Navigating the NFL Injury Report: Concussion

A concussion is defined as any traumatic and temporary impairment of neurologic function. Though sometimes applied confusingly in the past, this definition includes all brain injuries regardless of severity or length of symptoms. Minor symptoms, including a player having his “bell rung” without loss of consciousness or memory loss or an injury associated with only a few minutes of headache or confusion, should correctly be considered a concussion. Concussions commonly occur after a direct blow to the head, but rotational impacts around the jaw and neck can also cause a concussion.

Athletes that have sustained one concussion are at increased risk of experiencing another and are especially vulnerable while the brain is recovering from a prior concussion. A second concussion before the previous concussion has fully resolved or more than three concussions often lead to more serious and prolonged symptoms. That vulnerability and the increased understanding of long-term effects like chronic traumatic encephalopathy have pushed the NFL toward a more rigorous evaluation and treatment plan for concussions on the sideline and between games.

Though there are no standard grading systems or algorithms universally agreed upon in the medical community, concussions may be loosely divided into three groups. Grade 1 concussions are not associated with loss of consciousness or symptoms that last longer than 15 minutes. Grade 2 concussions are not associated with loss of consciousness but symptoms that last longer than 15-30 minutes. Grade 3 concussions include injuries with loss of consciousness of any duration. There is a good argument that a large gray area exists between Grade 2 and 3 concussions using the above criteria, i.e. an injury without loss of consciousness but prolonged neurologic symptoms is just as concerning as an injury associated with a brief period of loss of consciousness and short period of neurologic symptoms.

The NFL uses its own algorithm to decide how quickly a player with a concussion may return to play. Any player with concussion-like symptoms must be immediately removed from the game and examined. That exam should include both physical and cognitive exams, which are then repeated after a period of observation. If a player who had only mild symptoms shows no symptoms after 15 minutes of observation and has no concerning exam findings, return to play that day is at the discretion of the medical staff. A player with more severe initial symptoms, whose symptoms do not clear after a period of observation or who have had a recent concussion should not be allowed to return to play that day.

The algorithm also includes strict guidelines for clearing a player for future contact. A player must pass a series of neurologic exams, after 24 hour periods of no activity, light exercise and more vigorous exercise. The process must be started over if there is any recurrence in symptoms. He must also pass cognitive tests (when compared to preseason healthy baselines) and be cleared by an independent neurologist. The process generally takes a minimum of 4-5 days.

The NFL continues to assess and incorporate measures to prevent and monitor concusssions. Education directed at the culture of underreporting head injuries by players and medical staff personnel, impartial sideline and press box observers, penalties and fines for helmet-to-helmet contact, mandatory use of mouth guards, improvements in helmet design and fit, and IMPACT algorithms and testing are all intended to reduce the number of concussions and improve their management on the sideline.

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