Curr Neurol Neurosci Rep (2015) 15:11 DOI 10.1007/s11910-015-0535-3
NEUROTRAUMA (J LEVINE, SECTION EDITOR)
Concussion and Football: a Review and Editorial Kalil G. Abdullah & M. Sean Grady & Joshua M. Levine
# Springer Science+Business Media New York 2015
Abstract The issue of concussion in football is of substantial interest to players, coaches, fans, and physicians. In this article, we review specific cultural hindrances to diagnosis and treatment of concussion in football. We review current trends in management and identify areas for improvement. We also discuss the obligations that physicians, particularly neurosurgeons and neurologists, have toward brain-injured football players and the larger societal role they may play in helping to minimize football-associated brain injury. Keywords Football . Concussion . Traumatic brain injury . Professional sports . Athletics
popular sport in America and an important component of our culture. As in any sport, participation carries the risk of injury, which can be catastrophic. Recent evidence suggests that playing football subjects athletes to a series of concussive and sub-concussive injuries that may result in serious longterm brain damage [1••, 2, 3]. What is the role of the neurosurgeon and neurologist in light of this data? In this article, we discuss particular cultural issues pertaining to concussion in football players, including diagnosis and reporting, associated stigma, and our obligations toward decreasing the incidence and severity of concussion.
Identification and Reporting of Concussion Introduction Football is an undeniably violent sport. It is also a sport of strategy, intellect, and physical grace. It has become the most This article is a part of the Topical Collection on Neurotrauma K. G. Abdullah : M. S. Grady : J. M. Levine (*) Departments of Neurosurgery, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA e-mail: [email protected] J. M. Levine e-mail: [email protected] J. M. Levine Departments of Neurology, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA J. M. Levine Departments of Anesthesiology and Critical Care, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
There are many difficulties in the treatment of an athlete with a suspected concussion. The first is identifying a concussive injury. In this regard, football is unique. Some concussions are clearly visible. Recall any number of times during a broadcast game that a player is Bshaken up on the play.^ Video review often reveals a direct, blunt force trauma to a player’s head, neck, or chest followed by a momentarily stunned, immobile player who then returns to his team’s huddle after the play finishes. Interviews with players confirm that these are often brief losses of consciousness or a moment of altered mental status. Even more obvious are discrete images of players wobbling to their feet and then careening forward unsteadily after sustaining a blow to the head. It is difficult to deny that this is not evidence of a concussive force, which we know diagnostically and heuristically to be a form of traumatic brain injury. Troublingly, many players report that despite brief losses of consciousness, mental status changes, and visual and auditory hallucinations that persisted throughout parts or totality of games, they appeared normal to their teammates and training staff. So while even the untrained eye may identify concussive episodes during a game, there exist
11
Page 2 of 4
brain injuries that are likely unreported and undiagnosed [4]. These do not include the Bsub-concussive^ classification of injury that is increasingly being investigated and which may occur multiple times throughout a high-level football game. Complicating diagnosis is underreporting of concussive injury. Concussions, and in particular concussions that occur during football games, are diagnostically unique in this regard. Heart failure patients report their shortness of breath, diabetics report their neuropathy, and patients with brain tumors report their headaches. Football players do not seem to report their concussions as often as they occur. In some cases, they do not even report long-lasting concussive symptoms. What accounts for this difference? Some of this problem is a lack of education in what constitutes an injury. More troubling is an athlete’s concern that reporting a concussion will likely result in loss of Bplaying time^ [5, 6]. Playing time is not a frivolous concept to a professional or collegiate athlete. Even elite players remain concerned that missing work will result in their replacement. Enough missed work can leave a player tagged as Binjury prone^ and can impede chances of employment later in their career. In a study of collegiate athletes, 1/3 reported that they failed to report their concussion for Bfear that being diagnosed with a concussion would result in negative repercussions from the coach or coaching staff^ [5]. Placing aside the immediate effects of an injury, it is important for practitioners to understand the distinct difference between a professional football player and a patient who plays at an amateur or recreational level. A professional football player requires his full physical prowess to maintain his career and livelihood; doing so not only entails a sense of professional pride, but also represents maintenance of their sole source of income. This makes the findings of the cited study even more troubling when taking into account the finality and seriousness with which professional football players compete. We often think of football players as wealthy and well-compensated, but the majority of football players on NFL teams earn wages closer to a league-minimum salary (the league minimum for a rookie player is $420,000) [7]. Most NFL players have a career lasting 3.5–6 years depending on their draft rank, playing position, and on-field achievements. Postfootball careers for others than the elite are far less lucrative. Many are poorly trained for other professions and not all players complete a college degree. The stakes are in many ways just as high for some students in high school and college. High school students need playing time to vie for desired scholarships, and college athletes require playing time to impress NFL scouts. Those of us who have treated ambitious and dedicated young football players for concussions can easily recall the difficulty in sidelining a player who pleads a Blife-altering^ need to get back on the field. For these players, it is conceivably
Curr Neurol Neurosci Rep (2015) 15:11
undesirable to report an injury that has no direct physical correlate (not a knee, elbow, rib), that may result in lack of playing time, and that may be detrimental to their career longevity (or trajectory).
The Stigma of Concussion To an active player, concssion is relatively poorly understood compared to other types of work-related injuries. This can result in the player being stigmatized for a lack of Btoughness^ when the concussion leads to a decrease in playing time. Anatomical correlates to other injuries highlight this. For example, the tearing of an anterior cruciate ligament is easy to explain. It is evident to the player, as they experience physical pain and a near inability to walk. It is also clear to the player’s teammates, coaches, and fans that the athlete has experienced physical harm and cannot perform the duties of their occupation. There is an easily identifiable imaging correlate on MRI and a clear solution to the pathology through surgical intervention. This clear and visible treatment paradigm is familiar and unshakable. When a high profile athlete is injured, the time frame and treatment for that injury is almost immediately available. A torn ACL is season ending, it requires surgery, and the patient should return during the next season. Instant replay and video evidence highlights the mechanism and the injury, showing the exact moment the injury occurred. The same can be said for a broken bone or sprained ligament. Fans, coaches, and other players have no reason to question the toughness or Bgrit^ of the injured player. How does this compare to a player with a concussion? At times, the concussion is unseen to teammates, players, and fans. Following that concussion, the player is shuttled off to the locker room and frequently does not return. He is sent home and may return to practices and games in street clothes and to other players, coaches, and fans appears to be completely physically normal. There is no imaging correlate and the time frame for return is nebulous. Repeated concussions compound the amount of time missed and further complicate the understanding of the player’s peers, coaches, and fans. What is truly unfortunate about the current state of concussions in football (and other sports) is the questioning of a player’s Bmental toughness.^ This can include referring to the player as Bskittish^ and Bjumpy.^ Phrased another way, players with repetitive concussions are Bscared^ to get another concussion and play without the fearlessness that we expect of a competitive athlete. These are unfortunate assignations given troubling early evidence that even non-professional football may result in long-term neuroanatomical changes [8, 9, 10•]
Curr Neurol Neurosci Rep (2015) 15:11
Obligations and Steps Forward The evidence regarding chronic traumatic encephalopathy (CTE) and its correlation with the onset of dementia after a professional football career is a long-standing debate and outside of the scope of this article. But as physicians, we cannot refute the scientific concept that concussions are form of traumatic brain injury and that repetitive traumatic brain injury may result in irreversible brain damage. We have several standard medical obligations in the treatment of football players who suffer concussions. These include proper diagnosis and evaluation at the time of concussion and thorough clearance prior to return to activity. From the paradigm of the doctorpatient relationship, we must ensure that our patients understand the seriousness of each concussion and the risks associated with repetitive concussions. Our obligation continues past the field and office and into the community. As neurosurgeons and neurologists, we must actively engage in the local and national discussions of concussions to protect our patients from character attacks that result from misunderstanding of a disease state that we treat. We must address this on an individual level while supporting our patients in the clinic and on the field, on a team level to their coaches and peers, and on a community and national level when this topic is discussed in the media. This may be the most important of our obligations—to ensure that as a group of medical professionals, we are involved in the policy changes and public discussion necessary to ensure the safety of our patients. What has our community done so far to remedy this? Since being brought to Congress to answer for an Bepidemic of concussion^ in 2009, the NFL has responded with the help of organized neurology and neurosurgery to establish committees and guidelines to evaluate and decrease the incidence of concussion and repeat injury. In 2009, the NFL revised guidelines for concussions to prohibit the return of any player with an observed concussion during a game or practice, a revision from the 2007 statement which allowed the player to return after a brief examination (unless he experienced loss of consiousness) [11]. This was historically remarkable. Prior to this 2009 guideline, an NFL-sponsored prospective analysis of game and practice records between 1996 and 2001 showed that nearly one half of all players suffering a visible concussion returned the same day they were concussed [2]. In 2010, the NFL created the Head, Neck and Spine Committee with two neurosurgeons as co-chairs. The committee then established a protocol for the diagnosis and management of on-field concussion, which called for uniform and regimented changes to management [12••]. First, it mandated the use of the NFL’s Sideline Concussion Assessment Tool (SCAT) on the day of the injury and implemented Bchain-of-command^ for concussion diagnosis. A Bbig-hit^ became a reason for removal from the game if there was a reasonable chance of concussion, despite the lack of definitive visible concussive
Page 3 of 4 11
signs. It also called for each game to be staffed by an Bindependent neurological consultant^ (neurosurgeon, neurologist, emergency physician, or sports medicine-trained physician) to remain on the sidelines and assist with identification of concussions. This along with more frequent and serial postconcussion management also represents a large step forward in the identification and immediate treatment of concussion. Until very recently, however, a player’s return after a concussion had not followed a standardized protocol [13]. In 2014, the committee provided a formal set of recommendations that instruct and educate team physicians on how to reintroduce a player back into full activity. The new guidelines also require clearance by an independent neurological consultant prior to returning to play. While the past 5 years have brought a substantial amount of change to the NFL’s handling of concussion, several issues still remain unresolved, including more specific guidelines for return-to-play and a better understanding of the effects of concussion on youth. While the NFL is a league of adults, those adults almost always spend a substantial portion of their lifetime in full contact activities. This is especially troublesome at the collegiate level, where the NCAA (currently battling multiple concussion lawsuits) has only recently adopted guidelines for full-contact drill frequency and concussion management but does not have a mechanism for guideline enforcement. Further, internally released memoranda from a federal lawsuit revealed that as late as 2010, up to 50 % of concussed players were never evaluated by a physician and that in one particularly troubling case, an NCAA Division I institution allowed a player who was knocked unconscious to return to the field in the same quarter of play [14••].
Conclusion Awareness of these issues should lead to a better understanding of our obligations as physicians treating brain injury in a special population. The most troublesome concern is the lack of education and understanding that prevails among this patient population, their fans, and the media. We have a strong obligation to educate our patients on the risks of repeated concussions, to promote awareness of these risks among the general population, and to clearly and without exception prevent perpetuation of the myth that forced resting of players with concussions is nebulous or shows a lack of toughness. This is our obligation not only in the office and on the field but also in the media. We must actively counter the incorrect assumption that because a concussion does not require a cast, brace, or surgery, it is somehow less serious than an orthopedic injury. As neurosurgeons and neurologists, it is our obligation to remain advocates for our patients even when they are football players. At this time, it may be particularly important in the
11
Curr Neurol Neurosci Rep (2015) 15:11
Page 4 of 4
college community, where the NCAA has not presented a cohesive and enforceable plan for concussions analogous to the one present in the NFL. Some of our advocacy will be on the field in the diagnostic capacity, but the majority will be off the field as we become increasingly involved in the ways we educate and support football players and our broader communities. We have made laudable progress in this capacity, but as we continue to understand more about the science of concussion, our continued involvement in this conversation is both a medical and, perhaps, an ethical obligation that is necessary as neurosurgeons, neurologists, and concurrently, football fans. Compliance with Ethics Guidelines
3. 4.
5.
6.
7.
8.
Conflict of Interest Kalil G. Abdullah, M. Sean Grady, and Joshua M. Levine declare that they have no conflict of interest. 9. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
10.•
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.•• Lehman EJ. Epidemiology of neurodegeneration in American-style professional football players. Alzheimers Res Ther. 2013;5:34. A 6 year prospective study of TBI in the NFL that included analysis of 787 injuries evaluated by the authors. Concussions were broken down by situation, severity, and return-to-play. 2. Casson IR, Pellman EJ, Viano DC. Concussion in the national football league: an overview for neurologists. Neurol Clin. 2008;26:217. 41; x-xi.
11.
12.••
13.
14.••
Edwards JC, Bodle JD. Causes and consequences of sports concussion. J Law Med Ethics. 2014;42:128–32. Myers G. Former NY Jets WR Wayne Chrebet, who sacrificed body for love of NFL, dives headfirst into new career. New York Daily News. 2013. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA. Why university athletes choose not to reveal their concussion symptoms during a practice or game. Clin J Sport Med. 2014. doi:10. 1097/JSM.0000000000000112. Hirth RA, Chernew ME, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making. 2000;20:332–42. Ginnitti M. NFL Minimum Salaries & Veteran Discounts. In: 2014. http://www.spotrac.com/blog/nfl-minimum-salaries-veterandiscounts/. Davenport EM, Whitlow CT, Urban JE, Espeland MA, Jung Y, Rosenbaum DA, et al. Abnormal white matter integrity related to head impact exposure in a season of high school varsity football. J Neurotrauma. 2014. doi:10.1089/neu.2013.3233. McAllister TW, Ford JC, Flashman LA, Maerlender A, Greenwald RM, Beckwith JG, et al. Effect of head impacts on diffusivity measures in a cohort of collegiate contact sport athletes. Neurology. 2014;82:63–9. Singh R, Meier TB, Kuplicki R, Savitz J, Mukai I, Cavanagh L, et al. Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. JAMA. 2014;311:1883–8. Early but compelling research that correlates concussion with anatomical and functional brain changes. National Football League. League announces stricter concussion guidelines. In: 2009. http://blogs.nfl.com/2009/12/02/leagueannounces-stricter-concussion-guidelines/. NFL Head, Neck and Spine Committee. Protocols regarding diagnosis and management of concussion. 2013. Recent guidelines of the NFL’s safety committee on brain and spine injury. National Football League Head, Neck and Spine Committee. Protocols regarding return to participation following concussion. 2014. Fenno N. Internal NCAA emails raise questions about concussion policy. Washington Times. 2013. Investigative article that outline the start of an investigation into the policies and practices of the NCAA in regards to concussion safety.
NEUROTRAUMA (J LEVINE, SECTION EDITOR)
Concussion and Football: a Review and Editorial Kalil G. Abdullah & M. Sean Grady & Joshua M. Levine
# Springer Science+Business Media New York 2015
Abstract The issue of concussion in football is of substantial interest to players, coaches, fans, and physicians. In this article, we review specific cultural hindrances to diagnosis and treatment of concussion in football. We review current trends in management and identify areas for improvement. We also discuss the obligations that physicians, particularly neurosurgeons and neurologists, have toward brain-injured football players and the larger societal role they may play in helping to minimize football-associated brain injury. Keywords Football . Concussion . Traumatic brain injury . Professional sports . Athletics
popular sport in America and an important component of our culture. As in any sport, participation carries the risk of injury, which can be catastrophic. Recent evidence suggests that playing football subjects athletes to a series of concussive and sub-concussive injuries that may result in serious longterm brain damage [1••, 2, 3]. What is the role of the neurosurgeon and neurologist in light of this data? In this article, we discuss particular cultural issues pertaining to concussion in football players, including diagnosis and reporting, associated stigma, and our obligations toward decreasing the incidence and severity of concussion.
Identification and Reporting of Concussion Introduction Football is an undeniably violent sport. It is also a sport of strategy, intellect, and physical grace. It has become the most This article is a part of the Topical Collection on Neurotrauma K. G. Abdullah : M. S. Grady : J. M. Levine (*) Departments of Neurosurgery, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA e-mail: [email protected] J. M. Levine e-mail: [email protected] J. M. Levine Departments of Neurology, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA J. M. Levine Departments of Anesthesiology and Critical Care, The Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
There are many difficulties in the treatment of an athlete with a suspected concussion. The first is identifying a concussive injury. In this regard, football is unique. Some concussions are clearly visible. Recall any number of times during a broadcast game that a player is Bshaken up on the play.^ Video review often reveals a direct, blunt force trauma to a player’s head, neck, or chest followed by a momentarily stunned, immobile player who then returns to his team’s huddle after the play finishes. Interviews with players confirm that these are often brief losses of consciousness or a moment of altered mental status. Even more obvious are discrete images of players wobbling to their feet and then careening forward unsteadily after sustaining a blow to the head. It is difficult to deny that this is not evidence of a concussive force, which we know diagnostically and heuristically to be a form of traumatic brain injury. Troublingly, many players report that despite brief losses of consciousness, mental status changes, and visual and auditory hallucinations that persisted throughout parts or totality of games, they appeared normal to their teammates and training staff. So while even the untrained eye may identify concussive episodes during a game, there exist
11
Page 2 of 4
brain injuries that are likely unreported and undiagnosed [4]. These do not include the Bsub-concussive^ classification of injury that is increasingly being investigated and which may occur multiple times throughout a high-level football game. Complicating diagnosis is underreporting of concussive injury. Concussions, and in particular concussions that occur during football games, are diagnostically unique in this regard. Heart failure patients report their shortness of breath, diabetics report their neuropathy, and patients with brain tumors report their headaches. Football players do not seem to report their concussions as often as they occur. In some cases, they do not even report long-lasting concussive symptoms. What accounts for this difference? Some of this problem is a lack of education in what constitutes an injury. More troubling is an athlete’s concern that reporting a concussion will likely result in loss of Bplaying time^ [5, 6]. Playing time is not a frivolous concept to a professional or collegiate athlete. Even elite players remain concerned that missing work will result in their replacement. Enough missed work can leave a player tagged as Binjury prone^ and can impede chances of employment later in their career. In a study of collegiate athletes, 1/3 reported that they failed to report their concussion for Bfear that being diagnosed with a concussion would result in negative repercussions from the coach or coaching staff^ [5]. Placing aside the immediate effects of an injury, it is important for practitioners to understand the distinct difference between a professional football player and a patient who plays at an amateur or recreational level. A professional football player requires his full physical prowess to maintain his career and livelihood; doing so not only entails a sense of professional pride, but also represents maintenance of their sole source of income. This makes the findings of the cited study even more troubling when taking into account the finality and seriousness with which professional football players compete. We often think of football players as wealthy and well-compensated, but the majority of football players on NFL teams earn wages closer to a league-minimum salary (the league minimum for a rookie player is $420,000) [7]. Most NFL players have a career lasting 3.5–6 years depending on their draft rank, playing position, and on-field achievements. Postfootball careers for others than the elite are far less lucrative. Many are poorly trained for other professions and not all players complete a college degree. The stakes are in many ways just as high for some students in high school and college. High school students need playing time to vie for desired scholarships, and college athletes require playing time to impress NFL scouts. Those of us who have treated ambitious and dedicated young football players for concussions can easily recall the difficulty in sidelining a player who pleads a Blife-altering^ need to get back on the field. For these players, it is conceivably
Curr Neurol Neurosci Rep (2015) 15:11
undesirable to report an injury that has no direct physical correlate (not a knee, elbow, rib), that may result in lack of playing time, and that may be detrimental to their career longevity (or trajectory).
The Stigma of Concussion To an active player, concssion is relatively poorly understood compared to other types of work-related injuries. This can result in the player being stigmatized for a lack of Btoughness^ when the concussion leads to a decrease in playing time. Anatomical correlates to other injuries highlight this. For example, the tearing of an anterior cruciate ligament is easy to explain. It is evident to the player, as they experience physical pain and a near inability to walk. It is also clear to the player’s teammates, coaches, and fans that the athlete has experienced physical harm and cannot perform the duties of their occupation. There is an easily identifiable imaging correlate on MRI and a clear solution to the pathology through surgical intervention. This clear and visible treatment paradigm is familiar and unshakable. When a high profile athlete is injured, the time frame and treatment for that injury is almost immediately available. A torn ACL is season ending, it requires surgery, and the patient should return during the next season. Instant replay and video evidence highlights the mechanism and the injury, showing the exact moment the injury occurred. The same can be said for a broken bone or sprained ligament. Fans, coaches, and other players have no reason to question the toughness or Bgrit^ of the injured player. How does this compare to a player with a concussion? At times, the concussion is unseen to teammates, players, and fans. Following that concussion, the player is shuttled off to the locker room and frequently does not return. He is sent home and may return to practices and games in street clothes and to other players, coaches, and fans appears to be completely physically normal. There is no imaging correlate and the time frame for return is nebulous. Repeated concussions compound the amount of time missed and further complicate the understanding of the player’s peers, coaches, and fans. What is truly unfortunate about the current state of concussions in football (and other sports) is the questioning of a player’s Bmental toughness.^ This can include referring to the player as Bskittish^ and Bjumpy.^ Phrased another way, players with repetitive concussions are Bscared^ to get another concussion and play without the fearlessness that we expect of a competitive athlete. These are unfortunate assignations given troubling early evidence that even non-professional football may result in long-term neuroanatomical changes [8, 9, 10•]
Curr Neurol Neurosci Rep (2015) 15:11
Obligations and Steps Forward The evidence regarding chronic traumatic encephalopathy (CTE) and its correlation with the onset of dementia after a professional football career is a long-standing debate and outside of the scope of this article. But as physicians, we cannot refute the scientific concept that concussions are form of traumatic brain injury and that repetitive traumatic brain injury may result in irreversible brain damage. We have several standard medical obligations in the treatment of football players who suffer concussions. These include proper diagnosis and evaluation at the time of concussion and thorough clearance prior to return to activity. From the paradigm of the doctorpatient relationship, we must ensure that our patients understand the seriousness of each concussion and the risks associated with repetitive concussions. Our obligation continues past the field and office and into the community. As neurosurgeons and neurologists, we must actively engage in the local and national discussions of concussions to protect our patients from character attacks that result from misunderstanding of a disease state that we treat. We must address this on an individual level while supporting our patients in the clinic and on the field, on a team level to their coaches and peers, and on a community and national level when this topic is discussed in the media. This may be the most important of our obligations—to ensure that as a group of medical professionals, we are involved in the policy changes and public discussion necessary to ensure the safety of our patients. What has our community done so far to remedy this? Since being brought to Congress to answer for an Bepidemic of concussion^ in 2009, the NFL has responded with the help of organized neurology and neurosurgery to establish committees and guidelines to evaluate and decrease the incidence of concussion and repeat injury. In 2009, the NFL revised guidelines for concussions to prohibit the return of any player with an observed concussion during a game or practice, a revision from the 2007 statement which allowed the player to return after a brief examination (unless he experienced loss of consiousness) [11]. This was historically remarkable. Prior to this 2009 guideline, an NFL-sponsored prospective analysis of game and practice records between 1996 and 2001 showed that nearly one half of all players suffering a visible concussion returned the same day they were concussed [2]. In 2010, the NFL created the Head, Neck and Spine Committee with two neurosurgeons as co-chairs. The committee then established a protocol for the diagnosis and management of on-field concussion, which called for uniform and regimented changes to management [12••]. First, it mandated the use of the NFL’s Sideline Concussion Assessment Tool (SCAT) on the day of the injury and implemented Bchain-of-command^ for concussion diagnosis. A Bbig-hit^ became a reason for removal from the game if there was a reasonable chance of concussion, despite the lack of definitive visible concussive
Page 3 of 4 11
signs. It also called for each game to be staffed by an Bindependent neurological consultant^ (neurosurgeon, neurologist, emergency physician, or sports medicine-trained physician) to remain on the sidelines and assist with identification of concussions. This along with more frequent and serial postconcussion management also represents a large step forward in the identification and immediate treatment of concussion. Until very recently, however, a player’s return after a concussion had not followed a standardized protocol [13]. In 2014, the committee provided a formal set of recommendations that instruct and educate team physicians on how to reintroduce a player back into full activity. The new guidelines also require clearance by an independent neurological consultant prior to returning to play. While the past 5 years have brought a substantial amount of change to the NFL’s handling of concussion, several issues still remain unresolved, including more specific guidelines for return-to-play and a better understanding of the effects of concussion on youth. While the NFL is a league of adults, those adults almost always spend a substantial portion of their lifetime in full contact activities. This is especially troublesome at the collegiate level, where the NCAA (currently battling multiple concussion lawsuits) has only recently adopted guidelines for full-contact drill frequency and concussion management but does not have a mechanism for guideline enforcement. Further, internally released memoranda from a federal lawsuit revealed that as late as 2010, up to 50 % of concussed players were never evaluated by a physician and that in one particularly troubling case, an NCAA Division I institution allowed a player who was knocked unconscious to return to the field in the same quarter of play [14••].
Conclusion Awareness of these issues should lead to a better understanding of our obligations as physicians treating brain injury in a special population. The most troublesome concern is the lack of education and understanding that prevails among this patient population, their fans, and the media. We have a strong obligation to educate our patients on the risks of repeated concussions, to promote awareness of these risks among the general population, and to clearly and without exception prevent perpetuation of the myth that forced resting of players with concussions is nebulous or shows a lack of toughness. This is our obligation not only in the office and on the field but also in the media. We must actively counter the incorrect assumption that because a concussion does not require a cast, brace, or surgery, it is somehow less serious than an orthopedic injury. As neurosurgeons and neurologists, it is our obligation to remain advocates for our patients even when they are football players. At this time, it may be particularly important in the
11
Curr Neurol Neurosci Rep (2015) 15:11
Page 4 of 4
college community, where the NCAA has not presented a cohesive and enforceable plan for concussions analogous to the one present in the NFL. Some of our advocacy will be on the field in the diagnostic capacity, but the majority will be off the field as we become increasingly involved in the ways we educate and support football players and our broader communities. We have made laudable progress in this capacity, but as we continue to understand more about the science of concussion, our continued involvement in this conversation is both a medical and, perhaps, an ethical obligation that is necessary as neurosurgeons, neurologists, and concurrently, football fans. Compliance with Ethics Guidelines
3. 4.
5.
6.
7.
8.
Conflict of Interest Kalil G. Abdullah, M. Sean Grady, and Joshua M. Levine declare that they have no conflict of interest. 9. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
10.•
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.•• Lehman EJ. Epidemiology of neurodegeneration in American-style professional football players. Alzheimers Res Ther. 2013;5:34. A 6 year prospective study of TBI in the NFL that included analysis of 787 injuries evaluated by the authors. Concussions were broken down by situation, severity, and return-to-play. 2. Casson IR, Pellman EJ, Viano DC. Concussion in the national football league: an overview for neurologists. Neurol Clin. 2008;26:217. 41; x-xi.
11.
12.••
13.
14.••
Edwards JC, Bodle JD. Causes and consequences of sports concussion. J Law Med Ethics. 2014;42:128–32. Myers G. Former NY Jets WR Wayne Chrebet, who sacrificed body for love of NFL, dives headfirst into new career. New York Daily News. 2013. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA. Why university athletes choose not to reveal their concussion symptoms during a practice or game. Clin J Sport Med. 2014. doi:10. 1097/JSM.0000000000000112. Hirth RA, Chernew ME, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making. 2000;20:332–42. Ginnitti M. NFL Minimum Salaries & Veteran Discounts. In: 2014. http://www.spotrac.com/blog/nfl-minimum-salaries-veterandiscounts/. Davenport EM, Whitlow CT, Urban JE, Espeland MA, Jung Y, Rosenbaum DA, et al. Abnormal white matter integrity related to head impact exposure in a season of high school varsity football. J Neurotrauma. 2014. doi:10.1089/neu.2013.3233. McAllister TW, Ford JC, Flashman LA, Maerlender A, Greenwald RM, Beckwith JG, et al. Effect of head impacts on diffusivity measures in a cohort of collegiate contact sport athletes. Neurology. 2014;82:63–9. Singh R, Meier TB, Kuplicki R, Savitz J, Mukai I, Cavanagh L, et al. Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. JAMA. 2014;311:1883–8. Early but compelling research that correlates concussion with anatomical and functional brain changes. National Football League. League announces stricter concussion guidelines. In: 2009. http://blogs.nfl.com/2009/12/02/leagueannounces-stricter-concussion-guidelines/. NFL Head, Neck and Spine Committee. Protocols regarding diagnosis and management of concussion. 2013. Recent guidelines of the NFL’s safety committee on brain and spine injury. National Football League Head, Neck and Spine Committee. Protocols regarding return to participation following concussion. 2014. Fenno N. Internal NCAA emails raise questions about concussion policy. Washington Times. 2013. Investigative article that outline the start of an investigation into the policies and practices of the NCAA in regards to concussion safety.
