NFL Concussion Protocol: An On the Record Discussion with Team Doctors

This past Saturday afternoon, I took part in a roundtable discussion with several NFL medical professionals, including the Carolina Panthers’ team physician, Dr. Robert A Heyer, M.D., and the President of the NFLPS (NFL Physicians Society), Dr. Robert J. Matava, M.D., regarding the army of doctors that are on the sidelines or in the stadium of every NFL game.

According to both doctors, all in all there are more highly trained medical professionals on the sidelines than there are players on the field for any given play. That was a fact I wasn’t aware of so I wanted to hear more about the NFL’s concrete actions that are currently in-place as opposed to ideas or thoughts regarding what might or might not happen in the future.

Professionals on the sidelines include primary care physicians (ie: “family” doctors), a Chiropractor, Orthopedists, Athletic Trainers, and unaffiliated neuro-trama consultants – for each team. Each stadium has an unaffiliated Athletic Trainer (who notifies the sidelines of possible injuries from the press box), an Ophthalmologist for eye health, a Dentist, a Radiology Technician who takes X-rays, an Airway Management Physician for possible intubation of severely injured players/non-breathing players, and an EMT/Paramedic crew.

The total medical staff on game day is 27 professionals.

Oct 20, 2013; Atlanta, GA, USA; Atlanta Falcons head coach Mike Smith checks on cornerback Desmond Trufant (21) after an injury against the Tampa Bay Buccaneers during the second half at the Georgia Dome. The Falcons defeated the Buccaneers 31-23. Mandatory Credit: Dale Zanine-USA TODAY Sports

The discussion centered on the NFL’s “Concussion Protocol” and exactly what it entails. As I couldn’t record the call and only took notes as fast as I could, I’ll give you the overview of how the NFL handles it:

First of all, each and every player undergoes computerized neuro-psychological testing before they enter the league. This test, called an ImPACT test, establishes a “normal” range for each individual. It contains a number of different things, takes about 30 minutes to complete, and focuses on reaction times and memory. Somewhere in the middle of the discussion I recall one of the doctors saying “Some players who have a concussion cannot learn.”

THAT was an interesting tidbit and I suspect the severity of the injury has a hand in that as well.

Click on “Baseline ImPACT Test,” for the full information on the test. They even have a version for game days for mobile devices as I understand it.

The tests are repeated with each player before every season.

When a concussion is thought to have occurred, the officials immediately stop play. Next, the player is brought to his respective bench, sat down, and asked the “usual” questions we’ve all heard: What city are we in, who’d we play last week, where are we, etc. and they go inside – mainly for a quieter environment because of crowd noise. The player is given a balance test as well and asked more questions once inside the facility and out of the field area.

This is where the “learning” part comes in. The player is given a set of words to recall and asked to repeat them at different intervals. If a player can do this, he still might be concussed. If he cannot, he very, very likely is.

Then, their reaction times and cognitive abilities are tested on the computer and compared with the “scout” exam from the beginning of the season. A persistent headache keeps the player from returning and the trainer stays with them – it’s the real world application of “The Madden Rule.”

It basically states “When in doubt, leave them out.” Once a player is found to be concussed, the doctors tell the coach “He’s out,” and the coaches leave them alone until after the game.

Players generally would want to go back into the game, football being football, so the first thing done on the sidelines you’ll see is they take away the player’s helmet and give it to the equipment manager so the player cannot go back in.

Someone stays with the concussed/suspected concussed person to make certain the condition does not deteriorate and/or to help intervene if it does.

After the game, doctors involved with the concussed player meet with the family and go over the issues. The player is usually allowed to go home that night but is not allowed to drive.

Oct 20, 2013; Green Bay, WI, USA; Green Bay Packers and Cleveland Browns watch medical personnel attend to Green Bay Packers tight end Jermichael Finley (88) during an injury in the 4th quarter at Lambeau Field. Mandatory Credit: Benny Sieu-USA TODAY Sports

The following day, the ImPACT test is repeated and responses compared with the baseline and from the previous day to see any improvement (or deterioration) and action is taken accordingly.

In order to return to play, the player MUST return to activity first – no practicing, no playing. Here, an independent neurosurgeon examines them. Independent doctors are used to eschew even the appearance of impropriety as the doctor has no personal feelings as to whether a player plays or not. That’s the idea, and frankly, I think the team doctor for ANY team would very likely treat them the same way.

You don’t want to bring an injured player back too soon and sacrifice long-term performance for a short-term “gain.” Multiple medical professionals are involved in the process for a number of good reasons.

Even if a player is cleared to practice, it doesn’t necessarily mean he’s cleared to play. First, the player must have no headache, no symptoms, and feel good. Secondly, they have to return to their baseline on the ImPACT test. They need to be able to exercise without headaches, and then they must be cleared to play by an independent physician.

But it’s the team physician who actually has the final say, oddly enough. Why?

It’s because the team physician knows the player and their personality. This might sound a bit counter-intuitive, but it isn’t. Someone who knows you can say with a lot more certainty if you’re “acting like yourself” or not more than someone who doesn’t, of course.

They’ll notice differences, subtle or not, that an independent doctor won’t have the data to give an informed opinion on and are widely regarded to be the best person to make that call.

Oct 19, 2013; Columbia, MO, USA; Missouri Tigers defensive lineman Lucas Vincent (96) is helped off the field after an injury during the second half of the game against the Florida Gators at Faurot Field. Missouri won 36-17. Mandatory Credit: Denny Medley-USA TODAY Sports

Don’t forget, while a doctor might be employed by a team, they give the oath to their profession to “do no harm” so there really is no conflict of interest at work.

Meanwhile, they need to rest. They need to avoid light, video games, TV, noise, or anything else that bothers them.

Other Health Matters:

The discussion wasn’t solely on Concussion protocol as other related areas were also involved.

One question I had was if any given person was more likely to get a concussion after they’ve had their first one. The answer was yes.

As the doctors spoke and questions were asked, the discussion got to CTE, or Chronic Traumatic Encephalopathy. That’s what the late Junior Seau, Mike Webster, and others have found to have suffered from and at this point is only diagnosed through an autopsy.

Obviously, this doesn’t help those suffering from it in the slightest. Since I have some training in Nuclear Medicine myself, I asked if there were any promising imaging techniques that could change this in the near future, and the answer to this was also a yes.

Oct 20, 2013; Landover, MD, USA; Chicago Bears quarterback Jay Cutler (6) is helped off the field after suffering an apparent injury against the Washington Redskins during the first half at FedEX Field. Mandatory Credit: Brad Mills-USA TODAY Sports

PET (Positron Emission Tomography) was the first area mentioned. PET is very much akin to CT/CAT scan, which uses X-rays to paint a 3-D picture, where positrons are higher in energy being antimatter. Whereas in a CT/CAT scan, X-rays are shot through you from 360 degrees, a PET scan requires that the patient be injected with some form of radioactive isotope where the positrons are emitted from within the body as a result of the decay of the radioisotope. While I won’t get more into the technical details here, the higher energy means higher resolution and a clearer picture for the Radiologist, in short.

Diffusion Tensor Imaging (DTI) is a form of MRI and is another area discipline being examined for CTE detection in living patients.

Ideally, researchers will someday find some sort of “bio-marker” that can be tested for in the blood that red-flags a person for it – something akin to a blood test for Hepatitis, for example.

The league says there doesn’t appear to be a cause/effect relationship between concussions and CTE, but I specifically think there probably IS one – it just hasn’t been found as of yet. One thing is for sure; more data on the subject are needed.

This brings up a question many fans have: “Why don’t all stadiums have their own MRI machine?”

That one is rather simple: time.

Ask anyone who has ever been shoved in a narrow tube for an MRI how long it takes, and the universal answer is usually something sarcastic.

For the rest of you, the luckier ones, the answer is about 45 minutes. Then, you need the trained Radiologist to interpret the image, plus the time it takes to get someone inside, placed, back out, and records compared, and the process takes well over an hour.

By then, the game is going to be pretty much over anyway or at least the second half if the player were injured early in the contest in the first place, so having an “MRI at the ready” isn’t so important as making sure a possibly concussed player doesn’t go back in to play to begin with. Once concussed, there is no handy “cure” other than the time and rest that I’ve mentioned.

Oct 20, 2013; Landover, MD, USA; Chicago Bears quarterback Jay Cutler (6) lays on the field with an apparent injury against the Washington Redskins during the first half at FedEX Field. Mandatory Credit: Brad Mills-USA TODAY Sports

That said, three stadiums do have their own MRI anyway and a couple have medical clinics.

Switching gears, a question came up regarding MRSA – something several Tampa Bay players have recently come down with. Yes, that’s the horror-film flesh-eating bacteria, but the reality is that it’s really not all that uncommon.

In fact, 40% of all staph infections are MRSA, so it’s quite common. Hospitals fight such things on a daily basis and more and more it’s thought that any place where people congregate on a regular basis could be a spawning place for the bacteria – including locker rooms. That is the most obvious/logical culprit in Tampa, for now, at least. The doctors said educating players is the key to fighting it.

If any player has an open wound of any sort, no joking around and cover up the wound. Don’t share towels or water bottles.

The doctors say as much press as it gets in the NFL, it’s worse in college and worse yet at the high school level. Why?

Well, once again…follow the money. The NFL has vast resources, colleges some but less, and high schools the least.

I asked a question regarding the Carolina Panthers first round pick, defensive tackle Star Lotulelei, and what the issue and story was regarding his heart.

Aug 29, 2013; Charlotte, NC, USA; Carolina Panthers defensive tackle Star Lotulelei (96) sits on the bench during the fourth quarter against the Pittsburgh Steelers at Bank of America Stadium. The Panthers defeated the Steelers 25-10. Mandatory Credit: Jeremy Brevard-USA TODAY Sports

The answer was that an ECG, or Electrocardiogram, is given to each player at the NFL combine because of sudden death and cardiac disease. One thing Dr. Heyer pointed out was that, in a lot of cases, the exams players get at the NFL Combine are going to be the most complete physicals they’ve ever had. some have never really seen a doctor for much in their entire lives, so any abnormality they may have would have gone un-diagnosed previously. A lot of these guys come from impoverished backgrounds.

Specifically, what they’re looking for, according to the doctors, is Hypertrophic Cardiomyopathy. It’s the “enlarged heart” in the vernacular – what you’ve heard of a few times as the cause of death when you hear a seemingly healthy person collapsed and passed away on the football field or basketball court or what have you.

Hank Gathers is one of the most famous cases of this.

Doing an EKG/ECG is a more recent thing, only done the past 3 years or so as understanding continues to develop. Star’s came back abnormal. As a logical precaution, doctors held him out of the combine pending further investigation. In Star’s case, an MRI confirmed things and in the course of treatment it was found that he had had a viral infection in February, some six or eight weeks prior to the Combine, which is thought to have caused the abnormal test.

A month later he was re-tested and the results were normal, pretty much confirming that the viral infection was by far the most likely reason and was a transient thing. However, most teams don’t like to invest a high draft pick in anyone with any “odd” medical issues and avoided taking him until he fell to the Panthers, who obviously drafted him. In his case, it was transient and had the ECG never been given to him, it likely would have gone undetected and without any harm to Star in the first place, and nobody would have been the wiser.

Star’s “case” as it were was simply one of timing. Lots of things can cause an abnormal ECG/EKG and not all of them are life-threatening. However, it’s a sign that something isn’t right and always needs to be further examined.

The last question I asked was “We have all heard of concussions, but what is the most under-reported malady that you see?”

The answer there is spinal issues among linemen, which makes a lot of logical sense.

Sep 15, 2013; Baltimore, MD, USA; Baltimore Ravens running back Ray Rice (27) is looked at by a team trainer after suffering an apparent hip injury against the Cleveland Browns during the second half at M

With all the weight linemen carry with them as it is, and adding to that all the stress placed on the skeleton by other large, strong men the same size or even larger, and adding to THAT the blocking, tackling, shoving and pushing around that goes on in the trenches, and lower back pain among really all NFL players is commonplace.

What most don’t know is if there’s some underlying problem or if it’s just a strain.

More often than is generally known, stress fractures can and do happen in the lumbar (lower back) area of the spine – again, due to repeated blocking or hyper-extension and the repeated nature of the forces involved. Anyone who engages in such “heavy-lift” activity on any sort of regular basis is at risk for the condition, but NFL lineman are especially vulnerable to it due to the nature of their specific jobs.

Also, coming into the draft, each player is given an “orthopedic grade,” which can and sometimes does affect their draft grade.

How would YOU feel if Ndamukong Suh was hammering away on YOUR shoulders 75 times a week?

Me, either!

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