In recent years, the handling of concussions has become one of the recurring topics across the biggest sports across the globe.
Be it contact sports which revolve around tackling -- such as American football, soccer or rugby -- to the combat sports of boxing and MMA all the way through to the supposedly genteel game of cricket, each has had to reckon with the difficulties of an injury you cannot see.
So we asked reporters from across ESPN about the challenges their sports have faced and are still facing, and what protocols are in place in each.
Does the sport you cover have an existing concussion protocol? And is there a mandatory period of time that an athlete with concussion has to sit out?
Boxing (Nick Parkinson): It is up to the ringside doctor, referee and trainer in the corner to determine if a boxer is concussed, and if a fight needs to be stopped. A ringside doctor can step in at any time to tell the referee to stop a fight, and a referee can halt the contest if a boxer becomes unresponsive or unable to defend himself. A trainer can throw in the towel at any time.
World governing bodies like the WBA state that "any boxer who has suffered an actual knockout shall be suspended for at least 60 days", and if the same boxer suffers a knockout in his next bout or within three months he will be suspended for six months (and refrain from sparring during that time).
MMA (Marc Raimondi): Not exactly. MMA promotions don't have injury protocols and, for the most part, don't regulate themselves in that way. State, provincial and tribal athletic commissions regulate and sanction mixed martial arts events. When a fighter gets a head injury or another kind of injury in a bout, the ringside physicians will administer a medical suspension. The severity of the injury will determine the length of such suspension. Usually a fighter who is knocked out gets anywhere from a 30-day suspension to a six-month suspension.
Where MMA (and boxing) runs into trouble is that many injuries, including concussions, happen during training, especially sparring. Then, it's up to the individual fighter's coach to determine what to do next. There are no hard and fast rules. When a fighter is concussed during a bout, the commission will impose a suspension and a "no contact" suspension, meaning the fighter in question should not be sparring until the length of time is up. But there's no real way to enforce that -- it's not like commission officials can come into a fighter's gym and see if he or she is training or not. MMA and its rule set are very decentralized in that way.
NFL (Kevin Seifert): The NFL has an extensive concussion protocol, beginning with mandatory evaluations if any symptoms are noticed or reported. The league doesn't have a mandatory period of time for sitting out. Instead, every player who is diagnosed must follow a five-step process before they can be cleared to fully participate in practice or a game.
Rugby (Tom Hamilton): Rugby has a global concussion protocol, called the head injury assessment (HIA). If a player is concussed mid-match, or if there is any suspicion of a concussion then they are permanently removed from play. If there is any ambiguity, then they use the HIA which assesses the player -- it takes 10 minutes and the player is not allowed to return in that time. If a player fails any of the cognitive tests (their score is measured against a pre-season baseline test when they were symptom-free) then they are removed from play. If a player is deemed to have suffered a concussion (they are also tested post-match) then they have to go through a mandatory six-step Return to Play protocol. The player has to pass each stage symptom-free to return to the field. If they fail any stage then they must start again.
Cricket (Andrew Miller): It has protocols, plural -- a reflection of the differing speeds at which governing bodies around the world have woken up to the issue. The recent Ashes series between England and Australia is the first at international level to allow for concussion substitutes -- and that provision was required in the second Test at Lord's when Steven Smith was struck on the neck by a Jofra Archer bouncer and replaced mid-match by Marnus Labuschagne. However, Smith actually returned to complete his interrupted innings at Lord's, having passed the mandatory tests in the immediate wake of the incident before suffering delayed symptoms the following morning. That move attracted criticism, not least because he was clearly not his usual self at the crease, but also because Cricket Australia's own code calls for medical professionals to "adopt a conservative approach" when in doubt.
Most protocols call for a "graded" return to action. The ECB's code is currently the most robust, requiring that "all symptoms need to be absent for 24 hours" at every stage of the recovery, which adds up to a minimum of six days' rest. The ICC code (which governs international cricket) rather vaguely states that the "typical recovery process will take about seven days to complete", although that did at least inform that decision to omit Smith from the subsequent third Test at Headingley.
Soccer (Jeff Carlisle/James Tyler): Soccer's ruling body, FIFA, has a protocol but the problem is that it's unevenly and inconsistently applied around the world. The amount of adherence seems to vary from league to league. As for mandatory periods of rest time following a concussion, the bare minimum as defined by FIFA is six days of rest before someone "returns to play," though there is an additional guideline stating that players cannot return to full training and/or match play until any concussion issues have been resolved and they have been medically cleared. In MLS, for example, every player does baseline testing at the beginning of the season, and that is one of the main criteria used to determine how long a player must sit out. If a player doesn't reach their previous baseline, they are not allowed to return.
What measures is the sport you cover taking to educate athletes about concussion?
Boxing (Parkinson): It varies, globally. In Britain, the British Boxing Board of Control regularly runs educational, or awareness, workshops for boxing trainers, boxers and those in the trade on matters such as concussion, and effects of punches in later life. Boxers also undergo regular medicals and brain scans.
Boxers do not need reminding what a dangerous sport they are in, but recently boxing has mourned the deaths of two boxers due to punches to the head. Russian Maxim Dadashev and Argentine Hugo Alfredo Santillan died of injuries suffered in the ring in July.
Also, in recent years, due to medical research there has been an increased understanding of the effects of blows to head in later life. Chronic traumatic encephalopathy (CTE), formerly known as "punch-drunk syndrome", has affected many famous boxers. Some brain injury experts are convinced that Ali's suffering post-boxing was a result of the poundings he took in the ring and argue that head trauma increases the risk of Parkinson's. Others suspected to have suffered in later life from the effects of blows to the head include the great Sugar Ray Robinson.
MMA (Raimondi): The UFC has held several summits where they'll bring coaches and fighters to Las Vegas to the UFC Performance Institute and talk to them about a host of different things, including health and safety. They'll bring in speakers and experts to discuss different topics. So much in MMA is resting on coaches and the fighters themselves. The fighters are all independent contractors and the UFC has no real sway over the coaches, since they're not tied to the UFC in any meaningful way.
The UFC Performance Institute, a $14 million facility which opened in Vegas in 2017, has been a huge boon for fighters. There is a full-time staff there of coaches, strength-and-conditioning trainers, doctors and physical therapists. They work with fighters on site and remotely. And they do pass on education to fighters about the dangers of concussions. Other, smaller MMA promotions don't have those kinds of resources and are not as active in that way.
NFL (Seifert): The NFL and NFL Players Association holds training sessions to teach players to recognize symptoms. A portion of the training also makes clear that players are required to abide by instructions from team physicians and/or independent neurologists who may be evaluating them in the immediate aftermath, as well as those who monitor recovery.
Rugby (Hamilton): World Rugby has a dedicated Concussion Management website which has concussion guidance, a guide to the HIA and resources to learn online. Their 'Recognise & Remove' campaign is also pushed out the world over. Players at the elite level are also briefed on the dangers while at amateur and school level, there are a series of charities -- like Headway, Heads Up and Return2Play -- and organisations that focus on concussion education, training and awareness.
Cricket (Miller): There's heightened awareness, but it's hard to pretend there are any notable measures to "educate" as such. After all, the dangers of fast, short-pitched bowling are self-evident and unlike other sports in which collisions are a necessary and regular risk, the best means to avoid concussion in cricket is (without wishing to sound glib) to watch the ball and not get hit.
To that end, rules limiting the number of bouncers in an over were introduced in the 1990s as a reaction to the ubiquity of West Indies' fast bowlers, while helmets have been de rigueur for generations now. They are mandatory in junior cricket in many countries, so players simply grow up wearing them these days.
However, there's always scope for improving helmet technology, and most recently stem-guards have been introduced to protect the vulnerable area at the back of the skull. Australia's Steve Smith was reluctant to wear them before Lord's, but was completely unhindered when scoring 211 in his first innings back at Old Trafford.
Soccer (Carlisle/Tyler): Again, awareness is uneven worldwide and not every league follows the same guidelines. MLS does sessions with players prior to the season every year. The U.S. Soccer Federation also has a program called Recognize to Recover that has a concussion component and is intended to educated parents, players and coaches about how to recognize and treat concussions. In 2017, the USSF, MLS and the National Women's Soccer League held a Head Injuries in Soccer summit to bring together various stakeholders on the topic.
FIFA's medical portal is full of information and tools they can deploy with their teams but, in practice, it's inconsistent. A shocking head injury to Swiss defender Fabian Schar back in March, where he briefly lost consciousness following a clash of heads in a match with Georgia, didn't lead to his removal from the match. He went on to play the full 90 in a 2-0 win.
Has the sport's culture around concussion changed in the last 10-15 years? And what could sports learn from each other?
Boxing (Parkinson): Boxing fans are a bloodthirsty lot and a knockout is -- and always has been -- a popular and thrilling end to a contest, at any level. Concussions are a regular occurrence in boxing, and will continue to happen. When a knockout does not happen, fans can even be left disappointed. There were grumbles of disappointment on social media, and even from experts, that the world's best boxer, lightweight Vasiliy Lomachenko, did not render his latest victim Luke Campbell unconscious last month, despite putting on a technical (and entertaining) masterclass. There is, however, more appreciation of the need to prevent boxers who have been beaten by knockout returning to action too swiftly.
Boxing could perhaps learn from other sports in relation to adopting stricter protocols for longer suspensions -- or time away from the ring -- after repeated knockouts. This would impact mostly on journeyman boxers, rather than the high-profile, elite boxers who don't need to fight as regularly.
MMA (Raimondi): The knowledge and understanding of head injuries and concussions have expanded over the years in MMA, but being knocked out is very much a part of the sport. Some fans and promoters still expect fighters to return relatively quickly after being knocked out and/or concussed.
What has changed is the philosophy on sparring. Years ago, when MMA was in its infancy, fighters sparred several times per week. Sparring is basically a fight in the gym that athletes are not getting paid for that helps them prepare for the actual competition. Rafael Cordeiro, who coaches Kings MMA in Huntington Beach, California, told me recently that when he was coaching Chute Boxe Academy in Brazil in the mid-to-late 2000s that his fighters would spar seven days per week during training camps. They would even spar the day before the fight and sometimes the morning of the fight. Now, that would be viewed as crazy. Cordeiro's fighters at Kings now spar twice a week -- a light spar on Monday and a hard spar on Friday -- during training camps.
One of MMA's biggest issues is its decentralization and not just because of concussions or injuries. MMA's ruleset is disjointed and in some cases there are different in-fight rules depending on the location of the fight. MMA is at the mercy of what the individual athletic commissions are able to pass as regulations. So with the UFC holding an event almost every week in different areas of the world, every week can be different depending on the commission. Overseas, the UFC regulates itself, which also presents a conflict of interest. A hardline concussion protocol like those found in other sports that could be applied across the board in MMA would be beneficial to the sport and its athletes.
NFL (Seifert): The NFL has engineered a massive internal culture change around concussions. A decade ago, none of the current protocols existed. In addition to having mandatory diagnosis and treatment requirements, the NFL also uses three unaffiliated neurotrauma consultants at each game, including one who watches video playbacks. New helmet requirements and rules designed to minimize head trauma have all been introduced in recent years. That wholistic approach -- medical, engineering and football operations -- could be replicated in other leagues.
Cricket (Miller): Cricket's attitude changed beyond all recognition in November 2014 when the Australian batsman Phil Hughes died after being struck on the back of the head while playing for South Australia against New South Wales in a domestic fixture. On-field deaths are sadly not uncommon -- the Indian cricketer Raman Lamba was killed by a blow to the head while fielding at short leg in 1998, and as recently as August, John Williams, an umpire in Pembrokeshire, died after being struck during a club fixture. But the high-profile nature of Hughes' death, witnessed by many via a live stream, shook the game to the core, and Cricket Australia were the first movers when it came to tackling concussion more seriously. These days, all players are subject to an immediate on-field check after any blow to the head.
Beyond the adoption of a single concussion protocol to govern all levels of the game, and the exchange of knowledge about the types of incident that can be encountered, there's not a huge amount that cricket can take directly from other sports, or vice versa. This is because of the broadly non-contact nature of the sport -- play stops naturally between deliveries, so there are no grey areas about playing "advantage" or "to the whistle". And when incidents happen, the severity tends to be self-evident, unlike the sort of glancing blows or unsighted impacts that can occur in rugby in particular.
Rugby (Hamilton): The sport has completely changed its attitude to concussion in the last seven or so years. As news of the NFL lawsuits started to come out, rugby had a wake-up call and a mixture of player testimony and a growing spotlight on the issue saw the sport act. Watching players battling on after a concussion used to be a badge of honour, but now that is shifting. Concussion diagnosis used to be player-led on the field -- the player had the last say-- but protocols were brought in to leave it in the hands of medics. Concussion is now taken extremely seriously, with player welfare paramount.
Rugby will face challenges in the future as we learn more about the neurological strain a player has undergone in their career. High profile players like Tatafu Polota-Nau have already said they'll leave their brain to science, to look into whether they have any long-lasting damage from the game.
Concussion management is not an exact science, and we are still in the learning stage of this specific injury, but rugby is ahead of some sports in terms of protocols, awareness and management. Other sports like football and cricket have been pointed in rugby's direction after high-profile incidents in their own sport.
Soccer (Carlisle/Tyler): Very much so. There were several players in the U.S. who had to retire due to post-concussion syndrome, in particular ESPN analyst Taylor Twellman. Twellman has in fact started an advocacy group called ThinkTaylor.org that has been pushing for greater awareness of concussions. The aforementioned USSF program "Recognize to Recover" has also been at the forefront of this. Included in this is a guideline about when it's appropriate for kids to begin heading the ball. Even in Europe now, there is (slowly) an increasing awareness.
The single biggest improvement would be the use of a "concussion substitution." At present, if a player has a head injury, the coach must decide whether to burn a substitution or play short-handed while the player is treated. Because of this, there is an impulse to put the player back on the field before they've been properly diagnosed. There is currently a proposal before the International Football Association Board to allow for a temporary concussion substitution, following the example set by rugby, that would allow the player to be treated while not forcing the team to play short-handed.
There also needs to be a standard, one-size-fits-all approach to concussion diagnosis and treatment that is broadcast down from FIFA and adhered to by all leagues at all levels in every country. (The fact that a recent study showed MLS players sit out an average of 37 days following concussions, while Premier League players miss 10.9 days says it all.)