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AANS Neurosurgeon | Volume 28, Number 2, 2019


Return to Play following Concussion in Football: Our NFL Experience Part 2

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Part 2: This is the second article of a two part series describing the authors’ experience working with the NFL’s concussion protocol. Read Part 1

Multi-Disciplinary Care for the Concussed Athlete

A multidisciplinary treatment team offers the most comprehensive approach to actively treating the clinical profiles associated with concussion.1 In the past, concussions have been treated as a ‘one size fits all’, homogeneous injury, despite often identifying varying symptoms and manifestations across patients. The modern approach to concussion management defines different clinical profiles and recovery trajectories. Thorough, multi-domain assessment is warranted to properly identify concussion subtypes and management is multidisciplinary, involving team physicians (including neurosurgeons), training staff, the independent neurological consultant and neuropsychologists – at a minimum. Additional specialists, such as vestibular and vision therapists, are then added based on the patients’ clinical subtype. This approach allows active and targeted treatments that enhance recovery.2

Strengths and Limitations of the System

Athlete Symptom Self-report

The increased number of clinicians observing the game has improved the detection of potential concussions. The effectiveness of the Concussion Protocol is enhanced when players contribute to their own health and report symptoms of concussion. It has been demonstrated in multiple studies that appropriate education of the athlete and medical personnel on the dangers of concussion improves the reporting of concussions.3,4 The modern athlete understands, better than ever, that removal from play and proper concussion evaluation and management leads to a more rapid return to play, not a delay. This is evidenced by more NFL players self-reporting concussion symptoms during practice and games. In fact, in 2017 and 2018, more than one-fourth of concussion evaluations were triggered directly by a player self-reporting5, the highest figures since NFL concussion tracking began.

Variability of Symptoms and Treatments

Currently, no broadly-accepted and objective test for a concussion exists. Even seemingly quantitative exams of balance and cognitive function are subject to interpretive differences by clinicians. Symptoms are, by definition, subjective, vary between individuals and are interpreted differently by both clinicians and patients. This makes the absolute diagnosis of a concussion extremely difficult. To ensure the safety of the athlete, we would rather error on the side of diagnosing too many than missing any. This acceptance of a high false positive rate is exemplified by the mantra “when in doubt, sit them out.”

Effects of Increased Game-day Personnel

The current game-day system utilizes three or four UNC physicians and two ATC spotters, in addition to the dozens of medical personnel already present at the game. The system carries obvious additional expense. The additional personnel can also make the often chaotic sideline and locker room more so. Training of these personnel regarding where and where not to be during the game is essential to comply with NFL rules and for their own safety. In addition, the system must work the same whether the game is preseason or the Super Bowl, and it cannot differentiate between a backup lineman and the starting quarterback. If the NFL determines that the concussion protocol rules are not followed, substantial fines and even loss of draft picks can occur. The penalties are more severe if the concussion was not treated for competitive reasons.

The full NFL program is not feasible in lower levels of play, such as high school (despite a much larger at-risk population). Nevertheless, the NFL Concussion Protocol and game-day approach provides a framework for concussion care for all levels of football and across all contact sports. The protocol further underscores the vital role of collaboration between medical personnel and athletic training staff.

The Integral Role of Neurosurgery

For over a century, neurological surgeons have been involved in the medical management of athletes.6 This includes the direct treatment of injuries to the brain, spine and spinal column and peripheral nerves. Our specialty, unlike any other, can address pathology in all these areas of neurotrauma. Advancement in the science of brain and spinal cord injury has also been driven in large part by neurosurgical laboratories. Neurosurgeons have been instrumental in the development of treatment paradigms, including return-to-play guidelines and the acute management of severe brain and spinal cord injuries. From the development of modern neuropsychological testing to the first diagnosis of chronic traumatic encephalopathy, our specialty has led the way. The emphasis on player safety over the past decade has and will continue to allow us the opportunity to advance the science of concussion diagnosis and active management.   

Note: Drs. Joseph Maroon, Vincent Miele and David Okonkwo are members of the Pittsburgh Steelers Football Club Medical Staff; John Norwig is Head Athletic Trainer for the Pittsburgh Steelers Football Club. The views expressed in this article are their own.


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1. Collins MW, Kontos AP, Okonkwo DO, et al. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79(6):912-929.

2. Kontos AP, Collins MW, Holland CL, et al. Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Intervention with Chronic mTBI Patients. Mil Med. 2018;183(suppl_1):333-338.

3. Bramley H, Patrick K, Lehman E, Silvis M. High school soccer players with concussion education are more likely to notify their coach of a suspected concussion. Clin Pediatr (Phila). 2012;51(4):332-336.

4. Taylor ME, Sanner JE. The Relationship Between Concussion Knowledge and the High School Athlete’s Intention to Report Traumatic Brain Injury Symptoms. J Sch Nurs. 2017;33(1):73-81.

5. 2019.

6. Stone JL, Patel V, Bailes JE. The history of neurosurgical treatment of sports concussion. Neurosurgery. 2014;75 Suppl 4:S3-S23.


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