If in doubt sit them out.
While injury to the brain can be fatal, most concussions recover completely with correct management
A concussion is an injury to the brain
Incorrect management of concussion can lead to further injury
Loss of consciousness does not occur in the majority of concussions
Anyone with any concussion symptoms following a head injury must be removed from playing or training
Return to education or work must take priority over return to play
There must be no return to play on the day of any suspected concussion
An injury to
the cervical spine (neck) may occur at the same time as a concussion and normal principles of cervical spine care should also be followed
Introduction
These guidelines are intended to give guidance to those managing concussion in football at all levels. Professional and elite level players sometimes have access to an enhanced level of medical care which means that their concussion and their return to play can be managed in a more closely monitored way. In this situation only, the guidelines for return to play in an enhanced care setting may be followed.
These guidelines are based on current evidence and examples of best practice taken from other sports and organisations around the world, including the Rugby Football Union, World Rugby and the Cross-Sports Scottish Sports Concussion Guidance. Advice has also been sought from The FA’s Expert Panel on Concussion and Head Injury in Football. The guidelines are in line with the Consensus Statement
on Concussion in Sport issued by the Fifth International Conference on Concussion in Sport, Berlin 2016.
This version has been updated as of August 2019 .
While these guidelines aim to reflect ‘best practice’, all accept that there is a current lack of evidence in respect
to their effectiveness in preventing long- term harm. The FA will continue to monitor research and consensus in the area of concussion and update these guidelines accordingly.
*modified from World Rugby’s
‘Guidelines on Concussion - Management for the General Public'
The following guidance is intended to provide information on how to recognise concussion and on how concussion should be managed from the time of injury through to safe return to football.
At all levels in football, if a player is suspected of having a concussion, they must be immediately removed from the pitch, whether in training or match play. IF IN DOUBT, SIT THEM OUT.
What’s Inside
1
What is concussion?
If in doubt sit them out.
4
What is concussion?
Concussion is an injury to the brain resulting in a disturbance of brain function. There are many symptoms of concussion, common ones being headache, dizziness, memory disturbance or balance problems.
What causes concussion?
Who is at risk?
Concussions can happen to players at any age. However, children and adolescents (18 and under):
Studies indicate that concussion rates in women are higher than in men in football.
A history of previous concussion increases the risk of further concussions, which may also take longer to recover.
Concussion can be caused by a direct blow to the head, but can also occur when a blow to
another part of the body results in rapid movement of the head
e.g. whiplash type injuries.
The symptoms of concussion typically appear immediately, but their onset may be delayed and can appear at any time after the initial injury
Loss of consciousness does not always occur in concussion (in fact it occurs in less than 10% of concussions).
A concussed player may still be standing up and may not have fallen to the ground after the injury.
2
How to recognise a concussion
If in doubt sit them out.
6
How to recognise a concussion
If any of the following signs or symptoms are present following an injury the player should be suspected of having a concussion and immediately removed from play or training and must not return to play that day. The Pocket Recognition tool may be used as an aid to the pitchside assessment (see Useful Links section)
If in doubt sit them out.
Visible clues (signs) of concussion
What you may see
Any one or more of the following visual clues can indicate a concussion:
Symptoms of concussion
What you may be told by the injured player
Presence of any one or more of the following symptoms may suggest a concussion:
These should be tailored to the particular activity and event, but failure to answer any of the questions correctly may suggest a concussion. Examples with alternatives include:
or
Which half is it now?
or
Who scored last in this game?
or
What team did you play last game?
or
Did your team win the last game?
or
An incorrect answer to these questions may suggest a concussion, but a concussed player might answer these questions correctly.
Video footage: If video footage of the incident is available this may be of assistance in establishing the mechanism and potential severity of the injury and can be used to contribute to the overall assessment of the player. This may be viewed by the person assessing the injured player or can be commented on by a third party, such as the tunnel doctor in an elite professional setting. A coach or parent may have video
footage that could be helpful in a non-elite setting. However video evidence must not be used to contradict
a medical decision to remove the player.
3
What to do next
Immediate management of a suspected concussion
If in doubt sit them out.
8
What to do next
Anyone with a suspected concussion MUST be IMMEDIATELY REMOVED FROM PLAY.
Once safely removed from play they must not be returned to activity that day.
Team-mates, coaches, match officials, team managers, administrators or parents who suspect someone may have concussion MUST do their best to ensure that they are removed from play in a safe manner.
If a neck injury is suspected
suitable guidelines regarding the management of this type of injury at pitchside should also be followed (see useful links for pitchside injury management training)
If ANY of the following are reported then the player should be transported for urgent medical assessment at the nearest hospital emergency department:
Deteriorating consciousness (more drowsy)
Increasing confusion or irritability
Severe or increasing headache
Repeated vomiting
Unusual behaviour change
Seizure (fit)
Double vision
Weakness or tingling/ burning in arms or legs
In all cases of suspected concussion it is recommended that the player is referred to a medical or healthcare professional for diagnosis and advice, even if the symptoms resolve.
4
Returning to play
Ongoing management of a concussion or suspected concussion
If in doubt sit them out.
10
Ongoing management
Rest the body rest the brain.
recover and in the non-professional setting allows a return to work or study prior to resuming training and playing.
Rest means avoiding:
recovery, such as additional time for classwork, homework and exams
Returning to play after a concussion
Anyone with a concussion or suspected concussion should NOT:
The graduated return to play (GRTP) protocol should be followed in all cases. This staged programme commences at midnight on the day of injury and stage 1 (initial rest period) is 14 days in all players unless they are in an enhanced care setting. In all cases, progression to stage 2 of the GRTP can only occur if the player has no symptoms.
At the non-professional level, adults must have returned to normal education or work and students must have returned to school or full studies before starting physical activity (stage 2) in a GRTP program.
Graduated return to play protocol
Stage 2 of the GRTP protocol should only be started when a player
The GRTP Protocol contains six distinct stages
Stage 1 | Stage 2 | Stage 3 | Stage 4 | Stage 5 | Stage 6 |
Stage 1 is an initial rest period during which symptoms should resolve. This stage must be extended if symptoms persist | The next four stages are restricted, training based activity | Return to full training and match play | |||
Under the GRTP Protocol, the individual can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.
If any symptoms occur while going through the GRTP program, the individual must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms (this is 48 hours in players under 19 years of age).
It is recommended that a Doctor or Health Care Practitioner confirms recovery before an individual enters Stage 5 (full-contact practice).
The 6 stage GRTP protocol should be followed in all cases.
Graduated return to play protocol
EART RA
Stage 1 Initial rest period 14 days modified in enhanced care setting | Stage 2 Light exercise | Stage 3 Football-specific exercise | Stage 4 Non-contact training | Stage 5 Full contact practice | Stage 6 Return to play | |
ExERCISE ALLOWED |
|
|
e.g. running drills
|
e.g. passing, change of direction, shooting, small-sided game
|
e.g. tackling, heading, diving saves |
|
% MAx H TE |
| <70% | <80% | <90% | ||
DURATION (MIN) | <15 | <45 | <60 | |||
ObjECTIVE |
|
|
|
|
|
|
13
Standard Return to Play Pathway
The minimum time in which a player can return to play in the standard care setting is summarised in the table below. Each day comprises a 24-hour period. The pathway begins at midnight on the day of injury.
Stage 1 Initial rest period | Stage 2 Light exercise | Stage 3 Football-specific exercise | Stage 4 Non-contact training | Stage 5 Full-contact practice | Stage 6 Return to play | ||||
ADULT | 14 days beginning at midnight on the day of injury. The player must be symptom-free at the end of this period before progressing | Return to academic studies or work | Clearance by doctor recommended | Minimum duration 24 hours | Minimum duration 24 hours | Minimum duration 24 hours | Clearance by doctor/health care professional | Minimum duration 24 hours | Day 19 Earliest return to play |
4 days if symptom-free | |||||||||
UNDER 19 | 14 days beginning at midnight on the day of injury. The player must be symptom-free at the end of this period before progressing | Minimum duration 48 hours | Minimum duration 48 hours | Minimum duration 48 hours | Clearance by care professional | Minimum duration 48 hours | Day 23 Earliest return to play | ||
8 days if symptom-free | |||||||||
It must be emphasised again, that these are minimum return to play times and in players who do not recover fully within these timeframes, return to play times will need to be longer | |||||||||
It is recognised that players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to:
How are recurrent or multiple concussions managed?
Any player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
doctor/health
After returning to play, all those involved with the player, especially coaches and parents must remain vigilant for the return of symptoms even if the GRTP has been successfully completed.
If symptoms recur the player must consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding and deal with emotional problems and anxiety should also be considered in the management of concussed players.
Enhanced Care Setting
for return to play (RTP) may be possible, but only under strict supervision by the appropriate
medical personnel as part of a structured concussion management programme. It is never appropriate for a player under the age of 16 to follow this pathway.
The minimum criteria for an Enhanced Care Setting are as follows:
If any element of the above criteria is absent, the player should follow the standard Return to Play Pathway.
15
Enhanced Care Setting
The minimum time in which a player can return to play in the Enhanced Care Setting is summarised by the table below. Each day comprises one 24-hour period. The pathway begins at midnight on the day of injury.
Stage 1 Initial rest period | Stage 2 Light exercise | Stage 3 Football-specific exercise | Stage 4 Non-contact training | Stage 5 Full-contact practice | Stage 6 Return to play | ||||
ADULT | 24 hours minimum rest period after which the player must be symptom-free before progressing | Clearance by doctor recommended | Minimum duration 24 hours | Minimum duration 24 hours | Minimum duration 24 hours | Clearance by doctor before stage 5 | Minimum duration 24 hours | Day 6 Earliest return to play | |
4 days if symptom-free | |||||||||
UNDER 17-19 | 7 days minimum initial rest period after which the player must be symptom-free before progressing | Return to academic | Minimum duration 24 hours | Minimum duration 24 hours | Minimum duration 24 hours | Clearance by stage 5 | Minimum duration 24 hours | Day 12 Earliest return to play | |
4 days if symptom-free | |||||||||
The whole return to play process must be supervised by a suitably qualified doctor within a structured concussion management programme
It must be emphasised again, that these are minimum return to play times and in players who do not recover fully within these timeframes, return to play times will need to be longer
It is recognised that players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to:
How are recurrent or multiple concussions managed?
Any player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
studies or work
doctor before
After returning to play, all those involved with the player, especially coaches, support staff and parents must remain vigilant for the return of symptoms
even if the GRTP has been successfully completed.
If symptoms recur the player must consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding and deal with emotional problems and anxiety should also be considered in the management of concussed players.
Useful links
Berlin concussion group consensus statement
https:/ /bjsm.bmj.com/content/51/11/838
SCAT5
https://bjsm.bmj.com/content/bjsports/ early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
Paediatric SCAT5
https://bjsm.bmj.com/content/bjsports/ early/2017/04/28/
bjsports-2017-097492childscat5.full.pdf
Pocket Recognition Tool
http://bjsm.bmj.com/content/47/5/267.full.pdf
Cogstate
Baseline cognitive testing
imPACT
Baseline cognitive testing
ISEH
Multidisciplinary concussion management team
Headway
Guide for GPs
Brain andiSnpe F oundation Charity offering support and advice www.brainandspine.org.uk
FA ATMMiF course
Advanced pitch-side trauma management for doctors, physiotherapists and allied health care professionals working in football http://www.thefa.com
FA ITMMiF course
Intermediate pitch-side trauma management for doctors, physiotherapists and allied health care professionals working in football http://www.thefa.com
Birmingham Sport Concussion Clinic http://www.uhb.nhs.uk/sport-and-exercise- medicine.htm
Spire Perform - Southampton http://www.spireperform.com/southampton/ services/concussion-service
Version: August 2019 17