Will the brains of our athletes be protected by the current Return to Play Guidelines?
By Nicholas H. Wright
In its recent settlement with the Players Union, the NFL has accepted an actuarial estimate of 30% for the number of players who eventually will need to be compensated for dementia. This settlement is part of a growing national awareness of the extent of brain injuries incurred by high school and college athletes. Findings from recent autopsy studies that have identified the tau protein buildup of chronic traumatic encephalopathy (CTE) have drawn the obvious relationship to repeated concussion. These findings are supported by imaging studies on the size of certain critical regions of the brains of college football players.
These and other findings are a forceful reminder of why most US colleges and universities gave up boxing by mid-20th century. Cases of “dementia pugilistica” from repeated blows to the head was a more immediate outcome of concussion than the longer term consequences we are now seeing, especially related to earlier participation in collision sports. While premature dementia or early cognitive impairment is only a part of the symptomatic/pathological picture, it is the most challenging since it cannot be fixed medically. It is also troubling because it is occurring in sports sponsored by institutions devoted to the cultivation of the mind. The NCAA’s long term (1988-2003) surveillance project monitoring all serious athletic injuries, and published in 2007 shows no change in the level of rates of defined serious injury—except for concussion, which increased 7% over the 1988-2003 period—despite claims that NCAA rules governing play were tweaked in selective instances to lower risk of specific injury.
There are several reasons why this situation has developed. While the earlier goal of sport was the development of a “sound mind in a sound body,” the driving philosophy of the new athletic activities (now called programs) has morphed into a “be all you can be” environment. Bodies are bigger each generation, and, with increasing pressure to win, more aggressive training and playing — all on faster artificial surfaces – has been the rule. Although the objective evidence is thin, at some educational institutions, “successful” athletic programs are seen not only to motivate more generous alumni giving, but perhaps even more importantly, to generate immediate and substantial cash revenue at the gate (not to mention TV contracts). Finally, compared to earlier writing about sport, the “role” of athletics in educational institutions is seen as important to personal development, personal discipline and encouraging the kind of sharp competitiveness and team play thought to be useful in a society like ours.
The consequences for short and long term health have been shown by the NCAA Surveillance Study to be significantly greater in the contact sports, especially men’s football (although this study did not include rugby). Health and prevention has not been taken seriously enough as the number of injuries piled up. The common belief that modern orthopedic surgery and sports medicine can fix serious injuries is strong, although the evidence for the brain is, to say the least, not at all encouraging. Brain damage in most of the collision sports starts long before play at the college level. For example, a concussion suffered by a Williams football player playing in the New England Small College Athletic Conference (NESCAC) is most unlikely to be his first. Since the natural history of CTE is poorly understood and its development cannot as yet be followed by imaging, it is not clear which blow, of what force, and in which direction to the brain started the process of tau protein buildup, or how subsequent blows may have moved the pathology along to what has been seen at autopsy in men as young as 30.
This situation prompted the adoption of a ‘Return to Play after Concussion’ protocol within most, if not all NESCAC
Schools, from late 2011. While the exact content of the return to play protocol at, for example, Williams College, has not been made public, it appears to rely on a series of post-concussion clinical appraisals, presumably by the same observer, and a neurocognitive test package that can be compared to a baseline test done pre-season by an experienced technician. In effect, these are screening tests. Because variation in clinical observation is well known, even by the same observer, it would be folly to rely on clinical observation alone as a reliable guide to letting a player return to the game and/or study. As for the neurocognitive testing, there is significant variation of test results within the same individual in a healthy state, throwing into doubt the ‘sensitivity’ of the test, i.e., its ability to truly diagnose return to brain health. The weakness of the test will lead to too many concussed players declared ready to return, when they are not. All this is further complicated by the question of whether or not the technician is adequately trained to interpret the test. Many are not.
Finally, since it is clear that we know very little of the natural history of concussion and its short and long term effects, and are employing a testing sequence with dubious reliability, it must be asked if this strategy is protecting the athletes’ health.
Since a concussed player is at much higher risk of having another one, has this strategy reduced the rate of repeat concussions? Will the policy reduce the incidence of the rare “Second Impact Syndrome?” No one seems to know and there is no evidence of a significant evaluation protocol designed to answer these questions. Without questioning the motivation of the educational institutions that have adopted the Return to Play Protocol, it appears–and at some considerable expense— that the strategy protects the game, and perhaps even the still current state of denial in some quarters, rather than the players. Until the most unsafe 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 possible.
Nicholas Wright, MD, MPH, is a 1957 graduate of Williams College who now lives in Williamstown.
Note: The author thanks Ms. Lindsay Von Holtz for background information on concussion policy at Mount Greylock Regional High School. All opinions, however, are the responsibility of the author. Williams College has denied two requests to provide a representative for interview on these issues.