How the NFL can, and should, tackle its concussion problem

Very few doctors, fans or players deny that the risks associated with cumulative head injuries are a primary concern in the NFL today. The league itself has paid lip service to its commitment to reducing the effects of multiple brain traumas and their frequent outcome, Chronic Traumatic Encephalopathy (CTE).

The heat was turned up on the league when in December of 2011, Browns quarterback Colt McCoy was sent back into a game shortly after he had clearly been concussed. Given the general acceptance of the potential severity of this concern, it might suprise you that the league is now claiming that having a neurologist available on sidelines (who would have checked McCoy before he was sent back in) would be a detriment to player safety.

The NFL claims that they are doing everything possible in the fight against the outcomes of years of impacts to the brain and spine. This contradictory quote came from Richard Ellenbogen, current co-chair of the NFL's Head, Neck and Spine Committee, and was reported two weeks ago by Doug Farrar:

The league still does not have independent neurologists on every team's sideline, and after Cleveland Browns quarterback Colt McCoy went back into a December 2011 game against the Pittsburgh Steelers after he was obviously concussed by Steelers linebacker James Harrison, the NFL responded by saying that independent neurologists -- i.e., doctors not paid and employed by teams -- would simply confuse the issue.

"Independent experts on sidelines would make [the] situation worse, unless they had a baseline exam on each player," Richard Ellenbogen, co-chair of the NFL's Head, Neck and Spine Committee, told Jarrett Bell of USA Today Sports in November 2012. "No one knows the players as well as the athletic trainers, period.”

I talked to a neurologist about this, as well as some other physicians of my acquaintance, and found no one who wasn’t employed by the NFL who agreed with that statement. My concern, to put it bluntly, is that the league has a history of stacking their associated committee (and by ‘stacking’ I mean putting their own guys in charge of it) with poorly credentialed doctors whose main function seemed to be arguing against the better quality research in this area. We’re still hearing the idea that better trained people on the sidelines would somehow (and how isn’t really stated) create a bigger problem.

Most teams still don’t have an independent neurologist. Trainers are important in this situation and certainly, they can help. They can check their charges by position and refer any to the neuro who might need confirmation of the diagnosis of concussion. There are things we can do now.

The idea that repetitive brain trauma/CTE has a long term negative effect on the patient isn’t new. We’ve known about that in boxing for decades, and the issues are not dissimilar. When Congress called Roger Goodell on the carpet about the NFL’s stance on concussions, the former heads of the committee were replaced, much as you’d rearrange the deck chairs on the Titanic.

The new docs were more qualified, but the quotes that have come out haven’t changed. The quotes I read from Bell and Farrar leave me questioning whether the league has even had a minor change of heart on this. The NFL has provided $30 million in funding for research on the concern, and that’s a start. It’s also a comparative pittance, considering the extent of this problem and the number of lawsuits they’re facing.

The league has fought a rearguard action for years against spending money to prevent or catch early-on the head traumas of the game. They’re still at it. One of the points contained in these quotes is even more bizarre than usual, even for the spokesman of the NFL’s pet committee:

Examination by a specialist would confuse the issue. Trainers (much as I greatly respect their work) are not better qualified than a neurologist to evaluate a player’s level of neurologic damage. If they were, they’d be neurologists. The idea would be ludicrous if it weren’t for the fact that the long term health of many people is on the line. My own perspective is that the only way you could confuse the issue any further is by listening to anything that the league or its wholly owned subsidiaries are saying about the issue without either laughing or crying.

I have been on record for years about the importance of valid, independent physicians handling the players’ needs whenever a specialist is required. With more than 4,000 retired players already involved in the lawsuit against the league that center around this issue and comparatively little overall progress, it seems clear that only a massive financial hit against the NFL will reduce their knee-jerk, players-be-damned approach. It’s clear from the number of incidents that were reported in the media this year (as well as the Colt McCoy incident) that the NFL is a long way from having a basic grasp on how to minimize the damage to the players. My good friend Dr. Denny Clifford also made a very good point:

I'm all for having a trained specialist on the sidelines to evaluate for concussions. The problem that remains is the player who gets dinged and doesn't let on and stays in the game which happens all the time. Mark Schlereth said he never played a game where he didn't see stars at least twice and how could we control that? We need to know more about the little trauma and its cumulative response.

He’s right, of course. Let’s start with what we can do immediately: The first thing I’d like to see is every player being evaluated every year (at the least). We know that people get dinged each week. And, the players could lie and say all’s fine. You’ll have less of that as your people become more expert in seeing the small signs - differences in tone of voice, facial muscles, and attitude.

UCLA recently completed an important pilot study, and from it we can now see the buildup of the tau, the protein that causes CTE in people by essentially strangling the brain cells. This is a huge step and a promising tool for both research and diagnosis of current players. Would a yearly exam that can track the buildup of that protein be out of the question? Not if the players’ health really is important.

Said Dr. Julian Bailes, co-director of NorthShore Neurological Institute in Evanston, Ill., and one of the study's co-authors:

I've been saying that identifying CTE in a living person is the holy grail for this disease and for us to be able make advances in treatment. It's not definitive, and there's a lot we still need to discover to help these people, but it's very compelling. It's a new discovery.

Some starts have been made. High school and college coaches and trainers are learning to emphasize health over playing time and are being taught to spot the basic signs of a concussion. That’s a good start. So is going back to tackling fundamentals - you can’t stop all hits to the head and you can’t stop the kinds of small but cumulative traumas that OL players, for example, will develop. There will be other options over time, but the reality is that you stop much of the problem via two simple means.

First, you put an independent neurologist on each team's sidelines, and he becomes responsible for seeing any player on which there is a question. If a player isn’t sent to him, that becomes the team’s responsibility. There are assistant coaches and assistants to the coaches and coordinators. They need to step up, because one of the keys to managing this problem is putting eyes on it.

Putting an independent neurologist in with every team wouldn’t be a difficulty - we’re blessed with a lot of well-trained people. Get the players a baseline exam, if that’s really your concern. Doing a yearly exam to follow the course of the disorder should be added as quickly as possible now that we know some of what to look for. Since many players have concussions in more games than not, having them evaluated a couple of times a year seems a small price to pay.

Undoubtedly, the teams would hate that. Someone being seen medically should have a reasonable expectation of an independent finding and a doctor being on the teams’ payrolls will always obscure those waters. As Farrar suggested at the end of the article I quoted above, a neurologist would have to be accepted by both the NFL and the NFLPA, must have access to a baseline on each player (my own feeling is that two per season wouldn't be an unreasonable burden). The trainers should certainly offer their opinions, but an independent specialist needs to be there to make the final call. Otherwise, you will never get a realistically independent opinion, and the league knows that. It’s why they’re fighting this.

Second, the position coaches and/or their assistants, as well as the trainers, would become responsible for checking their players whenever there is a question. If you don't have anyone checking your QB's knees (as in the RGIII situation), I guarantee you aren't checking their eyes, either - which the Colt McCoy situation showed. The coaches would have to take a course in recognizing the basic signs of a concussion, if they haven’t already. The look in the players’ eyes, how they respond to questions, any problems with balance, clarity of the player’s answers, and similar markers would signal to send  a player to the neurologist whenever there is any aberrant potential for recent trauma.

The training department certainly can and should participate. If someone isn’t checking on these guys at least a couple of times during games, we now have identified a major part of the problem. It has to be a priority. Ellenbogen’s response?

Having said that, some teams already have neurosurgeons on the sidelines. Having a doc show up just for a game takes away from the all-important baseline exam and continuity of care. It would be like getting operated upon by a surgeon who did not see you pre-operatively (sic). Is that safer than having someone who saw you beforehand? The baseline is all important in making an assessment if a player is OK after a hit.

There is something in medicine called an at-risk patient. In its simplest terms, if your both of your parents died of the same cancer, you are an at-risk patient for that disease, and you’d want to get it monitored. If you play pro football, you’re at risk of CTE. Would it be far less safe to have a neurologist see these at-risk people once or twice a season than for an athletic trainer to handle it? How on earth do those poor neurologists function? Just fine, is the truthful answer. This is a straw man argument, if it’s an argument at all. I don’t think it is - it’s just a pretty flimsy excuse.

We know that a concussion takes place in nearly every NFL game - probably more than one, and in all of them. How can we claim to be concerned with the problem if we’re not even making the effort of looking to see who has one? That’s really the bottom line.

Well, why don’t the players become more involved and ask to be checked, you might ask?

Simple. Even if you believe that the team will not take any punitive actions against players who they perceive as not being tough enough (and in some cases, I don’t), a post-concussive player isn’t in a condition that permits that approach.

When you have a concussion, your judgment is, by definition, impaired.

You can’t let young men make those decisions about themselves and whether they should be checked, period. They have too much invested in playing, regardless of future consequences. You can’t let the trainers decide without recognizing their own professional vulnerability - any trainer who gets a rep for being too player-oriented can too easily be disposed of.

The NFL has done worse things.

The situation requires what amounts, in legal terms, to a Special Master, someone above the fray whose opinion is beyond reproach. That person should be an independent, qualified, board-certified neurologist, and he should be working with, but not for, the teams and NFLPA. Now that we have confirmation of the presence of the protein implicated in CTE in living people, the work of finding a cure can move forward.

It won’t come too soon.

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

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