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Serious Questions Remain About the Embarrassing MLS Concussion Protocol After Last Week

What is currently being done during games to diagnose a concussion. And does it fall short of accepted medical standards? If so, why is it happening and what can be done to fix it?

Matt is a First Aid/CPR instructor for the Red Cross and a Registered Nurse

This article is in response to the recent concussion protocol shown in the Vancouver Whitecaps v. Columbus Crew SC game. It has come out since that Wil Trapp had concussion symptoms since March 20th that were cleared after several days and then flared back up (Editors Note: Crew SC appears to have followed all protocol). I do not intend to attack any individual team or staff, but instead I intend to fire shots at the entire process implemented from a league that in 2015 should know better.

I will look at who is to blame when concussion protocol is not followed correctly, but this will mostly be in general terms. My goal is to add transparency into what concussion protocol should be to ensure all players on the field are concussion free.

Concussion

Not getting the job done

What is currently being done to diagnose concussions on the sidelines?

This is a difficult question to answer, as teams in all sports are so tight lipped about this topic. In general, it involves a player interview and a few physical challenges similar to a sobriety test. The doctor/trainer is evaluating a players dizziness, nausea, balance, fatigue, sensitivity to light and noise, concentration, and memory. If the player clears these tests he is allowed to head back out onto the field. If he fails, he is sent back to the locker room for further testing.

The method used to test these things  typically involves a few quick questions, a pen light checking pupil accommodation, the now infamous "stand on one leg" test, having  a player close his eyes and touch his nose, walk a straight line, etc. But there are four major flaws in this line of testing:

1) Players lie: No player wants to be taken off the field. If he did, he wouldn’t be playing a professional sport.  A player will say what he needs to say in order to help his team win. Most players have gone through concussion protocol in the past and have learned the right and wrong things to say. Players' answers that lead to the conclusion of no concussion may be false, and thus shouldn’t be relied on.

2) Concussion symptoms often take hours or even days to appear: The player can test negative for a concussion after proper testing even if they actually have a concussion. This is because a concussion is a bruise to the brain and it can take time for swelling/bleeding to occur in the amounts needed to cause symptoms. Since concussion symptoms may not be evident immediately after a concussion, results from initial sideline tests should not be relied on for proper diagnosis.

3) Adrenalin can mask symptoms: Adrenalin is an amazing thing. It is a chemical that the body produces when it senses it is in danger (like during a scary movie) or during exercise (to allow peak performance). Both of these are present in a head injury during a game or practice. The purpose of adrenaline is to allow the body to perform at or above maximum capacity, even if a serious injury is sustained, in order for the individual to be able to get to safety. During a game, with adrenalin pumping, a player can pass tests that, in normal circumstances, he or she may fail. This means that even "objective" tests such as balance can lead to false negatives in the heat of the moment and therefore should not be trusted for a proper diagnosis.

4) Conflict of interest in doctors/trainers: we will discuss this more later, but when a doctor is employed by a team and wearing the team jacket it is reasonable to assume he or she is pulling for a win. This can lead to him or her getting emotional as a game closes down and clouded judgments.

So if what is being done now is wildly ineffective, what should teams be doing? I'm glad you asked.

The best way to determine/rule out a concussion

Diagnosing a concussion is unreasonably difficult, which is why we see it mishandled so often. First, a baseline for each player is needed in order to determine if the player is above or below his normal cognitive levels. This baseline includes a cognitive test, a (often computer based) neuropsychological test. These are compared to a Post-concussion symptom scale to determine deviation.

Next, the post-concussion test, strength/weakness tests, and sensory change tests need to be repeated every 15-30 minutes for the reasons listed above. Symptoms don’t show up right away so the doctor needs to keep an eye on change in condition. Under no circumstances should the player be allowed to re-enter the game.

If symptoms stay the same or get better, the player would be allowed to head back to the team locker room/hotel/home with strict instructions for strict physical and cognitive rest for at least 48 hours and up to two weeks if symptoms remain stable. Physical and cognitive rest includes: no physical activity and no mental activity such as studying, video games, reading, etc. The player would also be evaluated again 24 and 48 hours after the incident occurred.

An example of proper concussion protocol can be found at mayoclinic.com. This is not something I am making up, the above procedure is the accepted practice designed and insisted upon by the American Medical Society.1

It is plain to see the current "protocol" is overwhelmingly insufficient for diagnosing a concussion during a game. A player should never be allowed to re-enter a game with a head injury. It is asinine to rely on "in the moment" concussion testing, as it is common knowledge in the medical field that head injury symptoms do not occur immediately. My own opinion is that the current system is an embarrassment on the medical profession.

Doctors need to resist temptation to let pressure of the moment influence their diagnosis. After all, a concussion is a concussion regardless of how many minutes are left in the game. This is why there is no "best way to determine a concussion during a game" protocol vs "best way to determine a concussion when no game is being played"

So just who is at fault?

In short, the doctors who evaluate the patient (I say patient because when evaluated, the doctor should not take profession into account),  and the league for not implementing independent concussion doctors. It's hard for me to blame the player because players by nature are competitive and want to play. It's difficult to blame the coach, who is relying on the expert opinion of the doctors in making lineup decisions. Even if the coach is pressuring the medical staff to clear a player, the medical staff must have the integrity to protect their patient as well as their licenses.

So how do we fix this?

Speaking of team doctors; they take the Hippocratic Oath which includes the phrase "first do no harm." It does not include the phrase "rush potentially compromised players back on the field to help secure a result." On Wednesday night I saw a doctor/trainer wearing a team jacket while evaluating a player. I understand this is common practice so singling him out is unfair. So listen up all team doctors, wearing the team logo shows a massive conflict of interest between doing what is best long term for the patient, and doing what is best short term for the team (That employs him).

Doctors and trainers on the sidelines should wear standard medical attire that is appropriate for the situation. They should also be employed by the league, independent from any specific team. This will allow them to answer to the Chief medical officer of the league (who, we assume, wouldn’t care about any one team's performance on any given night), who would be concerned with running a reputable practice, holding members accountable, and ensuring proper tests are done at proper times.

About on field play? This is the easiest problem in the world to fix. If the independent doctor rules a concussion is suspected then the team is allowed one additional sub (four subs instead of three) to sub off the injured player. This way the team is not penalized and tempted to keep the player in for strategic reasons. Can this be taken advantage of? Sure, but it is worth the risk.

Why go to all this trouble?

Perhaps this seems unrealistic, or over the top expectations from a disgruntled medical professional. I assure you, however, that it is not. From a humanistic stand point, protecting players is the right thing to do and no other motivation should be needed. I am not naive however and understand multiple forces are in play. One of those forces, though, is a massive lawsuit that could come down at any time if players suffer issues due to being put back in a game when they shouldn't. Does the MLS want to face a lawsuit under the accusation that they knew the proper way to diagnose a concussion but didn’t follow it? All it takes is one re-injury after improper testing to get a class action suit going. Do the right thing MLS, for your players and for yourself.

Matt Weisgarber RN,BSN,COS-C

Footnote

American Medical Society for Sports Medicine position statement: concussion in sport.http://www.ncbi.nlm.nih.gov/pubmed/23243113