Who Should Clear a Student Athlete to Play Following a Concussion?

As the revenue generated by income-producing sports continues to grow, so does the pressure to win. That pressure too often translates into keeping the best players on the field, even after an injury. For years, coaches advised players to "play through the pain" and sent them back into the game after they sustained a concussion. Even now, some coaches discount evidence that players are at risk of disabling, life-changing injuries if they return to play before a brain injury has healed.

Athletic trainers who should know better sometimes defer to the coach's desire to return a player to the field when the player may have a concussion. Coaches often choose their own training staff. As revenues have increased, so have the salaries of athletic trainers. The fear of losing a lucrative job creates a conflict of interest for an athletic trainer who must choose between the coach's desire to win and the best interests of the student athlete. Given that conflict, it is reasonable to ask whether trainers or staff members working under a coach's direction should be empowered to clear a student athlete to return to play.

Trainers Under Pressure

A 2013 survey of more than one hundred head athletic trainers and other sports medicine professionals working with major NCAA football programs provides evidence of the conflicts they face. More than half reported that they have felt pressure to clear concussed student-athletes to return to play before they were medically ready.

The survey, conducted by the Chronicle of Higher Education and the National Athletic Trainers' Association, gathered results that were consistent with a 2010 NCAA survey. Nearly half of the schools responding to the NCAA survey admitted returning athletes to the same game after a diagnosis of concussion.

New Guidelines Respond to Hidden Conflicts

The NCAA survey results were recently publicized after a settlement was reached in a class-action lawsuit brought by student athlete victims of brain injuries. The settlement will require the NCAA to implement new guidelines to protect student-athletes who sustain a concussion. It is unclear, however, whether the guidelines will be enforced. According to CBS Sports, the NCAA and its member schools fear they will create liability issues if they make the guidelines enforceable.

The guidelines urge member schools to have medical staff with concussion training present when contact sports are played, and to give those health care providers clear and transparent authority when managing concussed players. Even if a school implements that guideline, the question remains whether the guideline will resolve potential conflicts of interest. The Chronicle found that the Directors of Sports Medicine in some schools report directly to the head coach. If the medical staff depends upon the coach for job security, will medical staff members who have a borderline suspicion that a player sustained a concussion feel pressure to rule out a concussion and return the player to the game? If they diagnose a concussion, will they feel pressure to clear the player to participate in the next game, knowing that the player's brain injury might not have healed?

The Need for Independent Professional Judgment

A concussion researcher from the University of North Carolina told the Chronicle that allowing a coach to supervise or influence medical staff is "asking for trouble." The ultimate victim of that "trouble" is the unfortunate athlete who, having been prematurely cleared to return to play, sustains a second concussion before the first has completely healed. Successive concussions can cause severe injuries that may leave an athlete with permanent brain damage.

A position statement issued by the American Academy of Neurology in 2013 stresses that the decision to return a youth athlete to play should be made by "a licensed health care professional, such as a neurologist, whose scope of practice includes being properly trained in the evaluation and management of concussions." The AAN would apply the same standard to collegiate sports, to sports recognized by high school athletic associations, and to community-based youth and recreational leagues.

Along similar lines, a consensus statement issued by the National Athletic Trainers' Association recommends that athletic trainers work under the direction of the team physician or school medical director. The team physician, in turn, should have "the ultimate authority for making medical decisions regarding the athlete's safe participation" and should be governed only by sound medical judgment.

While the AAN and NATA statements serve the laudable goal of assuring that properly trained professionals make unchallengeable medical decisions to protect players from the risk of further brain injury, they may not go far enough. The NFL now requires independent neurologists to clear concussed players, removing the decision from team physicians who are vulnerable to pressure from their employers. Requiring an independent neurologist to sign off on "cleared to play" decisions involving concussed student athletes would go far to alleviating the conflicts of interest that now plague student sports.