The Impact of Modern Medicine on the NFL

Dave Siebert, M.D.@DaveMSiebertFeatured ColumnistMay 16, 2013

NEW YORK, NY - MARCH 11:  Jeff Immelt (L), chairman and CEO of General Electric and Roger Goodell, commissioner of the National Football League (NFL), are seen at a news conference introduce an initiative and research program to study concussions in an effort to improve the safety of professional football players,  March 11, 2013 New York City. (Photo by Allison Joyce/Getty Images)
Allison Joyce/Getty Images

Back in the 19th and early 20th centuries, surgeons used chloroform—yes, that chloroform—as a general anesthetic.

It was during that time in 1886 when Dr. William Martin published a suspected case of chloroform toxicity in the British Medical Journal. These days, the National Toxicology Program lists chloroform as "reasonably anticipated to be a human carcinogen."

Ah, how far we've come.

For better or for worse, medical science is in a constant state of flux.

For instance, treatments based on tradition and "how it's always been done" mentalities are now giving way to evidence-based decision making. What's more, less-invasive interventions are trumping more-invasive ones while improving rehabilitation plans continue to reshape recoveries.

Yet not all is coming up roses.

Performance-enhancing drugs continue to plague the news on a seemingly daily basis, and elsewhere, mandatory bench time for athletes following a concussion could deter players from reporting symptoms.

Unfortunately, the NFL is no stranger to such controversies.

As America's most popular sport, professional football is one of the most publicly visible venues at which the latest medical and pharmaceutical knowledge is applied—for both good and bad. Though stories of incredible injury recoveries abound, so do those of drug use. Players set examples, and recoveries set precedents.

Additionally, the speed at which medicine is evolving will only continue to increase.

The result? An ever-changing NFL medical landscape highlighted in several distinct ways—some obvious, some not so much.

Brain Injury Education and Safety Reform 

As the saying goes, knowledge is power. It can enlighten, but it can also burden.

Depending on one's point of view, new knowledge on the nature of concussions has the potential to do both.

For the NFL, sweeping changes started in 2007 when the league formulated its first concussion management guidelines (h/t ESPN):

(The) policy stated that a player could not return to a game or practice in which he lost consciousness and that a player must be completely asymptomatic and pass his neurological tests normally before returning to play.

The NFL also pledged to expand neurological testing for all players, particularly those who had suffered a concussion before. If a player suffered a concussion in the season, he would be required to undergo extra neuropsychological tests later in the year.

In 2009, the guidelines expanded to include any concussion symptoms—such as headache, nausea and dizziness—not just loss of consciousness. The athlete now also required clearance by a neurological consultant and team physician before returning to play.

By 2011, the NFL had bolstered its regulations even further (h/t Gary Mihoces, USA Today), and in Jan. 2013, the league announced the future placement of independent neurological consultants on the sidelines to assist with concussion diagnoses (h/t Curtis Crabtree, NBC Sports).

Last November, ESPN's Mike Sando described some of the most recent changes to NFL concussion policy in detail:

The process begins before the season when team doctors administer tests measuring orientation, memory, concentration and balance. They determine which symptoms associated with concussions might exist in the absence of a concussion.

According to Sando, after a suspicious hit to the head, teams ideally remove an athlete from play immediately. Using a standardized assessment tool to test memory and orientation, doctors and trainers then determine whether or not the player is concussed.

If the medical staff diagnoses a concussion, the concussed player must retire to the locker room to rest and cannot play again that day. He must also complete a standardized return-to-play protocol before taking the field once again.

As Sando discusses, that return-to-play process does not begin until concussion symptoms resolve entirely. The afflicted athlete must then complete physical tasks of steadily increasing intensity.

While the column doesn't mention precise details, the tasks almost certainly closely resemble the regimen described by the guidelines set forth at the fourth International Conference on Concussion in Sport.

In brief, a player needs to complete five phases of exercise and recovery before taking the field. The phases consist of, in order:

  1. Being symptom-free for 24 hours
  2. Performing light physical activity without re-developing symptoms for 24 hours
  3. Performing sport-specific activities without re-developing symptoms for 24 hours
  4. Participating in non-contact practice without re-developing symptoms for 24 hours
  5. Participating in full-contact practice without re-developing symptoms for 24 hours

If symptoms recur, the player must rest for 24 hours before resuming the process one step lower than when symptoms returned.

A protocol, however, is only effective if followed properly. As the severity of the issue at hand becomes more apparent, the league could decide to implement formalized player education and even fine or otherwise punish players found hiding symptoms.

More Knowledge Creates More Responsibility

Why is such a strict concussion protocol necessary? Simply because the burden of knowledge is too great.

The medical community now knows that concussions carry not only short-term, but also long-term, consequences. The age of "shaking off" a blow to the head is forever over.

Though rare, Second Impact Syndrome (SIS) represents a potentially lethal consequence of a poorly managed concussion. In SIS, some believe a second blow to the head shortly after a first causes rapid and potentially fatal swelling of the brain—though the exact nature of the condition is controversial.

Despite that controversy, the possibility of SIS is frightening enough to warrant action.

As discussed by Bleacher Report's own Brian Toporek, many U.S. states already tout legislation mandating the proper management of concussions in student-athletes (h/t Education Week, access required).

Not only do the laws help players recover, they also help protect against lasting consequences.

For example, mismanaged concussions can linger for extended periods of time, hampering one's quality of life. Repeated concussions may also lower the force necessary to cause future ones.

Perhaps most frightening, however, is the potential for permanent brain damage in the form of chronic traumatic encephalopathy (CTE).

Defined by Boston University as a "progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma," CTE gained infamy after doctors discovered it posthumously in the brains multiple NFL players—most recently following the suicide of former NFL linebacker Junior Seau.

CTE symptoms include depression, anxiety and sleep disturbances, leading many to believe the disease played a role in Seau's death.

To be clear, proof that concussions lead to CTE does not yet exist. In fact, the official position of the aforementioned international conference states:

(A) cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously.

In other words, those in the medical and football communities must exercise caution to not over-interpret anecdotal evidence. Additionally, much remains unknown about both concussions and CTE alike.

Nevertheless, it is that degree of unknown that highlights what is truly important—proactivity.

As research continues to mount, the NFL will—or at least, should—stay current with the latest research and developments. It may also continue to expand on research partnerships such as the one it formed with General Electric Co. and Under Armour Inc. in March.

After all, there is much to do.

For instance, new methods to detect concussions may not be far off. University of Missouri sports medicine specialist and team physician Dr. Aaron Gray weighed in on the prospect of helmet sensors, a tool designed to measure forces delivered to a player's head:


Helmet sensors have the potential to give us large amounts of information about the direct impact and rotational forces of 'hard hits. Medical staffs will be able to be alerted when players have suffered high-impact hits during a game or practice. They can also measure the cumulative effects of multiple small-to-medium hits over the course of a game.

That said, helmet sensors are only one piece of the puzzle, said Gray:

One challenge for this technology is that it measures forces but doesn't actually diagnose a concussion. Individual players have different susceptibilities to concussions, and a hit that causes one player to suffer a concussion does not always cause another player to have the same brain injury.

Gray noted that players must receive individualized examinations and care for proper treatment. What's more, he added, sensors will serve only as a guide at best:

Helmet sensors will not reduce concussions by themselves. Hopefully, players that repeatedly suffer high impacts will be able to modify their tackling technique or playing style to decrease repetitive, dangerous blows to their head.

Potential for Future Anticipatory Neurological and Psychological Care

In addition to helmet sensors, the ability to detect brain damage at the microscopic level remains an active area of research.

In Jan. 2013, CNN's Stephanie Smith reported researchers employed a novel imaging technique to detect accumulations of a protein called tau.

As described by Dr. Ann McKee and colleagues in the journal Brain, researchers believe tau and CTE are closely related (h/t Pub Med). Moreover, the relationship between tau and Alzheimer's disease—a disease with some similar characteristics to CTE—is already well established.

Once again, it is important to not over-conclude. Detecting clumps of tau proteins only represents the first step of many. The relationship, or lack thereof, between accumulations of tau protein, hits to the head, activity in sport and the development of CTE remains very unclear.

Regardless, should researchers establish causal relationships in the years to come, a Pandora's box of research opportunities will open.

For example, experts could investigate new standards of care for those at higher risk of developing CTE. Then, detection of the disease before it psychologically or physically presents itself could follow. Doctors could also theoretically employ newfound knowledge to fine-tune medication regimens to help treat the symptoms of the disease.

That being said, a world where doctors identify and treat athletes with CTE early in the disease's course is years—perhaps decades—away.

However, the ball is already rolling.

Identifying Problems Before They Arise

In 2010, University of Southern Indiana's Jeron Lewis collapsed during a basketball game. Tragically, he did not recover, passing away soon thereafter (h/t Myron Medcalf, ESPN). Doctors later determined he died from complications stemming from an undiscovered heart condition.

Numerous conditions can lead to such a heartbreaking outcome, and while some are readily identifiable with proper investigation, others are not.

Dr. Jonathan Drezner—past president of the American Medical Society for Sports Medicine and current team physician for the Seattle Seahawks and University of Washington Huskies—actively researches heart conditions in athletes. He is the lead investigator of a study aimed at determining the feasibility of implementing electrocardiogram (ECG) screening to detect silent but life-threatening heart conditions in NCAA athletes.

Results are promising (h/t AMSSM.org). In the study, Dr. Drezner and his colleagues diagnosed seven athletes with serious disorders. While all seven had abnormal ECGs, only two had an abnormal history and subsequent physical exams.

In other words, ECGs hinted something was wrong in five otherwise normal patients.

In the NFL, standard screening is already in use.

"NFL athletes are screened yearly with an ECG to improve detection of silent cardiac disorders that often have no signs or symptoms but are at risk for (sudden cardiac arrest)," Dr. Drezner said. "Screening models that utilize ECG for college and high school athletes are becoming more common."

Dr. Drezner added that a standardized protocol is necessary for proper interpretation of potentially abnormal findings.

While electrical abnormalities aren't exactly common, they certainly do come up. This past season, Houston Texans running back Arian Foster left a game against the Minnesota Vikings with an irregular heartbeat (h/t Nick Scurfield, HoustonTexans.com).

In a somewhat different vein, screening echocardiography—or ultrasound of the heart—can identify diminished heart function that could otherwise go unnoticed. Usually identified as a low ejection fraction—the proportion of blood pumped outward with each beat—a weaker heart can lead to potentially life-threatening irregular heartbeats in and of itself.

However, as Carolina Panthers defensive tackle Star Lotulelei now knows, sometimes abnormal findings create much ado about nothing (h/t Jordan Raanan, NJ.com).

Using echocardiography, doctors measured Lotulelei's ejection fraction as 44 percent at the NFL combine—below the normal level of 55 to 70 percent. Details are unavailable, but his heart is now healthy—and perhaps always was save a temporary, minor condition.

"Echocardgiography has been used at the NFL Combine, but its routine use in identifying at-risk disorders above and beyond ECG is still uncertain," Dr. Drezner explained.

Unfortunately, certain findings that are normal for highly trained athletes—such as a slightly lower ejection fraction—can mimic disease states, and the overlap can make distinguishing between normal and abnormal hearts difficult. That may soon change with more experience and further research.

New Surgical Techniques: Advancing Knowledge, Quicker Recoveries

Just as screening for disease helps limit unnecessary medical testing, recent advances in surgical technique limit unnecessarily invasive operations. Houston Texans safety Ed Reed is the latest to benefit.

On May 3, John McClain of the Houston Chronicle reported Reed underwent arthroscopic hip surgery to repair a torn acetabular labrum—a supportive ring of cartilage located where the thigh bone meets the pelvis. According to the Chronicle's Tania Ganguli, the Texans expect Reed back in action by the middle of training camp at the very latest.

Not long ago, such a timetable was impossible, as hip repairs usually required the complete opening of the joint.

Conversely, modern arthroscopic technique involves inserting a small camera and other tools through small incisions in an otherwise closed joint.

Depending on the procedure performed, patients can return from a hip arthroscope in as little as six weeks—though usually more time is needed. On the other hand, open surgeries often require several months of recovery.

According to an August 2011 article by Dr. Dean K. Matsuda, director of hip arthroscopy at Kaiser West Los Angeles Medical Center, the arthroscopic technique is gaining momentum when it comes to hip repairs.

Dr. Matsuda writes:

Supportive evidence is growing for hip arthroscopy, a procedure once held in low regard by many orthopaedic surgeons and considered by some as a challenging procedure without an indication. According to one source, the number of hip arthroscopies performed will double by 2013.

Even better? Hip "scopes" may help doctors better understand various hip conditions—both acquired and genetic.

Dr. Matsuda elaborated further:

The arthroscopic method not only is less invasive, but also permits detailed visualization of intra-articular pathology. . .Just as arthroscopy was instrumental in furthering the understanding of pathology and pathological mechanisms in the knee, it appears to be doing likewise in the hip.

As NFL players put their bodies through frequent, repetitive and maximum stress, further information about joint injury and degeneration could prove vital from both a preventative and therapeutic standpoint.

Expansion of the Already-Vital Role of Physical Therapists, Athletic Trainers

Equally as important as advancing surgical technique—if not more so—is modern day physical therapy. For proof, look no further than Adrian Peterson of the Minnesota Vikings.

Peterson's nearly incomprehensibly speedy recovery from a torn anterior cruciate ligament (ACL) and medial collateral ligament (MCL) is just that—nearly incomprehensible. By no means does it represent the norm, and athletes sustaining similar injuries in the future will almost certainly not be able to follow in his footsteps.

What's more, athletes at the youth, high school and collegiate levels should not view professional athlete recovery times as a standard on which to base their own.

Nevertheless, the ability of physical therapists to help isolate and strengthen specific muscles is invaluable. Doing so not only takes stress off the injured ligament, tendon or bone in question, it also optimizes how an athlete regains any strength he or she may lose during a prolonged recovery.

Therapists, trainers and conditioning coaches can also help prevent injuries from occurring in the first place by helping devise a warm-up exercise routine uniquely suited to an individual athlete—especially given recent research questioning the utility of pre-game stretching (h/t Alexandra Sifferlin, Time Healthland).

Finally, just as every injury is unique, so is every athlete's rehabilitation. As individualized care continues to take more and more of a hold, the results and importance of both physical therapy and therapists should only continue to skyrocket.

The Developing Field of Regenerative Medicine

The brutal nature of professional football isn't going anywhere, and shoulders, knees and hips will continue to feel the brunt of it. However, new therapies may carry the potential to counteract the damage that inevitably occurs.

Platelet-rich plasma (PRP) is gaining popularity as a way to speed healing. Last season, now-retired Ray Lewis used it with the goal of enhancing his recovery from a torn triceps (h/t Michael Silver, Yahoo! Sports).

Dr. Mark Niedfeldt—team physician for the Milwaukee Brewers and associate clinical professor of Family and Community Medicine at the Medical College of Wisconsin—described the theory underlying PRP:

"PRP contains a more concentrated amount of platelets than whole blood. These platelets contain powerful growth factors and are fully functioning, complex coordinators of coagulation, inflammation and repair. Concentrated growth factors within the PRP work to initiate a healing response within the injured tissue."

In other words, PRP uses large amounts of an athlete's own platelets, with each carrying within them proteins that stimulate growth and healing, to accelerate tissue recovery.

Does it work? The jury is still out, but early results carry at least some promise.

Dr. Andrew Blecher, a sports medicine specialist at the Southern California Orthopedic Institute, offered a positive opinion:

PRP treatment does seem to hold promise for providing faster recoveries from certain types of athletic injuries. Although the research is still lacking, there are numerous case reports of excellent outcomes, and this seems to be the case with my personal experience with PRP in my own practice as well.

Even then, PRP is likely just the first of many such treatments, added Dr. Blecher:

PRP is just the tip of the iceberg in the field of regenerative medicine. While PRP acts by recruiting stem cells to a site of injury to repair the damage and promote healing, we can now also directly inject stem cells themselves...Another alternative is Regenokine. Somewhat similar to PRP, Regenokine is designed to knock out the body's inflammatory receptors, ending the inflammatory response and improving pain and other symptoms.

That said, Dr. Blecher also agreed that much work needs to be done:

Unfortunately, the research in the entire field of regenerative medicine is still in its infancy, but as always, athletes are looking for any competitive edge they can get. We will continue to see the results of these treatments on the NFL football fields long before we see the research to back it up.

An Increasingly Complicated Battle Against PEDs

Regrettably, the desire for a competitive edge to which Dr. Blecher refers implies the fight against performance-enhancing drugs (PEDs) is just beginning.

It may also get more complex than ever.

In 1994, both the Holton (h/t pubs.acs.org) and Nicolaou (h/t Nature.com, access required) laboratories artificially synthesized the anti-cancer drug, paclitaxel.

In addition to being an important step to combat cancer, the synthesis of paclitaxel marked a landmark achievement in the field of organic chemistry. Owing to its immensely complex molecular structure, the creation of paclitaxel from simple building blocks hinted at one powerful truth: With enough effort, chemists can make just about anything.

While such a feat certainly means better treatments for the most serious diseases are on the horizon, it similarly suggests the development of more-powerful PEDs—and possibly more-dangerous ones—may also loom.

Last week, Bleacher Report's lead writer for Sports Medicine Will Carroll described the use of "peptides," the most recent chapter in the PED story:

Why should peptides be getting everyone's attention? Because they work, because there are signs they are becoming more popular and because anti-doping efforts can't afford to lag too far behind doping efforts.

The story arose after investigations linked Australian rugby player Jon Mannah's death to peptide use (h/t Wide World of Sports).

To make matters worse, peptide use is very difficult to tease out.

"An effective, dangerous substance that's hard to detect?" Carroll posed. "That's a major problem for sports and for those committed to keeping sports drug-free."

After all, when it comes to PEDs, all that is necessary for their continued propagation is a market for them. At the rate medicine and athletic competition are changing, that market isn't going away any time soon.

Dave Siebert is a medical writer for Bleacher Report who will join the University of Washington as a resident physician in June. Medical information discussed above is based on his own knowledge except where otherwise cited, and quotes were obtained firsthand unless otherwise noted.

Follow Dave on Twitter for more sports, medicine and Sports Medicine.


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