The NFL's Committee on Mild Traumatic Brain Injury changed its leadership in February, but its positions on the management of football concussions continue to clash with those of experts outside the league.
Elliot Pellman, MD, who directed the committee since its inception in 1994, stepped down and was replaced by two co-chairs — David Viano, MD, director of sports biomechanics at Wayne State University, and New York City neurologist Ira Casson. Dr. Pellman, a rheumatologist, remains on the committee.
One point of contention is whether players should be evaluated according to concussion guidelines. In an interview with Neurology Today, Dr. Casson said the committee does not recommend that team physicians follow guidelines. While it does provide NFL medical staffs — including internists and neurologists — with the most up-to-date information about concussion, decisions about when to return players to the game after a head injury are made on an individual basis.
“We think guidelines are cookbook; they're a bane on medicine,” said Dr. Casson, who has worked on several of the NFL studies on mild traumatic brain injury.
Several guidelines for the evaluation of concussion have been proposed and there is no one prevailing set. The guidelines differ in how concussions should be classified and managed. One rule experts tend to accept is that athletes should not return to play until symptoms clear.
The AAN Quality Standards committee published its first practice parameter for the management of concussion in sports in 1997. According to that document, “Questions addressed during neurologic or neurosurgical consultation for sports-related concussion require advice to the patient that is guided by neuroscience and the consensus of experts, rather than local lore and individual opinion.”
Dr. Casson disagrees. “The current guidelines out there are not based on science, but are based on people's opinions, and the consensus does not include everybody, it just includes the experts that the people making the guidelines want to include.”
Jay Rosenberg, MD, who co-authored the AAN guidelines, said they show physicians the best strategy of care. “The problem is that the evidence often doesn't tell you what to do and is frequently equivocal, unclear, or not very good. At some point, you have to bring together some formal consensus and clinical judgment.”
The guidelines also protect physicians from liability, he said. “If you follow these strategies then you are going to provide the best possible care. …They offer an opportunity for you to balance what you would normally do against what other people would do and what the evidence says.”
But what if the “formal consensus” is constantly changing? Many guidelines differ on when players should return to the game after a concussion.
The AAN guidelines, which Dr. Rosenberg said are being updated this year, make it clear that players should only return to play if concussion symptoms last no more than 15 minutes, and if there is no loss of consciousness. Yet the so-called Prague concussion guidelines, issued in November 2004 by experts convened at the International Conference on Concussion in Sport held in the Czech Republic, state that athletes who have a concussion should not return to play the same day of injury.
Published data from the NFL committee seem to contradict that recommendation. In 2005, the committee reported that players returning to play after a concussion don't incur “significant risk of a second injury either in the same game or during the season” (Neurosurgery 2005;56:79–90). The study concluded that “the current decision-making of NFL team physicians seems appropriate for return to the game after a concussion, when the player has become asymptomatic and does not have memory or cognitive problems.” Essentially, this means a player could return to play immediately after an NFL physician determined him to be clear of symptoms.
However, a 2003 study from UNC reported that 91.7 percent (11) repeat concussions in NCAA football players occurred within 10 days of the first injury, and 75 percent (9) came within seven days (JAMA 290(19):2549–55).
According to Dr. Casson, the NFL research does not demonstrate that existing guidelines should apply to professional players, who might be better at recovering from concussion. “Whether they are useful for college or high school players,” he said, is “a question for another day.”
The NFL has taken heat after several reports tied the effects of concussion to persistent neurocognitive problems and depression in retired players. In January, Bennet Omalu, MD, a neuropathologist at the University of Pittsburgh, told the New York Times that multiple concussions caused severe anatomic pathology in the brain of former Philadelphia Eagle Andre Waters, who committed suicide in November 2006. Then Ted Johnson told the media he has had depression and mild cognitive impairment beginning with two concussions sustained only four days apart while he was a middle linebacker for the New England Patriots.
Dr. Omalu's earlier work on the brains of former players Terry Long and Mike Webster also revealed evidence of chronic traumatic encephalopathy (Neurosurgery 2005;57:128–134; Neurosurgery 2006;59:1086–1093).
A much-cited study — from the Center for Retired Athletes at the University of North Carolina-Chapel Hill (UNC) — found that retired players with three or more reported concussions had a five-fold prevalence of mild cognitive impairment and a three-fold prevalence of serious memory problems compared to retirees without a history of concussion (Neurosurgery 2005;57:719–726).
Dr. Casson criticized that study as unreliable because the data were culled from surveys completed by players and family members rather than through neurological examination. “You're relying on the ex-players themselves to tell you what symptoms they have, what their diagnosis is, and what their doctors think they have, without verification.”
In the next few months, the NFL concussion committee will start work on a study that will assess neurocognitive effects in about 120 retired players. Researchers will take medical histories, including the number of concussions suffered, but unlike the UNC study, players will have comprehensive neurological evaluations and will be compared to 60 age-matched controls. The controls will include men with some football experience, either at the high school and college level, or with less than one season with the NFL.
“We're hoping to answer some of the questions about whether a career in the NFL predisposes or is related to any type of chronic brain injury,” Dr. Casson said.
Barry D. Jordan, MD, chief medical officer for the New York State Athletic Commission, said more research on concussion is needed to standardize the plethora of guidelines. “They serve as a good rule of thumb…but you need to take each case on an individual basis. And we do need more research in that area because most of the guidelines were devised based on expert opinion as opposed to evidence.”
Since athletes can have symptoms for a week to two months, concussions don't always fit into predetermined grading scales, he added. “You can't access the severity of a concussion until it is actually resolved.”
He also said that concussion studies need to take genetic predisposition into account because two players can have the same amount of trauma but respond very differently. A 1997 study by Dr. Jordan and colleagues found apolipoprotein E epsilon4 genotype to be associated with chronic traumatic brain injury in boxing (JAMA 278:136–140).
Julian Bailes, MD, chair of neurosurgery at West Virginia University, and a former team physician for the Pittsburgh Steelers, said that professional players seem to recover from concussion more quickly than high school and college players. “Just like a boxer who can take a punch, it may be that by the time someone gets to the NFL level, he's been selected out, he can handle these hits and not get symptomatic concussion.”
Dr. Casson agreed that genetic predisposition may explain why some athletes suffer long-term brain damage from concussion while others do not. “How many concussions they had may not be an important factor.”
THE ROLE MODEL PROBLEM
But Dr. Rosenberg was concerned by what he said is the NFL's habit of returning players to the game soon after injury. The problem, he said, is that the NFL serves as a model to younger players. “If [high school and college athletes] see the NFL not taking head injuries seriously, why should they?”
Another issue is that while NFL teams have access to numerous trainers and on-field physicians who can evaluate concussion, most high school teams have to rely on the judgment of coaches, he said. “I think it's absurd to leave the coaches out there without some guidance.”
The ideal would be for all teams to use a standard sideline assessment tool, perhaps a computerized program, that is objective, fast, and can be repeated easily, he said.
Not that the NFL is likely to follow the advice of outside experts, Dr. Rosenberg said. “The NFL is a political organization with a huge sum of money. How they manage [concussion] is how they manage [concussion]. Nobody is going to tell them what to do.”
A COMPARISON OF THE MOST WIDELY USED GUIDELINES
COLORADO MEDICAL SOCIETY GUIDELINES (1990, 1991)
RETURN TO PLAY:
* If Grade 1, return if asymptomatic for 20 minutes.
* If first Grade 2, only return after one asymptomatic week.
* After second Grade 3, terminate play for the season and consider discontinuing all future contact sports.
(Report of the Sports Medicine Committee. Guidelines for the management of concussion in sports. Colorado Medical Society,1990 (revised May 1991).)
RETURN TO PLAY:
If Grade 1, return if asymptomatic for 15 minutes.
If first Grade 2, only return after 1 asymptomatic week.
After second grade 3, withhold from play for a minimum of one asymptomatic month.
SPORT CONCUSSION ASSESSMENT TOOL (INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT, PRAGUE 2004)
Grading Scale: Should be abandoned because severity can only be determined after all concussion symptoms have cleared, the neurologic examination is normal, and cognitive function has returned to baseline.
Return to Play: Not on same day of injury.
(Clin J Sport Med 2005;15(2)48–55)
THE NFL DEFINITION OF MILD TRAUMATIC BRAIN INJURY
The NFL defines mild traumatic brain injury as a traumatically induced alteration in brain function, which is manifested by 1) alteration of awareness or consciousness, including but not limited to being dinged, dazed, stunned, woozy, foggy, amnesic, or, less commonly, rendered unconsciousness or, even more rarely, experiencing seizure; or 2) signs and symptoms commonly associated with postconcussion symptoms, including persistent headaches, vertigo, light-headedness, loss of balance, unsteadiness, syncope, near syncope, cognitive dysfunction, memory disturbance, hearing loss, tinnitus, blurred vision, diplopia, visual loss, personality change, drowsiness, lethargy, fatigue, and inability to perform usual daily activities.