Media Conference Call
With Dr. Jeff Miller, Dr. John York, Dr. Nancy Dreyer, Dr. Elizabeth Nabel, Dr. Richard Ellenbogen, Dr. Robert Heyer, Dr. Matthew Matava
Jan. 29, 2016
Jeff Miller, Senior Vice President of Health and Safety Policy for the National Football League: As part of our regular effort to provide updates on our health and safety effort, including our annual discussion around injury data, we wanted to hold this call and share the most recent injury data that we have received from Quintiles, a third party group that compiles it for us. We also want to offer you the interpretation of that data from a number of medical experts who we talk to on a regular basis as we continue to look for ways to make our game better and safer for those who play it.
I'm joined on the call today, and you'll get a chance to hear from each one of the following people – I'm joined by Dr. John York, the Co-Chairman of the San Francisco 49ers and the Chairman of the NFL owners' committee on Health and Safety. We'll then hear from Dr. Nancy Dreyer, who is the Global Chief of Scientific Affairs and a Senior Vice President at Quintiles. Following Dr. Dreyer we'll hear from Betsy Nabel. She is the NFL Chief Health and Medical Advisor, President of the Brigham and Women's Hospital in Boston and a professor of medicine at Harvard Medical School. Then Dr. Rich Ellenbogen, who is the Co-Chairman of the NFL's Head, Neck and Spine Committee, a professor at the University of Washington and Chairman of their Department of Neurological Surgery. Then we'll hear from two team doctors. Rob Heyer, who has been the Team Internist for the Carolina Panthers for the past 20 years and is the current President of the NFL Physicians Society – that's the medical society comprised of the 32 teams' physicians. Joining Dr. Heyer will be Dr. Matt Matava, who is the immediate and is past President of the NFL Physicians Society and is currently the Chief Medical Officer for the Rams. He's been with the Rams for the past 16 years.
Before we turn it over to Dr. York, I want to make a couple of brief comments. As many of you know, there's been some dynamic changes at the NFL as it relates to the health and safety of our sport and the game. We have added in the past couple of years unaffiliated neurotrama consultants – those are concussion specialists on the sidelines of each game – to assist the team physicians in the screening, review and diagnosis of this injury. We've added athletic trainers in the media box to help spot the injuries and call down to the team physicians when they identify something – everything from the top of the head to the bottom of the foot – that needs to be reviewed by those team physicians. In this past year, we've augmented those rules. As you know, we introduced the medical timeout allowing that independent athletic trainer to stop the game if he sees a player who needs some level of medical attention and isn't receiving it. Those measures have been positive ones and we continue to integrate those elements into our game to assist the medical staff in the jobs that they do. We've also made it a point of emphasis over the last couple of years to work closely with the team medical staff, the trainers and others, to raise the level of education around concussions, specifically the symptoms. We are working with the players and with the coaching staffs to see that they have a better appreciation for this injury and hopefully are more readily available to identify it, and therefore to report it.
With that as background, you'll see in the data that was sent over, that this year we're reporting an increase in concussions in regular season games in the NFL by 58%. We saw an increase over a three-year average – from 2012-2014 – of 26%. We are working closely with the doctors, including many on this call, and independent experts like the committee that [Dr.] Rich [Ellenbogen] runs to identify the factors that would lead to those numbers. We've identified a few so far and you'll hear more about this from the team doctors and others. We know, for example, that we have doubled the number of screenings of players who are being screened for purposes of identifying whether or not they have a concussion. Those athletic trainers in the sky box or those unaffiliated neurotrauma consultants on the sideline are much more actively participating in identifying this injury. We hear from the doctors, and I believe they'll go into this a bit, that we're seeing unprecedented levels of player reporting signs and symptoms of concussions, and the level of education and discussion around this injury from those players and from the coaching staffs and others has increased.
And I think we'll also hear from the team physicians as another one of the factors that we'll continue to explore on this injury that doctors may be putting players into protocol more readily for the purposes of ensuring that their signs or symptoms resolve before their allowed to return to play. So these are factors, these are issues that we're going to pursue and as a matter of practice we spend a great deal of time throughout the year with the focus at the combine with our different medical committees, with the players association, with Dr. Nabel, Dr. York's Committee and others to explore these numbers in great specificity and see what trends we can divine and where we can work to change our game to make it better for the players. We'll work with the competition committee likewise and in the past as you know there has been a number of rule changes – at least 39 – over the last 10 years or so related to the health and safety, such a typical part of what we do and this year will be no different in that regard. We'll pour over these numbers, we'll break them up, we'll talk about them, we'll share them widely and we'll look for a way to continue to improve the health and safety of our sport.
So with that as background I'm going to turn it to Dr. York for his comments.
Dr. York: First an early welcome to the Bay Area and the Super Bowl 50 at Levi's Stadium. As the Chairman of the Owners Health and Safety Committee I can share with you that there is no higher priority at the league than the health and safety of the players. Our committee analyzes the injury data and works collaboratively with our clubs, our medical committees, club medical staffs and the competition committee to explore ways to improve player care. We have worked very closely with Quintiles over the last several years to improve our data collection and surveillance. The addition of the electronic medical records system on the sideline for all clubs significantly enhanced our ability to track, record, and address injuries. Next month at the combine our medical committees with convene and as we do every year we will pour over the injury data to identify areas that need to be addressed. We do this in conjunction with the players association and their medical representatives as well.
Let me give you an example – Last year we identified that concussions occurring in preseason practices were an area where we thought we might be able to make some progress. As a result we identified a number of teams that were seeing the most concussions during these preseason practices. Each of these clubs took the issue very seriously and this year witnessed a drop in the concussion rate in preseason practices across the league by 31%. These changes take time and effort. I believe this year's statistics represent positive culture changes as it relates to reporting concussions. We must uncover whether our players have experienced more concussions this year, and if so why. Self-reporting has occurred more often and there's been an ability to identify concussions in an improved manner. This may also be a mix of factors which we will study. Concussions remain a serious concern for the league and we will continue to implement new policies, protocols and rules to address them. There is much more to do in this area and our work will be guided by the data and by the experts. Thank you.
Jeff Miller: Thank you John. Now let me introduce Dr. Nancy Dreyer with Quintiles to review the injury data.
Dr. Dreyer: Hello everybody. I'm Dr. Nancy Dreyer. I'm an Epidemiologist and the Global Chief of Scientific Affairs at Quintiles and I'm based in Cambridge, Massachusetts. I'm also an adjunct professor of epidemiology at the University of North Carolina at Chapel Hill. Quintiles if you don't know is a Fortune 500 Company. We're best known for our work in bringing new drugs and medical devices to market and for working with clinicians, patients and pairs to understand what treatments work best for which patients and in which circumstances. We've been leading the Injury Surveillance and Analytics program for the NFL since 2011. By way of introduction and before I give you the report for this year I'd like to offer you a couple of quick facts about the program. The NFL Injury Surveillance and Analytic Program records injuries during preseason, training and throughout the regular season and playoffs. In 2015 we started including offseason Injury Surveillance too, so we captured the full gamut of injuries whenever they may occur during the year. We started using electronic data capture in 2012 and switched to an electronic medical record in 2014 and we continue to fine tune the data collection efforts. There is one unusual aspect about the program, which is the extensive efforts we use to ensure a complete and accurate reporting. For example: we regularly compare the counts we get of high priority injuries to what's been reported in the media with the goal of checking for any injuries that might not have been reported to our system yet and we regularly review the data and check with the team medical staff if a players injury record has any information that is unclear or incomplete.
With that said, let's look at the results of our surveillance for the full regular season games for the 2015 season. As you heard from Mr. Miller, the most notable finding this year relates to concussions. There were 182 concussions reported in the regular season games this year compared to 115 in 2014. So that is a one year increase of 58%. But, we know there is always natural variability in the occurrence of illness and injuries, and last year could have been an unusually low year. If you look at a broader period for comparison and take an average of the past three years when we used pretty much the same techniques of data collection then you would say that concussions are up 26% this year, compared to the average of 145 over 2012-14. Is this a real increase? Or, could it be caused by something else? Like more extensive screening, or more sensitive diagnostic testing or more self-reporting.
One way we were able to look at that is simply to look at the number of players called out for evaluation of head & neck injuries. We had screening data for all games in weeks 1-13, for 2014 and 2015. So, looking at that interval, weeks 1-13, we saw more than about twice as many call downs for head and neck injuries from athletic trainers, spotters and sideline staff in 2015 compared to 2014. So if you want to put that as a rate per game, there were 2.8 call downs per game in 2015 compared to 1.4 per game in 2014 for all games were any reports were available. Now we are looking more into the data to see what we can learn. We are also looking to see how we can fine tune data collection, particularly to collect information about the way teams screen players and the diagnostic criteria used for concussions.
Moving on to other high priority injuries of interest. ACLs – there was essentially no change in the regular season in the occurrence of ACL [injuries] this year, compared to last year. Actually, they were slightly fewer ACL injuries this year 2014 in 2015 regular games compared to 27 last year, but, keep in mind, with the natural variability we expect numbers to go up and down and small differences probably are not meaningful unless there is a trend that persists over time
In contrast, MCL [injuries] were slightly up. You look at injuries that would cause the player to be pulled out of the practice or game. We had 110 in 2012 vs 98 in 2014, so up about 12 percent. The majority of that increase was due to partial or incomplete tears of the ligament. So MCLs were up about as much as ACLs were down. And, then the last piece of data I want to offer you relates to Thursday Night games. Now as you know there are not many Thursday Night games and it's hard to draw firm conclusion when there is not much data. With that said, the injury rates are lower on Thursday night compared to games held on Sunday and Monday, and we saw this exact trend in the last three years.
But we actually think it's more meaningful to look at the time between games, the time interval between games. When we look at intervals of four, six and seven days between games, we see similar injury rates, pretty much no difference. Interestingly, when we look at games where teams have longer intervals between games, we see a very small increase in injury rates with those longer time intervals. Thanks very much.
Jeff Miller: Thank you Dr. Dreyer. Now we turn to Dr. Betsy Nabel, who is the NFL Chief Health and Medical Advisor.
Dr. Betsy Nabel: Thank you very much Jeff. I would just make a few comments on the information you've heard from Dr. Dreyer. The depth and breadth of information from Quintiles will serve the league very well as we look for ways to continue to make the game as safe as possible. As we know there has been a lot of increased awareness in the public over the past couple years about injuries, particularly head injuries, particularly in football, and as you've also heard from Mr. Miller earlier today the NFL has increased its health and safety program. It's done through education, through protocols, through rule changes, through the UNC position, the ATC position, the medical timeout and general awareness. So it's not that unusual in medicine to see increased reporting that typically follows increased awareness about a particular condition.
The data today does show an increase in concussions and the NFL is committed to understanding the reasons. Several possibilities include, as you've heard from Dr. Dreyer, increased screening, increased detection, increased self-reporting and potentially an absolute increase in the number of injuries. As you'll hear subsequently from other physicians here on the call, collectively we've begun to see a culture change among the players and the coaches with more attention towards injury and self-reporting. So these are the data and now we seek to understand the reasons. We will clearly continue our efforts to educate the players and those who surround them about the signs and symptoms of concussion and other forms of injury. In working with the owners, the coaches, and the players association, we will continue to evolve the culture to ensure that every player feels comfortable coming forward and we will continue to invest in research and focus on driving innovation that will lead to a better understanding of how we can prevent, diagnose and treat not just head injury, but all injuries as well.
Jeff Miller: Thank you Dr. Nabel. Let's turn now to Dr. Rich Ellenbogen, who as I mentioned is the co-chairman of the NFL's Head Neck and Spine Committee in addition to his roles at the University of Washington.
Dr. Ellenbogen: I don't have prepared remarks per se, but I want to emphasize what has been said so far. Quite frankly, I think that our hypothesis is going to prove correct. Look, we have far better tools in 2015 than we have had before. It's sort of like looking at an issue through a microscope instead of through your bare eyes and I think now we have a microscope. We have the video monitors that we are using all the time and we have eight camera angles so you see things that even the fans can't see. I see the culture change. As an unaffiliated neurotrauma consultant, I see how the the culture has changed. I see coaches report players and pull them out of the game. I see players report themselves. I see players report each other. That is certainly new and different and quite frankly this sort of culture change parallels what we are seeing in youth sports. I work with the team to manage a large youth sports clinic at the University of Washington and Seattle Children's Hospital and we went from seeing hundreds of athletes, student athletes, to thousands. I think this is all good things. I think the education is working. I think we are lowering the threshold. Years ago, you nearly had to be knocked out or knocked out to for it to be called a concussion. Now if a player gets knocked down and the mechanism of injury is such where the head hits the ground and they stagger when they get up the team's physician and athletic trainer will pull that player out to be evaluated. So clearly we've lowered the threshold for diagnosing concussions for pulling players out and evaluating them. We got better tools and we've become, as the education has become more sophisticated, we've become more sophisticated and we're now looking at this through a microscope. I think these are all good trends, they're expected, and I suspect the bottom line is that we're doing the right thing for the player and the players and the game.
Jeff Miller: Thanks, Rich. I'll turn now to two team physicians, first the president of the Physicians Society. And he has priority – first, because he's president and because his team won the NFC. Dr. Rob Heyer with the Carolina Panthers.
Robert Heyer: I would like to highlight a couple of items that we see from the physician's perspective. First, the NFL concussion protocol has been refined over the past two years and we now have a very specific and detailed protocol regarding the evaluation of every player suspected of having a concussion. In addition, the team physicians and the UNCs have developed a very professional, collegial and productive working relationship on the field when involved in diagnosing concussions. Prior to the opening of training camp, an event occurred which had not occurred at every team in the past. All 32 teams were addressed for one hour by the teams' medical staff including the head athletic trainer, the head orthopedist, and medical physicians. The handling of all injuries were discussed with a particular emphasis on concussions. As a result of this education, the players have learned not only information from the classroom but they've seen the consistent implementation of the protocol by the team physicians and the UNCs on the field during the season. This example has led to an increased awareness of the players and coaches regarding the optimal evaluation of our players when they may have a suspected concussion.
As Jeff mentioned, I've been a team physician for 20 years, and one of the items that I've noticed is the self-reporting of concussions a day or two after the game. In the past, players would rarely come forward with any symptoms unless they were feeling very poorly. The self-reporting is I think a unique phenomenon that we're seeing more and more frequently. During the last two years, I've had three players come to the training room a day or so after the game, complaining of a mild headache. In the past, they would've ignored that headache. After appropriate evaluation we did determine that two of the players had suffered a concussion and this allowed us to make the diagnosis, care for them properly, and return them to play safely.
The last item I'd like to mention is similarly underappreciated when the player is in the concussion protocol and they're in the return to play portion of the protocol, the player is evaluated frequently by the medical physician involved, a neuropsychologist, the independent neuro-consultant and the head athletic trainer. All these four individuals are involved in making certain that the player is well and the players understand that we want them to be well before they return to play. I think that the players and coaches understand and appreciate our increased efforts to take care of them, and from a perspective we've had no objections or pushback from any of the coaches or players regarding their health.
Jeff Miller: Thanks Dr. Heyer. Dr. Matava, the head physician with the Rams.
Matthew Matava: I would echo everything that Rob mentioned. I can say that the biggest thing I've noticed over the past 16 years is definitely a culture change. Because a lot of these coaches who we have to address with first, they're ex-players. They never went through a similar protocol when they were players. Now that has changed. As an orthopedic surgeon, just as an example, I've often asked players would they rather injure their knee or would they rather injure their head. To a man, historically, they would rather sustain a concussion and take my chances. Now that is changing. Now they have to hesitate. Now they consider the fact that, with all the information, with all the emphasis we've placed on concussions they consider that option and let it be known that they know that a brain is something they can't reconstruct unlike a knee.
All the education, the changing culture reminds me, several years ago when we had several patients who had MRSA infections. Again, there was a culture change there. The players did not know what that condition was. They were informed through education, through the physicians, through the athletic trainers, through posters from the training room, the coaches were educated, and they, as the time went on, they notified us when they had any sort of skin infection just in case it was MRSA. The same thing I see is happening with concussions. And they get hit in the head, they may not have any symptoms, but they let us know that they got hit in the head. Their co-linemen next to them notifies us when they think something may be awry. And a lot of times, they may not end up having a concussion, which is fortunate for them, but they at least notify us to evaluate them. So again, I think the change in culture has been the biggest thing I've seen over the past three to five years.
Unprecedented level of player reporting, that was mentioned twice so far. Jeff can you or somebody quantify that compared to previous years?
Jeff Miller: I think this is something, John, that's one of the areas we are going to take a closer look at as we talk to team physicians over the course of the year to see if whether we want to put more stringent metrics against that. This is unfortunately at this point, anecdotal, but we do talk to all the team physicians and I suppose Drs. Heyer or Matava can talk to this, and the stories are consistent this year with anecdotes about player self-reporting in ways that they haven't in the past.
Matthew J. Matava, M.D.: I don't have any firm numbers but I can say that it is an observed trend by myself as well as the two internists on my team that take care of the players from the medical side, as well as the athletic trainers. It's just an observation that we noticed over the course of the past season or two.
John York, M.D: Our medical physicians and head athletic trainers have also seen this [trend]. We have had two players who self-reported. One was diagnosed with a concussion, one was not.
Jeff was there any data so far gleaned from the CFL and NFL test this year?
Jeff Miller: We anticipate getting that data presented to our head, neck and spine committee at Combine this year. That was the timeframe we set against it.
So, the researches where working on the Canadian Football League side were compiling and presenting whatever the last details of that are, so we'll be looking at that next month.
There were a couple of incidents, Teddy Bridgewater being one, when he was knocked out on the field and his coach within 24 hours had said he passed the 1st level of protocol. Is the NFL going to consider this offseason instituting a minimum threshold where there is no physical activity or no level passing say, whether it is 48 hours or 72 hours, which does exist many other elements of sports?
Dr. Ellenbogen: You know that's a good question. I have to tell you that the science is changing. To give you an example, there are groups around the country that are starting a more active rehab approach. The thought for years has been that we rest people until they are asymptomatic. And, there is different, another school of thought put forth by many concussion researchers – most notably the group from UPMC – who feel that active rehab yields a quicker and safer return to play.
So, the protocol that exist now is they have to be asymptomatic. You have to remember probably 50 to 80 percent of these concussions resolve by the time the player comes off the field. It's really the minority of the concussions that have more long standing return to play issues. Having said that, we are pretty cautious and conservative. The average time that a player is out ranges anywhere from 10-12 days. There is an entire range of it. So, the thought that people are coming back quicker is just factually not true. And, the idea that you should rest a player for months or weeks we found in youth sports that always does not work well. There is a significant number of thought leaders who think that active rehab is the ways to go.
I'm wondering if it's possible to hear anything more broader data and how that compares to past seasons.
Jeff Miller: Dr. Dreyer, do you want to talk a little about injury collection and what we did this year that we haven't' done in the past.
Dr. Dreyer: Yes, I'm happy to do that. Mr. Miller, we are not going to be providing data comparing this year to past years because we made a dramatic change in what we collect. In past years, we had a definition of what we considered a reportable injury, which required every concussion to be reported and a few other conditions. But, for the majority of other injuries that were sustained, the focus was on injuries that caused missed time from a practice or game. Prior to the 2015 season, if I looked at all the injury counts, they were predominately injuries that caused a player to be removed from a practice or a game. With the 2015 season, we changed our data collection dramatically using an electric medical record we collect every injury, whether it was serious enough to bring a player out of the game or practice, or whether it was something that bothered them later and they went to talk to the team doctor about. So it is total apples and oranges. So we don't have good data to make that comparison easily this year.
What about just releasing the data to give an indication of this season's data rather than a comparison?
Jeff Miller: We will certainly take a look at it and think about it. We are probably interested in getting some comparative numbers with the new tracking system so we sort of know what the normalized numbers are. We will certainly consider it.
There was a point in the call when it was mentioned that there were teams that were seeing the most concussions during preseason practices. My two related questions is, is there any looking into why those teams where experiencing those levs of concussions? And also if the date if there is any movement to show certain positions, plays or points in the game in the season when those are most likely to happen?
Jeff Miller: I'm answering them in reverse order. What you articulated is exactly what we do over the course of the offseason after we have gotten the data from Quintiles, which we received recently in its report form. We'll spend some time over the next several weeks and with our medical committee at [the] Combine to take a look at whether or not there are any significant trends one direction or the other as it relates to position, types of plays, even particular times of the year, and that sort of thing.
For example, we've tracked over the past few years the mechanism of injuries as it relates to concussion to take a look at the number of concussions caused by helmets hitting the turf. This year, as I understand it, there was a significant increase in that mechanism of injury, and that drives some of the work that we do as it relates to, for example, investment in technology. One of the grant winners from our process with GE was a company that has a new turf under layer, which holds a lot of promise to making turf safer – not just at the NFL level but throughout sports – so that's a positive thing. But we also look through that data very carefully as it relates to position and type of play and such because it's important information for our competition committee to look at. And so, with all of the rule changes that have been made over the last several years related to the health and safety of our sport, many of those come from the data. As we like to say, if you can measure it then you can address those things. And that's what we try to do. John York's committee and others will meet with the competition committee and talk about the trends in those spaces.
Concerning preseason data: So, what we did in that case was we looked at several years of data and injury trends in practices in the preseason to see whether there were outliers. And we found in a couple of circumstances there were some clubs, a small number, that had an outlier number of concussions compared to the median. We shared that data with the clubs, our football operations people shared it with the football people at those clubs and took a look at the sorts of practices and drills that they may have been running that others were not. Or the amount of times that on those drills that others had variance in. And I think that there's just the very nature of raising those clubs attention to that issue was enough for them to take a more careful look at it. And as Dr. York suggested, we think that there is a direct correlation between talking about it, investigating it, and the drop that we saw this year as clubs changed their behavior as a result. So that's not a conclusion, that's a good first step, but that's the sort of thing that we will need to continue to do this offseason and future off seasons as we examine that data.
Dr. York: I'll add that none of those clubs were actually aware that they had more preseason concussions than other clubs. Without Quintiles surveillance and data reporting and watching this over a three-year period, Quintiles and our committees probably would not have recognized this either. Keeping the data the way that we do and looking at it in as many ways possible and always finding a new way to do it will lead to improvements.
How are you determining whether increase in concussion is from culture change and self-reporting or from additional injuries?
Jeff Miller: The first thing you do as it relates to the culture change aspect of this and players self-reporting, is to spend a lot of time with the medical staff at each particular club. We'll go through with them all the concussive injuries they suffered. And we will talk to them about those and get their reaction as to whether the players self-report and what the mechanism was of how they learned about it. Was it the ATC calling down, was it the team physician identifying it, was it the players self-reporting, etc. So we will go through that. I do think that we'll spend some time thinking through, too, as it relates to work being done by the epidemiologists, whether we want to collect that information in more formal way. The nature of the injury reporting is important.
That is the reason we have added so many of the elements to the game from the unaffiliated neurotrauma consultants on the sidelines to the athletic trainer up in the media box. If tracking the culture change becomes something we think we want to do, which it may make sense to, we'll talk to the epidemiologists about how we would go about doing that. But this all starts, I think, with the team physicians. Dr. Heyer and the Physicians Society have been terrific in terms of not just educating themselves and their players, but also about communicating around these issues.