(A full version of the Daily Mail publication, page 75, November 7). The Daily Mail @DailyMailUK is doing a tremendous service to improve concussion awareness and player management. Kudos Daily Mail.

Now that the dust (if not Hugo Lloris’ scrambled brain) has settled on the Spurs keeper’s knock to the head on Sunday, let’s review the situation and ask what we can learn. Let’s remember that the focus must be on what is best for this player, and sportsmen and women the world over

THE STORY SO FAR

• Lloris was clearly concussed. He was knocked out, was wobbly on his feet and in his manager’s own words after the game “Hugo still doesn’t recall everything about the incident”
• The Spurs doctor (who is highly regarded and was commended for his work on resuscitating Fabrice Muamba) wanted the player removed from the pitch. I have looked at the TV coverage numerous times and he clearly signals that the player should go off. In fact Villas-Boas admitted as much after the match when he said “the medical department was giving me signs that the player couldn’t carry on because he couldn’t remember where he was” and that “he went against medical guidelines to keep the goalkeeper on the pitch”.
• The decision to keep the player on the pitch was solely the Managers. He admitted that after the game “’It was my call to delay the substitution, you have to make a decision in situations like this”
• Loris had a CT scan performed after the game and the club’s website said “The Club can confirm that Hugo Lloris underwent a precautionary CT scan and was given the all-clear and travelled back to London last night”
• A CT scan is performed to rule out more serious head injury. It cannot exclude concussion which probably explains why the Spurs statement said given “the all-clear” which in reality was from serious head injury but the media interpreted as from concussion
• Despite the clear cut evidence of concussion and the Manager’s admission that he was responsible for the decision, Spurs changed their tune the following day presumably on advice from the club’s PR department (otherwise known as the “Protect the manager at all cost department”)
• Their Head of Sports Medicine, physiotherapist Wayne Diesel was quoted as saying “Once the relevant tests and assessments were carried out we were totally satisfied that he was fit to continue playing.”
• Spurs have a Europa League game on Thursday, 5 days after the Everton game
• The most recent World Concussion meeting was co-sponsored by FIFA and held at the FIFA headquarters in Zurich last November. The Consensus Statement from that conference published in March this year is quite clear on management guidelines for concussion
• Regarding return to play (RTP) on the same day, it states “it was unanimously agreed that no RTP on the day of concussive injury should occur”.
• Regarding a graduated RTP following concussion “RTP protocol following a concussion follows a stepwise process as outlined in table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed”.

• Following the recommended protocol, the minimum time before returning to play is 6 days assuming that the player is totally asymptomatic (no headaches, nausea, “foggy” feeling etc) the day after the incident and right through the rehabilitation
• Most Premier League clubs would also perform a computerised neuropychological test at the end of the rehabilitation process to confirm full recovery
• The Spurs Manager explained his decision to over-rule the club doctor on this basis “I made the call to keep him on the pitch because of the signs he was giving. When you see this kind of assertiveness from the player it means that he is able to carry on. He was determined to continue and looked concentrated, driven and focused enough for me not to make the call to replace him. The saves he made after the incident proved that right”.
• The Manager was overly influenced by the player, rather than the expert medical opinion. The fact that Lloris made some good saves after continuing is not relevant, as it is the long term effects of playing concussed that are a concern. There are plenty of historical precedents for players playing quite effectively immediately after a concussion. It does not justify the decision.
• To be fair to the Manager, the medical profession’s stand on the management of concussion has changed over the past few years and the Manager may not be aware of this
• Previously concussion was thought to be a self-limiting relatively benign condition. In the past few years there is increasing evidence of long term brain problems in retired footballers. Most of the research has come from the NFL who recently settled a lawsuit form a large group of retired players for $750 million (without admitting any guilt).
• Clearly we as a profession have not succeeded in educating football club managers as to the change of attitude and the new protocols
• Football in the UK would be wise to follow the lead of the English Rugby Union who have summoned all their coaches to Twickenham this Thursday to hear the latest on the management of concussion.
• When a player is suspected of being concussed, he should be immediately removed from the field of play and assessed to determine whether he indeed has concussion. This assessment, which should ideally be done in the medical room, takes approximately 5 minutes. See SCAT3 (Free). As a result the other football codes have introduced a temporary substitution which can be made while the player is being assessed. In rugby this is a 5 minute period, in Aussie Rules football it is 20 minutes. Soccer needs to consider something similar.

What now?

The short term dilemma for Spurs is whether Lloris plays tonight (Thursday night). They have put themselves in a difficult position. If he plays, then in addition to their breach of concussion protocol on Sunday, they will be breaching the RTP protocol which requires a minimum of 6 days graduated rehabilitation

• If they rule him out, then they are admitting that he was concussed and that they were wrong to allow him to continue playing
• If that PR department had been doing its job they would have said that they had always planned to play their No 2 goalkeeper on Thursday and got out of it that way!!
• The team doctor has the expert knowledge and is the one person who has the player’s health as his/her primary responsibility and therefore should be the sole arbiter of whether a player is concussed.

[BJSM Editor’s note: Credit to Tottenham for clearly following the Zurich Concussion Guidelines here: The Manager is quoted as resting Lloris as a result of Sunday’s concussion. For non-expert readers, when Lloris returns to play should depend on his symptoms (and potentially neuropsychological tests, not a specific ‘time’ . One week is a minimum to progress through the stages (above) but it can take longer if symptoms (headache, unusual tiredness, dizziness) persist. ] Posted on Thursday Nov 7th after the Europa Cup game.

How should this have been handled?

• It would have been nice yesterday instead of Spurs trying to shift the blame to their (absolutely innocent) medical staff, to hear the Manager publicly state that he had made a mistake, that he was not up-to-date regarding the changes in guidelines for the management of concussion, state his total support for the club’s medical team, and state clearly that he will not interfere in the future.
• That would have made a positive out of a negative.
• Instead Villas-Boas has come out and abused those of us who have expressed concern calling us “incompetent”.
• Sadly he had missed a wonderful opportunity to get the message out there that concussion must be taken seriously.