Like any other physician, Thom Mayer, MD, tries to use evidence-based medicine to keep his patients healthy. The only difference is that there's a lot more money and attention focused on his patients, the players of the National Football League (NFL).
Concussions are one of the biggest issues currently facing Dr. Mayer, the medical director for the NFL Players Association and national executive vice president with EmCare. He spoke about the challenges of concussion diagnosis and treatment for professional football players, as well as more typical patients with concussions, at the Advanced Emergency and Acute Care Medicine Conference, held by EmCare in September in Atlantic City, N.J.
First of his kind
It was actually a different medical issue that led Dr. Mayer to become the association's first medical director in 2001. Korey Stringer, an NFL player, died during a training camp in August that year. “He died of heat stroke. How is that possible that someone could die of heat stroke? This is 2001,” said Dr. Mayer.
This tragedy led to the creation of his job and stronger efforts to improve health care for NFL players. “We began to put evidence-based approaches together,” said Dr. Mayer. “We're still evolving.”
Much of the current evolution is focused on concussions, he noted. As recently as 2011, the NFL teams' physicians had a standardized exam to determine whether a player had suffered a concussion, but it wasn't mandatory to perform that before sending the player back onto the field.
In 2012, the exam became mandatory. “We realized it wasn't enough. We had to have emergency action plans. We had to have spine protocols. We had to drill on those protocols,” he said. Dr. Mayer also had new clinical roles added to the sidelines—airway management physicians and unaffiliated neurological consultants.
The latter, who are often emergency physicians, play a key role in concussion evaluation. “They needed to be unaffiliated, in our view, because if they're part of the team's medical staff, then they're going to be acting on behalf of the team and its competitive advantage as opposed to the players themselves,” said Dr. Mayer.
Of course, the players themselves may not want to be diagnosed with a concussion, either. “Overtriage is a financial/political issue. In other words, players don't want to come out,” Dr. Mayer said. “The problem is undertriage is a medical issue, with very, very serious consequences.”
Instances of undertriage are still evident in NFL play, he noted, showing and narrating recent videos of players appearing to suffer concussions during games. “He's shaking his head, trying to get right, and finally the sideline judge comes up to him. He was out for exactly 1 play,” said Dr. Mayer. “He never got the exam, despite the fact that it was mandated.”
He described the league's mandated exams for players who may have sustained concussion, which are based on the commonly used Sport Concussion Assessment Tool, 3rd edition, or SCAT3. The goal is to determine that players retain their judgment, balance, and reaction time. “It's on an iPad, you read it off, and it makes it very clear when it's done. It's also recorded so we can look at it,” he said.
Testing for a concussion should include questions specific to the setting. “A player will tell you they're fine, and you say, ‘Did you get something to eat at halftime?’ They'll say, ‘I got plenty to eat at halftime.’ Well, it's the second quarter. They're just kind of desperately trying to stay in,” he said.
Part of the test also involves memorizing a list of words, preferably not the same one with every test, since military physicians found that Marines were memorizing the word list in advance so that they wouldn't be taken out of battle due to a concussion, he reported.
Symptoms are an important sign of a concussion, but diagnosis can't be based just on the patient's reported symptoms, according to Dr. Mayer. “What we hear from the league all the time is the player didn't report. Let's think about this. We're asking a brain-injured patient to articulate very effectively their brain injury,” he said.
In both NFL care and regular medical practice, it's more effective to ask others about these patients' symptoms, advised Dr. Mayer. “‘Does he seem normal to you?’ They say, ‘No, he seems really quiet. Something's wrong.’”
If a player demonstrates dramatic symptoms, such as loss of consciousness, confusion, or amnesia, he is automatically pulled from the game. But the majority of concussion patients have less severe injuries and will recover relatively quickly.
Treatment and recovery
For a timeline of treatment and recovery after a concussion, Dr. Mayer recommends physicians use the CDC's Heads Up program, because patients and their families will already know it. “I keep that app on the iPhone so I can pull it up and I can show them. Sixty percent of the people I've talked to said, ‘Yeah, I pulled that up before I came.’”
Despite extensive research, treatment of concussions is still very simple. “There's 1 treatment, and it's rest,” he said. Not total rest, though. “We've now found, at least in kids and adolescents, that cocoon therapy—you put them in a dark room and don't let them come out, don't let them text or do anything computer-wise for a whole week—is actually not effective. It is actually bad for people.”
Current thinking is that recovery should include a balance of rest and rehabilitation, with increasing activity as long as it doesn't cause symptoms, Dr. Mayer explained. No other treatments have proven effective. “We've chased—affectionately I say this—progesterone, biofeedback, hyperbaric oxygen therapy, all kinds of different things that didn't work,” he said. “We haven't found any magic bullets out there, unfortunately.”
Experiments in diagnosis haven't provided many solutions, either. Biomarkers, electroencephalograms, and functional MRI have not yet been shown to be helpful, he noted. Another scientific uncertainty is why concussions prove more damaging and lasting to some patients than others.
About 15% of patients will have persistent symptoms over weeks, months, or years, which is known as postconcussion syndrome, Dr. Mayer reported. Worse than that is chronic traumatic encephalopathy (which is diagnosed only after death) and traumatic encephalopathy syndrome. These patients have radical changes in their behavior with temper and mood issues. “Dementia pugilistica, those people had dull affect; that's not the same thing,” he noted.
The simplest way to treat concussions would seem to be preventing them, and both health and football experts have been working on that.
In recent years, the NFL made rule changes that aim to reduce concussions, including penalizing players for hits to the head. “You may remember at the Super Bowl last year the league was crowing about, ‘Oh, concussions have dropped down,’” said Dr. Mayer. “Well, you know what? They went back up. [In 2015], concussions in regular-season games have increased by 58% over 2014 and 18% above the 4-year mean.”
The 2015 total of 271 concussions works out to a 16% incidence rate, he noted. But it doesn't necessarily mean that concussion-reduction efforts have failed. “It could mean that we're reporting better. It may mean that we're screening and diagnosing people better. What it probably means is that we're at baseline...with all this education of the team physicians, of the [unaffiliated physicians], of the players themselves, of the referees,” he said.
But the new rules may also be having some unintended negative medical consequences, too. “What you notice is a pretty dramatic increase in the number of MCL [medial collateral ligament] sprains,” he said. “Shoulder injuries have also gone up for defensive secondary and defensive line.” Players are now tackling each other with lower parts of their bodies, which results in more lower-body injuries, both on those tackling and those being tackled, he explained.
Another potential avenue of prevention is helmet design. There's some evidence that larger-volume helmets reduce concussions, but in-helmet sensors have not proven helpful, he noted.
“We tested them in the NFL. Not only could they not tell us the G-forces, they couldn't tell us what direction the hit came from,” Dr. Mayer said. But he's optimistic that scientists can find solutions. “There's a major launch to go to the research community and say, ‘Help us develop a helmet which prevents the injury,’” he said.
Clinicians can help, too, especially to reduce concussions among young athletes in their communities, he said. “At your high schools, whether it's football, whether it's soccer, whether it's lacrosse, whether it's hockey, frequency is an issue. I encourage you, especially if you've got kids, to make sure that frequency goes down as much as possible.” Some college football teams have taken tackling out of practice, Dr. Mayer noted.
He urged his physician audience to talk to their schools and communities about the issue of concussions in young athletes. People often ask him whether he would let his sons play football, given all that he knows now. “Yeah, but I wouldn't start contact football until 12 to 14 for a couple of reasons,” he said. “One is the brain's developing and number 2, you're not going to learn anything about football that you can't pick up when you're 12 to 14 years old.”