The NFL's New Concussion Guidelines Are a "False Start"

The recent high-profile on-field injury of Miami Dolphins quarterback Tua Tagovailoa on September 25, 2022, prompted the release of a modified concussion protocol from the National Football League on October 8th. As amended, the revisions now mandate ataxia–defined as “an abnormality of balance/stability, motor coordination, or dysfunctional speech”–as a “no-go” symptom for determining the removal of a player from play. The change is a worthwhile addition but also falls far short of protecting players from the psychiatric aftermath of these aggressive biomechanical injuries.

Clinical signs and symptoms of concussion are broad in scope. Some are immediately observable with quick onsets, such as loss of consciousness, hypersensitivity to external stimuli such as light or sound, and impaired or stumbling gait.

Others, including cognitive dysfunction, are often more subtle. Historically, sideline assessment of athletes after concussion has included neurological examination and tests of memory, calculation, and other areas of neurocognition. However, behavioral manifestations such as personality changes, agitation, impulsivity, and aggressivity are largely overlooked as a component of return-to-play assessments.

H3 psychiatric disorders are common after concussion and adversely impact the quality of life.

Emerging data clearly shows an increased risk of psychiatric disorders after a concussion. One 2022 study in the Journal of Neurotrauma found that men who sustained a concussion showed increased rates of depression 180 days after the initial assessment, regardless of whether the injury resulted in a loss of consciousness. However, suicidal ideation was more evident in both men and women who experienced a loss of consciousness.

The development of mental health problems such as depression is directly tied to lower self-reported quality of life and identified among former NFL players who sustained repeated concussive injuries during their careers.

Children and adolescent student-athletes may be especially at risk for post-concussion sequelae. A March 2022 study in JAMA evaluating over 400,000 children between the ages of five and eighteen with a concussion and orthopedic injuries revealed that sustaining a concussion increased the risk of future self-harming behaviors by 49 percent and the need for psychiatric hospitalization by 47 percent.

Psychiatric risk factors may help predict the sequelae of concussion injury.

Can these undesirable mental health outcomes be predicted on the sidelines? Data suggest that psychiatric history may inform return-to-play decisions. In a 2021 study examining the longevity of psychiatric sequelae among concussed children and adolescents, the presence of a preinjury psychiatric disorder (e.g., bipolar disorder) predicted ongoing psychiatric illness well into adulthood and as much as 24 years following the initial injury. Extensive family history of mental illness and low socioeconomic status is associated with an increased risk of psychiatric illness after a concussion, even when a personal history is absent.

A certain frequency of concussions is inevitable in high-contact sports. But the focus of sideline assessments in professional sports has repeatedly been driven by whether it is safe to return to play. A more conservative strategy that involves sidelining athletes as a precaution based on other predictors of poor post-concussive outcomes besides neurological status will be met with criticism. Professional athletes attain high compensation to fulfill the premise that “the game must go on” cherished by cultural fandom.

In many instances, the incentive to remain in play surpasses any logic of pulling a player off the field. But this myopic view that it is only the game that counts–and not a player’s later quality of life–has distal repercussions. When one considers that professional athletic associations like the NFL could invoke such guidelines to derive standards of care in other settings, such as high school and collegiate athletes, the risk of undue future psychiatric harm to players becomes substantial.

Buried in the NFL’s newly modified protocol is the recommendation that an examiner attends to “subtle deficits in personality and behaviors that can occur with concussive injury” as a component of decision-making when a player performs favorably on the Locker Room Comprehensive Concussion Assessment outlined in the document.

But using a behavioral or psychiatric screen for predictors of post-concussive sequelae should be more than an afterthought. Incorporating these data points do not replace existing practices of comprehensive neurological assessment on the sideline. However, professional and student-athletes would benefit from their consideration when evaluating the long-term risks of returning to play.