by Don Brady, PhD, PsyD, NCSP, LMFT
“A Preliminary Investigation of Active and Retired NFL Players’ Knowledge of Concussions”
August 14, 2004
After examining the concussion literature and present research findings, it becomes apparent that varying degrees of concussion-related knowledge and differing theoretical orientations exist among health care professionals and athletes. These varying and sometimes opposing theoretical perceptions regarding aspects of a concussion directly influence the assessment, management, and return-to-play decisions made after an athlete sustains a concussion. Despite the different perspectives and resultant controversy, Putukian (1998) pointed out that the athlete’s health should remain the first priority when making return-to-play decisions.
Additional brain injury along with other injuries may occur as a result of returning to play too early in the functional recovery process. An athlete may be at risk for experiencing further physical injury after sustaining a concussion since an individual may manifest diminished cognitive abilities and corresponding physical reaction time while participating in a game or practice (Lovell, 1998; McSherry, 1989). Furthermore, an adequate time-lapse may not have occurred for possible secondary effects of the initial brain injury to have overtly revealed themselves and thus be adequately evaluated. Permitting a player to return prematurely to competition before an appropriate and thorough evaluation has occurred may also place the athlete at risk for permanent disability or death (Kelly & Rosenberg, 1998). Given these potential significant risks, pressure to allow the athlete to prematurely return to competition, especially in the “big game,” must be ignored (Asthagiri, Dumont, & Sheehan, 2003; Genurdi, & King, 1995; Roberts, 1992). Health care providers need to be not only vigilant of athletes underreporting the presenting symptomatology of their concussion (Echemendia & Julian, 2001; Kelly & O’Shanick, 2002; 2003; Lovell, 1998; Lovell & Collins, 1998; & Wills & Leathem, 2001), but must also rule in or out the presence of numerous possible symptoms.
Sports team health care personnel also need to focus primarily on the athlete’s health and well being, and not minimize an injury (Huizenga, 1994) or primarily focus on the player’s capacity to perform (Matheson, 2001; Pipe, 1998). This is necessary in order to avoid any real or perceived conflicts of interests emerging in the return-to-play decision-making process (Pipe, 1998; Matheson, 2001).
This particular concern has long been raised within the sports field and in particular by the National Football League Players Association (NFLPA) (Moore, 1982). In a 1982 article, the sports medicine coordinator for the NFLPA advocated for “improved medical care that he thinks is lacking in the injury world of professional football” (p.162). Moore (1982) also pointed out the existence of apparent COIs existing for team physicians and athletic trainers via conflicts in their dual roles of “allegiance to their team owners and the best interests of their patients”(p.162). Huizenga (1994), a former team physician for the Oakland Raiders, voiced similar perspectives pertaining to these two medically related concerns.
Several months ago, when football player, Terrell Owens, returned to the competition after sustaining a concussion earlier in the game, former All Pro NFL player and current Fox TV sports announcer and attorney, Cris Collinsworth, created controversy when he declaimed: “team doctors and players have a messy, triangular relationship. It’s not a one-on-one situation where my doctor tells me what he thinks is best for me. With a “team doctor,” by definition you’re dealing with someone who has been hired by the club, so there are conflicts of interest…I would have a “players” doctor on the sidelines, someone hired by the players (Orlando Sentinel, Sept 15, 2003). ”
It should be noted that the NFLPA advocated for a players’ physician over 20 years ago (Moore, 1982). Further input on this topic was provided by another player who responded to this writer’s survey. The athlete offered his unbridled perspective pertaining to COIs and some NFL team physicians when he opined that “they are soulless gatekeepers protecting the money, that’s why they are there” (anonymous NFL player, personal communication, September 16, 2003).
Perhaps football could take guidance from boxing, another sport in which concussions are a concern. Certain state boxing laws mandate the removal from the ring, for a significant period of time, of a boxer who has been knocked out. Rhode Island boxing statutes forbid a knocked out boxer from resuming participation for 70 days (Title 41 Sports, Racing & Athletes, 2004). Oregon boxing statutes require that a boxer who sustained a knockout be made medically ineligible to return to the ring for 60 days (Oregon Boxing & Wrestling commission, 2004). It appears ironic that two athletes, participating in their respective sports within the same state, have significantly differing criteria for returning to competition: An NFL player who loses and regains consciousness during a game may subsequently return to the field to play, while a boxer who loses and regains consciousness has a mandated removal from participation for an extended period of time.
Acknowledged pressure exists to minimize sports injuries and “play through the pain” (Huizenga, 1994; Moore, 1982; personal communication, anonymous NFL football player, September 16, 2003). Therefore, it seems plausible and logical to assume that similar research and clinician biases related to adverse pressure to minimize concussion injuries may also be present in the concussion field. Statements such as “just a ding” and “had his bell rung” serve to verify this perspective as these phrases minimize, discount, or invalidate the adverse implications of sustaining a concussion. Recent support for the existence of sports-related clinician bias may be found in Kelly and O’Shanick’s (2003) discussion of the formulation of the 1997 AAN concussion management guidelines. The presenters shared that the Quality Standards Subcommittee of the American Academy of Neurology–which devised these concussion management guidelines–included NFL team physicians. These team physicians reportedly influenced the committee’s decision that determined that a timeframe of 15 minutes was ample time for an athlete to “sit out” after sustaining an initial concussion. This recommended timeframe was reportedly not based on empirical evidence but was arbitrarily and directly related to the 15 minute quarter of a football game, so that an athlete would be able to return to play in the same game he sustained the initial concussion, if the symptoms resolved” (Kelly & O ‘Shanick, 2003).
By Don Brady and Flo Brady
NASP Communiqué (CQ) Volume 39, Issue 8 June 2011
• Although athletes may appear to have fully recovered from concussion, their brain may require more effort or energy to complete a task than was required prior to sustaining a concussion (Gronwall, 1989). Because the brain has been injured, the use of the concept of “functionally recovered” is encouraged over “recovered.”
• Individuals recovering from concussions may typically display fatigue along with difficulty with concentration, memory, new learning, organization, insight, irritability, and emotional self-control (Wrightson & Gronwall, 1999).
• The developing brain of a child or adolescent appears to take a longer period of time to functionally recover from sustaining a concussion than does the brain of an adult.
• Unfortunately, at the present time, functional recovery from a concussion typically focuses on when an athlete is resuming participation in sports, ignoring how well the student part of the student-athlete is able to adequately function within the classroom, home, or social setting.
A statement written approximately 35 years ago, advocating for both the exercise of reasonable concussion healthcare delivery and reasonable caution, remains pertinent to the management of SRCs:
“Doctors [and other health-care providers] do have a duty to convince controlling bodies and participants in sports where concussion is frequent that the effects are cumulative and that the acceptance of concussion injury, though gallant, may be very dangerous. (Gronwall & Wrightson, 1975, p. 997)”
Sports team healthcare personnel need to focus primarily on the athletes’ health and well-being, and not minimize an injury or primarily concentrate on the players’ capacity to perform on the field.
Don Brady (2014):
“While narrow and so-called screenings and their corresponding screening results have been interpreted as being asymptomatic…
Various studies have revealed the presence of other brain injury symptoms when other instrumentation is used to assess the same concussion / brain injury….
Thus the absence of evidence is not necessarily the evidence of absence…
Sadly some of the COI pseudo screeners desire the public to accept these false negative findings as accurate. “
Editorial by Andrew Blecher MD:
It is important to understand the differences between “functionally recovered” and “recovered”. Currently our management of sports-related concussion focuses around the “functionally recovered” athlete. This is due to several factors. First and foremost it is easier, cheaper and quicker for us to measure functional recovery than it is to measure actual recovery. We have developed many tools (such as computerized neuropsych testing and sideline assessment tools) to do this. There is tremendous pressure to use these tools and rely on them to determine management and return to play decisions. These pressures have developed due to the conflict of interest concerns of both the doctors utilizing the tools as well as those who developed the tools themselves. We all want to see the “functional recovery” of the athlete so that they may return to their athletic pursuits. Unfortunately, the true brain recovery timeline from concussion remains unknown to the practitioner who is making the management decisions. The long -term pathologic recovery from concussion will not always remain unknown however. With new forms of imaging and blood testing that are rapidly being developed this unknown world will soon become more visible to us all. What is now believed to be the truth by some and critically panned as junk science by others may someday become a well-accepted standard by all. But until we can completely and accurately measure true brain recovery from sport-related concussion, it will continue to remain a potentially dangerous unknown that if ignored in our management of the athlete may end up coming back to haunt us as the long-term affects continue to be discovered. The possible relationship between CTE and the “mismanagement” of the unknown true concussion recovery timeline will someday be confirmed or denied. In the meantime healthcare personnel must make their own management decisions knowing that someday those decisions may have serious long-term consequences. Hopefully those decisions were, are and will continue to be made in the best interest of the long-term health of the athlete, free from bias and conflict of interest. Unfortunately, in the real world, this is often not the case. It certainly hasn’t been in the past. But we can be hopeful for the future.