Football-Specific On-Pitch Concussion Assessment Protocol-International Consensus Recommendations

Concussion is a high-profile and important brain injury, yet the on-pitch assessment of concussion in football (soccer) remains challenging due to the absence of a standardized, evidence-based assessment protocol that can be completed within a time-restrained on-pitch football-match environment. The objective of this study was to develop a football-specific, standardized on-pitch concussion assessment protocol informed by research evidence and expert opinion using an international consensus process and steering committee deliberation, which included medical experts from each of the 6 football confederations.

Nominated global medical representatives with experience in the on-pitch assessment of concussion in football (≥5 assessments within previous year) from Fédération Internationale de Football Association (FIFA)-member associations completed a 2-round Delphi questionnaire to score all identified assessment items that have been used to assess an athlete with a suspected concussion within an on- or off-pitch environment (in any sport) along with expert recommendations. Consensus (≥80% agreement) was required for assessment items to be included in a football-specific on-pitch concussion assessment protocol. Results demonstrated that from 101 identified assessment items, 41 achieved greater than or equal to 80% agreement for inclusion in round 1, and 6 additional items achieved greater than or equal to 80% agreement in round 2. Four items (scoring 75%-79%) were added after steering committee review. Twelve items were merged to avoid duplication of items that assess the same issue. This resulted in the final Football-Specific Standardized On-Pitch Concussion Assessment Protocol (FOCUS) comprising 45 items categorized into 11 domains as follows: player medical history, mechanism of injury, visible signs, level of consciousness, cervical spine assessment, symptoms, orientation, balance, proprioception, oculomotor function, and activity-based assessment, with each structured for rapid on-pitch evaluation.

FOCUS provided a standardized, evidence-informed protocol for the on-pitch assessment of a suspected concussion during football match play, addressing a critical gap in player health and safety. Adoption of FOCUS has the potential to harmonize concussion management globally; however, implementation feasibility and diagnostic accuracy require further evaluation.