FIFA didn't follow its own concussion guidelines at 2014 World Cup: study

The world’s biggest soccer body did not follow its own guidelines for assessing concussions at the 2014 World Cup, says a Canadian neurosurgeon.

Too much pressure on team doctors to keep players in game, Canadian researchers say

Bastian Schweinsteiger of Germany tackles Lucas Biglia of Argentina during the 2014 FIFA World Cup final match on July 13, 2014 in Rio de Janeiro, Brazil. (Robert Cianflone/Getty Images)

The world's biggest soccer body did not follow its own guidelines for assessing concussions at the 2014 World Cup, according to a new Canadian study.

Dr. Michael Cusimano, a neurosurgeon at St. Michael's Hospital in Toronto, led a team of four researchers who reviewed video footage of all 64 matches, looking for any plays involving "head collision events" — defined as head contact after which a player did not immediately continue playing — and how they were handled.

We put a person's health as a secondary issue.— Dr. Michael Cusimano, St. Michael's Hospital

They looked for potential signs of concussion, such as if a player was slow to get up, seemed disoriented or was unconscious, if they had obvious problems with equilibrium, made seizure-like movements or clutched their head. 

According to guidelines set in 2012 — by the International Conference on Concussion in Sports, of which FIFA is a key participant — players showing any sign of a concussion should be immediately taken off the pitch and assessed by sideline health-care personnel. Those guidelines were reaffirmed in 2016.

The team's research, published Tuesday in JAMA, the Journal of the American Medical Association, found those guidelines were not followed in 63 per cent of the head collisions at the 2014 World Cup. 

While 19 head injuries were reported by team doctors to FIFA, the study found a total of 81 head collisions in which:

  • 14 players showed one or no signs of concussion.
  • 45 players showed two signs.
  • 22 players showed three or more signs.

Of the cases in which players showed two or more signs of concussion: 11 received a sideline assessment by health-care personnel and were sent back onto the field; 42 were assessed on the field by either a fellow player, referee or another official; and 11 received no assessment.

Just three were removed from the match.

In one cringe-inducing incident during the 2014 final, Germany midfielder Christoph Kramer continued playing for 14 minutes after taking a heavy blow to the face in a collision with Argentina defender Ezequiel Garay. The 23-year-old Kramer was replaced after he slumped to the ground, and appeared to be disoriented when helped off the field.

Christoph Kramer concussion

6 years ago
Duration 1:20
Germany player goes down after intense hit to the head during 2014 World Cup final

"They were getting some cursory assessments — maybe given some water, something like that — and sent back into play," Cusimano said in an interview with CBC's Kas Roussy.

"Only in a minority [of cases] are people being actually assessed by the sideline personnel," he said, adding that even those were not long enough to make a "proper" assessment.

"What's at stake are often millions of dollars… and it often boils down to money and power," Cusimano said. "We put a person's health as a secondary issue — or maybe as a tertiary or quaternary issue."

But since about 265 million people, or four per cent of the world's population, play soccer, Cusimano said the sport's governing body should set an example for others to follow, especially in amateur leagues and those involving children.

After being widely criticized for its handling of concussion risk in 2014, FIFA proposed giving referees the power to stop the game for three minutes to allow a team doctor to do an on-pitch assessment of the player. 

FIFA declined to comment on Cusimano's study specifically, but a spokesperson pointed to the three-minute stoppage recommendation and the organization's continuing involvement in researching concussions. 

"FIFA regularly monitors the situation of head injuries, maintaining constant contact with current and ongoing studies on this matter and reviewing its protocols," the spokesperson said in an email to CBC News. 

New Canadian guidelines 

Cusimano says team doctors are under a lot of pressure: Fans and sponsors want players to stay in the game, as do the players, who might downplay their symptoms or protest being sent off. 

That's why there should be independent physicians — who have no skin in the game — doing the evaluations, Cusimano said.

It's just as important is to teach young players it's OK to ask for help, says Dr. Kevin Gordon, a pediatric neurologist at IWK Health Centre in Halifax and a member of the sports medicine committee of the Canadian Soccer Association (CSA).

Young players should be taught that it's OK to ask for help if they've been hit and think they might be hurt, says Dr. Kevin Gordon, a pediatric neurologist at IWK Health Centre in Halifax and a member of the Canadian Soccer Association's sports medicine committee. (Romrodphoto/Shutterstock)

"There's no harm in putting your hand up to say 'I'm not feeling right, I took an impact, I'm worried about myself,'" said Gordon. 

That's the kind of recommendation likely to be included in an updated and harmonized set of guidelines being developed by a federal-provincial-territorial committee, of which the CSA is a part.

"Canadian parents want to know their kids are safe," said Gordon, whose own two children suffered four concussions between them while playing sports in their youth.

"The fact that we are going to have a unified approach to concussion across sports, across health, across teaching … I think that's really profoundly exciting. As a physician, as a parent, as an athlete, these are all exciting things for us right now."

With files from CBC's Kas Roussy, The Associated Press