The Consensus in Sport (CIS) guidelines were developed following the first international conference on concussion in sport in 2001.
This was convened by the International Ice Hockey Federation, FIFA (Federation Internationale de Football Association), and the International Olympic Committee Medical Commission in recognition of the inevitability of concussion in high speed and contact sports.
The guidelines were further developed at subsequent conferences in 2004 and 2008. They now standardise the definition of concussion, and broaden it to include being knocked to the ground and dazed.
They stipulate that all players must undergo cognitive assessment and be thoroughly tested for concussive symptoms before the season starts, with those deemed to be concussed gradually returned to play, and only when free of all symptoms.
After a high profile incident in 2007 during a cup final, the Football Association clarified its recommendations on concussion for club medical officers.
But there is no guidance on how to recognise the signs and symptoms of concussion or any requirement for club doctors to demonstrate any expertise in concussion management, the authors point out.
So they sent a questionnaire to all 92 clubs in the English Football League, which is divided up into four separate leagues—Premier League; Championship League ; and Leagues 1 and 2—at the start of the 2009/10 football season.
The response rate was 39%, with similar proportions of completed questionnaires returned by each of the leagues.
Around one in four (28%) clubs across all the leagues said that they had not heard of the CIS guidelines.
Fewer than half (44%) of the Premiership teams routinely carried out a cognitive assessment before the season got under way, although they completed significantly more of these than any of the other leagues. Similarly, only one in 10 teams carried out a concussion symptom score.
Following a concussion, over half the Premier League and Championship clubs used tests that measure both cognitive assessment and symptoms, as recommended.
But only half of the teams who were aware of the CIS guidelines did so. And few teams deployed the pre-season cognitive assessment in their evaluation.
The recommended stepwise return to play, with a review of symptoms every 24 hours, was not widely enforced.
Almost half (44%) of teams did not comply with CIS guidelines, which indicate that the earliest a player could return to play would be 6 days, and that no fixed rest period should be applied.
The length of rest periods varied from 3 to 28 days, the survey responses showed, with fixed rest periods applied by several teams in the lower leagues and one premier league club enforcing a two week rest period.
Relying on subjective assessments by the team doctor or the player to make return to play decisions could be unsafe, say the authors, who emphasise: "It is widely accepted that medical teams are under constant pressure to return players to fitness as soon as possible."
The responses indicated that clubs didn't take concussion sufficiently seriously to dedicate resource to it, yet it accounts for up to 11% of all footballing injuries, and including training, works out at one incident almost every month for a squad of 25 players, say the authors.
"It is in the interests of clubs and their players for the Football Association to endorse the CIS guidelines [which are] followed by the majority of world sporting organisations," they conclude.