Why the NFL's Concussion Policy Is Failing

Will Carroll@injuryexpertSports Injuries Lead WriterOctober 7, 2013

The system is supposed to work. A player is watched by not only a team's medical staff, but also the officiating crew, a specialized observer up in the booth with the replay official and the plethora of cameras that show every angle of every play.

When any of these people spots a possible concussion, an independent neurologist on the sidelines will conduct a series of tests and determine whether a player needs to be taken off the field or if he'll return to the game.

Except that's not how it works at all.

The NFL has made continuous progress in improving its concussion protocol, but the system that has been created is failing. Not only is it not working as intended, or at least how the NFL sold it, but there's also no reduction in concussions due to any other factors such as rule changes, fines or improved equipment. 

The NFL's leadership, under the guidance of Roger Goodell, has gone from the obstructionism and obfuscation of the Paul Tagliabue and Elliot Pellman timeline to making progressive changes. While baby steps should be lauded, they're certainly not laurels to rest on. Failing to make the next step will render anything the league has already done moot.

One of the major problems of concussions is that they're not visible. A player can look normal but have a traumatic brain injury. The outward signs, altered speech or loss of muscle control doesn't always happen. Subconcussive impacts take a toll that only shows up in advanced tests and brain damage down the line. 

But at another level, they are visible. With HDTVs and replay, it's easy to see concussions. If you follow me or someone like Dustin Fink, who runs The Concussion Blog (@concussionblog), you'll see notes on some players discussed over and over again.

Helmet-to-helmet hits, like the one that Eddie Lacy took, are easy. Lesser blows, like the one David Wilson took in Week 5, are more complex.

Oct 6, 2013; East Rutherford, NJ, USA; New York Giants running back David Wilson (22) does a back flip after scoring a touchdown against the Philadelphia Eagles in the first quarter during the game at MetLife Stadium. Mandatory Credit: Robert Deutsch-USA
Robert Deutsch-USA TODAY

Wilson is an exemplar of the problem. His play that barely missed a safety shows a clear hit to the head.

He stayed down in the end zone on one knee. As he came off the field, he was shown being checked by doctors, but the cameras didn't come back to him until he was walking off the field. Presumably, that would be for a concussion evaluation, or perhaps X-rays. Wilson came back to the field wearing his helmet, but was then sent off again and said to have a neck injury.

That may well be the case. The Giants medical staff is qualified and was dealing with Wilson promptly and professionally. Wilson may have complained of neck pain, just in the way that Colt McCoy complained of hand pain on the play where he was clearly concussed, leading to the concussion-observer program.

We simply don't know if Wilson was ever checked for concussion. That diagnosis may or may not be correct, but not knowing whether the player was even tested is very problematic. We don't know whether the observer requested a check. We don't know whether the independent neurologist ever even spoke to Wilson. 

Dr. Jene Bramel, a physician who writes for FootballGuys.com, was able to obtain significant information about the workings of the observer and the independent neurologist. What Dr. Bramel found, detailed in a great series of articles, shows that the program itself does not work how it is often explained.

The so-called "eye in the sky" is usually an unaffiliated athletic trainer who is equipped with an HD screen. He has the ability to call down to sideline personnel to request an evaluation, but there is no clear method for knowing whether those have been followed up.

Bramel is the first one to do outline these procedures publicly. Most damning is the independent neurologist's limitations.

Called the unaffiliated neurotrauma consultant, or UNTC, this doctor is kept at the 25-yard line, away from team personnel. Rather than acting as an independent expert, he can only enter the personnel box and evaluate players when called over by the team physician. It is unclear when this is done or how often, if at all, it has been done. 

There are simple solutions to this problem, ones that do not involve additional expense or personnel.

As I have called for since 2007, I believe that the UNTC should not just be unaffiliated, but independent. Assigning the UNTC to referee crews would work well. The team ATs and physicians would still work with players on a day-to-day level, but on game day, all return-to-play decisions would have to go through the UNTC. 

Moreover, it would be very easy for all players being evaluated for concussion to necessitate a press-box call. Since these evaluations are done in full view of the crowd—and theoretically the media—this would not be a violation of any medical privacy.

When an evaluation is performed, the media relations department would alert the press box with a simple announcement: "John Doe is being given a neurological screening." If the observer requests an evaluation, the announcement would be slightly altered to something such as "A request has been made for a neurological screening on John Doe." 

This simple additional transparency would take a program that isn't working and open it to show just how it is working. If we wanted to take this a step further, the NFL and NFLPA could mandate the use of sensors to detect concussion.

Sensors similar to the accelerometers inside most smartphones could be installed inside helmets, as they have been on a few test occasions and for a landmark concussion study performed by Purdue University.

There's even a new product marketed by Reebok that gives a visual indicator and is available for about $150. There's simply no reason the NFL could not use either solution. They could do it by next week if they wanted. 

The management of concussions is also a problematic area for the NFL. Additionally, Dr. Bramel uncovered that the NFL's return-to-play guidelines were not as advertised.

The NFL, like many organizations, accepted the so-called "Zurich Guidelines," a policy statement created in part by the NFL's new concussion guru, Dr. Robert Cantu. Dr. Cantu is widely acknowledged as one of the leading experts in the field. His hiring by the NFL was lauded and considered a major step.

Last week, just before Dr. Bramel published his piece, an a blog article by David Barron of the Houston Chronicle had a seemingly innocuous quote by one of the Texans doctors that set off a firestorm.

In the piece, Dr. Kenneth Podell gave the first public indication that the NFL was not following Zurich and instead letting players go through two stages per day in the five-part return to play protocol, rather than one per day. I was able to confirm this independently, as did Dr. Bramel. 

The RTP guidelines were set up in such a way to prevent problems with symptoms re-emerging. By making it a five-day process, such setbacks were essentially built into the system—a safety net.

Think this doesn't happen? Terrelle Pryor exhibited concussion symptoms a day before the Oakland Raiders played in Week 4 and was held out by the Raiders medical staff. This is despite the fact that Pryor had been fully cleared by the NFL's protocol. 

In Pryor's case, which is under investigation by the NFLPA, he was actually left on the field after the hit that gave him a concussion. While the Raiders are thought to be a conscientious and thorough medical staff, it was clear from videos, such as this one, that they missed this trauma.

The delay could be problematic, but remember, once again, this is precisely the kind of thing that the "eye in the sky" is supposed to be watching for, and there's no sign that he or she called down.

The most troubling thing that Bramel found in his dig into return-to-play is the idea that it's a guideline, not a rule.

Dr. Podell was quoted in the Ultimate Texans blog as saying:

Once symptoms have subsided, players submit once again to the standard baseline testing, plus the 30-45 minutes required to complete more advanced versions. Sometimes there is additional testing with the neuropsychologist. Even then, there are no pass-fail grades, only additional data for doctors to interpret.

Interpret? No pass-fail? This is not what the NFL has led us to believe.

Again, the easy fix would be to have truly independent arbiters. These independent doctors would be responsible for signing off on any return to play. The team doctor would be responsible for care and treatment, just as always, but he or she would not be able to clear players to return at any point. 

The NFL has made progress, but there are enough loopholes and problems in the current policy, as it exists, that they're still heading toward a bigger issue. In both the lack of reduction, the diagnosis and management of concussions, the NFL is showing action without results. They're more focused on the appearance and perception than actual change.

The NFL will have to make those changes, or else outside forces will require it to change.