In 1905, President Teddy Roosevelt considered shutting down the game of football due to an alarming number of deaths and serious injuries, triggering a series of iterative rule changes that coalesced into the modern game. More than a century later, American football is safer than at any point in its history. However, despite improvements in player equipment and extensive concussion protocols to instill a safer game, there still exists broader concerns for the game of football and other contact sports.
As neurosurgeons and national leaders in the evaluation and management of brain and spine injuries, we have dedicated extensive efforts and careers to improve player health and safety in professional football, and offer a cautionary tale about our ongoing stewardship of that responsibility. Neurosurgeons and our peers in complementary specialties are committed to working with the NFL Players Association and the NFL to incorporate a robust, peer-based quality improvement process into the NFL Concussion Protocol, once again providing a model for other sports to adopt.
Medical care in professional sports, including the National Football League (NFL) and National Hockey League (NHL), reflect the highest standards in medicine. The NFL Concussion Diagnosis and Management Protocol has been developed, implemented, published and refined through a rigorous collaboration among the NFL, the NFL Players Association and Unaffiliated Neurotrauma Consultants. These groups encompass many of the very best physicians in the United States for concussion and traumatic brain injury. We commend the NFL and NHL, as well as their respective players’ associations, for their profound commitment to player safety and brain health.
At present, the diagnosis of a concussion is based on player self-reporting of symptoms and a neurologic exam. Notably, 40% of NFL concussion evaluations in 2021 were triggered by athlete self-identification. This fact, frankly, reflects a tremendous shift in culture. Forty percent also now represents the floor; players must continue to receive proper education about concussions so they might be even greater advocates for their own health. Players who “game” the system to avoid detection are doing a disservice to themselves, their families and teammates, and the sport itself. At the same time, we desperately need objective tools, such as blood or imaging tests, which might enhance our capacity to diagnose concussions. Resources from stakeholder organizations across sports should be devoted to research to develop these diagnostic modalities.
The NFL Concussion Protocol has imparted an enormous, positive benefit to player health. It is the highest standard for concussion evaluation and management of any sport or sports organization in the world. The NFL Concussion Protocol, along with grassroots efforts like Lystedt Laws (mandating return-to-play processes), has revolutionized concussion care and produced a spillover effect across all sports at all levels. These efforts have improved public health and saved lives. The NFL, its players and the contributing physicians should be lauded, not demonized.
We are committed to actions that promote quality in brain and spine injury care for all, not just elite athletes. Recent events throughout the 2022-2023 NFL season have identified one clear opportunity: The need to implement a quality improvement process within the NFL Concussion Protocol. Similar review mechanisms already exist throughout medicine, allowing a protected space for an unfettered exchange of information among peers and providing a conduit for constructive changes to practice when indicated. If it is to succeed, such a process must be led by physicians; it must be confidential for both player and provider; and it must allow for any stakeholder to initiate it.
American football has improved drastically from the brutal dangers of the game Teddy Roosevelt witnessed at the turn of the 20th Century. We remain ready to partner with athletes and sports leagues to win the day in player health and safety.
