials combined with light -weight sophisticated designs have shown new promise. 

Does headgear work to prevent soccer concussions? Even basic designs tested in Canada a decade ago showed that headgear cut concussion risk in half. Several large scale studies are now underway to accurately assess whether or not modern headgear will decrease your risk of first-time and repeat head injury. FIFA and US Soccer have taken a wait and see approach to the value of headgear, allowing their use since 2007, but stopping short of full endorsement. Despite the lack of big data, the use of headgear has continued to grow with international stars such as Wayne Rooney and Petr Cech wearing them to reduce their chances of re-injury. Should you wear headgear when you return? You can come to your own conclusions, but if I was recovering from a concussion, I would not hesitate to strap that bad boy on before hitting the pitch again. Some might say that wearing headgear might actually increase the risk of concussion by making players more reckless in their challenges. Sorry, but there is no real data to support that contention.

Can Heading Cause Brain Injury?

Welcome to the third rail of soccer. The controversial dangers of heading have been recognized for decades in soccer, but in a sport built on traditions, little has changed. There is no doubt that a soccer ball can do harm. The standard #5 soccer ball can travel at speeds in excess of 70 mph with pressures that vary between 8.5 and 15.6 psi. This results in a contact G-force from a standard kick that can exceed 100g (more than a helmet-to-helmet spearing tackle in American football. Trust me, I was a goalkeeper and my nose and cheekbones will confirm the pressure measurements. Now multiply that force by the usual 6-12 headers a game and 900-1500 headers per season and you can see why there is concern about the potential for long-term brain injury. New studies have shown that even 10 headers in a single practice can lead to visual focus problems that last more than 24 hours. More disturbing have been the findings of permanent changes in the frontal lobe white matter in both younger and older players without a known history of concussion.
 

Source: Kawata K, Tierney R, Phillips J, Jeka JJ: Effect of Repetitive Sub-Concussive Head Impacts on Ocular Near Point of Convergence Int J Sports Med. 2016; 37(5):405-10. doi: 10.1055/s-0035-1569290.

Source: Kawata K, Tierney R, Phillips J, Jeka JJ: Effect of Repetitive Sub-Concussive Head Impacts on Ocular Near Point of Convergence Int J Sports Med. 2016; 37(5):405-10. doi: 10.1055/s-0035-1569290.

So the jury remains out on the heading issue. More studies on the way to see if these changes are pathological or simply adaptive changes to the stresses of heading. US Soccer, however, is not waiting for more data. Under extreme legal pressure to take some type of action, the organization has banned all heading in youth players under 11. Time will tell whether or not these decreases head injuries in soccer, since most are due to player collisions, and not heading.

The biggest unsolved question is whether or not concussive and repeated subconcussive head trauma can lead to the disabling and potentially lethal brain disease CTE. Although some high profile soccer players  like Bellini, the Brazilian soccer star, who led his team to the winning of the 1958 World Cup — have been diagnosed with the condition at autopsy, no firm link has been established. 

Still, deep concerns linger and even former US World Cup winner, Brandi Chastain, has  committed to have her brain examined for CTE after she dies. So what should you do about heading now? Concentrate on proper technique, keep your neck and torso strong, keep a personal “header-count” at practice (and keep it under 10), and pick your moments tactically when heading makes sense. Can headgear help take the risk out of heading? With so much at stake here, a great deal of research is in play and answers will come. Should you wait for more data before considering headgear use that’s a call you will have to make for yourself but I personally would recommend you consider gearing up for the sake of your most important organ.