Analyzing MLB's concussion policy

On March 29, Major League Baseball and the Major League Baseball Players Association announced new protocols related to concussion management for both players and umpires, effective from Opening Day forward.

MLB is following in the footsteps of the NFL and NHL, which have both made changes in concussion management as well as the rules that govern the types of hits that often lead to concussive injury. (Even the next version of EA Sports' "Madden NFL Football" will prevent concussed players from returning to play.)

The new protocols are part of a broader policy developed by a committee of experts, including independent neurological experts and representatives from several MLB medical staffs and aimed at establishing a measure of consistency by which players and umpires are both removed from and returned to play when there is suspicion of concussion.

Although MLB released the protocols just days before the start of the season, these policies have been in development for several years, said Dan Halem, MLB's senior vice president and general counsel, labor.

There are four primary components for this new policy:

1. All major league clubs are requiring baseline neurocognitive testing for all players and umpires using ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). The battery of tests, developed in the early 1990s by Drs. Mark Lovell and Joseph Maroon of the University of Pittsburgh Medical Center, evaluate things such as brain processing speed, memory and reaction time. Preseason testing can provide baseline data against which future postinjury tests can be measured. Even when a player reports the absence of symptoms and there are no observable signs, a neurocognitive test can show a deficit in information processing, indicating that the brain has not yet fully recovered. Halem said while MLB adopted ImPACT testing several years ago, the fact that the new policy calls for baseline testing to be conducted on all players and umpires during spring training or when a player joins a club during the season formalizes the practice.

2. Specific recommendations have been issued for on-field and sideline evaluation of players and umpires suspected of suffering a concussion. These protocols follow already established guidelines from the National Athletic Trainers Association. Additionally, the SCAT2 (Sport Concussion Assessment Tool, version 2) has been adopted as the sideline concussion assessment tool of choice. Although this tool is already in use by the majority of club personnel, the formal adoption of this tool helps establish consistency across the league.

3. A seven-day disabled list for concussions has been established. Given the longstanding nature of the current DL system, this modification is particularly striking. The aim is to allow time for a player's symptoms to clear and prevent premature return from injury while permitting a club to retain a full complement of players in his absence. As Halem says, "The DL is -- and has been -- a roster management tool. If you're on the DL, you're not on the 25-man roster." However, the designation of a concussed player to the seven-day DL remains a club choice. While it is not mandatory that a player who suffers a concussion is assigned to the DL, the league clearly expects that teams will make use of the new designation when appropriate and avoid returning players to activity too soon.

4. Perhaps the most significant component of the policy involves protocols for return to play. Any player who has been diagnosed with a concussion, regardless of whether he was assigned to the seven-day DL, must follow a specific protocol to return to play. The club must submit a return-to-play form for the player to MLB's medical director to obtain clearance for game participation of any kind (major league, minor league or extended spring training). In that form, the club's head physician must establish:

• all symptoms at rest and with exertion (including baseball-related activities) have cleared
• ImPACT results have returned to baseline
• the club physician, in his or her judgment, feels it is safe for the player to return to competition

The medical director then has the right to request further documentation or consultation with other physicians before providing final clearance. Similar return-to-field criteria will be required for umpires.

Additionally, each club is required to designate an MTBI (mild traumatic brain injury) specialist, who is not one of the club physicians, in its home city.

Even in the presence of scripted protocols, the management of concussions -- from time of injury to point of return -- is an individual process affected by the unique nature of each concussive episode. Members of each team's medical staff will draw on their specific experience and expertise in the course of evaluation and management of any player, just as they would for any other medical condition. But a common set of parameters and evaluative tools can help shape best practices when it comes to caring for athletes with this condition.

Halem says that one of the appealing aspects of introducing some measure of uniformity is that there is the potential to collect data that can be used to study the issue. Baseball recently implemented an electronic medical record system. "Now we have the capability to capture detailed, specific information related to concussions, since it will be documented in the medical record system," Halem said. "Hopefully we can learn which types of incidents result in concussion and which players may be more at risk."

Given the rapid implementation of this policy, MLB is holding conference calls with all club medical staffs throughout the week and is developing webinars to roll out this year. The seven-day DL is the only element that is being considered on a trial basis, meaning its use and effectiveness will be evaluated when the 2011 season is over. The other components of the policy, however, are here to stay. The hope is that this will be a step in the right direction toward enhancing player and umpire safety when it comes to the issue of concussions.

Stephania Bell is a physical therapist who is a board-certified orthopedic clinical specialist and a certified strength and conditioning specialist. She is a clinician, author and teacher with extensive experience in the area of orthopedic manual therapy and sports medicine. You can e-mail her here.