National Collegiate Athletic Association targeted for legal action on the issue of concussions amongst student athletes

December 3, 2011 by

There was an interesting article in the New York Times this week highlighting a recent class action lawsuit aimed at the NCAA over alleged negligence in relation to prevention and treatment of brain injuries in athletes.

The action represents the first attempt to target the NCAA rather than individual colleges or schools, as pointed out by Nikki Wilson on the Collegiate and Professional Sports Law Blog. Four plaintiffs, three with a history of participation in College football and one who played soccer, have filed lawsuits alleging a ‘long-established pattern of negligence and inaction with respect to concussions and concussion-related maladies sustained by (the NCAA’s) student athletes.’

There are a wide range of claims made, including allegations that the NCAA has failed to implement :

– A support system for players unable to continue to play or lead a normal life after sustaining concussions

– Legislation addressing treatment and eligibility of players who have sustained multiple concussions

– Guidelines for screening and detection of head injuries

– Return-to-play guidelines for players who have sustained concussions

– Effective ways of addressing or correcting coaching of tackling methods that cause head injuries

One plaintiff, Adrian Arrington, claims to have suffered ‘numerous and repeated concussions’ during his playing time at Eastern Illinois and now is alleged to suffer from memory loss, depression, and near-daily migraines as a result. The lawsuit claims that the NCAA ‘..has failed its student-athletes choosing instead to sacrifice them on an altar of money and profits.’

Perhaps unsurprisingly, Donald Remy, the NCAA General Counsel and Vice President for legal affairs, has called the lawsuit ‘wholly without merit.’

The organisation responded by stating that ‘..the NCAA has been concerned about the safety of all of its student-athletes, including those playing football, throughout its history,’ and claimed that ‘..we have specifically addressed the issue of head injuries through a combination of playing rules, equipment requirements, and medical best practices.’

The NCAA and the CDC have collaborated to create educational resources for coaches, student-athletes, medical staff and college sports supporters. The NCAA Sports Medicine Handbook has 4 pages on concussions including information on symptoms, and has a revised management plan for all athletes with concussion.

The outcome of the legal actions will no doubt be watched closely by all former college athletes who believe that they may be suffering from ongoing symptoms as a result of repeated concussions during play.

For a further discussion on the lawsuit issues, readers can listen to the EDUsports podcast on the subject.

In the meantime, CJSM would like to hear your thoughts.

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Pro-bowl picture by Cpl. Michelle M.Dixon

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Sideline assessment of concussion and return to play – are we practising what we preach?

October 27, 2011 by 9 Comments

The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.

The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.

Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.

He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.

The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.

Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’

Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’

What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines – see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’

In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.

Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.

The Rugby Law blog was particularly vociferous on these events.

For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.

Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?

CJSM would like to hear your experiences and opinions.

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Concussion to consequence webinar – 12 days to go!

October 7, 2011 by

The Ovid Concussion to Consequence Webinar will be live in 12 days’ time, with Margot Putukian, Director of Athletic Medicine at Princeton University, Past President of the American Medical Society for Sports Medicine, and member of the NFL’s Head, Neck and Spine Committee joining John D. Corrigan, Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University and Editor-in-Chief of the Journal of Head Trauma Rehabilitation in a 60 minute discussion on topics related to concussion in sport.

The webinar goes live at 12:00hrs EST on Tuesday the 18th of October, and can be accessed here.

Dr Margot Putukian comments :

‘Concussion is a challenging injury to assess and manage, and the research is evolving at an exponential pace.  The upcoming webinar will be an opportunity to discuss the definition of concussion as well as some of the essentials regarding recognition and management of this injury.  We will discuss a comprehensive approach which includes the pre-season planning as well as sideline and post-injury assessments, return to play considerations, and finally prevention and areas of future research.  We will hope to provide a comprehensive review of a very challenging and important topic.’

In addition to these topics, there will be further discussion on the lifetime risks associated with repeated episodes of concussion, and emerging data on the delayed consequences of early episodes of concussion. Some of the evidence presented will be extrapolated from studies of armed forces veterans and other groups who have a higher incidence of early traumatic brain injuries than the general population.

It’s been over 172 years since Baron Guillaume Dupuytren, perhaps better known for his description of Dupuytren’s Contracture and his treatment of Napoleon Bonapart’s haemorrhoids, described the differences associated with unconsciousness following traumatic brain injury in individuals sustaining brain contusions compared with those without macroscopic evidence of neural damage. Our understanding of the topic of concussion has come a long way since over the years, and we have now have clear guidelines for the assessment and management of concussion in sport which have been produced by the Concussion in Sport group and published widely, including in CJSM here.

Despite this, controversies still exist such as the possibility of the existence of the ‘second impact’ syndrome, differences in return-to-play protocols based on evidence, and the issue of subsequent morbidity and mortality associated with repeated episodes of concussion in earlier life.

The Concussion to Consequence webinar should help to shed light on some of these controversial issues.

Sign up here to join in.

(Illustration – Baron Guillaume Dupuytren October 5, 1777 – February 8, 1835, available here )

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Ovid Concussion to consequence Webinar – Managing Sport-related Concussion On & Off the Field – Tuesday 18th October 2011 12:00pm EST

September 18, 2011 by 1 Comment

 Many of our readers will be involved on a regular basis with the management of sports participants with concussion, whether that is at the pitch side, at the training ground, or in a secondary or tertiary care environment.

As part of the Ovid webcast series, there is a forthcoming event on the Management of Sport-related Concussion both on and off the field on  Tuesday, October 18, 2011 at 12:00PM Eastern / 9:00AM Pacific time.


Margot Putukian, Director of Athletic Medicine at Princeton University, Past President of the American Medical Society for Sports Medicine, and member of the NFL’s Head, Neck and Spine Committee will be joining John D. Corrigan, Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University and Editor-in-Chief of the Journal of Head Trauma Rehabilitation for a 60 minute discussion on what is known, and what is not known about managing concussion as an acute event – particularly in the context of sports, and as a marker within a person’s lifetime history of effects on brain functioning.

You can register for the Concussion to Consequence Ovid Webcast here.

For those of you who are not familiar with the Ovid Webinars and podcasts, these resources highlight a wide range of current issues in the health sciences and medicine and are well worth checking out. Archived Webinars can be found here, and the iTunes series of Ovid podcasts has free podcast downloads here.

Most of you will be familiar with the Consensus statement on Concussion in Sport from the 3rd International Conference on Concussion in Sport held in Zurich, 2008 which is available in full text online from CJSM, together with appendices including the second full Sports Concussion Assessment Tool (SCAT2) and Pocket SCAT2.

Some questions I have for our blog readers include :

1) How useful do you find the Pocket SCAT2 in practice? What are it’s pros and cons?

2) Are you using SCAT2 as part of preparticipation evaluation baseline screening and, if so, how useful do you find it?

3) What improvements do you think could be made to SCAT2 and the Pocket SCAT2?

CJSM would like to hear your views.

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