Because of the paucity of evidence about whether recommendations differ for athletes at different levels of competition, the answer to this question must be based largely on personal experience and on expert opinion; that is, on class III data, as detailed below.

Background

The following reflections are from my personal experience as a neurosurgical consultant for head-injured athletes in most central Indiana high schools, for 10 universities and colleges in Indiana, and for the Indianapolis Colts football team. I am also a consultant to the National Football League (NFL) Combine (i.e., the centralized evaluation program in which all NFL teams and scout-selected college football players participate every year) and a member of the NFL Committee on Mild Traumatic Brain Injury, and I have stood on the sidelines during college and professional football games for many years. My colleagues and I also care for and evaluate head-injured race drivers in various auto-racing leagues, including IRL and NASCAR.

Screening Prior to Play

Indiana high schools are required to ask students only two relevant questions: “Have you ever had a head injury?” and “Have you ever been knocked out or been unconscious?” If the response to either question is yes, further information is obtained during a physician interview. If the player has no residual signs or symptoms from a remote brain injury that was not serious enough to cause prolonged loss of consciousness or hospitalization, he is ordinarily allowed to play without further testing. On the other hand, if the previous injury was considered serious, full details are obtained from the medical record. Depending on the nature of the injury, and if there is no clinical evidence of residual neurologic deficit, I usually recommend that he be allowed to participate in all sports. However, the parents and player are counseled regarding cumulative injury that could occur during collision or contact sports. In almost every instance, the family takes my advice to permit or restrict the child from playing. I express my opinion in a letter to the referring physician, with a copy to the high school athletic department (with the permission of the player and family), confirming that I have counseled that player and family. If the athlete is to practice with the team, I usually have to fill out a form for the school. In reality, it is rare that I have found it necessary to reject a player with a previous head injury who has recovered well enough, both mentally and physically, to be eligible for his high school team. On a few occasions, second opinions have been sought after I have rejected a player, and my decisions have always been upheld.

Most colleges usually require completion of a standard application form for all sports that is somewhat more specific than that used by high schools. For example, the Indiana University Athletic Department application form asks, “Have you been knocked out or experienced a concussion in the last three years, and if yes, were you hospitalized overnight?” If affirmative, medical records will be obtained by university staff prior to the time of my consultation. If the injury was remote and I can ascertain that there are no residual deficits, I usually grant permission to play. If the applicant played high school sports without a neurologic problem, my decision is easier. If the records suggest that a serious head injury occurred, I feel obligated to pursue a further workup, which may include magnetic resonance imaging (MRI) and a neurocognitive test battery by a neuropsychologist with experience in sports-related head injury. If an athlete is asymptomatic and the neurocognitive tests are normal, an abnormality on the MRI would not necessarily exclude the player. The imaging study also serves as a baseline in the event of further injury. Each case is considered individually, and the player is counseled. Sometimes, before rendering an opinion, I may run the case by some of my colleagues in sports neurosurgery. The university almost always accepts my advice. No waivers (a release of liability for an injury) are offered to recruits by college teams with whom I work. Occasionally a family will ask for a second opinion if I advise against play, particularly if a scholarship is at risk. My recommendation that a player not be accepted because of a previous head injury has never been reversed by a second consultant and has never resulted in legal action.