Concussion: We need to talk about subs

This weekend has offered yet another set of opportunties to discuss the ineffectiveness of the application of concussion and head injury assessment protocols in the national game. BBC Sport have published thoughts on the slow intervention to protect Robin Koch of Leeds United (pictured) who went down after an incident involving Manchester Utd's Scott McTominay. It was yet another incident where I caught myself flinching and telling my wife "that could have caused a concussion", for the second time this weekend (the first was in reference to Marco Reus after a collision with his keeper playing against Borussia Monchengladbach). The patch up by the medical team appeared to focus more on the presence of blood and less on the cognition of the player but is this necessarily their fault?

Medics find themselves in a difficult position requiring them to make a decision about the welfare of the player based solely on their involvement in a collision which could, but hasn't necessarily, have caused a mild traumatic brain injury (MTBI or concussion). Signs and symptoms can develop immediately or over minutes, hours and days so they can only work with how the player is presenting. However, I don't see enough evidence of validated assessment tools being used pitchside and can only assume this is for one reason. Time.

Performing a full head injury assessment (HIA) involving a SCAT-5 or SAC assessment and all it entails takes time and only indicates that the player may have suffered a concussion. Also, this is only likely to be used if they have developed symptoms by this point. Alternatively, a player displaying signs of a concussion (e.g. being slow to get up, clutching their head etc) can be removed with more conviction, though we failed to see this when Marco Reus went down holding his head this weekend - after a brief intervention from the medics he returned to the field. Even with two additional permanent concussion substitutions medics are forced to decide between removing a player who may not have a concussion permanently from the game or inadvertantly leave someone on the pitch who has suffered one just in case they haven't. The risk of them suffering a second, potentially more dangerous, concussion is hugely increased. We saw John McGinn of Aston Villa remove himself from the game earlier this season after a second collision.

The solution seems obvious, trial the use of temporary concussion replacements. It works well in Rugby Union and the benefit of including an independent medic at games was shown to great effect in the Engalnd v Italy game last week. This would relieve the pressure on medics and allow them to take time ensuring the player is safe. Returning them to the pitch if they feel sure they have not suffered a brain injury and make the replacement a permanent substitution if they have is made much easier. It may also relieve some of the concerns of the coaches if the replacement player performs well. While this is not the problems golden bullet it could be a silver one. Medics surveyed in a paper published by Vincent Gouttebarge last year made it clear they thought a temporary substitution should be trialled for suspected concussions as well as compulsory omission from the following game falling within a week (this would actually simply fall in line with the Football Association's Enhanced Care Setting Return-to-Play guidelines). My understanding from discussions in the last 6 months is that this is not being considered by the Premier League. Ideally this needs the Football Association to take the lead to better protect the welfare of players and enhance the detection of concussions in the professional game.

We need to approach concussions more from a player welfare, less from a performance, point of view. These players may only be at the top of the game for 10 years after which they will live the with long-term effects of their concussions and injuries and it is the responsibility of the clubs and bodies such as the Premier League, Football Association and Player's Football Association (PFA) to protect the players. The PFA have become much more vocal in raising awareness of the risks of concussion with the setting up of a Neurodegenerative Care Department to be led by Dawn Astle (daughter of former West Bromwich Albion striker Jeff). Removing players who may have a concussion from a game for 15 minutes for an assessment is unlikely to factor in their wider career and a piloting of this rule appears to be the obvious choice. It has been extremely effective in removing players from rugby matches. Effective, but not perfect.