by Gary Vitti
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It is week 15 of the 2019 NFL season and ROTOWORLD is reporting there are 33 players currently listed in the concussion protocol. That’s not the total number of concussions for the season to date, that’s just how many players are in the concussion protocol this week. To put that figure in perspective let’s look at some numbers.

There are 32 NFL teams with a maximum of 53 roster spots for a total of 1696 players. According to playsmartplaysafe.com the NFL documented 214 concussions in 2018 down from 281 in 2017. This number includes all concussions sustained in practice, pre-season and regular-season games. There are 256 regular-season games (16 games per team) played over 17 weeks with 1 bye. Not all NFL teams have the same start date for training camp. In 2019 the earliest start date was July 17th. The last regular-season game will be played this year on December 29th with a January 4th Super Bowl. From the earliest start date to the last regular-season game there will be 164 days of NFL action. Using the number of concussions in 2018 that comes to 1.3 concussions per day in the NFL. Now that we have established that there is an inordinate amount of concussions in football, let’s talk about what that means to the 1.3 players per day that are concussed.

Concussion should be looked at as injury of function not structure. It’s not a bruise or bleeds to the brain. The brain is comprised of millions of neurons and because concussion is an injury of function, what the athlete does in terms of exertion can make it worse. Concussion should be looked at in 3 different time scales:

How does the athlete feel at the time of injury

How does the athlete feel between the time of injury and return to play

How does the injury affect the athlete over a career or a lifetime

First off, how is a concussion recognized? In my experience, players will try to hide their symptoms because they want to play. But also they may not recognize their injury because it is the brain that is injured, the very thing that is supposed to recognize the injury. As a result, you can’t just ask an athlete how they feel because they may not recognize their own symptoms and sometimes the symptoms aren’t recognizable until the next day.

Symptoms may begin at the moment of impact or a few minutes later. A classic scenario is a player is dazed initially, then feels better but later more symptoms begin to manifest themselves. As a result, the injury cannot be a one-time evaluation.

You do not have to be knocked unconscious to be concussed. In fact, only 7 – 8% of concussed athletes lose consciousness. Brain injuries can continue to be present and not produce symptoms. In recent years much has been learned about concussions and protocols have been put into place to protect that athlete from long term disability.

We know the two most important things about post-concussion is to first protect that athlete from sustaining a second concussion prior to recovering from the first and that physical exertion may make symptoms worse and delay recovery.

The NFL was the first professional sports league to address the need for a concussion protocol that went beyond asking the athlete how they felt and how many fingers do have up. The NBA followed suit and adopted the same multi-phase return to play concussion protocol. The first phase of concussion protocol is bot physical and mental rest. That includes staying away from electronics, social media and any types of team activities including meetings until the athlete is 100% asymptomatic.

In the NBA the athlete must present themselves as being asymptomatic for a period of time designated by the neurologist before the sports medicine team can begin to tax the brain. The protocol begins with a cardiovascular workout on a stationary bike for approximately 30 minutes with the last 10 minutes at 80% of max heart rate. The idea is to draw energy from the brain to see if it produces symptoms.

If the athlete continues to be asymptomatic, they can progress to treadmill running. Running is repetitive and will allow us to see if the brain can process the movement. If asymptomatic, we progress to sports-specific drills which require a change of directions, explosive movements and burst of energy to see if the brain can process the sensory signals needed to play.

Next is to put a cognitive burden on the brain. That is to put them through a low impact practice to see if they know what play the team is running and what their assignment is. If that is tolerated, the athlete is released without restriction. The process can take a day or two or a week or two, it’s highly variable.

Concussion protocol begins during the preseason physical exam which includes baseline testing. There is a neurological screening and a computerized cognitive assessment. There is also an educational video that all players, bench coaches and medical staff are required to view.
Baseline testing includes filling out a form that is loaded into an electronic medical reporting system: demographics, concussion history, a standardized assessment and the neurological exam are all recorded.
The cognitive portion is done on a computer using playing cards with questions like:
is the card there? to test reaction time
is it red or black? to test decision making
was the card there before? to test memory
is it the same as the previous card? to test working memory

For a baseline to be acceptable the athlete must be able to:
have processing speed greater than 90%
have attention accuracy greater than 80%
and have learning accuracy greater than 53%
The American Journal of Sports Medicine reported that at 7 days post-injury 18% of recorded concussions were still symptomatic using the Cognitive Screening Test.
There is also a neurological exam which includes:
eye movement, pupil response, motor coordination and balance tests.

The eye movement test begins with having the athlete fixate on your finger and then move horizontally until they can go no further then vertically and then back to the midline and then to the other side forming an H pattern.
The test is to establish if both eyes function equally in all directions. This is important because some athletes have abnormalities so it’s important to establish this at baseline to know what normal is for them or what is due to injury. When testing eye movement you want to move at a speed to test for smooth pursuit making sure there is no saccadic intrusion which is the eye jumping from place to place. Most athletes should not have saccadic intrusion if they do it must be noted on their baseline form. The baseline test is also looking for nystagmus at the end of the range horizontally, which is the eye jumping at the end of the range, 2-3 beats up to 5 beats is normal, more than that needs to be recorded.
The baseline then tests for convergence. After the athlete has completed the H pattern the tester will bring their finger back to center and have the athlete refocus. Then the testers’ finger will move towards the nose. The athlete will alert the tester when they see two fingers. About 6 inches away is normal, more than that should be noted. If an athlete is concussed the convergence can cause headaches, especially in the right frontal midline.
Pupil response requires each pupil to be tested with a penlight in a dim setting to see if there is an asymmetry. This should be followed by swinging the penlight from one eye to the other (Swinging Lamp Test). Both tests should then be repeated in a bright setting and a record should be noted which if any of the tests caused the greatest asymmetry.
The strength part of the exam begins with the pronator drift test. The athlete is asked to put their arms out parallel to the ground with their palms up and eyes closed. The athlete should be able to maintain this position for 20 – 30 seconds. If the palms begin to turn towards the floor, that is an indication of abnormal function. While the athlete is still in this position they will be asked to turn the palms to the floor and spread their fingers to test for fifth digit adduction or finger curling.
The last test is for balance. The athlete is asked to stand with the feet together and the eyes closed for 8-10 seconds. The tester is looking to see if the athlete can hold that position without swaying to either side. The tester will then apply a gentle tug to see if they can still maintain balance. The test will then progress to one foot and then the other, then to a one-legged knee bend to be held for a few seconds then to switching legs.
The baseline is now complete
In the event, the athlete sustains a concussion the baseline is pulled up on a computer along with a description of the injury and hopefully a video clip of the contact.
Concussion prevention and especially the prevention of repetitive concussions are paramount. There is more and more evidence of dementia, Alzheimer’s, depression and chronic traumatic encephalopathy (CTE) associated with concussion. Symptoms of CTE range from forgetfulness to violent behavior. At this time CTE is not fully understood. There is a theory that brains with CTE accumulate a protein called TAU that clumps together interrupting critical information flow.
Much is being done to prevent concussion in the NFL from rule change, to safer helmets to mouth guards with sensors to measure frequency, magnitude and direction of impacts. But by accident or not, high-velocity ballistic trauma to the head is part of the game.
The question of youth sports comes to mind. Do we really want our youth in a position to sustain head trauma before their brains are fully developed? .

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Richard Correa December 14, 2019 - 7:04 am

That’s a thought I’m battling with myself in regards to my 6yr old son whether or not to put him in a sport that I grew up playing and love which is football (among other sports). After reading this, my direction is pointing to no, but knowing what this sport is capable of and what measures the league and medicine is providing, I think there is hope that with technology and the advance of mouth guard and helmets, we might still have a future in football. But still there’s much needed debate and there’s always flag football to develop.


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