NFL Concussions

Tuesday, September 9, 2014

Packers’ Eddie Lacy: concussion.

Bengals’ Vontaze Burfilt: concussion.

49ers’ Chris Culliver: concussion.

Jaguars’ Johnathan Cyprien: concussion.


The first week of the NFL season had its share of hard hits and at least four players were identified as having sustained a concussion. The good news is that the league policy makes certain that the injured player is evaluated, removed from the game and not to return until there is healing of the brain. The bad news is that even with all the awareness about head injury, the diagnosis of concussion is difficult at best, and especially when there is a delay in presentation of symptoms. Coaches, athletic trainers and doctors are good at looking after players on the sideline if a concussion is documented or diagnosed, but what happens to the player who doesn’t realize that he is injured.

No matter what the high tech world of medicine says, there is as yet, no test to confirm or deny the presence of a concussion. The diagnosis is one that is made clinically, based on history. There may be subtle neurologic findings on physical exam (for example nystagmus, abnormal eye movements that can signal problems with the balance system of the brain) but the physical exam in a concussed patient is almost always normal. Imaging the brain with CT scan or MRI is not always necessary based on the situation. To make things more challenging, players may not appreciate that they have been hit or have their head shaken enough to even consider that the potential for concussion exists.

It’s easy to make the diagnosis is the patient is knocked unconscious or gets up after  getting hit and is dazed and confused.  Vomiting, unsteady walking, slurred speech and slow response to questions are symptoms that can be observed, but the rest of the brain injury symptom spectrum may more subjective and requires the player and family and friends to appreciate those subtleties and report them. There may be hours or days delay between the head a hit and the recognition of symptoms that cannot be measured or found on physical exam. A few include the following:

  • Difficulty concentrating
  • Short term memory issues. In students this can lead to problems studying and significant affect grades to the downside
  • Increased light and noise sensitivity
  • Change in sleep patterns, either sleeping too much or inability to get to sleep
  • Changing personality including irritability and depression

The goal of a concussion protocol is to protect the player from sustaining a second injury and allowing the brain time to heal. The ability to meet this goal requires close attention to detail but it’s hard to evaluate all the players after every down. The NFL has an independent physician trained in concussion assessment on the sideline for each team. There is a spotter for each team in the booth to look for potential head injury victims. Only obvious symptoms, that can be observed, trigger the rule that removes the player from the field for further testing. Subtle is not easy to observe. While the NFL is has the resources to surround their players with medical personnel, those same resources are not available to most amateur players from peewee to college.

And while the NFL has spelled out a protocol to decide when the brain has healed completely, every brain responds differently to being concussed. Every timeline needs to be customized to the specific person and their situation. Believing that there is a reliable road map for return to play that is the same for every player and situation is not reasonable. The return to play guidelines depend on the patient progressing from one milestone to another and there may be roadblocks that delay moving to the next checkpoint.

The bottom line about concussions is that while research is making strides in understanding the brain, the medical community continues to struggle in managing head injury patients. While the patient and public expect precision, doctors can only deliver a best guess opinion.



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