Health and Safety: Concussions

Anthony Rizzo has landed on the IL for concussion symptoms. I have a lot of feelings about this. We need to talk.

But, before I begin, I'll give a little background. I am an athlete, and through my athletics in baseball and soccer, I have been part of concussion protocols. And, while I am not a doctor, I studied the brain in great detail as part of my Bachelor of Science degree in neuroscience from Lafayette College. I'm not an expert, nor do I claim to be, but I do have strong opinions and background about traumatic brain injuries (i.e. concussions).

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The MLB Concussion Protocol:

In 2010, Major League Baseball (MLB) and the Major League Baseball Players Association (MLBPA) agreed to create an all-encompassing system to report and track the medical histories of players. After this measure was taken, an alarming amount of concussions were being put into the system and before the 2011 season, the MLB began a slew of new rules related to diagnosis and treatment.

The rules that the MLB and MLBPA put into play are as follows:

1. Preseason neurocognitive baseline testing (via the SCAT5)

2. Use of SCAT5 as an industry standard for on-field/during play diagnosis

3. A 7-Day IL specifically for concussion recovery

4. A required neurological assessment before returning to play

5. Prohibition of same-day return to play after concussion testing

I'm going to address the SCAT5 in a new section (find that below), so I'm going to forgo my thoughts on the first two points for now.

For points 3-5, however, I can agree with their implementation. However, I do have one major concern addressing rule #4.

Because a 7-Day IL may often not provide enough time for a full recovery from a concussion, the importance and stress on having a neurological assessment take place before a player can return to play is a great safety measure to make sure teams don't bring back players too early. However, I would hope that there is an additional clause to the 4th rule that any neurological assessment is being done by doctors who are outside of employment with the team involved (if this is the case, it is not clear upon my research). The worry would be that a team could send a player to a doctor under their payroll who could be influenced by the organization to clear a player before he is ready. If this is not in place, I'd be extremely worried about this being a huge potential place for conflicts of interest in healthcare.

Rules #3 and #5 are both very strong measures in promoting player safety in that they allow players (and teams) to have specialty measures in place for approaching a difficult situation. The indication of same-day return (and not a same-game return) is also a very nice and subtle measure that would keep a player who hypothetically had a concussion scare in Game 1 of a doubleheader from being allowed to play in Game 2 if that was to happen. It's already impossible for a player to re-enter a game in the MLB, and this allows for time to be on the players side as symptoms from a major hit could take some time to display for a proper diagnosis.

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The SCAT5:

The SCAT5 concussion assessment tool is the go-to tool for use across many sporting bodies that includes the IIHF (International Ice Hockey Federation), the Olympics, FIFA, and more. However, just because it is the industry standard does not mean that it is a perfect measure.

To familiarize yourself with the SCAT5, you can find the entire protocol here.

Ultimately, the SCAT5 is split into 6 different parts:

1. The On-Field Assessment

2. The Off-Field Assessment

3. A Cognitive Screening

4. A Neurological Screening

5. A Delayed Recall Assessment

6. A Medical Decision

The on-field assessment consists of 4 different steps. The first of which is to mindful of a number of "red flags", of which, if noticed, should immediately have any player or athlete removed from the sport and evaluated by a medical professional. The second step is to notice 5 different visual signs of the player after the observed action. The third step is to assess some simple memory recall about what led to and came before the concussion scare (aka the Maddocks Questions). And the final step is to run through the Glasgow Coma scale and to check for any cervical spine injury.

The off-field assessment consists of 2 steps. The first of which is to get a detailed background on the athlete's medical history. The second step is a self-symptom-indication and evaluation done by the athlete across 22 symptoms on a 0-6 scale of no effects (0) to severe effects (6). This data is then compared to a players original baseline from the most recent test. (More on this later.)

The cognitive screening tests an athlete's orientation, immediate recall, and concentration. Orientation comes in the form of asking questions surrounding the date and time at the evaluation. Immediate recall concerns the athlete remembering a list of 5 or 10 words over the course of 3 consecutive trials. Concentration is tested by testing the athlete through a list of numbers and asking them to repeat them in opposite order; to list the months in backwards order as well.

The neurological screening consists of a physical component, wherein the athlete will go through the Modified Balance Error Scoring Screening (mBESS).

The final step involving the athlete is the delayed recall, which is to happen at least 5 minutes after the original cognitive screen. The delayed recall involves one question, to remember as many words from the previous list of 5 or 10.

Once all the above steps have been completed, the diagnosis is completed and a decision can be made using the data retrieved from the multiple measures taken.

Included in the SCAT5 is also this- VERY IMPORTANT- line that is bolded, included multiple times on the form, and is purposefully included in a big red box underneath the area to write a formal decision:

"SCORING ON THE SCAT5 SHOULD NOT BE USED AS A STAND-ALONE METHOD TO DIAGNOSE CONCUSSION, MEASURE RECOVERY OR MAKE DECISIONS ABOUT AN ATHLETE’S READINESS TO RETURN TO COMPETITION AFTER CONCUSSION."

If you want to see a video of the immediate aftermath from the Anthony Rizzo-Fernando Tatis Jr. collision after reading this, you can find it here. See if you can notice anything to note in the SCAT5 for concussion diagnosis.

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The Worries about the SCAT5:

I've already addressed the worrying concerns about the SCAT5 being administered by a doctor who has a conflict of interest with the team that any athlete is involved with. And, while that will always be an issue there is a much bigger problem with this measure:

The player.

Allow me a second to provide a personal anecdote to explain what I mean.

One day during the preseason ahead of my senior high-school soccer season, my school brought a bunch of the fall athletes into a room to take an online concussion baseline test. I was sitting beside a kid on the football team and while I was doing everything as best as I could, I also couldn't help by notice how the athlete next to me was going through much slower. I knew the kid from being in my classes and the performance wasn't indicative of his abilities in the classroom, which confused me at the time.

Until I learned that he was purposefully going just a hare slower than he could to ensure that he would "pass" the test even if he suffered a concussion. He was making sure to skew his own data to make it easier for himself to get cleared for a return to football quicker. He had scholarships on the line from his performance and couldn't risk not being in the games.

It was terrifying to see.

Unfortunately, even with all the appropriate measures in place with concussion testing, players ultimately have the greatest say in their treatment. They are the ones who control their baseline measures and reporting symptoms. If they purposefully omit data or act slow, it will almost always go unnoticed.

Unfortunately, it's impossible to know if this took place and whether or not this was an Anthony Rizzo or New York Yankees problem.

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Protecting Players from Themselves (i.e. Anthony Rizzo):

In a combat sport like boxing or MMA, it is the responsibly of the corner- namely the athlete's coaching staff- to notice how their fighter is doing and to make sure that they are not putting the athlete in danger. Top level fighters will continue to push through immense pain and damage to forgo looking weak. It's up to their corner to notice this and protect their fighter by knowing when to throw in the towel.

It's also the responsibility of a ballclub to keep notice of their players to protect them from themselves.

Anthony Rizzo has clearly been suffering from something since his May 28th collision with Fernando Tatis Jr. This tweet clearly indicates the substantial drop in performance since:

In the reports that came out from yesterday, the Yankees made it very clear that after the collision, Anthony Rizzo was evaluated through the tests (a.k.a. SCAT5) and passed. (Tweet)

If we remember from what I bolded above, just passing the test on its own does not indicate that the player is free from a concussion.

It also came out that Anthony Rizzo reported to the team about "brain fogginess" after the recent series against the Baltimore Orioles. (Tweet)

Instead of immediately putting Anthony Rizzo on hold, the Yankees continued to play him for two games against the Tampa Bay Rays.

In a press conference yesterday, Anthony Rizzo also addressed how he needed to go to an outside neurologist in order to get a proper evaluation. (Tweet)

This is exactly the type of concerning medical conflicts of interest that I addressed in the very beginning of this post. A neurologist outside of the Yankees affiliation should've been consulted immediately to diagnose the concussion. It shouldn't have taken 2 months- while Rizzo was still in the everyday lineup- for an outside doctor to be consulted.

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On the surface level, this is an issue about Anthony Rizzo. However, this is also an issue with the New York Yankees.

Just a few years ago, the Yankees had another major issue with another player who was dealing with concussion issues. That player was Clint Frazier.

I'm not going to blame the New York Yankees for any type of misconduct or negligence. However, I am also not going to purposefully notice that this isn't the first time that the Yankees have forgone assuming any medical responsibility. That may extend beyond concussions and beyond just Anthony Rizzo and include Clint Frazier. It should also include Jose Trevino and his recent move to be shut down for the rest of the 2023 season with a torn wrist ligament, which requires surgery, which has been known for a large part of the season (and potentially even in spring training), and which the Yankees allowed him to play through.

The Yankees also do not have a good history of throwing in the towel to protect their players.

Aaron Judge was just rushed back from a broken toe injury to return to a ballclub that has been playing below .500 to try and make a push for the postseason.

It's just coming out this morning that the players and staff tried to "sober up" Domingo German by holding him in a sauna after an alcohol-fueled incident on Tuesday that has resulted in German getting checked into rehab for alcohol abuse. Alcohol (like coffee and soda) is a diuretic and through that is often a dehydrating agent as consumers don't consciously think to drink a lot of water. Making a player lose more water by forcing them to sit in a hot sauna is the opposite of what they should've done.

It's baffling how common mistakes about the Yankees, in terms of player safety and healthcare, are reported. And that isn't to mention the likes of the countless times a players timelines for a player to return are pushed back due to reinjuring themselves from rehab assignments coming too soon, or a misdiagnosis of the original injury, or an IL stint quickly occurring after another for a similar injury that should've been previously addressed.

Anthony Rizzo was being tossed to the wolves for months with a concussion. It was clear as day to anybody watching.

A concussion, which, could've lead to a much worse fate than missing some baseball games.

Second-Impact Syndrome is not an uncommon thing to happen. Second-Impact Syndrome can only happen when a player did not fully recover from a concussion and gets hit in the head again. Second-Impact Syndrome could've been triggered by another collision at first base, or a pitcher losing control of a pitch and hitting Rizzo in the head, or Rizzo tripping while running around the bases and landing hard on his helmet. Second-Impact Syndrome can prove fatal.

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Whether it was Rizzo, the Yankees, or the medical professionals and/or athletic trainers and staff involved in this case, this whole incident is a worrying sign.

It also shows the delicate balance of playing a sport at the highest level and the extreme limits that an athlete is willing to put their bodies through to not appear to be anything other than in perfect shape.

Somebody should've stepped in a long time ago. Thank goodness somebody finally stepped in and has put a pause to this nonsense and stopped Rizzo from playing. It shouldn't have taken until Rizzo reported some brain fogginess however.

The team should've run another analysis months ago. They should've given him some time off already to evaluate again. So many things should've been done to protect Anthony Rizzo from himself.

And we are all lucky that nothing worse happened in the (over) two months since the collision.

And it infuriates me that it took this long.