Editorial

As this issue of The Lancet Neurology went to press, the Fédération Internationale de Football Association (FIFA) was facing criticism over its handling of head injuries during the 2014 FIFA World Cup. The world players’ union, FIFPro, called for an investigation of concussion protocols and return-to-play standards after the Uruguayan defender Álvaro Pereira returned to the pitch to see his team beat England shortly after a blow to the head that left him in an apparent state of concussion. Changes are clearly needed to protect athletes at risk of head injury. Cerebral concussion is the most common form of sports-related traumatic brain injury (TBI) and there is growing recognition of the lasting effects of mild TBI. A range of symptoms such as headache and dizziness can continue for weeks or even months after a concussion; the causes of post-concussion syndrome are unclear and do not seem to correlate with the severity of injury. The long-term consequences of repeated mild TBI have been recognised for some time—symptoms of chronic traumatic encephalopathy (CTE), including dementia years or decades after brain trauma, were first recognised in boxers at the beginning of the last century, when the condition was termed dementia pugilistica—and CTE has recently been identified post-mortem in professional athletes who have sustained repeated concussions or sub-concussive injuries in a range of sports. As the failure of FIFA’s “recognise and remove” policy was sinking in—the protocol should ensure that signs and symptoms of concussion are recognised and that a player with suspected concussion is immediately removed from the game—we learned that the US National Football League has agreed to remove a $675 million cap on total damages from thousands of concussion-related claims. The new settlement will cover retired players who develop dementia, amyotrophic lateral sclerosis, or other neurological disorders believed to be associated with repeated concussions. Many sporting organisations now acknowledge the potentially serious consequences of mild TBI and have drawn up new protocols to protect athletes who sustain a head injury. Guidelines for the management of concussive brain injury in sport were recently published by the American Academy of Neurology. But much more needs to be done to reduce the incidence of mild TBI and to improve the assessment, monitoring, and care of adults www.thelancet.com/neurology Vol 13 August 2014

and children with sports-related concussion. Because signs and symptoms of concussion can be delayed, removing an athlete when there is any suspicion of injury would seem to be the safest approach. The decision on whether Pereira should leave the field for assessment was left in the hands of the Uruguayan team doctor and team officials, but such decisions should surely be taken out of the hands of those with a vested interest in the player’s performance. Serial assessments and return-to-play decisions should be made on an individual basis. Education of players and the public will be of paramount importance in preventing, recognising, and responding to the effects of mild head injuries in sport. But research efforts will be key to tackling both short-term and longterm effects of mild TBI. Concussion signs and symptoms are not necessarily sensitive indicators of brain injury and we know that these symptoms can pass quickly even when neurological damage remains. Advanced neuroimaging and biochemical markers are needed to identify and quantify mild TBI and to follow its course. Similarly, measures are needed to diagnose and monitor CTE—characterised by progressive tauopathy and neurodegeneration—during life. We need to characterise the factors that affect the risk of and response to brain injury—such as age, sex, frequency of sub-concussive or concussive head trauma, duration of exposure, and genetic factors—including risk factors for CTE. And we need to learn more about the neuropathology of concussion and how early changes lead to progressive pathology in the long term. On May 29, 2014, US President Barack Obama hosted a Healthy Kids and Safe Sports Concussion Summit, calling for more research, improved safety equipment, and better protocols to protect young athletes in a range of sports. He highlighted commitments by key stakeholders to expand our knowledge of concussion, among them a landmark $30 million study of concussion and head injury by the US Department of Defense and the National Collegiate Athletic Association. These and other research efforts, including the International Initiative for Traumatic Brain Injury Research, give us hope that when teams gather in 4 years’ time for the 2018 FIFA World Cup, football and other sports will feel like a safer place for athletes of all ages. ■ The Lancet Neurology

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Tackling the sports-related concussion crisis

For more on FIFPro’s concerns see http://www.fifpro.org/en/ news/fifpro-calls-for-concussionreview For more on sports-related consussion see http:// headgamesthefilm.com For more on sports-related TBI see Nat Rev Neurol 2013; 9: 222–30 For more on chronic traumatic encephalopathy see Brain 2013; 136: 43–64 For more on dementia pugilistica see Psychol Med 1973; 31: 270–303 For the AAN guidelines see Neurology 2013; 80: 2250–57 For more on biomarkers of mild TBI see Nat Rev Neurol 2013; 9: 201–10 For more on tau pathology and neurodegeneration see Review Lancet Neurol 2013; 12: 609–22 For more on the neuropathology of single and repetitive TBI see Nat Rev Neurol 2013; 9: 211–21

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Tackling the sports-related concussion crisis.

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