Dear Commissioner Goodell:

I hope that you have had an opportunity to read this book. If you or any members of your staff have any questions, comments, or suggestions please contact me at pigskin.crossroads@gmail.com . I would be happy to conduct any additional statistical analyses of my data that would interest you.

You have been called the “Concussion Commissioner” [314], and I can understand why. Congratulations for everything that you’ve done in this regard. At the same time, you may also realize by now that the fight against concussions requires extensive and ongoing efforts. It is impressive how the NFL is now taking a leadership role in the battle against concussions. I sincerely hope that the tens of millions of research dollars currently being spent by the League will help to improve the situation for NFL players as well as others at risk for concussions.

There are references sometimes made in the NFL related to “value,” like a “value pick” in the draft. The concept of value can also be applied to the type of research that’s supported by an organization like the NFL, and the value of epidemiological research will likely be amongst the most noteworthy in this regard. This has been the case historically for countless diseases and injuries. Dollar for dollar, epidemiology can provide the utmost value because prevention is almost always a primary focus. Some of the top concussion researchers in the world would agree that “very little of the money that has been going into concussion research has been going into concussion prevention” [315]. It is a cliché, but definitely worth saying, that “an ounce of prevention is worth a pound of cure.” I urge the NFL to continue its leadership role on the concussion front and to consider investing more of its research dollars towards the goal of preventing concussions.

A 2010 New York Times article said that Drs. Batjer and Ellenbogen “concurred that data collected by the NFL’s former brain injury leadership was ‘infected’” [316]. I have cited the work of Drs. Pellman, Casson, and colleagues dozens of times in this book. As I am sure you know, these former leaders of the League’s Mild Traumatic Brain Injury Committee published many articles in scholarly biomedical journals that included 12 years of epidemiological studies of concussions in the NFL. Are any of the data contained in any of the published papers written by Pellman, Casson, and colleagues problematic? If so, please elaborate.

If the Pellman and Casson epidemiological data are okay, then there are many additional analyses that could be done. I’ve outlined some of the possibilities on this throughout the book. It’s common for epidemiological and other research data to be under-analyzed. I strongly believe that plenty more could be learned by conducting additional analyses on the existing data and the costs of such a project would be relatively inexpensive. You also would not have to wait years to collect and analyze the data.

If the Pellman and Casson epidemiological data are okay, then there are many additional analyses that could be done. I’ve outlined some of the possibilities on this throughout the book. It’s common for epidemiological and other research data to be under-analyzed. I strongly believe that plenty more could be learned by conducting additional analyses on the existing data and the costs of such a project would be relatively inexpensive. You also would not have to wait years to collect and analyze the data.

There were several notable players during the 2012 regular season who sustained concussions, appeared to follow the NFL protocol, sat out a few games, and subsequently lost their starting jobs. Obviously, it’s a good thing that these players are coming forward and out of the “concussion closet.” Unfortunately, losing one’s starting job cannot be a good incentive for other players to do the same. Can you think of any ways to protect the roles and playing time of players who follow the NFL protocol and report their concussions?

As I have noted numerous times in this book, one of the limitations of using the NFL Injury Report to determine who has been concussed is that it is only published for teams which play the next week. Why not ask teams to complete the Reports on bye weeks and the final week of the regular season? This would make the Report more complete, and hence, improve its usefulness for research purposes. Another possibility is to create a “concussion registry” for NFL players. This would be an organized database of all players who have concussions, along with relevant contextual information, like player background information, position, team, type of play, type of contact, and so on. With the permission of the NFL, the data from this registry could be made available to researchers with specific ideas on how to analyze the data. In order to maintain some privacy for the players included in the concussion registry, identification numbers, rather than names, can be used in the database. Disease registries have become common and very useful in the biomedical sciences and may even help to improve health outcomes at reduced costs [317].

The current policy in the NFL is to keep all concussed players out of the games when they sustain concussions. Yet there have been reports of players continuing to play with at least suspected concussions [206]. What is the NFL doing to maximize compliance with its return to play policies? Are you now confident that the NFL’s policies and procedures related to concussion and return to play are optimal and minimize the potential for longer-term neurological risks to players?

Thanks very much and best of luck.

Sincerely,

Jeffrey S. Markowitz, Dr.PH

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