Medical professionals in many big-time college football programs are using deliberately vague language about head injuries or avoiding mention of concussions on injury reports as public scrutiny of the problem has increased.
Those moves allow teams more leeway in returning injured athletes to the field if their symptoms improve, but they also cast doubt on the accuracy of colleges’ reporting on how often players suffer concussions.
As more states have required mandatory rest times for minors following a diagnosed concussion, and coaches have exerted pressure to return concussed players to action as soon as possible, medical officials who work with college teams say they have become reluctant to put a label on head injuries.
Part of the responsibility, the officials say, lies with the players. Athletes don’t want to miss games, so many of them play down or hide their symptoms. Some athletes who are diagnosed with a concussion don’t want the information publicized, seeing it as a black mark on their records.
“There is no question that if you have on the books a law that says a student-athlete suspected of concussion must be removed until they’re cleared by a licensed health-care provider, that kind of law is going to drive some concussions underground,” says Jeffrey S. Kutcher, an associate professor of neurology at the University of Michigan at Ann Arbor and director of its NeuroSport Program. “You see people not wanting to use the C-word because it counts against them in some way.”
Team physicians and athletic trainers insist that any lack of disclosure has not harmed player care. Taking a cautious approach to diagnosing head injuries, they say, is more medically accurate and has allowed them the flexibility to treat athletes on the basis of their individual needs.
Brian Hainline, chief medical officer of the National Collegiate Athletic Association, says he doesn’t blame colleges for their response. Policies governing players’ return to competition, says Dr. Hainline, a neurologist, can sometimes feel too prescriptive: “Individualized care always wins out over protocol.”
“If someone only has a headache and it’s gone in a day,” Dr. Hainline adds, “why would I keep them out a week?”
Medical professionals say their hesitancy to document concussions stems in part from the difficulty of diagnosing the injury. They are also concerned about liability. In recent years, many players have sued over their treatment following concussion, and medical officials say they must be more careful than ever with their written records of players.
Colleges are also routinely second-guessed on their response to potential head injuries, which has led some institutions to take unusual steps to conceal their concussion-management efforts.
After football players at Virginia Tech take big hits during games, the university’s medical staff performs a series of concussion tests on the sidelines, says P. Gunnar Brolinson, the team’s head physician.
But before evaluating for concussion, he says, his staff members often look as well at a player’s shoulder, knee, or back, even if the player did not appear to suffer an injury there.
Those exams, Dr. Brolinson says, are intended to distract television commentators and fans, who have become more vocal in their criticism of medical treatment. The approach allows more time to perform a full medical evaluation.
“There are so many cameras and so many people with cellphones and high-powered personal cameras, you never know who’s taking pictures of you or filming you,” he says. “We want to make the right diagnosis for the athlete and communicate to the coaching staff. But we don’t want to be immediately communicating something, and three to four hours later, what we thought was one thing turned out to be not as bad.”
Increasing Awareness
The number of reported concussions in major-college football has increased steadily in recent years. During the 2013-14 season, the most recent year for which data are available, football programs in the NCAA’s top level reported an average of 6.5 concussions per team, up from 4.7 in 2011-12, according to figures that Dr. Hainline provided to The Chronicle.
The numbers come from the Datalys Center for Sports Injury Research and Prevention, which conducts the NCAA’s injury-surveillance program, using information that colleges submit. Colleges typically do not report those numbers publicly.
The number of concussions per 1,000 “athlete exposures"—with one practice or game equaling an exposure—has also gone up slightly. In 2013-14, there were 1.1 concussions per 1,000 athlete exposures in the biggest 125 or so football programs; the year before that, there were 0.9.
Dr. Hainline says the increases are to be expected because of all the attention to mild traumatic brain injury.
“The culture is shifting. Kids are much more willing to report concussions, coaches are much more willing to say, ‘You have to report concussions,’ and athletic trainers and physicians are much more on the lookout for concussions,” he said. “In the past, when someone took a head hit and developed a headache, that might not have been considered a concussion, whereas today it would be.”
Colleges report some concussions publicly, but those injuries almost always represent a small fraction of what they report to the NCAA’s injury-monitoring program. The biggest football programs publicly reported 143 concussions this past season, some 30 percent fewer than in the previous season, according to data collected by Timothy Bella, a reporter for Al Jazeera America. Over the past two years, he has tracked the concussions reported publicly by the 126 largest NCAA institutions.
Within the five most powerful conferences, 29 programs did not report any concussions this past season, according to his research, which is based on teams’ injury reports, NCAAFootball.com, and news reports. Colleges are not required to report injuries publicly, and some say there are competitive reasons for not doing so.
According to Al Jazeera, the University of Nebraska at Lincoln reported no concussions on its football team this season. But Arthur Maerlender, a neuropsychologist who analyzes head injuries for the athletic department, says the team had at least 10. Lonnie S. Albers, director of athletic medicine, had no comment on the discrepancy.
Over all, athletes are more likely than in the past to report a concussion to the doctor, says Mr. Maerlender, director of clinical research at the university’s Center for Brain, Biology and Behavior, a leading center for the study of brain function. “But there are still places and coaches that think concussions are a bunch of baloney.”
When asked how many concussions the Huskers’ football program has had in recent years, Dr. Albers declined to say.
“All this stuff is pretty sensitive,” Mr. Maerlender says. “People are really concerned about how they are perceived.”
Muddied Reporting
The variety of ways that colleges diagnose and report head injuries, and the lack of uniformity in accounting for players’ exposure to potential concussions, further muddies institutions’ reporting.
A recent survey of colleges in the Big Ten and in the Ivy League, which have a research collaboration focused on traumatic brain injury, found that six of the 22 institutions do not use the Sport Concussion Assessment Tool 3 (SCAT3), the assessment protocol used by the majority of colleges. (The six institutions use different tools instead.)
Concussions are notoriously difficult to define and to diagnose. Because they cannot be confirmed with an objective test—they require a clinical diagnosis—there is a certain amount of error in reporting, several physicians said.
What may at first appear to be a concussion may be something else, says Dr. Brolinson, of Virginia Tech. For example a player who comes off the field reporting dizziness might be dehydrated or overheated.
“Obviously, you’re playing football, so you’re getting hit in the head,” he says. “Well, is that a concussion or heat injury? Weak and wobbly can mean a lot of things.”
Immediately following a suspected head injury, he says, he and his staff often note a general description of the problem, such as “head,” rather than providing a more specific diagnosis. If a head injury becomes clearer, he says, he will use more-definitive language. “Once you get to concussion, you say, ‘concussion.’ "
Other medical officials say that while they inform coaches about players’ concussions, they rarely do so in writing.
“I’ve stopped putting down a diagnosis on injury reports,” said one athletic trainer with more than 20 years of experience, who insisted on anonymity out of fear about how his actions would be perceived. “‘I’ll talk about it, but I won’t put it down on paper.”
Dr. Brolinson, a past president of the American Osteopathic Academy of Sports Medicine, says he does not believe that there’s a “big conspiracy” to hide concussions. “But there’s no doubt that there’s some sleight of hand and subterfuge going on.”
A Stigma to Labels
Many athletes are motivated to play down head injuries because they don’t want to be seen as damaged goods, says Randy Cohen, associate athletics director for medical services at the University of Arizona and chair of the college and university committee of the National Athletic Trainers’ Association.
“Now everyone wants to label, label, label, and there’s a stigma to labels,” he says. “If all of a sudden you have this label and you’ve got these concussions and you’re trying to go to the NFL, you’re out.”
The heightened media exposure has led to a “frenzy” of concerns that concussions can cause degenerative brain disease, says Dr. Hainline, of the NCAA. He hopes that new research, some of which the association has helped finance, will prove otherwise.
“If you look over a multitude of years, yeah, people do recover,” he says. “But we have to prove that.”
Dr. Hainline says he is working to create a better definition of concussion as part of a research partnership with the Defense Department. One idea is to come up with a “stage definition” of the injury—Stage 1, Stage 2, and so on—that would more clearly signify the severity.
“That way, you come out and you say, ‘I know exactly what that means,’ " he says. “That’s the way we have to move.”
Dr. Kutcher, of Michigan, has tried to be clearer in defining head injuries. He has created three categories of concussion: “possible,” “probable,” and “definite.”
He would like to see other programs adopt the same language. But some people are still looking for absolutes, he says.
“The world doesn’t see it that way. You’re either concussed or you’re not, yes or no,” he says. Acknowledging gray area “sounds like a cop-out, like you’re hedging your bet.”
But more-detailed language, he says, would be better than masking the problem.
“I don’t prescribe to checking fake injuries or doing things that aren’t real,” he says. “I say accept the uncertainty and be more accurate.”
Brad Wolverton is a senior writer who covers college sports. Follow him on Twitter @bradwolverton.
