Bouncing Ideas Around in the Concussion Think Tank
NEW YORK — A sixth-floor conference room at the NFL’s headquarters on Park Ave. housed an international think tank last weekend to deal with one of the most pressing issues in sports: head trauma and concussions.
Rich Ellenbogen, the Seattle-based neurosurgeon who co-chairs the league’s Head, Neck and Spine Committee, helped put on the event that brought together more than 30 experts representing a variety of sports leagues from across the globe, including the NHL, the NCAA, FIFA, the International Rugby Board and the Australian Football League, as well as the U.S. Army, U.S. Olympic Committee and equestrian organizations.
Ellenbogen was among the nearly two dozen scientists and doctors who revised the international consensus statement on concussion in sports during a benchmark conference two years ago in Zurich, Switzerland, but last weekend’s conference had a different focus. Instead of standardizing the guidelines for diagnosis, treatment and management used in leagues around the world, the think tank dealt with everything that is unknown about concussions—and what can be done to fill in the critical blanks as quickly as possible.
We had the smartest people here in the room saying, ‘How can we accelerate the healing? Can we look at this differently?’
“We are not going to make sports safer unless we have the research to give us the evidence to change,” Ellenbogen says. “We need to know what to change, and what’s not working.”
Research isn’t a sexy topic to the general public. It usually takes several years to conduct, while concussions happen weekly in the NFL. The balance that leagues must strike is helping players preserve their health in the short-term while pursuing answers for a better long-term understanding of concussions. Here is a good example: The current return-to-play protocol, as laid out in the international consensus from the Zurich meeting, is a graduated return based on a player being asymptomatic before advancing to the next step. The first step is no activity—physical and cognitive rest.
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“But we have no evidence that it is the safest,” Ellenbogen says. “We know there are people who have different reactions to no activity. What if active rehabilitation is better than no rehabilitation or waiting until people are asymptomatic? That’s a question that’s never been asked and never been answered.”
It was finally asked by the think tank, and an answer could change procedures everywhere from the World Cup to the Super Bowl to youth sports. The corresponding proposal was a randomized clinical trial to be held over the next two years, comparing athletes’ reactions and recovery times using different return-to-play protocols. The test subjects would be athletes in one of the sports leagues that attended the conference.
The goal of the think tank was to propose research projects that would allow different sports leagues to collaborate, with funding from the NFL helping to fast-track the research. An educational grant from the NFL sponsored the conference, though some in attendance (such as Jiri Dvorak, chief medical officer of FIFA) paid their own way. The NFL will decide which research to help fund and participate in over the next few months.
Another proposed project could provide something that has long been missing in the concussion discussion: context. The focus is often on individual case studies. But Dvorak said “one of the top-priority programs” is a comparison of concussion incidence rates across different sports in which athletes are prone to head injuries (soccer, football, rugby, even bicycling and skiing). Researchers also want to compare rates across different competition levels, and even compare those sports against regular leisure activities. Says Dvorak, “The fact that the NFL is open for this epidemiological study and comparison clearly indicates they mean it seriously.”
If approved, this project would quantify the relative risk rates of different sports, which could serve an important purpose at all levels. “It’s something we want to know, and I think parents want to know,” Ellenbogen says. The first step would be setting uniform criteria so that apples are being compared to apples. FIFA, for instance, currently records concussions per 1,000 player hours while the NFL charts them per season. Another meeting has been tentatively scheduled to take place during the 2014 NFL season to green light some of this research.
This summer’s World Cup was a very public reminder that the challenge in managing concussions is shared across the highest levels of many sports. FIFA came under scrutiny for two incidents—one in which Uruguayan defender Alvaro Pereira was knocked out cold by a knee to the head but, after coming to, overruled the team doctor and returned to the game; and another during the final between Germany and Argentina, in front of hundreds of millions of viewers worldwide, in which German midfielder Christoph Kramer played on after receiving a blow to the head, only to be helped off the field, groggy and glassy-eyed, 15 minutes later. Dvorak said the organization is strengthening the position of the team doctor; he and Ellenbogen also discussed the NFL’s employment of an unaffiliated neuro-trauma consultant on each sideline for every game.
“This is paradigm-shifting,” Ellenbogen says. “We had the smartest people here in the room saying, ‘How can we accelerate the healing? Can we look at this differently?’ Some very unique perspectives of getting people back to activity in a safe and effective way came out of the conference, and we are going to test the hypotheses.”