Kevin Love and the return to play from concussion protocol

Last night, Kevin Love took an elbow to the back of the head. I am not a medical doctor, and I did not evaluate Love, but every indication was that it was a potentially serious head injury. It may appear to be something that happens frequently, but Love’s behavior indicated something more. Love laid on the ground and did not move. He was under the basket, in clear danger of being trampled by large men as Draymond Green attacked the basket, and he did not move. He made no attempt to get off the court, and he made no movement to protect his body from the impending trampling. This, I would argue, is not normal behavior. At this point, I said to those around me that he should not re-enter the game. Again, this is not a medical diagnosis; instead, this is common sense.

I am acutely aware of these situations because I referee soccer, and concussions are a big issue in soccer. When we see a potential head injury such as the elbow to the back of the head, we are instructed to stop play. With most injuries, we have leeway to allow play to continue as long as the player is not in danger. However, with a head injury, even if a team has a clear advantage, we are instructed to stop the game to allow the player to be examined. Substitution rules differ in some tournaments when a head injury is involved. As a referee, I have told several coaches that players were not to return to the game without clearance from a medical doctor – not an athletic trainer – because the player exhibited signs of a concussion, and that is our responsibility to keep the player healthy.

From my experience, then, Love should not have returned to play without an examination by a medical doctor. I am not a member of the Cavs, and I have no idea if he was examined by a medical doctor before returning. However, when he returned to the court, he clearly looked like he was feeling the effects.

Truthfully, my interest is not in Love’s health or the medical decisions of Cleveland’s staff. Instead, I saw an opportunity for the NBA to demonstrate the seriousness of concussions and potential head injuries to a large television audience. Despite the increased knowledge about concussions, and the lawsuits against the NFL, U.S. Soccer, and others, parents, coaches, and athletes still underestimate the damage that can be caused by concussions and the time required to recover from a concussion.

A few years ago, I had two players suffer concussions. With no athletic trainer or medical doctor, I took charge of their return to play protocol. I emailed several doctors and athletic trainers for guidance. Eventually, I used this paper or one that was very similar.

Love is listed as day-to-day today, less than 12 hours after the elbow. I do not understand that timeline, just as I never understand NFL players who suffer a concussion one weekend and play the next weekend. A concussion is not a day to day injury; there is a progression to follow for a return to play decision:

After symptoms resolve and neurocognitive testing returns to baseline, the postconcussion RTP [return to play] exercise protocol follows 6 incremental stages of stepwise increase in exertion and physical challenges from no activity and cognitive rest to RTP.

First, this means that the player must show no symptoms of the concussion for a 24-hour period before even beginning the protocol. That means that on Table 1 below, Love isn’t even on Step 1 because he has not gone 24 hours without symptoms. He is essentially at Step 0, waiting for his symptoms to resolve.

Symptoms of a concussion can be grouped into 4 clusters: migraine (eg, headaches, visual problems, nausea/vomiting), neuropsychiatric (eg, sadness, nervousness, irritability), cognitive (eg, fatigue, difficulty concentrating/remembering), and sleep (eg, difficulty falling asleep, sleeping more/less than usual).

Because this diagnosis has been stated before there has been 24 hours since the injury, it obviously does not pertain to this return to play protocol. Any dizziness, headache, or other symptom of a concussion delays the start of the RTP progression.

Once the player is symptom-free, he enters into the progressive RTP protocol (Table 1).

concussions

When I used this protocol with my players, each of the six steps was a day in duration. If the player had symptoms return (headaches, difficulty sleeping), we started over at the beginning once the symptoms disappeared. In one case, this RTP took over 14 days.

With Game 3 on Wednesday, strict adherence to these guidelines would mean that the Cavs could state without ambivalence that Love is unavailable for Game 3 as he progresses through a RTP protocol. Best case scenario, he’d be on step 3 – No head-impact activities – on Wednesday. That’s absolute best case scenario, and probably rushing the beginning of the protocol. In reality, he is likely to be at step 1 or 2 depending on how he feels this morning.

Again, Love is a professional athlete, and an adult, and the Cavaliers are a professional organization. My concern is with the impact of their decisions on national television as it relates to the general public, and especially children playing basketball.

Hopefully the publicity from Love’s injury will lead to greater education in the media and ultimately the parents and coaches of youth players. As awareness and education increase, we can create a safer environment for the youth athletes.

By Brian McCormick, PhD
Director of Coaching, Playmakers Basketball Development League
Author, The 21st Century Basketball Practice and Fake Fundamentals

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