Alvaro Pereira lay motionless immediately after colliding with the knee of another player.
Damir Sagolj/Reuters via NYTimes

On Thursday afternoon at World Cup play, a Uruguayan player was hit in the head, inadvertently, by the knee of another player. The player, Alvaro Pereira, lay motionless and apparently unconscious on the pitch whilst the team doctor signaled for a substitution. Pereira came to consciousness and vociferously objected to being taken out of the game. Two minutes layer, Pereira was back out playing. The decision to allow Pereira to continue playing was made by Dr Alberto Pan. Dr Pan appears to be have a freakish talent for conducting speedy neurological examinations. According to the New York Times article referenced above, Dr Pan “completed a full neurological examination … on the sideline and determined [Pereira’s] condition to be ‘normal’.” [My emphasis]

Every year when I teach Medical Neurobiology to Pritzker Medical Students at UChicago, one of my neurologist colleagues comes in to teach “the neurological exam”. The lecture component of this takes a solid 50 mins. The small group practice sessions run roughly 2-3 hours. The neurological exam runs through cognitive function, cranial nerve function (there are 12) and touch and strength testing of spinal nerves (there are many). Obviously an expert can conduct a neurological exam in less time than it takes to either teach or learn it. Nonetheless, I simply do not believe that a full neurological examination can be completed in 2 minutes, even by the most talented and experienced physician.

In this world of cell phone videos, it is curious to me that no video of Dr Pan’s neurological examination of Mr Pereira has surfaced. Such a video could confirm or rebut my skepticism.

Obviously, Mr Pereira’s returning to play was a bad decision. Taking Mr Pereira’s objections to coming out of the game into account in any way and to any extent was another mistake. Finally, putting the decision in the hands of a physician paid by the team is non-sensical. We need evaluations of head injuries conducted by independent medical personnel.

In the wake of this incident, FIFPro, which is the union for football (aka soccer in American English) players across the globe, came out with a strong statement saying that players need to be protected, even from themselves. I am impressed that FIFPro has its constituents’ true best interests in mind. I am sure that readers will correct me if I am wrong but I have not seen the players’ associations for MLB, NBA, NHL, and NFL take such a stance. FIFPro deserves a great deal of credit for pushing FIFA (the governing body for world football) to act in the players’ best interest, even if active players themselves don’t hold the same views as the union.

The continued botching of treating head injury in athletes, particularly high-level (college, professional, Olympic, and in some cases high school) athletes where a great deal of money and/or pride/reputation is at stake, is absolutely shocking.

In this post, I want to emphasize the importance of head trauma over concussion as the event that triggers an athlete’s removal from competition. As stated in a recently published report from the National Academy of Sciences:

“because of the natural evolution of concussions, not all concussed athletes will be identified at the time of (presumed) injury even when personnel trained in concussion recognition are present (McCrory et al., 2013b). Duhaime and colleagues (2012) found that 50 percent of a sample of collegiate athletes who sustained a diagnosed concussion (with athletic trainers present for all games and practices) did not experience an “immediate or near immediate” onset of symptoms.”

What this means is that concussions naturally develop (evolve is the word used in the above quote) over time. Because of this “natural history,” concussions are often not evident immediately after the causative head trauma. Exactly this scenario occurred in 2013. Jeremy Kerley was hit on the head, sending his helmet flying. He was taken to the locker room where he passed a concussion test. He passed another such test immediately following the game’s conclusion. However on the next day, Mr Kerley started to show symptoms and was indeed found to have suffered a concussion which prevented him from playing the following week’s game. In conclusion, it appears that not even the most thorough and meticulous neurological examination performed in the best of circumstances (a quiet environment) could uncover every concussion; some concussions take time to develop.

The second reason that I believe that evidence of head trauma (rather than concussive symptoms) should trigger an athlete’s removal from competition is that repeated sub-concussive events appear to harm the brain and may bring on CTE. Sub-concussive events are often termed mild traumatic brain injury or MTBI.

The evidence that repeated sub-concussive hits may cause CTE down the road in some individuals is less conclusive than the evidence that repeated concussions can lead to CTE. One way that this issue has been studied is to look at the effects of heading in football (aka American soccer). The recently published report from the National Academy of Sciences considers a number of studies looking at the relationship between heading (in which the player “hits” the ball with the head) and cognitive function. Interestingly, older studies conducted when the ball was heavier (by up to ~20% due to greater water absorption) found that heading was associated with cognitive impairment whereas newer studies (with a lighter ball) have not found this association.

Another reason to suspect that repeated MTBI, which does not cause frank concussion, is dangerous comes from several cases of CTE in young individuals with no reported history of concussion:

• Justin Strzelczyk (NFL player): “Mary Strzelczyk did not recall her son’s having any concussions in high school, college or the N.F.L., and published Steelers injury reports indicated none as well.” – from NYT article
• Chris Henry (NFL player) who died at age 26 in a bizarre incident in which he fell out of a pickup truck driven by his fiance with whom he was fighting. Henry had never had a concussion during either his college or professional career according to several reports.
• Owen Thomas (college American football player) committed suicide at age 21. “Thomas never had a diagnosis of a concussion on or off the football field or even complained of a headache, his parents said, although they acknowledged he was the kind of player who might have ignored the symptoms to stay on the field.” – from NYT article 

Proving that these young people never ever had had a concussion is impossible at this point. As Mr Thomas’ parents say, most players at such a high level are highly motivated to play on. Many may indeed have hid concussive symptoms. Nonetheless, these cases give one pause. Further, the Boston University CTE Center, a leader in the study and understanding of the long-term consequences of head trauma on the brain, states:

“Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in people with a history of repetitive brain trauma, including symptomatic concussions as well as subconcussive hits to the head that do not cause symptoms.” [My emphasis]

It is my personal view that the evidence supports the idea that head trauma does not have to cause a concussion to potentially set a person on the road for cognitive decline and possibly CTE. In conclusion, here is my if-I-were-running-the-world-manifesto:

• Head trauma is the event that triggers an athlete’s removal from competition.
• Signs of concussion are not required for an athlete to be removed from competition.
• Evaluation of individuals who have suffered from head trauma is conducted by independent physicians in a quiet and calm environment away from the field of play and preferably after a delay of 12-24 hours.

I don’t know if or when organized sports will come to its senses and treat head trauma with the seriousness that it deserves, without waiting for the sometimes-relevant-sometimes-not-relevant and sometimes-accurate-sometimes-not-accurate assessment of whether a concussion has occurred. But I surely hope that that day comes very soon.

Thanks to Iboro Umana for first alerting me to this story.