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Sport-Related Neurotrauma and Neuroprotection: Are Return-to-Play Protocols Justified by Paternalism?

Abstract

Sport-related neurotrauma annually affects millions of athletes worldwide. The return-to-play protocol (RTP) is the dominant strategy adopted by sports leagues and organizations to manage one type of sport-related neurotrauma: concussions. RTPs establish guidelines for when athletes with concussions are to be removed from competition or practice, and when they can return. RTPs are intended to be neuroprotective, and to protect athletes from some of the harms of sport-related concussions, but there is athlete resistance to and noncompliance with RTPs. This prompts consideration of whether RTPs, as employed in adult, professional sports, are paternalistic, and if they are, whether they are objectionably so. If RTPs are uniquely effective at protecting current or future athlete autonomy, they might be justified by paternalism. I conclude that RTPs are paternalistic in their effects, but are not adequately justified, and thus they are objectionable.

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Notes

  1. The term “sport-related neurotrauma” will be used to refer to any mild traumatic brain injury related to sports, such as concussions and sub-concussive trauma. The risk of severe traumatic brain injury certainly exists in sports, but will not be addressed in this paper, as RTP protocols are not relevant to management of severe traumatic brain injuries.

  2. “Football” in this paper refers to American-style tackle football.

  3. The ostensible function of RTP protocols is to enforce or allow the period of rest for symptomatic athletes. As there is little evidence supporting the effectiveness of rest, it is questionable whether RTP protocols are effective for managing concussions.

  4. See footnote 3

  5. I have elsewhere considered appropriate strategies for preventing and managing sport-related concussion in youth sports [25, 59].

  6. Following two incidents in the 2013–14 season, in which players allegedly returned to play against medical advice, the NFL proposed enacting fines for players (but not teams) who violate the league’s “Madden Rule.” This proposal indicates that for the NFL, the onus is on players, and not teams or team medical personnel, to enforce “no go” judgments. [60]

  7. At other levels of football, for example, more diligent reporting and better diagnosis has resulted in a pronounced uptick in reported concussions. Rosenthal et al. found that concussion rates doubled among high school football players in a comparison between the 2005–2006 and 2011–2012 seasons, a period during which concussion education and awareness became more prevalent [61].

  8. Muratore concludes that the culture is such that “We have to protect players from themselves” [38].

  9. A recent lawsuit filed on behalf of retired NFL players charges that teams illegally distributed addictive painkillers to players to conceal injuries and mask pain [40]. A significant number of players report having been coerced to play—with the assistance of illegally provided drugs—while injured [41].

  10. Thanks to an anonymous referee for pointing me to this interesting debate.

References

  1. Daneshvar, Daniel H., Christopher J. Nowinski, Ann McKee, and Robert C. Cantu. 2011. The epidemiology of sport-related concussion. Clinics in Sports Medicine 30(1): 1–17.

    Article  Google Scholar 

  2. Greenwald, Richard M., Joseph T. Gwin, Jeffrey J. Chu, and Joseph J. Crisco. 2008. Head impact severity measures for evaluating mild traumatic brain injury risk exposure. Neurosurgery 62(4): 789–98.

    Article  Google Scholar 

  3. McKee, Ann C., Robert C. Cantu, Christopher J. Nowinski, E. Tessa Hedley-Whyte, Brandon E. Gavett, Andrew E. Budson, Veronica E. Santini, Hyo-Soon Lee, Caroline A. Kubilus, and Robert A. Stern. 2009. Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. Journal of Neuropathology and Experimental Neurology 68(7): 709–735.

    Article  Google Scholar 

  4. McKee, Ann C., Thor D. Stein, Christopher J. Nowinski, Robert A. Stern, Daniel H. Daneshvar, Victor E. Alvarez, Hyo-Soon Lee, et al. 2013. The spectrum of disease in chronic traumatic encephalopathy. Brain 136(1): 43–64.

    Article  Google Scholar 

  5. Omalu, Bennet I., Julian Bailes, Jennifer Lynn Hammers, and Robert P. Fitzsimmons. 2010. Chronic traumatic encephalopathy, suicides and parasuicides in professional american athletes: the role of the forensic pathologist. The American Journal of Forensic Medicine and Pathology 31(2): 130–132.

    Article  Google Scholar 

  6. Stern, Robert A., David O. Riley, Daniel H. Daneshvar, Christopher J. Nowinski, Robert C. Cantu, and Ann C. McKee. 2011. Long-term consequences of repetitive brain trauma: chronic traumatic encephalopathy. Physical Medicine and Rehabilitation 3(10): S460–S467.

    Google Scholar 

  7. Gavett, Brandon E., Robert A. Stern, and Ann C. McKee. 2011. Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clinics in Sports Medicine 30(1): 179–188.

    Article  Google Scholar 

  8. McCrory, Paul, Willem H. Meeuwisse, Mark Aubry, Bob Cantu, Jiří Dvořák, Ruben J. Echemendia, Lars Engebretsen, et al. 2013. Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. British Journal of Sports Medicine 47(5): 250–258.

    Article  Google Scholar 

  9. Talavage, Thomas M., Eric A. Nauman, Evan L. Breedlove, Umit Yoruk, Anne E. Dye, Katherine E. Morigaki, Henry Feuer, and Larry J. Leverenz. 2014. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. Journal of Neurotrauma 31(4): 327–338.

    Article  Google Scholar 

  10. Prichep, Leslie S., Michael McCrea, William Barr, Matthew Powell, and Robert J. Chabot. 2013. Time course of clinical and electrophysiological recovery after sport-related concussion. The Journal of Head Trauma Rehabilitation 28(4): 266–273.

    Article  Google Scholar 

  11. Dettwiler, Annegret, Murali Murugavel, Margot Putukian, Valerie Cubon, John Furtado, and Daniel Osherson. 2014. Persistent differences in patterns of brain activation after sports-related concussion: a longitudinal functional magnetic resonance imaging study. Journal of Neurotrauma 31: 180–188.

  12. Tremblay, Sara, Vincent Beaulé, Sébastien Proulx, Sébastien Tremblay, Malgorzata Marjánska, Julie Doyon, Maryse Lassonde, and Hugo Théoret. 2014. Multimodal assessment of primary motor cortex integrity following sport concussion in asymptomatic athletes. Clinical Neurophysiology 125: 1371–1379.

    Article  Google Scholar 

  13. Gosselin, Nadia, Martin Thériault, Suzanne Leclerc, Jacques Montplaisir, and Maryse Lassonde. 2006. Neurophysiological anomalies in symptomatic and asymptomatic concussed athletes. Neurosurgery 58(6): 1151–1161.

    Article  Google Scholar 

  14. Miller, Franklin G., and Alan Wertheimer. 2007. Facing up to paternalism in research ethics. Hastings Center Report 37(3): 24–34.

    Article  Google Scholar 

  15. Guskiewicz, K.M., S.W. Marshall, J. Bailes, M. McCrea, R.C. Cantu, C. Randolph, and B.D. Jordan. 2005. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery 57(4): 719–726.

    Article  Google Scholar 

  16. Weinbaum, William and Steve Delsohn. 2013. Dorsett, others show signs of CTE. ESPN Outside the Lines. http://espn.go.com/espn/otl/story/_/id/9931754/former-nfl-stars-tony-dorsett-leonard-marshall-joe-delameilleure-show-indicators-cte-resulting-football-concussions. Accessed 12 March 2014.

  17. Schwarz, Alan. 2010. Suicide reveals signs of a disease seen in N.F.L. The New York Times, 14 September: A1.

  18. Caron, Jeffrey G., Gordon A. Bloom, Karen M. Johnston, and Catherine M. Sabiston. 2013. Effects of multiple concussions on retired national hockey league players. Journal of Sport and Exercise Psychology 35(2): 168–179.

    Google Scholar 

  19. O’Neill, Onora. 1984. Paternalism and partial autonomy. Journal of Medical Ethics 10(4): 173–178.

    Article  Google Scholar 

  20. Buchanan, Allen E., and Dan W. Brock. 1990. Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  21. McCrory, P., A. Collie, V. Anderson, and G. Davis. 2004. Can we manage sport related concussion in children the same as in adults? British Journal of Sports Medicine 38(5): 516–519.

    Article  Google Scholar 

  22. McCrory, Paul. 2001. Does second impact syndrome exist? Clinical Journal of Sport Medicine 11(3): 144–149.

    Article  Google Scholar 

  23. Bey, Tareg, and Brian Ostick. 2009. Second impact syndrome. Western Journal of Emergency Medicine 10(1): 6–10.

    Google Scholar 

  24. McCrory, Paul R., and Samuel F. Berkovic. 1998. Second impact syndrome. Neurology 50(3): 677–683.

    Article  Google Scholar 

  25. Johnson, L. Syd M. 2012. Return to play guidelines cannot solve the football–related concussion problem. Journal of School Health 82(4): 180–185.

  26. Mayers, Lester. 2008. Return-to-play criteria after athletic concussion: a need for revision. Archives of Neurology 65(9): 1158–1161.

    Article  Google Scholar 

  27. Batjer, Hunt and Richard Ellenbogen. 2011. Memo: NFL concussion guidelines. NFLevolution.com. http://www.nflevolution.com/wordpress/wp-content/uploads/2012/08/nfl-hns-memo-2011v2.pdf. Accessed 29 May 2014.

  28. National Football League. 2014. NFL Sideline Concussion Assessment Tool. NFL.com http://static.nfl.com/static/content/public/photo/2014/02/20/0ap2000000327062.pdf. Accessed 27 May 2014.

  29. National Football League. 2009. NFL adopts stricter statement on return-to-play following concussions. http://www.nflevolution.com/wordpress/wp-content/uploads/2013/03/nfl_adopts_stricter_statement_on_return-to-play_following_concussions-508.pdf. Accessed 14 March 2014.

  30. Breslow, Jason M. 2014. NFL concussions: The 2013–14 season in review. Frontline. http://www.pbs.org/wgbh/pages/frontline/sports/concussion-watch/nfl-concussions-the-2013-14-season-in-review/. Accessed 14 March 2014.

  31. National Football League. Super Bowl XLVIII Health & Safety Press Conference. 2014. http://nfllabor.files.wordpress.com/2014/01/hs-press-conference.pdf. Accessed 14 March 2014.

  32. Breslow, Jason M. 2014. What we’ve learned from 2 years of tracking NFL concussions. Frontline. http://www.pbs.org/wgbh/pages/frontline/sports/concussion-watch/what-weve-learned-from-two-years-of-tracking-nfl-concussions/. Accessed 12 March 2014.

  33. Sporting News Staff. 2012. NFL concussion poll: 56 % of players would hide symptoms to stay on field. Sporting News. http://www.sportingnews.com/nfl/story/2012-11-11/nfl-concussions-hide-symptoms-sporting-news-midseason-players-poll.Accessed 13 March 2014

  34. Keim, John. 2014. Most would play SB with concussion. ESPN.com. http://espn.go.com/nfl/story/_/id/10358874/majority-nfl-players-play-super-bowl-concussion-espn-survey. Accessed 14 March 2014.

  35. Barzilai, Peter and Erik Brady. 2014. Knee injuries worry NFL players more than concussions. USA Today. http://www.usatoday.com/story/sports/nfl/2014/01/27/nfl-players-injury-survey-knee-head-concussions/4918341/. Accessed 13 March 2014.

  36. Reilly, Rick. 2011. Talking football with Archie, Peyton, Eli. ESPN. http://sports.espn.go.com/espn/news/story?id=6430211. Accessed 1 March 2014.

  37. Torres, Daniel M., Kristin M. Galetta, H. Westley Phillips, E. Mark, S. Dziemianowicz, James A. Wilson, Emily S. Dorman, Eric Laudano, Steven L. Galetta, and Laura J. Balcer. 2013. Sports-related concussion: anonymous survey of a collegiate cohort. Neurology: Clinical Practice 3(4): 279–287.

    Google Scholar 

  38. Crawley, Paul. 2014. Wake-up call: Rugby league concussion culture has to change says head doctor. The Daily Telegraph. http://www.dailytelegraph.com.au/sport/nrl/wakeup-call-rugby-league-concussion-culture-has-to-change-says-head-doctor/story-fni3fbgz-1226852942110. Accessed 13 March 2014.

  39. Goldberg, Daniel S. 2008. Concussions, professional sports, and conflicts of interest: Why the national football League’s current policies are bad for its (players’) health. HEC Forum 20(4): 337–355.

    Article  Google Scholar 

  40. Maese, Rick. 2014. Lawsuit: NFL pushed drugs on players. The Washington Post 20 May 2014. http://www.washingtonpost.com/sports/redskins/lawsuit-nfl-pushed-drugs-on-players/2014/05/20/7148e190-e068-11e3-9442-54189bf1a809_story.html. Accessed 27 May 2014.

  41. Jenkins, Sally and Rick Maese. 2013. Pain and pain management in NFL spawn a culture of prescription drug use and abuse. The Washington Post. 13 April 2013. http://www.washingtonpost.com/sports/redskins/pain-and-pain-management-in-nfl-spawn-a-culture-of-prescription-drug-use-and-abuse/2013/04/13/3b36f4de-a1e9-11e2-bd52-614156372695_story.html. Accessed 28 May 2014

  42. Levy, Neil. 2012. Forced to be free? increasing patient autonomy by constraining it. Journal of Medical Ethics. doi:10.1136/medethics-2011-100207.

    Google Scholar 

  43. Audi, Robert (ed.). 1995. The Cambridge dictionary of philosophy 2e. Cambridge: Cambridge University Press.

    Google Scholar 

  44. Millspaugh, J. A. 1937. Dementia pugilistica. US Naval Medical Bulletin 35: 297Y303.

  45. Martland, Harrison S. 1928. Punch drunk. Journal of the American Medical Association 91(15): 1103–1107.

    Article  Google Scholar 

  46. Leclerc, S., and C.D. Herrera. 1999. Sport medicine and the ethics of boxing. British Journal of Sports Medicine 33(6): 426–429.

    Article  Google Scholar 

  47. Herrera, C.D. 2002. The moral controversy over boxing reform. Journal of the Philosophy of Sport 29(2): 163–173.

    Article  Google Scholar 

  48. Patterson, Russel H. 1986. On boxing and liberty. Journal of the American Medical Association 255(18): 2481–2482.

    Article  Google Scholar 

  49. Warburton, Nigel. 1998. Freedom to box. Journal of Medical Ethics 24(1): 56–60.

    Article  Google Scholar 

  50. Husak, Douglas N. 1981. Paternalism and autonomy. Philosophy & Public Affairs: 27–46

  51. Pound, Richard. 2004. Remarks by WADA President Richard Pound at AAS annual meeting February 11, 2004. World Anti-Doping Association. http://www.wada-ama.org/en/Media-Center/Archives/Articles/Remarks-by-WADA-President-Richard-W-Pound-at-AAAS-annual-meeting/#. Accessed 15 May 2014.

  52. Wamplew, Wray. 2007. Playing with the rules: influences on the development of regulation in sport. The International Journal of the History of Sport 24(7): 843–871.

    Article  Google Scholar 

  53. Torres, Cesar R. 2000. What counts as part of a game?A look at skills. Journal of the Philosophy of Sport XXVII: 81–92.

    Article  Google Scholar 

  54. Tamburrini, Claudio. 2011. What’s wrong with J.S. Mill’s “harm-to-others” principle? Journal of the Philosophy of Sport 38: 1–26.

    Article  Google Scholar 

  55. Weimer, Steven. 2012. Consent and right action in sport. Journal of the Philosophy of Sport 39(1): 11–31.

    Article  Google Scholar 

  56. Weimer, Steven. 2013. Consent, context, and obligations: a response to Ciomaga. Journal of the Philosophy of Sport 41(2): 233–245.

    Article  Google Scholar 

  57. Ciomaga, Bogdan. 2013. Rules and obligations. Journal of the Philosophy of Sport 40(1): 19–40.

    Article  Google Scholar 

  58. Fraleigh, Warren P. 2003. Intentional rules violations. Journal of the Philosophy of Sport 30(2): 166–176.

    Article  Google Scholar 

  59. Johnson, L. Syd M. 2011. Concussion in youth ice hockey: It’s time to break the cycle. Canadian Medical Association Journal 183(8): 921–924.

    Article  Google Scholar 

  60. Farrar, Doug. 2014. NFL could fine players for violating concussion protocol. Sports Illustrated. http://nfl.si.com/2014/01/16/nfl-concussion-protocol/. Accessed 3 June 2014.

  61. Rosenthal, Joseph A., Randi E. Foraker, Christy L. Collins, and R. Dawn Comstock. National high school athlete concussion rates from 2005–2006 to 2011–2012. 2014. The American Journal of Sports Medicine doi:10.1177/0363546514530091.

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Johnson, L.S.M. Sport-Related Neurotrauma and Neuroprotection: Are Return-to-Play Protocols Justified by Paternalism?. Neuroethics 8, 15–26 (2015). https://doi.org/10.1007/s12152-014-9213-4

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Keywords

  • Return-to-play
  • Sports
  • Concussion
  • Neurotrauma
  • Paternalism
  • Autonomy
  • Consent
  • Football
  • CTE