Watch your head

A recent settlement between the Players Association and the National Football League (NFL) accepts an actuarial estimate that 30 percent of former players will be entitled to compensation for various outcomes of repeated concussion, among them premature dementia. It is widely understood that concussions are not limited to the NFL, but rather occur in the Pop Warner, high school and college leagues as well. Because at least half the concussions in sport occur while playing football, this sport gets the most public attention. While there is increasing public concern over the extent of brain injury in the various contact sports, this may be less true of players and their coaches. For example, a recent study of football players in highly competitive NCAA Div. I teams showed that less than five percent of concussive episodes were self-reported and that reporting was related to the player’s perception of how supportive the coach might be.

What remains difficult for many to understand is the lag period of 15 to 30 years between the concussions and their various morbid outcomes. It is not clear what first precipitates the formation of tau protein in the brain, and how it progresses to Chronic Traumatic Encephalopathy (CTE). The process cannot be visualized in life, greatly hindering our understanding of CTE’s long “natural history.” Moreover, we do not know about the possible role, if any, of co-factors like alcohol and performance-enhancing drugs. The situation has been compared to smoking and the various cancers it is known to cause after a long “incubation” period. It took 20 to 25 years of well-designed, observational epidemiological studies to demonstrate the causal relationship, eventually overcoming the tobacco company’s assertion that the connection was a mere “statistical association.” In a strict biological sense, there still is no “smoking gun,” i.e. an exact cellular mechanism that shows how tobacco and the by-products of its combustion cause various cancers. Fortunately, we do not need to know; the epidemic can be controlled by stopping smoking. In contrast, the consequences of boxing to the brain, called dementia pugilistica, were more immediately seen, and undergraduate boxing was progressively banned. Does any undergraduate institution sponsor boxing today? Would any condone its re-establishment?

Into this rapidly evolving situation came the “Return to Play After Concussion Policy” adopted by most, if not all New England Small College Athletic Conference (NESCAC) schools in late 2011 as “best clinical practice.” The basic idea involves the application of a series of post-concussion clinical appraisals and a neurocognitive test package that can be compared to a baseline, pre-season test, read by an experienced technician. When these screening tests return to “normal,” the player can return to play. Although Williams College has twice declined to nominate a representative to be interviewed on the application and evaluation of the policy in practice here, the objectives are clear, namely, to diagnose and treat promptly a concussed player, clearing her to play again as soon as she has truly recovered. This strategy may also hope to prevent the relatively rare Second-impact Syndrome, where a repeat blow to the head closely following the first, has devastating consequences. The policy may also be conceived more broadly as a strategy of secondary prevention, i.e., by prompt treatment to reduce the risk of a subsequent concussion and avoid future brain damage.

The effectiveness of the “Return to Play after Concussion” policy must be challenged on several different grounds, starting with the post-concussion screening tests. To reduce variation, clinical appraisals should be done by the same observer. Unfortunately, the neurocognitive tests show significant variation of test results within the same individual in a healthy state. This throws in doubt the “sensitivity” of the test, i.e., its ability to truly diagnose return to brain health. This weakness will lead to too many concussed players declared ready to return, when they are not. All this assumes that the test is read correctly. Many readers lack the necessary training.

Additionally, since we know so little of the natural history of concussion and its short and long term effects, and are employing a testing sequence of dubious reliability, it must be asked if the strategy is protecting the athletes’ health? Is the incidence of repeat concussion reduced by the application of this policy? Is the rare Second-impact Syndrome reduced? No one knows, and there seems to be no protocol addressed to evaluate these critical outcomes.

Finally, as mentioned above, a new study suggests that, in a convenience sample of 734 football players that six suspected concussions occurred for each one diagnosed, and that the extent of self-reporting was directly related to the perception of whether or not the coach supported reporting. Again, if “dings” and/or “bell-ringers” are considered, the estimate of self-reported concussive episodes is less than five percent. Arguably, reported episodes will be more visibly serious to trained health professionals on the bench, and might be detected independent of the player reporting them, but are these the shearing blows that set off and move CTE along? Can unreported blows, perhaps of less force, but more critical direction, be important? We do not know with any certainty, but it is clear that if underreporting of this magnitude prevails within NESCAC, the “Return to Play” policy cannot achieve its objectives.

Without questioning the motivation of the educational institutions that have adopted the “Return to Play Protocol,” it appears that the policy protects the game and perhaps the continuing level of denial in some quarters, rather than the player’s health. Until the most unsafe College sports are radically changed, or abandoned, like boxing, it would be just as rational, and I believe far more prudent to sideline for the season (and probably permanently) all players with a concussion, and get them back to their studies as soon as the fog of concussion lifts.

Nicholas H. Wright ’57, MD, MPH, lives in Williamstown, Mass.