World football has widely spurned the opportunity to introduce concussion substitutes to the game, with just five countries trialling the measure. English football has implemented the measures approved last year by the game’s law-making body, Ifab. The Premier League and FA Cup have both carried out trials this season, as have the Women’s Super League and Women’s Championship. But only two other European countries have followed suit: the Netherlands and Portugal. Elsewhere only Japan and the US among Fifa’s 211 member associations have also started trials. New protocols were authorised by Ifab at the end of last year after extensive consultation inside the game and years of work by campaigners. They allow for one or two permanent replacements to be brought into a match, over and above regular substitutes, if doctors believe a player could have concussion. The protocols insist “if in doubt, sit them out”, and Ifab explains “where there is any doubt about a player having been concussed, the player should be protected by being permanently removed from the match”. While there has been criticism of the protocols by some concussion experts, who say the game should have opted for temporary substitutes so as to lessen the risk of a player without visible symptoms staying on the pitch, the move was given the approval of the governing body Fifa, which trialled the one substitute protocol at the recent Club World Cup in Qatar. Uefa has opted not to implement a trial in the Champions League, Europa League or the men’s European Championship this summer. Instead it chose to trial concussion substitutes at the final phase of the under-21 championship in Hungary and Slovenia this year, before possibly extending the trials to the senior game. In Germany the Bundesliga chose not to apply the protocols this season, arguing the current limit of five substitutes allowed, expanded because of the pandemic, was enough to cover the possibility of concussion. (The protocols are explicitly designed to sit outside regular numbers so that “there is no numerical/tactical disadvantage when prioritising player welfare”.) Ifab sources say they expect more countries to trial the protocols. Scotland will be the next to join the list, with trials set to begin across the SPFL from 6 March. A Fifa spokesperson said: “The opportunity for the concussion substitutes trial has been made only since December 2020 and for many competition organisers the regulations were already established for the 2020-21 season. It is anticipated that a rise will take place for the forthcoming season, also considering that the trial is available until August 2022. “Fifa will be using the opportunity in as many competitions as possible to support the research in relation to this topic and to have as much information as possible when looking at any proposals to change the Laws of the Game. “This is an open trial open to everyone that is willing at all levels of the game, which is a departure from standard procedure in such trials. This shows the respect and priority that Fifa and the Ifab place on this matter.”