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Why the Concussion Rules in Professional Sports Leagues May Not Solve the Problem

Samson, Kurt

doi: 10.1097/01.NT.0000411142.81618.aa

Professional athletic leagues are moving to adopt rules to reduce concussions and requiring sideline concussion evaluations of injured players before they are cleared to play, but there remains a major issue with players ignoring or trying to mask symptoms in order to stay in the game.

A number of professional football players have spoken to the media over the last year about how easy it is to circumvent the National Football League (NFL) 2010 concussion sideline evaluation rules, albeit off-the-record. Because concussion rehabilitation can sideline a player for weeks or even months, it can significantly threaten their future earning potential, a powerful incentive for keeping symptoms to themselves whenever possible.

Players diagnosed with concussions may face weeks or even months of rehabilitation, depending on the severity of the injury and their ability to recover fully. Not unreasonably, they fear this will jeopardize their professional career, especially if they suffer repeated concussions, according to Robert Cantu, MD, clinical professor of neurosurgery and co-director of the Center for the Study of Traumatic Encephalopathy (CSTE) at the Boston University School of Medicine.

“All professional leagues, and not just the NFL, are taking concussion seriously and gradually improving their rules, but this is a process and we still have a long way to go, especially with regard to educating players.”

But it is not just the individual players who have incentives to mask symptoms — teams also have their reasons, he told Neurology Today in a telephone interview.

“Remember, these teams are private enterprises with their own medical staff, and generally their sideline concussion assessments are poor,” he said. “It is not uncommon for someone who has been mildly concussed to be returned to the game after sitting out just two or three plays, even though a thorough assessment takes at least 10 to 15 minutes.”

Establishing concussion rules and penalizing players overlooks this reticence to report injuries, and it may be impossible to resolve, according to Dr. Cantu. “Unfortunately better player education is needed, but for this to work players have to care about their own longevity and health,” Dr Cantu emphasized.

“It's a horrible deal. I can think of four or five players who had concussions and were put on the injured roster until they were cleared to play again, but once they were cleared they were dropped by their team and unable to find another team willing to pick them up. Basically, they are considered damaged goods, and I think this gets to the heart of the problem.”

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The NFL has been the leader in responding to concussion, adopting rules in 2010 and updating them again for the 2011 season, Dr. Cantu said, including moving the kickoff point to the 35-yard line and identifying “defenseless players” such as those passing or receiving a football who cannot be “blindsided” — hit in the head while they are focused on the ball. Under the new rules they cannot be hit either in or out of “the pocket” — the zone to which they are initially assigned.

Dr. Cantu said he expects that the league will further restrict players when it updates its rules in the spring, but doubts they will ban all head hits anytime soon. “But I think they will prohibit players from launching themselves head-first into an opponent, essentially becoming flying missiles. All intentional hits to the head may one day be prohibited, but launching will come first.”

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Like the NFL, the National Hockey League (NHL) has adopted concussion rules. Players who blindside opponents with head hits get called with an immediate flagrant penalty and possible suspension.

“Like the NFL, they are on the crest of taking out all intentional head hits, but they are not there yet,” said Dr. Cantu, who has worked extensively with concussed hockey players.

The league has made efforts to make shoulder and elbow protective equipment lighter and less rigid in an effort to reduce head trauma, and is considering further modifications. But some observers blame protective equipment for the increase in concussions, arguing that players encased in body armour feel invulnerable and play more aggressively, unlike during the “old days,” when players wore cloth caps instead of helmets and were more concerned about hurting themselves.

“The thing is, the game can be played without hits to the head, without making the game any less exciting,” Dr. Cantu said.

The NHL has been dogged by concussion-related tragedies, the latest of which involved Derek Boogaard, an “enforcer” who suffered a serious concussion in December 2010. Afterwards he began exhibiting short-term memory loss, disorientation, and behavioral problems, including drug addiction, and died of an overdose in November at the age of 28.

Boogaard reportedly participated in as many as 174 regular season fights and was knocked unconscious at least 20 times, according to family members.

A brain autopsy by researchers at BU's CSTE found early stages of chronic traumatic encephalopathy, and he is just one among several former NHL players to show such signs, but how this might have contributed to their behavior or deaths remains unknown.

In the NHL, shoulder and elbow hits to players' heads and being knocked into the walls of the rink are blamed for most concussions. But the impromptu fights that break out during most games are just as serious an issue, said Dr. Cantu. [Boogaard's history with concussion was the subject in a three-part series in the New York Times in December.]

“If the NHL wants to get serious about concussions, they have to take fighting out entirely.”

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On Dec. 12, the National Basketball Association (NBA) became the latest major league to require sideline head trauma evaluations and return-to-play rules, one of the most comprehensive of any major sport league to date and the only one designed by a neurologist.

If sidelined by a concussion, players will be required to complete a staged rehabilitation program of increasing intensity after symptoms abate before being allowed back on the field, according to Jeffrey Kutcher, MD, associate professor of neurology at the University of Michigan, Ann Arbor, who helped develop and will direct the program. Dr. Kutcher is also chair of the AAN Sports Neurology Section.

After each level of exercise, players will be re-evaluated to see if there are any recurrent symptoms and, if so, they will have to go back to a less strenuous level of training. The entire rehabilitation process could take several days, weeks or even months to complete, depending on the severity of the injury.

“We have developed an entirely new program designed to provide the best care across the NBA. It also provides us with an unprecedented opportunity to study concussions in basketball,” said Dr. Kutcher.

The program involves baseline testing designed to measure each player's neurocognitive abilities, family history, and other information, and will serve to gauge the degree of disability after a concussion as well as each player's recovery. “We designed this baseline assessment ourselves to provide a more in-depth protocol for returning an injured athlete to play, with a simple checklist to follow.”

According to Dr. Kutcher, the new program sets the NBA apart from other professional leagues by emphasizing educating not only players about symptoms and risks, but also general managers and other who work with teams. Based on collected data from ongoing assessments, the program will be updated every year.

“The program is already underway, and so far it is moving very smoothly, with no difficulties,” Dr. Kutcher said. “By now most players have already completed the baseline and education phase.”

Still, he emphasized that it is a work in progress.

“The proof of our effectiveness will only come with our first injuries, once the season begins.”

©2012 American Academy of Neurology