As we head into Super Bowl weekend we wanted to reflect back on our year of tracking concussions in the NFL with our physicians. We reached out to one of the top physicians in the field, Dr. Frank Conidi, the director of the Florida Center for Headache and Sports Neurology. He is a nationally recognized expert on sports concussions and the team neurologist for the NHL’s Florida Panthers. He is Vice Chair of the American Academy of Neurology (AAN) Sports Neurology Section and co-author of the AAN’s position statement on concussion in sports, and is currently involved in the development of the new ACOEM concussion guidelines.
We asked him his thoughts about everything from the NFL’s protection of their players to his opinion on the $765 million NFL settlement. The Q&A is below.
The number of concussions is down from a high last year of 160 to 146 for the regular season this year. Do you consider that a success? What factors did you think were helpful/not helpful?
Although the numbers are only about 9% , any reduction in the incidence of concussions is a positive. Interestingly, at the non-professional level there has actually been an increase in concussions due to increased awareness and reporting. One could argue that the NFL should have seen an increase in concussions due to the leagues educational efforts and player reporting. I do not think that this is the case and it is more likely that recent changes in the rules i.e. helmet to helmet, leading with ones helmet, defenseless receiver and moving the kickoff up are actually making a difference. With that said, at the same time there appears to have been an increase in the number of catastrophic knee injuries (i.e. Rob Gronkowski and Dustin Keller to name a few). This, of course, is a result of players tackling lower to avoid the helmet to helmet contact. As is often the case solving one problem creates another and unless the NFL plans on changing the rules further, which would necessitate a tackling zone from the knee to the neck, knee injuries are going to be a problem.
Is there a different set of protocol for handling concussions pre- or post-season? Are these measures sufficient?
The protocols are the same throughout the year. During the pre-season players undergo extensive baseline evaluations including a neurological exam, computerized or paper-and-pencil neuropsychological testing and a baseline sideline concussion assessment, i.e. SCAT 3. During practice or at a game any player suspected of suffering a concussion is to be immediately removed from play and evaluated by the team physician and independent neurological consultant. In most cases, the athlete is taken back to the locker room where a neurological exam and SCAT-3 is performed and compared to pre-season baseline. The athlete is then cleared after they complete a graded return to play protocol. This can only begin once the athlete is asymptomatic, with a normal neurological exam, and all baseline testing has returned to pre-concussion levels. The athlete then needs to be cleared by an independent neurologist. Which surprisingly in most cases is not a neurologist. Are these measures sufficient? Most likely they are not, but they are the best we have at this time. Many of the above measures (other than the neurological exam) are based on consensus opinion and have not been validated by scientific studies. In fact, the graded return to play may actually be too quick as some advanced MRI studies are now demonstrating brain hypermetabolism (i.e. concussion physiology) to be abnormal for up to 30 days. Given that most athletes complete the graded protocol in under a week, are they truly recovered???
Does the protocol change with multiple concussions? Should there be different protocols?
Unfortunately, the protocol does not change with multiple concussions. There is good evidence that athletes who sustain multiple concussion are at higher risk for another concussion and those athletes also take exponentially longer to recover. I recommend athletes with multiple concussions complete a more prolonged graded return to play protocol with at least three days in between steps. It is my personal opinion that any athlete who sustains a third concussion should be shut down for the season.
What could be done, if anything, to improve the current concussions management process in the NFL?
As was discussed above and especially with respect to athletes who not only sustain multiple concussions, but also have a history of multiple concussions, a prolonged graded return to play protocol would be one way to improve things. Again, shutting down athletes with a history of multiple concussions is another way. In addition, the NFL players association is currently working with the American Academy of Neurology (more specifically the Sports Neurology section which I am currently the vice chair) to put an independent neurologist on the sidelines. This would remove any possible conflict of interest that the team’s medical staff may have. It would also put more emphasis on the neurological examination, which in my opinion is still the best way to diagnose concussions. Continued education is also essential with an emphasis on changing the warrior mentality. Ultimately, it is up to the player to report their symptoms to the athletic trainer and team physician. Many players are still not on board, as was witnessed during the playoffs this year with one player, I believe from Seattle, refusing to go back to the locker room to complete the NFL’s concussion protocol. However, until the technology for diagnosing and, even more so, determining when brain physiology has returned to normal improves, things are going to remain status quo.
After retirement, what should athletes look for as signs they should see a doctor?
There appears to be a correlation with concussion and early onset dementia, as well as an increased prevalence of Parkinson’s like symptoms and ALS. With athletes sustaining multiple concussions being at higher risk for these types of disorders. Many athletes are starting to experience symptoms in their 40’s and 50’s. Early diagnosis may help slow progression and improve quality of life. Signs and symptoms that both the athletes and their families need to look for include: Early cognitive symptoms such as misplacing objects (i.e. their keys), trouble managing finances (forgetting to pay bills, not balancing their check book), declining performance at work, behavioral issues (having a short fuse and/or easily flying off the handle, trouble in stressful situations and inappropriate comments), depression, anxiety, loss of interest in previously pleasurable activities and even becoming withdrawn, difficulty remembering appointments, and trouble with executive function (task sequences such as following directions to an unfamiliar location or putting together their child’s bike). Motor symptoms such as progressive numbness or even weakness in their extremities, tripping over door stoops or curbs, trouble arising from a chair, feeling as if their muscles are tight, stooped posture with slowness in movement, tremor, change in speech and atrophy of the muscles in their hands.
In your opinion, was the $765M NFL concussions settlement enough?
For player compensation probably not. As for the amount going to research definitely not!!!
There are currently 4,500 players involved in the class action suit. That would be $170,000 per player and does not include the decrease of $75 million for player evaluation and $10 million for research. There are currently 18K retired players, and therefore every player is not included. Not every player is eligible as not every player has experienced permanent injury. Interestingly, my practice is one of the national centers currently performing evaluations of these athletes and have just started seeing retired players. The process is extensive and involves a comprehensive neurological evaluation, extensive neuropsychological testing and advanced neuro-imaging studies. Players receive compensation based on their diagnosis, i.e. dementia $3 million, ALS $4 million, etc. Until we have data back from a number of players we will not know how many players will qualify for the settlement money. Hopefully we can re-address this question next year.
The $10 million going towards research is not even close to the 1 billion dollars that is needed. For example, I recently applied for a research grant to perform longitudinal diffusion tensor MRI imaging as a possible objective measure to determine if an athlete has sustained a concussion and when the concussion process (physiological) has resolved. This would involve prescreening an athlete with the MRI study, as well as a computerized neuropsychological testing, and detailed neurological history and exam. Any athlete who sustains a concussion would then need to be re-tested using all the aforementioned modalities immediately after the concussion, 7-10 days later and after their symptoms resolve and testing normalizes. The estimated cost per player (you would need to screen an entire team) is approximately $10K per player (done at the testing facilities’ cost). This type of study would need to be performed at multiple sites and would cost upwards of ten million dollars. This is just one study and does not involve research for management (where there are little to no studies), equipment, prevention studies, education and long-term sequela (i.e. CTE, Dementia).
What are long-term care options for managing concussions in athletes? Does more need to be done?
When you look at concussion management you need to consider immediate post-concussion management, i.e. safely returning an athlete to play (which was discussed above) and the management of athletes with acute and prolonged post-concussion symptoms. The latter usually involves treating chronic headaches, sleep disorders, depression, anxiety and vestibular dysfunction, and addressing the athletes cognitive symptoms. The specifics are too entailed for this forum, however as there are currently little to no evidence-based studies. Treatment involves applying a slightly modified paradigm to accepted management principles. For example, using triptan medications to treat post traumatic headache. Another treatment option (which still needs to be validated) is the concept of physical and cognitive activity to tolerance. This usually begins about 3 to 7 days post event, when the athlete is starting to improve and involves the athlete attempting to perform activities such as light reading or school work, along with light physical activity, i.e. taking a brisk walk. If during the process the athlete begins to experience a worsening or return of their symptoms they are instructed to immediately stop what they are doing and rest. In the past, physicians would instruct patients to perform complete cognitive rest, i.e. do nothing. This concept has now been replaced with physical and cognitive activity to tolerance. Student athletes also require accommodations at school including a reduced course load and the ability to gradually return to full academic participation.
If the hypothesis that concussion is associated with a risk of dementia, ALS and Parkinson’s is true, then long-term care at this time would be palliative and involve the use of current medications used to slow the process of dementia, improve cognitive function and treat underlying behavioral issues. These individuals would also require either in-patient (i.e. nursing home and/or assisted living) or in-home care as they eventually would not be able to live independently and perform their activities of daily living. Similar treatment would be necessary for Parkinson’s symptoms and unfortunately there are little options to treat ALS.
Clearly, more research is needed at all levels. In fact, there really aren’t any good studies when it comes to management. The hope is that research will result in the development of evidence-based guidelines.
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