Soccer: Concussions at World Cup put head injuries in focus
For nearly five weeks, ESPN's World Cup studio hosts riffed off the day's events at Copacabana Beach in Rio De Janeiro, providing the kind of stunning views that come with a World Cup in Brazil. The lush green landscape, littered with towering building after building lay parallel next to the crashing waves of the world's most famous beach. But inside the studios, Taylor Twellman found himself cringing far too often when he should have been enjoying the latest brilliant moment or blunder.
It wasn't just Twellman. The world watched and also cringed this summer. When Alvaro Pereira's right temple was thwacked by the knee of Raheem Sterling, when Javier Mascherano smacked heads with Georginio Wijnaldum, billions watched it unfold.
Player after player, clearly suffering head injuries so bad that they looked too shaky to stay on their feet. In the World Cup final, at the grand Maracana Stadium in Rio, a game that was supposed to be sheer beauty transformed to ugliness. Germany's Christoph Kramer collided with Argentina's Ezequiel Garay in the 19th minute of the final, then played on for 10 minutes after the severe blow to his head.
At that point, after being briefly escorted off and supposedly checked out according to FIFA guidelines, Kramer could barely stay on his feet, his eyes glazed over. He needed help just to get off the pitch.
Inside the ESPN Studios miles away was Twellman, the former United States men's national team fixture and New England Revolution forward turned ESPN analyst and commentator. It was all too familiar for the man whose World Cup hopes were cut down as concussions mounted, leading to his eventual early retirement in 2010.
"It brought back a lot of old memories," Twellman said. "It brought back some of the symptoms I still deal with today and it wasn't easy to watch. But then there was a huge part of me that felt like saying, 'I told you so.'"
After the final was over and Germany had cemented itself as the best national team on the planet, Kramer was quoted as saying he didn't remember a single moment from the first half. He didn't know how we found his way into the locker room. To the 23-year-old, that day started once the second half started.
"Those athletes had no idea what they were doing," Twellman said. "The fact people still credit their heart is the reason I'm not playing anymore. I had a heart, I just didn't have a brain."
Finding the right protocol
Every hit that rattles the brain is different, with varying speeds and angles and lasting effects. What was clear this summer was that World Cup players were not assessed properly, returning to the field mere seconds or minutes after clearly sustaining a head injury through the run of play.
"If those happened in our league," Real Salt Lake general manager Garth Lagerwey said, "they would not have been permitted to return to the field. I think this is an issue where science and concussion are most advanced in the States. I do think that in international soccer, it has to improve. If [that happened to] a U.S. player, they would have been taken off, without question."
Major League Soccer prides itself on paving the way for how soccer leagues worldwide handle concussion protocol. A few years back, the league required players to go through rigorous baseline tests before the season and study a film based on concussions featuring the likes of Twellman, Colorado Rapids coach Pablo Mastroeni and others. Lagerwey said the concussion protocol is detailed in the RSL locker room. When a head injury occurs, that player cannot return until properly checked out. If a concussion is diagnosed, the player must sit out for a minimum of 24 hours.
"It doesn't hurt that we are maybe at the forefront," said RSL defender Chris Wingert who has sustained his share of concussions as a player. "We're seeing the repercussions of not handling it the right way."
Looking back at Twellman's case, and those of former RSL forward Alecko Eskandarian, Bryan Namoff and Ross Paule all of whom retired early due to concussion-related symptoms it took some time to realize the severity of head injuries stateside.
It was Aug. 30, 2008, when Twellman was knocked out as he was decked by a goalkeeper going for a ball against the L.A. Galaxy. He went through what he said, in jest, was "concussion protocol" at that time, one that featured counting down from 100, and asking to identify where he was. He was allowed to play soon after.
"Then my career was over," said Twellman, who has since started the ThinkTaylor Foundation, designed to increase awareness regarding traumatic head injuries in soccer.
FIFA has been bombarded with blame for how protocol was followed during this summer's World Cup. FIFPro, the worldwide player's union, called on FIFA for a thorough investigation regarding protocol after Pereira lay lifeless on the pitch on June 19. A consensus among most involved called for implementing independent professionals to patrol sidelines and assess head injuries should they occur.
"We're seeing people cleared way too soon," said Melinda Roalstad of Think Head First, a program designed increase awareness and treatment of concussions based in Summit County.
The grey area
Who determines the severity of a concussion minutes after the a brain is jarred inside the skull? Once that question has an answer, who decides it's ethical to give the green light to return to action?
Roalstad was the Medical Director for the U.S. Ski & Snowboard Association and helped the International Ski Federation (FIS) implement mandatory concussion guidelines for managing head injuries. Since furthering her studies of concussions with Think Head First, the awareness raised about the the injury has helped hike the number of those seeking advice and treatment.
As for the ideal length of time for a legitimate concussion test no matter the venue Â Roalstad said trainers and those examining must be willing to throw the flag.
"You sit them out and they're out for the rest of that day," she said. "It gives you time to evaluate properly. Many times symptoms do not show themselves until several hours later. There's a lot of adrenaline with competition. They think they're in tact, able to execute certain things."
Wingert provided a player's perspective and used Mascherano's moment as an example.
"If I was Mascherano, would I have kept playing? Probably," Wingert said. "You're in a semifinal of a World Cup â¦ it is sad in a way that we highlight people that play through it as the hero and being a tough dude, because it's really tricky. It's not easy to see 10 years and 20 years down the line."
As for giving independent examiners full control to make the controversial call?
"I don't know how I feel about saying it's always up to the doctor or up to the ref," Wingert said. "It's tough. I'll tell you right now, Mascherano would have absolutely flipped if somebody would have told him you have to come out."
Wingert said in hindsight, each time he wanted to continue on, it wouldn't have been worth the end result.
Roalstad, like many who are educated on concussions in soccer, said it is vital to have someone free of either team on the field to properly make the decision.
"People get caught up heat of the moment and forget their protocols," she said. "I think an independent person, firm on protocol, is necessary. If there's any thought that this kid or athlete might have had a head injury, pull them out quietly evaluate appropriately. It's just impossible to do on the sideline and it's not worth it."
What the future holds
The symptoms Twellman deals with daily fluctuate. He said he hasn't properly worked out in six years. He can't. There are days when a headache will rule and command what transpires until it slips away. There are days when he can't get out of bed, but those days have dwindled since he changed his diet among other things.
"My life has changed because of concussions," he said.
He's seen the other effects first hand. His former neighbor, Junior Seau, took his own life in May 2012 after playing in the NFL for 20 years. It was later revealed that the former star suffered from Chronic Traumatic Encephalopathy also known as CTE.
"We're starting to see new rules in sports, new rules in returning to play after these injuries thanks to literal education and awareness," Twellman said, "but ultimately what we need to get rid of are athletes like myself."
The idea of bigger, faster, stronger has been fingered by some as a reason why more people are paying attention to concussions and some think a direct correlation is there.
"There's absolutely no doubt [concussions] happened at a high rate before and they're at the same right now," Lagerwey said, "I suspect a lot of it is awareness and reporting of the injury."
Numbers will be crunched and analyzed in countries all over the world as more is made of what transpired this summer in Brazil. As ugly as it might have been, it may have been a necessary to showcase the seriousness of head injuries in soccer. After Kramer needed two people to help him off inside the Maracana, Twellman turned to former superstars Michael Ballack and Ruud van Nistelrooy inside the studio as sort of a point. He said they immediately knew something needed to change.
"This has been going on a lot longer than the 2014 World Cup," Twellman said. "It's just that no one else has been listening."
A closer look
The recent FIFA World Cup in Brazil drew rave reviews for its record-breaking number of goals, tantalizing finishes and routs during the knockout stage. But something marred the tournament: Several players appeared to suffer head injuries most likely concussions and were allowed to continue playing. FIFA has a "Pocket Concussion Recognition Tool" on it website "to help identify concussion in children, youth and adults." A notable section under "memory function" is as follows: "Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be returned to activity until they are assessed medically. Athletes with a suspected concussion should not be left alone and should not drive a motor vehicle." However, it's unclear whether this is FIFA's standard protocol. Do team trainers have enough time to evaluate players with head injuries during a game? If not, how long would it take to properly diagnose a suspected concussion?
Notable World Cup head injuries
• Uruguay's Alvaro Pereira suffers head injury in World Cup group stage match against England on June 19.
• Argentina's Javier Mascherano suffers head injury in World Cup semifinal against Netherlands on July 9.
• Germany's Christoph Kramer knocked out of World Cup final against Argentina on July 13.