NFL Concussion-Test Change a Positive Step, but More Changes Needed

Will CarrollSports Injuries Lead WriterJanuary 31, 2013

SAN FRANCISCO, CA - NOVEMBER 11:  Quarterback Alex Smith #11 of the San Francisco 49ers gets hit by linebacker Jo-Lonn Dunbar #52 of the St. Louis Rams during a run late in the first quarter on November 11, 2012 at Candlestick Park in San Francisco, California.  Smith sustained a concussion and left in the second quarter.  The teams tied 24-24 in overtime.  (Photo by Brian Bahr/Getty Images)
Brian Bahr/Getty Images

The NFL announced that they will make a change for how concussion tests are performed next season (per NFL Network's Andrea Kremer). More accurately, it will change who has the final say in whether a player has passed the test and is allowed back into the game. 

This change should be a positive step, one of many that have been made in the past few years, though there is still room for improvement.

The NFL said on Thursday that it will now require an "independent neurologist" on the sidelines of every game. It is unclear how these neurologists will be selected, though myself and others—including the NFL Player's Association—have called for years for this to be truly independent. In my proposal, the neurologist would be part of the officiating crew and would rotate as they do throughout the league. 

While the mechanics of how this would work are as yet unclear, it should be invisible to fans and have no effect on the length of games. The tests would be the same, and in theory, the outcomes should be the same as well. A marked increase in the number of players who are held out after concussions would create a great controversy—did teams push players back out or is the new independent doctor holding players to a higher standard?

This change does appear to take the decision for return to play out of the hands of team.

It is less clear whether it changes the protocols for return to play after concussion. Those protocols include passing baseline tests, including the ImPACT test, and being cleared by an independent neurologist. These neurologists are designated by the team in their town, but are not employed by the team. It is also unclear if the testing neurologist and the clearing neurologist can or will be the same person. 

This comes on the heels of a survey of NFL players that showed a high dissatisfaction with the quality of the medical care that they are currently receiving (via The Washington Post). Given the generally high quality of the team doctors and athletic trainers, this result is both troubling and a real problem. Almost every serious injury finds its way to a second opinion, usually by one of the "super surgeons" like James Andrews, Neal ElAttrache or Tim Kremchek.

If the current system does not work, it may take a complete dismantling of the paternalistic model used across sports. 

The NFL has made several changes over the past few years regarding concussion management. The most recent came after an incident where Cleveland QB Colt McCoy clearly had a head injury, but was not checked before coming back into the game.

McCoy came to the sidelines and said he had hand pain. The medical staff checked that (it had been hit on the play) but did not know to check McCoy for concussion. Later, McCoy said he did not remember the rest of the game. 

The NFL instituted a "concussion observer" program, where an ex-official was tasked with monitoring plays from the booth, calling down to the sidelines when he observed a possible head injury. The ex-official was quickly changed to an athletic trainer. The NFL did not identify this year's observers, but it is thought that they stayed with athletic trainers. 

Unfortunately, the results are mixed at best.

While the NFL said that the observer requested hundreds of concussion evaluations, the overall concussions stayed at a similar level to previous seasons. An analysis of the data shows that there was no significant change in the number or severity of concussions after the new protocol and observer was put in place.*

Worse, there remain many examples of where these did not work. Alex Smith lost his job due to concussion, while Greg McElroy admitted to hiding a concussion until the symptoms became so profound that he had to seek help. The injury to Jay Cutler showed that the return to play guidelines were either being ignored or were capricious and inconsistent. 

Similar issues occur in college, where the dramatic hit of USC WR Robert Woods showed a clear concussion, yet he was allowed to return to play. 

Dustin Fink, an athletic trainer who monitors concussions for The Concussion Blog, told me that the new change was welcome but "because the NFL has not disclosed how many were "spotted" by the observer then later confirmed, let alone how many times the observer had a player removed it difficult to tell the impact. I truly feel if the observer is left unimpeded and allowed to get players looked at in a quick fashion this mechanism will be another step in the right direction."

Fink also pointed out that there is a bigger issue here than is being discussed.

"Remember that the true problem is not the injury itself, rather it is the poor and improper management of the injury that is the elephant in the room," Fink explained. 

The NFL can do more, including noting when and who has been flagged for a concussion evaluation. Imagine if this worked along the lines of the booth challenge system. The broadcasters could be notified that a player was being flagged and a quick graphic could be added. Both the problem and the solution would be noted, a positive for everyone.

Today's action is a positive step, but it is only one along the journey to reducing the number of concussions in the NFL. Unfortunately, it is unlikely to be copied down through levels due to cost and availability of neurologists.

Getting an athletic trainer to all events would be a good start there. 


*My research assistant, Richard Ke, dug deep into the numbers. "The NFL implemented the concussion monitoring by independent trainers in week 16 (12/24/12) . I then took the number of week 17 concussions and added it to the 2012 total and normalized it by multiplying by (17/18) and took the pre-monitoring total and normalized it by multiplying by (17/16). The normalized total concussions in pre-monitoring was 172 and post monitoring 187.That resulted in a 8.7% increase in total concussions recorded. The normalized offensive player concussion count was 105 post monitoring and 89 pre-monitoring, resulting in about a 18 percent increase. This accounts for most of the increased concussion reporting. The normalized defensive player concussion count was 82 post monitoring and 83 pre-monitoring, resulting in less than 1% decrease, so essentially the same."

All quotes were obtained firsthand unless otherwise noted.

Will Carroll has been writing about sports injuries for 12 years. His work has appeared at, and Football Outsiders.