Head injuries: Changes for the better

The sight last Saturday of Derek Wolfe being taken from CenturyLink Field in Seattle via ambulance put a scare into a lot of Broncos fans; we all held our breaths to see whether his hands and feet would move.

Wolfe is fortunate - he’s listed as only day-to-day with his neck injury, but the difference in how it was handled over 5-10 years ago is a major positive development for players in the NFL. Let’s talk about some improvements the league has put in place.

Even a year or two ago, players were still constantly being sent back in whether they should have been or not. Teams had not been required to hire independent neurologists in the past - but in the future, they will have to. Despite my feelings on how long it’s taken the league to get these procedures in place, it’s good to see so many initiatives coming along.

As I’ve mentioned before, on Dec. 3, 2009, the NFL updated their rules on managing concussions, requiring players who showed any significant sign of concussion be removed from a game or practice and be barred from returning on the same day. Prior to that, players were prevented from returning only if they had lost consciousness. The memo stated that a player who gets a concussion should not return to action on the same day if he shows certain signs or symptoms; those symptoms included the inability to remember assignments or plays, a gap in memory, persistent dizziness, and persistent headaches. The MTBI (Mild Traumatic Brain Injury committee) was disbanded and replaced with the Head, Neck and Spine Committee - former heads Ira Casson and Elliot Pellman were no longer on it.

Symptoms that require immediate removal from a game include amnesia, poor balance, and an abnormal neurological examination, whether or not those symptoms quickly subside. For symptoms like dizziness and headache, however, a player can return to the field unless they are "persistent."

The new policy also states:

Once removed for the duration of a practice or game, the player should not be considered for return-to-football activities until he is fully asymptotic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physician(s) and the independent neurological consultant.

Essentially, the league’s gone from the player counting (or guessing) the number of fingers a trainer was holding up to SCAT card testing (see below), a few days of complete rest, and then a retesting of the symptoms. If nausea, dizziness, or any other symptom persists, more rest is required. If the symptoms are gone, the next step is walking around with no physical exertion. If problems arise, a return to rest. If not, the next step is to begin light physical activity. Then running, going through drills, then physical contact. That’s a smart progression.

Each step is followed by tests in order to progress to the next:

The standardized exam has three components: cognitive, with questions for the player; neurological, with the athletic trainer or doctor examining the player's eye movement and doing hands-on physical checks; and finally, the balance test. Twenty-four symptoms will be listed, including confusion, headaches, and trouble sleeping.

The SCAT Card

Many athletic trainers use a Sport Concussion Assessment Tool (SCAT) to check for concussions during games. This laminated sheet or card lists a procedure to follow after a player concussion. The first one is a version supplied by a doctor with the NFL's Head, Neck, and Spine Committee. The second, SCAT 2, as you will see, is not much different from the first. The second SCAT includes a test called the Maddocks questions and is also part of the Standardized Assessment of Concussion (SAC). The guidelines are intended for implementation by athletic trainers, athletic directors, and coaches.

Actual diagnosis of concussions and return to play decisions should be made by licensed physicians only. That reality was ignored for far too long.

Once the patient has been removed from the field and been stabilized, a full medical and neurological assessment exam should be undertaken. This assessment should include:

  1. Evaluation of potential signs and symptoms of concussion;
  2. Evaluation/diagnosis of concussion using a sideline mental status examination;
  3. Consideration for urgent hospital referral.

There is also a Post-Concussion Symptom Scale.

The Rivermead Post Concussion Symptoms Questionnaire, abbreviated as RPQ, is a questionnaire that is used to determine the presence and severity of post-concussion syndrome (PCS). The test, which can be self-administered or given by an interviewer, asks patients to rate the severity of 16 different symptoms commonly found after a mild traumatic brain injury (MTBI). Patients are asked to rate how severe each of the 16 symptoms has been over the past 24 hours on a scale from 0 to 4: absent, mild, moderate, or severe. In each case, the symptom is compared with how severe it was before the injury occurred.

The Stroop Test

The Stroop test is considered to measure selective attention, cognitive flexibility, and processing speed, and it is used as a tool in the evaluation of executive functions.

The test takes advantage of our ability to read words more quickly and automatically than we can name colors. If a word is printed or displayed in a color different from the color it actually names; for example, if the word "green" is written in blue ink we will say the word "green" more readily than we can name the color in which it is displayed, which in this case is "blue." 

What else is available?

In early 2010, one thing that Roger Goodell instituted that was for the better was to order all teams to implement baseline neuropsychological tests. ImPACT is one of a handful of computerized neuropsychological systems available (CogSport, the Concussion Resolution Index, and the Automated Neuropsychological Assessment Metrics are among the others). It has become the league's standard testing system. Thirty of the NFL's 32 teams now use ImPACT, according to the company's Web site.

The ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test gauges things like memory and focus, to see whether a player is still affected by a concussion.

The test is administered during minicamps before contact drills, when players are still healthy. Each player takes a 20-minute test to establish his baseline score of cognitive functions. Words, numbers, and drawings flash on a computer screen and the athlete must at varying intervals recall those which did appear. If an athlete suffers a concussion, they retake the test and must achieve their baseline score before being allowed to return to the field. The software costs $500 a year and is used by several NFL and NHL teams.

On the field, injury management has improved substantially. SCAT Card checks are in place. There’s constant public and media scrutiny of any concussive incidents - coaches who were getting away with sending players back in before it was safe are increasingly aware that they are playing with fire. Youth coaches are being trained to look for the signs of any concussive problems and to remove the young player without exception.

One extremely important area whose need has been well-documented is the simple importance of getting ice on a player’s neck immediately when a neck injury has occurred. This mattered with Derek Wolfe’s injury. If there is any numbness, tingling, or loss of movement at all in the arms, legs, fingers, or toes (and his extremities were numb as he lay on the field), special cold packs that fit the players’ necks can and must be immediately applied as the player is placed on a backboard and raised onto a cart. This is particularly essential if there is a bruising of or near the spinal cord.

The difference between the nerves’ impingement via a level of swelling that’s dangerous and a degree of swelling that doesn’t harm the spinal cord is often simply one of minutes - every minute that the neck isn’t cold-packed is another minute in which swelling can expand and more nerve cells can be crushed by that swelling. Some such cases heal - others don’t. Immediate care matters immensely in salvaging that nerve function.

Both mouthguards and four-point chinstraps have been proven to reduce the number of concussions. Unfortunately, neither is required by the NFL. In addition to simply being stupid, this also sets an example for younger players, who see their idols not bothering with proven methods of safety and want to be cool like them. We have to do better - and we can. Both options fall into the category of rule changes that the players don’t like, and the league should overrule them on it. When we find something that works, we owe it to the players to make sure it’s part of the plan.

Conclusions

It’s been a long road, but the NFL has come forward since December 2009 and accepted that they have a responsibility to the players’ health with regard to head injuries. I support and congratulate them on this. While it’s accurate to suggest that the league has been less than forthcoming regarding the players’ health up until now, we’re seeing a whole series of important procedures in place for managing some of the worst injuries. That’s very positive. With many it will take time to see the effects.

In 2011, the 150th concussion wasn't recorded until Dec. 5. There were a total of 266 concussions in 2011 — four fewer than reported in 2010. The 150th recorded concussion in 2012 was on November 21. It’s an improvement, but it’s still a small one.

With the increase of concussion-related lawsuits involving former players, league officials, and the NFL Players Association recently commissioned an independent study that identified three helmet models — the Revolution and Revolution Speed, and the DNA Pro, manufactured by Schutt — that supposedly better protected players from violent collisions (note - Bill Simpson’s helmets aren’t tested against them). However, the league stopped short of mandating all 32 teams test all three helmets.

Which makes sense, right? Just because you can prove that these helmets work better, why should you mandate them? What happens to freedom of choice? What if the players like the less effective ones?

Damned socialists.....

There’s a long, long way to go, but I do think that each successful effort should be feted. From having independent neurologists to installing proper cold pack preparations for in-game cervical injuries, and from baseline testing to post-incident rules and procedures. We’re getting to see some honest progress with regard to the central nervous systems of the players. If Derek Wolfe’s injury had been worse, there were protocols in place to minimize the severity of his injury and reduce the time it takes to return him safely to the game.

Congratulations on that to all concerned.

Learn to laugh at yourself. You will be ceaselessly amused. - Sri Gary Olsen

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