Everything is magnified in the playoffs. Controversial calls. Player gaffes. Clutch moments. And I think we can safely add the controversy of in-game concussion management to this list.
Last night provided us yet another example of this murkiness in professional sports’ biggest stages. Stephen Curry of the Golden State Warriors jumped over Trevor Ariza of the Houston Rockets, and Curry landed directly on the back of his head on the court. He laid prone on the court for several minutes, speaking to team medical staff, and able to move all extremities. There has been no report that he lost consciousness at any point following the injury. According to the mandate of the NBA Concussion Policy (which I will delve into later), he walked with team staff back to the training room for evaluation by the team physician. Following evaluation which included neurological testing as well as seeing whether riding an exercise bike exacerbated his symptoms, the team staff deemed that he was fit to return to play.
Cue the second-guessing of the medical staff. “Was he diagnosed with a concussion?” “What symptoms was he experiencing?” “Steph Curry just air-balled a shot, clearly there is something wrong with his brain”. “Are they putting him at risk for persistent symptoms unnecessarily?”
Let’s back up for one second and address why we all seem to have such a passion for concussion management. We’ve all read “League of Denial” by Mark Fainaru-Wada and Steve Fainaru (or we all should have by now). Many of us have patients with long-standing debilitating symptoms as a result of concussion. We’re finally at a point in our society where the overwhelming majority of us recognize concussion as a serious condition that cannot simply be ignored. Sports leagues have slowly come to the same realization, mainly over liability concerns. They can no longer minimize the potential consequences of concussion, and the leagues have each developed their own policies for concussion prevention, education and management. These policies have been developed by medical consultants in the field who have reached consensus between the leagues, its players, and its medical staffs.
I think for the most part we can commend sports leagues for their recent management of concussion-related issues. They are providing adequate baseline testing, adequate education to players, and return to play is generally done methodically according to the accepted standards of advancing activity only if the player is symptom-free. Whether we’re talking about a pro athlete or an 8 year-old, these same principles apply.
Even in-game concussion decisions in a typical pro game are usually clear. The definition of concussion from the American Association of Neurological Surgeons is “a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma”. The diagnosis is a clinical one based on the nature of the injury and presence of symptoms which may include confusion, headache, vision disturbances, dizziness, nausea or vomiting, impaired balance, confusion, memory loss, ringing ears, difficulty concentrating, sensitivity to light, or loss of smell or taste. The rule of thumb most primary care physicians and neurologists use is that if there has been head trauma, and even one symptom consistent with concussion is present, then you treat them as having a concussion (provided you have no concern about fracture, bleed, or other emergent symptoms). Is it possible that we will be removing athletes from competition that may not have gone on to experience debilitating symptoms? Certainly. But although there have been many interesting trials recently looking at blood biomarkers to distinguish concussed athletes at risk for severe symptoms and those at low risk, those biomarkers are far from being ready for widespread clinical use. Imaging doesn’t help either. So we’re left with our clinical acumen.
Bottom line, if you suspect a concussion, it’s a concussion until proven benign (or anything more severe). In the regular season, we don’t hear many stories of athletes being rushed back prematurely. Teams don’t want a hasty decision to limit their athlete for an unnecessarily long portion of the season.
But in a big game? Suddenly the ethics become a bit murky.
In the past calendar year, we’ve had three high-profile examples of players in big matches likely playing with concussion. Julian Edelman in the Super Bowl, Christoph Kramer in the 2014 World Cup Final, and Stephen Curry last night. Edelman continued in multiple plays despite being visibly unsteady and disoriented. In response, The NFL introduced a medical-spotter rule in the offseason to ensure players with concussion would be identified quicker. Kramer collided with Argentina’s Ezequiel Garay, and continued to walk aimlessly around the pitch for a number of minutes. Only after he asked the referee whether he was playing in the World Cup final did the referee signal to the sideline for a substitution.
In both of those incidents, as well as the Curry incident last night, TV viewers could identify that a head trauma had occurred, and that the player’s behaviour was abnormal. Even with Curry, laying on the court for several minutes after a head injury cannot be considered benign behaviour. It signals a likely concussion. We can debate the accuracy of early symptoms being indicative of severity of concussion, but he quite clearly met the criteria for concussion.
Why do we experience that visceral discomfort when viewing a player playing through an apparent concussion? We know that concussion often carries long-lasting, debilitating symptoms, and our reaction is often an expression of empathy. Part of our reaction is the general unease we have with seeing people in pain or suffering. Players play through musculoskeletal pain frequently, but seeing a player continue to persevere, despite the possibility of lingering cognitive, emotional and somatic symptoms, is a troubling sight to witness.
Should we care though? If a player makes a capable decision to continue playing despite being able to understand and appreciate the consequences, should they be allowed the autonomy to continue? The best analogy may be boxing and MMA, where the combatants are suffering mild traumatic brain injuries every second. The ringside medical personnel are essentially for decorative purposes, only stepping in when the risk of catastrophic injury is considered to be high. The fighters are willingly accepting the liability associated with concussion.
Could there be a sort of Advance Concussion Directives outlined for each player in advance of an important game? “Player A agrees to continue to be allowed to play in clinical situations X, Y and Z. He agrees that he will be removed from the game in clinical situation W.” Would this be too confusing and onerous? Perhaps. Another option would be a substitute decision maker (SDM) designated for each player in advance of the game. Should a concussion occur, the SDM would make a decision on return to play based on the player’s previously stated intentions. (Yes, a great deal of my practice involves care of the elderly, so I’m a little biased here.)
The simplest solution to all of this is for the team medical staff to make the appropriate diagnosis of concussion, rather than looking for excuses to declare a patient fit for play. From the NBA Concussion Policy, here are the points under the heading Evaluation and Management:
- If a player is suspected of having a concussion, or exhibits the signs or symptoms of concussion, they will be removed from participation and undergo evaluation by the medical staff in a quiet, distraction-free environment conducive to conducting a neurological evaluation.
- If a player is diagnosed with concussion, he will not return to participation on that same day.
This system is flawed from the outset. You are taking a player who has suffered a suspected head injury in a noisy environment, evaluating them in a quiet environment, and if the examination is pristine, you are sending them back to the noisy environment full of distractions. An environment which will likely exacerbate their symptoms, which the athlete will rarely disclose. They have their approval from the medical staff, and won’t come out of the game willingly. The other flaw in this system is that a “normal” neurological exam does not rule out concussion. Neither does a normal IMPACT test, or whatever metric the team decides to use. The player will understandably understate any subjective symptoms, which is a major part of the clinical picture. I think we’re naive to believe that Stephen Curry didn’t have any symptoms when he returned to the court. According to the second point, he should not have played again last night.
Here’s the question we need to answer. Are we comfortable with players attempting to play through concussion? If a player accepts the risks of longer-term symptoms with continuing to play, should they be allowed? As long as they can competently defend themselves against injury? (Edelman was vulnerable to a major collision at the Super Bowl and should have been removed regardless). It’s certainly not otherwise terribly life-threatening to play through a concussion after a proper neurologic examination (1.5 deaths/yr in the US according to the CDC), and if the player has been sufficiently educated, it may be reasonable to give them that option. This is where the concept of the SDM and advance directives are important, as a concussed player in an important game may make a decision that they would otherwise regret.
This entire topic is much more complex than simply watching TV and deciding from our couch whether or not we think a player has suffered a concussion. Medical staffs across the leagues always have players’ interests as a top priority, but unfortunately league policies on in-game concussion management has left them too vulnerable to subjectivity with respect to the initial diagnosis and return to play. There is a discussion to be had about how much autonomy we want to give players to play through concussion, but I’m not sure our knowledge of concussion is sufficient to allow the leagues to feel comfortable with the potential of liability.
My prediction? It will be mere months until we have this discussion yet again in another big game, and these controversies will continue until we have more accurate diagnostic tools. The simplest path will be for leagues to be even more stringent in terms of removing any suspected concussed athlete from play for the remainder of that game. But money talks. And when someone like Steph Curry may or may not have a concussion, the lines get very blurred.