Finding a true “independent” health care provider for concussions in the NFL is a sticky situation; the NFLPA says they want one and the League is saying no. Of course there are various reasons as to why the League would not want an independent neuro there; cost being one issue, the other issue is that the players may actually be in greater peril – and I agree. Dr. Richard Ellenbogen co-chair of the NFL Head, Neck and Spine Committee explained this in an article in USAToday;
“No one knows the players as well as the athletic trainers, period.
“Having said that, some teams already have neurosurgeons on the sidelines. Having a doc show up just for a game takes away from the all-important baseline exam and continuity of care. It would be like getting operated upon by a surgeon who did not see you pre-operatively. Is that safer than having someone who saw you beforehand? The baseline is all important in making an assessment if a player is OK after a hit.”
Concussion are so subjective, most cases do not involve overt signs and it is incumbent upon the player to report what is going on. Trust is a HUGE factor for players – of all ages – but more so in the NFL where they are making a living by playing football. Although the tests are there and meant to be as objective as possible it is still a clinical diagnosis overall. The only health care professional on an NFL sideline that knows the players best is the athletic trainer. This would be seconded by the team doctor; the other specialists that are on hand (including a team neurosurgeon) have limited intimate knowledge of the players as they see/interact on a weekly basis.
I do have a potential solution however, why don’t team employ a dependent neurologist or neurosurgeon? Granted they have to make a living working with the general public, certainly they can carve out time to provide better – not fully adequate – coverage from a “brain doc”.
Just as the team orthopedic surgeons do the preseason physical and consult on weekly injuries, then are on the sideline for evaluation of bone injuries; the team neuro could provide the same. The preseason baseline tests (NFL adapted SCAT2 and computer based tests) could be done by the team neuro, a weekly visit (or more) to familiarize themselves with players and discuss current issues with the athletic trainer and finally being on had during the game to make the all important decision.
I still believe that the athletic trainer would be the most qualified to make the decision but the ultimate “go/no-go” is often and usually exclusively made by a doctor, in this case you would have this. Granted any doc worth their salt would rely heavily on the input from the athletic trainer.
This proposal then would provide another benefit; when being cleared by the League via the independent neuro there would be peer-to-peer discussions in all cases. Plus, the team neuro would have a better picture of the player to present to the League.
I have many opinions as to why the current system may not be working as well as some hoped, the biggest issue being conflict of interest (as you will see in a later post) but this proposed system would add another specialist layer for the players. As an athletic trainer if I had a great working relationship with a neuro doc I would be much more inclined to defer (although in the current health care hierarchy we always have to) to their judgement if they had a clinical background of the patient.
Side note: Dr. Ellenbogen also wrote about why players were not pulled from the game (underling my post from Tuesday) when the world thought they sustained a concussion during the games last week;
“The physics of the hit do not always translate into a concussion,” Ellenbogen wrote. “The amount of impact does not always correlate to the concussion. It is often related to angular acceleration, not linear acceleration of the hit. Need to look at player and have baseline exam and compare to that.
“Smith was concussed on second, not first hit. Cutler was OK after first hit but got new symptoms as the game progressed. And remember the problem is that with all the adrenaline, the concussion was not immediately obvious to the players. Both became symptomatic as they played further. That certainly is not uncommon for concussions to evolve. If you have seen one, you have seen one. They are all different.”
The Concussion Blog 
It is interesting to me that they are pushing for “independent professionals” when the healthcare professions are pushing for more involvement in order to establish relationships and better understand each athlete in order to provide the best care possible…
Pure nonsense. It is amazing that Ellenbogen and Batjer said things would change when they tookover and nothing has changed (pimped by the NFL in record time). The NFL should have simply kept Casson, Pellman and Viano. Those guys were at least entertaining. I gather the old m-TBI committee is still running the show (Casson is still working with Jets and Pellman is Rog’s right hand medical man) with the two new guys acting as the front men. My favorite is when the NFL announces that a player has been sent to Pittsburgh for a second opinion from Collins, Maroon and Lovell (Mark and Joe were both founding members of the original discredited NFL m-tbi committee). Here is how it works. Team says I need this guy on the field. UPMC says right. The player passed his Impact test. Good to go.
Do any of the NFL docs know their patients or do they just do the physicals? These clowns pay to be team doctors and wait for suckers to come into their private practices based on the public’s belief these guys must be geniuses because they were hired by an NFL team (Not that the docs could pay the most for sponsorship). Word of warning, before you see an NFL affiliated doctor check his license, education and especially his malpractice record. The Chargers doc who nearly killed OL Dielman finally got his licensed pulled. Either Pellman or Casson have a degree for a Mexican medical school.
Where is the NFLPA, no where to be found. What a surprise!!! Thom Mayer is a NFL doc. He is just covering his and his buddies assess. Since the union leadership is asleep at the switch and has clearly demonstrated it has no interest in player health (the membership should stop paying dues as they get nothing for it), Alex Smith, Michael Vick, Matt Cassell, and Jay Cutler can chip in a buy independent medical advice for the players before all their buddies lose millions because no one had their backs.
PS: Can’t wait to see the research these NFL docs will approve. It does not really matter as it will be turn out to be whatever the lawyers in New York say it needs to be.
Joe, I think it’s time you wake up and smell the coffee. The NFLPA was just in the news two days ago!
Michael,
The NFLPA is doing nothing. Just talk. The INC was only the table during the mediation and dropped it. Please do think this is new. It is has been going on since 2007 and players’ are having their careers shortened and their lives destroyed because no one in DC has stepped up.
.Suggest followers of this blog read the below journal article.
NFL Players vs Owners: A medical care tug of war
by Mike Moore (1982)
30 years ago article appeared in Physician & Sportmedicine
More NFL history… nothing changes if nothing changes
If there are to be real advances in brain injury and player safety, etc. …it is essential to know accurate NFL -elated history
Please note the year…1982 – July…of the journal article
This article directly ties into some of the comments in this blog posts….and to many comments in recent posts.
The contents argue for AT’s , need for more acurate injury reporting, COIs, Player physician, need for neutral physicians in disability disputes, medical insurance, disability payments, “great increase in safety” and so on….
Thus a strong argument may be made that there has been much empty talk and meaningless rhetoric at the expense of the NFL Players…and the American public.
Michael and readers of this blog,
Re the NFLPA and status of various retired NFL Players. Suggest you read a posting on today’s Davepears.com/blog.
Below is a portion of the introduction of the post….
In one of the most public displays of just how far the Bert Bell/Pete Rozelle Plan and its overpaid NFL lawyers will go after a retired player during the process to access his earned disability benefits, US District Court Judge Ellen Hollander (District of Maryland) submitted her final 39-page ruling that very clearly details the many violations and fuzzy interpretations that the Plan and its lawyers have used over the years. Jimmie Giles (1977 – 1989: Oilers, Buccaneers, Lions, Eagles) had originally been awarded his Inactive Total & Permanent benefits (now called Inactive B) and the Plan and the NFL’s lawyers chose to aggressively deny his claim for Football Degenerative Total & Permanent benefits (now called Inactive A – got that?), leading to disability attorney John Hogan’s appeal on Jimmie’s behalf. The NFL’s law firm, Groom Law Group, publicly displayed some of the most egregious abuses of power and personal attacks on behalf of the Plan – all in their normal course of business-as-usual. At one point, they even tried to use the fact that Jimmie was “overweight” and it was pointed out to them that Jimmie’s teams had certainly never considered him overweight in his position as a tight end during his entire career! The Plan had been amended a few years ago to automatically accept an applicant’s Social Security designation as being Disabled, yet they continued to question and argue Jimmie’s actual “disability” going so far as to declare him still able to do “sedentary work” – as was also the case in Dave’s (and many others’) disability applications over the years. And their own Plan (the lawyers’) Questionnaire to their “neutral doctors” also continues to ask if a player was totally disabled as the Judge noted in her ruling.
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It’s been a long wait for Jimmie and his family as they struggled to make ends meet during this drawn-out appeals process that dragged on through the summer after a lockout, a new CBA and everything else that went by over the past two years. But Judge Hollander appears to have taken a very thorough approach to address each of the arguments posed against Jimmie’s already well-documented case. (We uploaded a copy of this final ruling below as soon as it was available.)
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One interesting observation: Jimmie Giles’ so-called Union, the NFLPA, has been nowhere to be seen at any time during Jimmie’s entire application process. No offers of assistance – legal or financial – during what has probably been the most difficult period of his life. In fact, the three alleged “retired players representatives” on the Disability Board had to have voted unanimously against Jimmie’s claim in lockstep with the three owners’ representatives in order for this case to drag out this far. Why has each member of the Board never been held accountable or sued for their ill-informed rulings? Would any AFL/CIO retiree in a REAL Union ever expect to be subjected to such an abuse of employees’ rights?
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The ruling is posted on Scribd for easy viewing and to make them downloadable for printing. You can also click the Enlarge icon in the lower right corner of the menu at the bottom of the viewing screen to go Full Screen for easier reading (just hit the ESC key to close):
I believe an independant specialist would be needed to remove any real or perceived conflict of interest.
Jake…
1- Agree with the concept of an independent…
but from my perspective the evaluator(s) should be an Independent multidisciplinary team…
who thoroughly assess the NFL player SUSPECTED of sustaining a concussion.
2- Sideline ” tests ” (or perhaps illusionary sreenings) are merely “smoke and mirror” illusonary activities…
these so- called screenings are not designed to evaluate ALL possible brain injury symptoms…
to me these screenings are equivalent to participating in a yearly physical exam….only having your knee evaluated…and conclusions being made about ALL aspects of your body’s health. Multiple disciplines are needed to fully evaluate the athlete’s health / injury status.
3- If a NFL Player is SUSPECTED of suffering a concussion then
the player should be “pulled for the reminder ” of the game /practice
BECAUSE the effects of a concussion / brain injury may not manifest itself for a period of days…
and returning the athlete back to play may cause further brain damage…
4- Medical ethics / Hippocratic Oath (Corpus) emphasizes … “First, Do No Harm” …
Returning to play without allowing time for secondary injuries of a concussion to manifest themselves… serve only as ” rush to judgement’ … and thus violates the concept of “First, Do No Harm”
Not to take sides Michael, but Joe nailed it. I turned to the NFLPA during the 81 Super Bowl season, BEFORE I had any idea what I was headed for. This is where my life has gone:
I was a member of the 1981 SF 49er’s Super Bowl championship team, when I developed hydrocephalus (water on the brain), from concussions and underwent emergency VP Shunt brain surgery. This was during my second year in the NFL at age 22, as I was coming back from my first knee surgery. They drilled a hole in my skull, inserted a tube into the ventricles in the middle of my brain, ran the tube under my skin to a pressure valve and pump on the back of my head, and ran a drain tube from there down the side of my neck, under the skin on my chest, and into my abdomen to drain spinal fluid from my brain 24/7. Back then, we were also worried about being labeled concussion prone as Hillenmyer stated, or a “paper head”, as my homeless 49er room mate Terry Tuatolo states in the following interview, after I tracked him down last month.
Channel 13 News Sacramento 10/29/12 Terry Tuatolo interview
http://sacramento.cbslocal.com/video/7898539-former-nfl-linebacker-falls-into-homelessness/
I suffered my final “diagnosed” concussion which ultimately caused my hydrocephalus in the first quarter of a Dallas Cowboy game during the prior season in 1980 (see link below).
KRON4 News in San Francisco …http://www.youtube.com/watch?v=GZpnI6W2 Sg – 114k – Cached – April 18, 2012 … George Visger, author of the ebook “OUT OF MY HEAD: My Life In and Out of Football” (January 2012), was featured in this report on KRON4 …
I was told later in the week when I began to remember things, that the trainers and team doctors gave me 20 – 25 smelling salts during the game to keep me on the field. They laughingly told me they would give me a few whenever I came out, I would pop a couple under my nose, shake my head and go back in the next series. This was with the doctor’s and trainer’s oversight.
Not only did I have emergency brain surgery, but while lying in intensive care for 14 days at Stanford, the trainers called to tell me they were looking at having a special made helmet to protect my shunt so I could keep playing. I was all in. Unfortunately they forgot to tell me shunts go out. Mine failed 4 months after we won Super Bowl XVI, and my brother brought me into the hospital in a coma, I had 2 more brain surgeries 10 hrs apart and was given last rites AND the hospital bills. I fought the 49ers creditors for years and was forced to sue for Workers Comp just to get my bills paid. During my Work Comp fight, I had 2 additional knee surgeries to repair what the 49ers’ orthopedic surgeon screwed up, the last being an experimental GoreTex ACL transplant. They basically drilled holes thru my femur and tibia, ran an artificial ligament through the holes and secured it to each bone with a large stainless steel molybolt.
I won my case in 86,and the 49ers offered me $35,000 to go away. Luckily, despite my brain injury , I still had the mental capacity at that time to decline their offer (even though I was living in a cheap apartment, swinging a hammer during the day and bouncing at night trying to make ends meet). I asked for what any injured employee had earned, my past and future medical left open and I utilized Vocational Rehab to return to school to complete my Biology degree. The NY Jets had drafted me in the 6th round out of Colorado in 1980 prior to graduating. I signed a contract worth $35,000 for the first year (never paid a cent of that as they cut me at the end of pre season) and received a $15,000 signing bonus.
During one 10-month period in 1987, while taking Organic Chem, Bio Chem and Physics, I had 4 more brain surgeries and several gran mal seizures during one 10-month period. It literally took me 5 more years of study to complete my bachelors degree in Biological Conservation, as I literally had (HAVE) no short term memory. I had to train myself to write everything down all day long, including where I parked my truck each day. I was 32 when I finally began my career as a wildlife biologist in Sacramento.
Here I am now at 54. I’ve survived 9 emergency VP shunt brain surgeries, several more gran mal seizures, and was diagnosed with frontal lobe dementia 3 yrs ago. They put me on 4 different dementia meds at once, Lexapro, Arricept, Namenda and Resperdal on top of my anti seizure med Lamictil, 2400 mg of Motrin/day for my arthritic knee and Ambien for sleep. Due to inflammation of my neurons, I am unable to turn of my thoughts at night, and have gone up to 4 nights straight with no sleep. Thus the Ambien. Three years ago I started on Hyperbaric oxygen treatments (HBOT), and mega doses of Dr Barry Sears Omega 3 fish oil and his natural anti oxidant supplements. Within the first year I quit all my drugs but my anti seizure med. As of today I have completed 206 HBOT treatments, and my micro cognitive memory test scores have improved 14.7% from pre treatment testing. And the best part of the story.
I STILL DON’T QUALIFY FOR ANY NFL BENEFITS
George Visger
SF 49ers 80 & 81
Survivor of 9 NFL Caused Emergency VP Shunt Brain Surgeries
Benefactor of ZERO NFL Benefits
Wildlife Biologist/Traumatic Brain Injury Consultant
The Visger Group