Transcript of 2016 Injury Data Results Media Conference Call

January 26, 2017

The NFL released its most recent injury data on January 26, 2017. The injury data is compiled and analyzed by QuintilesIMS, an independent third-party company retained by the NFL.

A transcript of a media conference call with reporters to discuss the data is pasted below.


An audio recording of the 2017 media conference call:


Media Conference Call

With Jeff Miller, Dr. John York, Dr. Christina Mack, Dr. Robert Heyer and Dr. Mitchel Berger.

January 26, 2017

THE MODERATOR:  We’ll begin today with the NFL’s executive vice president of health and safety policy, Jeff Miller.

JEFF MILLER:  Good morning, everyone.  Appreciate everyone joining us early on this Thursday morning to talk about updates in the NFL’s health and safety initiatives including our injury surveillance.  We have done a call like this or meeting like this regularly or annually where we’ve discussed the injury data as compiled in the NFLPA’s epidemiology firm, QuintilesIMS.  So we’ll get to that data in a minute.

I’m going to introduce today’s speakers and make a few brief opening comments.  With us today on the phone, Dr. John York.  He is the Co‑Chairman of the San Francisco 49ers, the Chairman of the NFL Owners’ Health and Safety Advisory Committee.  Dr. Christina Mack, she is the Director of Epidemiology and Outcomes Research Real World Insights at QuintilesIMS.

QuintilesIMS is a Fortune 500 company and a leading global health care provider of integration technology enabled services.  QuintilesIMS has led the NFL’s surveillance and analytics program since 2011.  Following Dr. Mack, is Dr. Robert Heyer.  He is the President of the NFL’s Physicians Society, Team Internist for the Carolina Panthers.  Lastly, but not least, Dr. Mitch Berger, Professor and Chairman, Department of Neurological Surgery at UCSF, and a member of the NFL’s Head, Neck and Spine Committee.  Each one of those folks will have an opportunity to provide opening comments after I’m done and answer your questions.

So let me start with a little bit of background.  It’s been an active year on health and safety initiatives of the NFL.  We continue a very strong partnership with the NFL Players Association on a number of different fronts.

We, as background in terms of issues that we have looked at on the field, again, reminders that we have unaffiliated doctors on the sidelines, unaffiliated neurotrauma consultants which are assisting team doctors in identifying and evaluating players for concussion.

This year we saw even greater integration with the team medical staffs than we have before, and added responsibilities for the UNC this year to include evaluating players for potential stingers.  I’m sure Dr. Heyer can go into that as well.  This year, we added to the athletic trainers in the media box.  Those who are there to help identify injuries, call down the team medical staff and send video to help them identify injuries and diagnose injuries, all injuries.

We added a second athletic trainer to the media box this year, to assist their work and help them identify potentially more injuries.  And as you know, last year for the first time, we allowed and empowered that athletic trainer to call, what we termed a medical timeout.  The first of its kind, we believe, in international sports where an independent medical observer could stop the game for the benefit of player health.

Last year, in the first year, we saw five of those calls.  This year we saw eight.  And those athletic trainers continue to advance players’ health and safety.

We also added this year, this was a change from previous years, an enforcement mechanism for the concussion protocol.  Again, we’ve worked on this closely with the Players Association, ways to emphasize the need for the concussion protocol to be followed in a detailed manner, along the lines that the medical observers, the Players Association medical director, and others have advised us it needs to be followed.

Finally, in addition this year on the field and in an educational way, the Players Association with our collaboration put out a very good video for players on how the concussion protocol works on signs and symptoms of concussion.  If you haven’t seen it, I would commend it to you.  It was very well done, and advances player education even beyond the work that the team doctors and the NFL have done with their individual teams to try to elevate the education level of players as it relates to concussions.

Off the field, it’s also been a very busy year in terms of research.  The NFL announced the Play Smart. Play Safe. campaign just a few months ago, which was Dr. York and his fellow owners’ commitment of $100 million of additional research beyond an additional $100 million research portfolio with partners that we had.

This hundred million of research is going to two primary areas, the first is what we call the Engineering Roadmap, which is a focused effort on advancing protective equipment through biomechanical engineering analysis and analytics.  We are a few months into that program, and we are working closely with the Players Association, biomechanical engineers as well who are consulting on this project.  We have high hopes that this will lead to the advance in protective equipment over the next five years.  The additional $40 million will be spent on more scientific research advised by a Scientific Advisory Board working with our medical committees to identify priority areas for medical research.  And we should be in a place over the next several months to announce some of those areas that we’re going to be looking to provide grants and mechanisms by which people can apply for the money.

Much of this, as many of you know, is conducted at the Combine coming up in a few weeks, where our team physicians, team athletic trainers, medical advisors, Players Association representatives, and others get together to talk about how the protocols work.  How the communication systems are working.  Whether we can do more to educate, work with the Competition Committee on potential rules changes, and analyze a lot of the statistical data that Dr. Mack and QuintilesIMS compiles for us.  So we are looking forward to that and looking for ways to get better at what we do.

So let me give you a quick top line on injury data and I’ll turn this over to Dr. York.  We saw concussions this year in the NFL in regular season games decrease from 183 in‑games to 167.  That is a decrease of 8.7%.  Overall concussions, if you combine preseason practices and games and regular season practices and games, we saw that number decrease from 275 in 2015 to 244 in 2016, which is approximately 11.3%.  That number 244 is aligned with about a five‑year average, so those numbers are relatively consistent in that regard.

Dr. Mack will go into more detail on that as well as some of the major other injury areas like ACL injuries, MCL injuries, injuries on Thursday night games and on the kickoff, which has been discussed since the kickoff rule was changed this year with the kickoff, the return line being moved ahead to the 25‑yard line.  We saw a decrease ‑‑ I’m sorry, an increase in touchbacks of about 2%, a decrease in returns by about 2%, and Dr. Mack will talk about the injury statistics related to that.

Importantly, that’s just one year’s worth of data.  We’ll look at this over time, and that will be shared with the Competition Committee at the Combine, and we’ll have further discussion about that rule and the injury implications for it.

Likewise, our injury data, as Dr. Mack will mention, has been looked at in any number of areas.  This is preliminary, top‑line data, we’ll have much more sophisticated information in the next few weeks as QuintilesIMS continues to look at it, and we look further to that.  That’s a top‑line overview, and I’ll turn this over to Dr. York if he has any opening remarks.

JOHN YORK: I will add that the 32 clubs, their owners and the commissioner maintain that player health and safety is a number one priority for the National Football League, and the Owners’ Health and Safety Advisory Committee is set up purely for that reason.  That committee works with the Players Association, with QuintilesIMS in terms of injury surveillance data, the club physicians and athletic trainers and the Competition Committee in order to look at data and propose rule changes that will be for the betterment of the players in terms of health and safety.

I will bring your attention again to the area of preseason practices, which we looked at last year.  We were concerned about the number of preseason practice concussions compared to the regular season.  The regular season has almost no concussions during practice, less than ten.  And there were almost, over 40 in preseason practices up until last year.

We went and discussed with the individual clubs the number of preseason concussions, and those discussions led to a significant decrease, over 30%, between 2014 and 2015, and that number has stabilized in 2016, actually, with the decrease of three.  So we’re happy those results shows that the clubs do listen and are very interested in the number of concussions in their players, and that we can have an effect on the culture of the National Football League.

We’ve also seen an increased number of self‑reported concussions this year over last year, with last year being the first year that we really saw a significant number of self‑reported concussions.  So those are all good changes with regards to the concussion protocol, and I would also say that they have an effect that may cause an increase in the number of concussions that we identify.  Probably those that are in less‑severe type of concussion, but we want to know every one of the concussions and identify those and take care of the players properly.

JEFF MILLER:  We’ll turn it over to QuintilesIMS Director Epidemiology and Outcomes Research Real World Insights.

CHRISTINA MACK:  Thank you, as Jeff said, I’m an epidemiologist, I lead the QuintilesIMS injury surveillance and analytics program along with Dr. Nancy Dreyer.  Overall this year we observed an 11% decrease in concussions compared to 2015.  Though we’re still seeing numbers higher than 2013 and 2014, and it’s still a point of emphasis.  It’s important to look at the concussion numbers by pre‑ and regular season to understand the trends, because as Dr. York described, they are different.

We saw a decrease in preseason concussions overall this year in both practices and in games.  And, again, it’s important to distinguish between the two, because we focused heavily on training camp and preseason practices, and we’ve continued to make progress in that area.  The decrease that we saw in 2015, based on the discussions that the League and the Health and Safety Committees had with the individual clubs was sustained this year, and preseason practice concussion reached a five‑year low at 26 concussions over the preseason practices.

So that amounts to concussions in preseason practices being down 32% from the four‑year average of 38.  In preseason games, concussions decreased 17% this year compared to 2015, with numbers looking closer to prior years.

Switching to regular season, we again saw a decrease of 8.7% going from 167 this season compared to 183 last year.  Although, again, higher than the experience in 2013 and 2014.

We also understand that the medical staff are even more observant than they previously were.  When we looked at data on the activity of the ATC spotters and the unaffiliated neurotrauma consultants, we saw a conservative approach to evaluating players.  For example, the ATC spotters are calling down to the medical staff on the field more frequently, and they’re calling down conservatively.  Almost 70% of the players called down by an ATC are cleared to return‑to‑play after examination, and a similarly high percent of players evaluated by the UNCs are not ultimately diagnosed with a concussion, but they’re evaluated through the concussion protocol.

So in fact over two‑thirds of the players put through the concussion protocol aren’t ultimately found to have a concussion.

Jeff Miller discussed that the league and the advisors are continuously improving on these programs, so they added a second ATC, they expanded the scope of the UNC program to evaluate stingers, so that is what we’re seeing in the data with this conservative approach.

Switching to knee injuries.  ACL tears were stable this year at 56 over the entire season.  There were slightly fewer than in 2015, and overall these have been stable over the past five years with some variation between seasons as expected.

There were fewer MCL tears this year than last year, but more than what we with saw in 2012 and 2013.  These injuries have more variability in reporting because of the range of severity of the injuries, higher than ACLs and concussions.  We have not seen any increase at all in full MCL tears, which is the most severe.

We continue to monitor Thursday night games and duration of play, and once again, we found there is no evidence of an increase in injuries when teams participate in a Thursday night game or examined another way—injury rates do not increase when teams have shorter intervals between games.

The change in the rules did reduce kickoff returns this year by about 4%.  And the data on kickoff returns show a two‑year decrease in hamstring strains, and general stability on the number of concussions on this play, although there was a low in 2014.

JEFF MILLER:  Thank you, Christina.  We’ll now go to Dr. Rob Heyer, the head of the NFL Physicians Society. Dr. Heyer?

JEFF HEYER: Thank you, Jeff.  I’ve been a team physician for 23 years, and during the past three years I think I’ve seen a cultural change concerning concussions.  At the beginning of the last two seasons, as Dr. York mentioned, the head athletic trainer and team physicians of each team formally address their players, coaches and general managers in a one of had hour meeting regarding concussions.  The signs, symptoms and taking them seriously.

As mentioned, the players are now more aware of the symptoms of concussions and are concerned for their health.  They understand the need for an evaluation by the team physician and the UNC if a possible concussion has occurred.

As a result of this ongoing education, players are more likely to speak up if they believe they have a concussion.  And this awareness has led to more self‑reporting of symptoms by players and then an appropriate medical evaluation by the team physician and UNC.

Our work with the league regarding concussions and education is not done, but I know what we are doing is currently making a difference, and we will and must continue to do more.

JEFF MILLER:  Thank you, there Heyer.  Rob, I appreciate it.  Now we’ll go to Dr. Mitch Berger, member of the Head, Neck and Spine Committee.  Mitch, if you have any opening comments?

MITCH BERGER: Yeah, Jeff, thanks very much. Just a few comments, so by way of background, I’m a neurosurgeon, I’ve been practicing for over 30 years.  I’ve seen lots of folks routinely with concussions.  I’ve also been a member of the Head, Neck and Spine Committee since 2009.  And over the past three years I’ve served as an unaffiliated neurotrauma consultant, so I’m down on the sidelines and have a very good understanding of how the protocol works and how it’s activated, et cetera.

And I must say, when I saw these numbers I was really relieved.  I was encouraged that the numbers are down, but I’m still far from satisfied.  As a health care provider, I think one of our absolute highest priorities is to get these numbers further down.  We’re going to have to really think about the ways in which we can do this.  I think as Jeff just said, that’s what the combine is about.  We’ve got to drill down into the Quintiles numbers and work with the medical community to find out how we can decrease the numbers.  So I am encouraged, but still far from satisfied, and we certainly have a lot more work to do as part of our committee.  So I’ll end it there, Jeff.

JEFF MILLER:  Great, Mitch, appreciate it.

QUESTIONS BEGIN

REPORTER’S QUESTION: I have two questions about concussions.  The first question is obviously like was mentioned, the concussions are down in all three categories, preseason and regular season together from 2015.  And I’m wondering if the sample of the one year, is that something that you consider statistically significant at this point?

JEFF MILLER:  I’ll take the first answer at it, and if Dr. Mack wants to weigh in.  It’s certainly positive that concussions were down this year across categories.  But I think putting too much focus on any one year would be mistaken.  The goal here is to drive those numbers down through rules changes, culture changes, protocol changes, through greater observation and treatment over a longer term period of time.

So I think Dr. Berger said it well, we’re heartened by a decrease, but that doesn’t change anybody’s efforts over the long‑term here in terms of making this game safer for those who play it.  Dr. Mack, from a statistical perspective, do you want to weigh in on that?

CHRISTINA MACK: Sure, so to your point, one year is not or never statistically significant, so we look at these trends holistically.  It’s certainly in a positive direction, but that said, there is still a lot of emphasis, concussions remain a serious concern.  What we do when we see the numbers looking like this, as epidemiologists, we drill much farther into the data to try to understand what the drivers might be, where we might be able to make more impact in reducing these numbers.  The example that Dr. York gave with the preseason concussions being one of those.

So the goal for us is to try to slice them enough to understand how we can continue to bring those numbers down.

REPORTER’S QUESTION: Then in a very sort of related question, when you look at like the largest samples, so you look at all five years, preseason, regular season, 2016 was still exactly basically average in terms of the total number of concussions.  So I guess what I’m wondering is do you feel there is progress in terms of overall concussion prevention over the five years if we’re still at basically the same total level?

JEFF MILLER:  Yeah, again, maybe I’ll take the first shot at this, and then if Dr. Mack wants to weigh in or others, I’ll open it up to you as well.  I think the numbers are the numbers.  But I think what we have to account for too are the additional protocols and people involved in identifying the injuries, which are all significant net positives, whether it be multiple athletic trainers in the media box with the ability to call down to the team doctors and athletic trainers on the sideline, or in a more extreme case, call a timeout themselves or the addition of unaffiliated doctors on the sideline to identify the concussions and treat them.  Or the raised awareness and education levels of everybody participating from the team officials, to the coaches, to the team doctors, to the players themselves, to either identify the signs and symptoms of an injury, point to a teammate who they think needs to be evaluated and such.

We’ve seen a significant culture change, I would argue, on those points.  So while the numbers are what the numbers are, the ability to identify more of the injuries and treat players appropriately are all very positive trends in the right direction.

I don’t know if Dr. Mack wants to take an opportunity after that or if others want to.  Dr. Heyer, you may have a perspective here.

ROBERT HEYER: I agree with what you said, Jeff.  I think I would make two points.  Number one, the self‑reporting of concussions by players is important in terms of their ultimate recovery.  If a player spends an extra quarter or even a game on the field with a concussion, it lengthens the amount of time required for them to return to their normal baseline state.  So that’s an important fact.

The other issue is the players trusting that they’re being cared for.  We still have a few players that will not report.  But I think we are identifying injuries that may not have been identified in previous years because of the self‑reporting by the players.

JEFF MILLER:  Dr. Mack, how does the changes and the way we observe concussions and identify them factor into your analysis?

CHRISTINA MACK: Sure, when you look over the past five years, the total number this year is almost equal to the total number in five years.  But we do take into attention as Dr. Heyer described vastly higher attention to detection.  And since 2012, the QuintilesIMS team has also changed the reporting program, and there is also vastly high era tension to reporting, and that’s through consistent and constant interactions with the athletic trainers on the team.  Making sure we see all of these, combing through the media on our end.  Making sure if there is something in the media, we have it in our database.  If not, we follow up to understand what that might be.

So the attention that we’re paying to making sure that we get all the concussions in the database has increased drastically over these five years.

JEFF MILLER:  I was just going to say, one sort of overlying theme here is the point of all of this, and the reason we work so closely and the Players Association works so closely with QuintilesIMS and the team physicians and others, is the efforts to identify the concussions where they happen so the players can get the treatment that they need as quickly as possible and as comprehensively as possible.  That’s why we spend so much time on these protocols, on the enforcement of the protocols, on the epidemiology, and working with all these many experts like Dr. Berger and others who advise us about the way we can improve.

The goal at the end of the day is to improve player health.  So if we can identify more of these injuries, those players are going to be better off.

MITCH BERGER: I just want to comment on what Rob said.  It’s very interesting to me as a physician on the sidelines in an independent way.  When we started the UNC program, there was just a significant amount of resistance from the players in terms of just being evaluated.  A lot of times we would say we thought we saw a pretty big hit, and we looked at it on the injury surveillance video system and agreed and we wanted to evaluate the players.  A number of them were resistant in the beginning.  But now I would say uniformly this past season, none of the players ever resisted.  Whether I was on the home side or the visiting side, they are much, much more aware of the whole concussion situation, and want to actively be engaged in the interview process on the sidelines as well as in the locker room.

So I agree with Rob that there has to be a huge change in culture that’s occurred in the past three years.  They really are much more aware of and interested in their safety than they ever were.

REPORTER’S QUESTION: This is for anybody, I guess, Jeff.  I’m most intrigued by the self‑reporting data.  Can you release the data of how players have indeed self‑reported concussions and what percentage of those ended up being concussions, whether it was almost 100%?  Because I think that maybe is responsible for maybe the rise last year in concussions if it’s true that so many more players are self‑reporting.  It would be nice to see those numbers alone.  And the second question, do you keep track of the ligament tears on the various types of turf, whether it’s grass or what type of artificial turf to see if there’s any change in that direction.

JEFF MILLER:  Thank you for the question.  And I’m going to send this over to Dr. Mack who can give you the details, but let me give a quick statement on this.

Hopefully, I mentioned at the outset of the call, this is top‑line data that we’re comfortable sharing because we’re comfortable that it’s accurate.  There is a lot more investigation and analytics that need to go into the depth of what these numbers mean and answering some of the questions that you posed.

Knee ligaments on turf are things we take a look at, but we don’t have that information in front of us today.  This is a busy time for QuintilesIMS and Doctors Mack and Dreyer as they go through this data as we run up to our combine, when the many medical committees and Physicians’ Society meet at the end of February and beginning of March.  So we will have that sort of data.

We will be able to take a closer look at self‑reporting, which is the other one that you mentioned, and try to quantify it.  We are working hard at those things right now, but we don’t have numbers, I don’t think.  Christina, correct me if I’m wrong, but I don’t think we have numbers in either of those categories right now that are sufficiently well‑analyzed and scrubbed.  But we will.  It’s just going to take a little longer in regards to those details than others.

Dr. Mack, is that a correct statement?

CHRISTINA MACK: Sure, I would add the progression of a player from the hit through the evaluation, diagnosis, and the concussion protocol is very complex, there are a lot of points of contact.  So that is extra hard to quantify over some of the injury data, so we don’t have that at hand at this point so close to the end of the season.

QUESTION: From previous seasons?

CHRISTINA MACK: We don’t have that from previous seasons, and the reason is, again, the complexity of quantifying that as the player goes from hits through the game, through their evaluation of multiple medical staff and into the next week, whether or not they have self‑reported can happen at any of those points.

So the reporting, where we’d be able to generate quality data and understand the numbers around that has changed a lot.  And this is one of the strongest years of that reporting, so we need to take some time to look at that.

REPORTER’S QUESTION: What are the working theories that explain why the numbers for ’13 and ’14 were so different than especially last year, but then the past couple years?  And I’ll ask my follow‑up after.

JEFF MILLER:  I think we discussed last year to some degree, and I think to the extent we had data on this point that was supported, at least based on the reactions of the team physicians, so Rob is probably a good person to speak to this.

We saw in 2015 significant more numbers of players self‑reporting, and we saw the athletic trainers in the media box, and we saw the medical timeout being used for the first time, and we saw a greater integration of the unaffiliated neurotrauma consultant with the team physician.  And on that last point, we saw nearly, I think, it was double the number of screenings by unaffiliated doctors on the sideline of players.

So if they were acting more conservatively around screening players, that would be a good thing, and as a result of screen screening more players they identified things from our perspective.  Similarly, if players are self‑reporting more.  And it’s harder to get the arms around the numbers, we’ll do a better job this year than we have in the past.  But those would also lead to that increase.

I think the numbers support that to the extent those numbers are analyzable, and I think that the experiences of people like Dr. Berger as an unaffiliated doctor, and Dr. Heyer as a team physician would support those notions.

Rob, do you have anything to add to that?

ROBERT HEYER: Yes, I think the term self‑reporting needs to be clarified a little bit.  It’s a broad term, and it occurs in many different manners.  Number one, another player may notice that a teammate not acting right or took a significant hit to the head, and has been a little slow in the huddle or maybe making mistakes.  We would consider that self‑reporting.  Someone other than the team physician or the athletic trainers or the spotters are reporting a potential injury.

The other area that I’ve seen is players coming in after the game, either the day of the game or even the next day saying, “I don’t feel well.  I’m not sure what’s going on.  I was hit in the head in the fourth quarter.  I didn’t think anything about it.”  And that’s the type of self‑reporting that we used to rarely see in players during previous years.

REPORTER’S QUESTION: Thank you.  My second question maybe doesn’t speak directly to the report, but we saw the release yesterday about Matt Moore.  For Jeff or Dr. York, are we satisfied that in most of these cases that protocol is being followed?

JEFF MILLER:  I can’t put a specific number on it, Christina can probably do a little better or Dr. Mack can probably do better than I can in that regard.  But there are hundreds of unaffiliated neurotrauma consultant reports identifying players that they’ve evaluated during the course of the game.  I’m not comfortable knowing exactly what that number is, so I won’t try to guess at it.  But in the hundreds, I think, is accurate.  And the UNCs and the team doctors do a terrific job in working together in analyzing these issues.

It’s important we get it right a hundred percent of the time, so that’s why you see enforcement mechanisms like this where we work jointly with the Players Association to identify those issues.

It’s important to us that everybody understands and follows the protocol, and we continue to enforce its importance and I don’t think that will ever change.  Dr. Berger and his colleagues at the Head, Neck and Spine Committee spend endless hours working on the protocol with the Physicians Society and the Players Association to improve it on an annual basis to get it right.  And we’ll spend more time educating team doctors, unaffiliated doctors, athletic trainers and others on whatever changes are made and improvements to make sure that they are working as well together for the betterment of the players.

But it’s important to say, too, that we are quite pleased with how these programs are working, and this enforcement protocol is important to make sure that everybody stays aligned with the work that’s being done, and the education level remains high around these issues.  But overall, this is a terrific program and one that we’re very pleased with.

REPORTER’S QUESTION: I wondered on the kickoff returns, the numbers for concussion did not really change a lot.  Does that indicate that this will change or hasn’t had a big difference or is it just too early to judge?

JEFF MILLER:  I’ll toss that over to Christina because I think she’d be better to answer it.  My initial reaction to it is that we’ll share this information with the competition committee and analyze this closely.  It is, as you mentioned, one year of data.  We saw the number of kickoff returns decrease, and we saw the number of concussions decrease.  But how much emphasis you put on one year versus a number of years is something that we would defer to the experts on.

CHRISTINA MACK: We have seen the concussion numbers on kickoff returns stay within some kind of stable range.  They’ve jumped around.  That’s an expected amount of variability over four years.  So certainly this is something that we’ll talk about and we’ll look a lot more closely at these data, what’s happening on these plays at the Combine.  But for now, the top line numbers, they fluctuate what we would call a natural fluctuation.

REPORTER’S QUESTION: My paper this year tried to track and set up a database to track concussions, and we saw a fairly wide variance in kind of team by team reporting of concussions.  The team I cover, the Panthers, and the one Dr. Heyer’s involved with was among the most reported.  But I’m wondering, is that something that’s being tracked by you guys, and what steps are in place and are there any concerns about kind of underreporting of these by certain teams?

JEFF MILLER:  I don’t know if Dr. York is still on the line.  I know he had other obligations.  But he mentioned the preseason concussion numbers as an example, where we had identified that in practices as an issue where there were a disproportionate number of concussions compared to the regular season, and spent time with each individual club to talk about what their particular practices were and what their concussion numbers were, and we saw an improvement.  Probably based largely on the fact that we raised it to their attention.

So we take a look at that for purposes of being able to change the culture.  As far as what’s done on a team‑by‑team basis or how this is tracked, I’m sure Dr. Mack can offer a little insight as far as that goes.

CHRISTINA MACK: Sure, thank you.  The most critical answer to this is around the culture on the teams and how they play, as Jeff described.  From a reporting perspective, particularly within games, we feel confident we are getting all of the concussions.  And overall, because QuintilesIMS works very closely with each of the teams throughout the full season to make sure that all of the concussions are reported and they’re reported accurately.  We feel confident that we’re getting the concussions in equal number from the teams.

We comb the media as well, and when we see something in the media if it’s not in the database, we call the club and ask about that, and find out if the media ‑‑ if it hadn’t been reported, or in a lot of cases it’s reported through the media, but was, in fact, not actually diagnosed as a concussion.

We also work with the clubs monthly, sending them reports with all of their injuries with focus on concussion, but with focus on all of the injuries, to emphasize complete reporting, quality reporting, and make sure all the records are in there in the way we can include them in the analyses.

The athletic trainer community, within the NFL, is very engaged in the reporting of the injuries, so we do feel confident that we’re getting the concussions reported.

REPORTER’S QUESTION: Dr. Heyer referenced the players who self‑report later, either day of game or the following day.  This is just a procedural thing perhaps for Dr. Mack.  Where do the players who report symptoms later fall as far as classification?  Does that come under game ultimately or where do those go?

CHRISTINA MACK: Yeah, that’s a good question. If a player is injured in a game, that falls under a game concussion.  So if the symptoms start the day after the game and that’s when the diagnosis happens, that’s still categorized as an in‑game concussion if the impact was from a game.

REPORTER’S QUESTION: Have there been documented cases, and if so, I’m curious as to the number of players who go through the protocol, are cleared appropriately to return‑to‑play, but later report symptoms and are subsequently diagnosed with a concussion?

JEFF MILLER:  So a player who has been identified as potentially having a concussion going through the protocol on the sideline?

REPORTER’S QUESTION: Right, even the locker room evaluation.  We know that there have been players who have gone to the locker room, been evaluated, cleared to return‑to‑play, have returned to play.  Are there any instances of those players later developing symptoms that were subsequently led to a concussion diagnosis?

JEFF MILLER:  In the days following the game or later in the game?

REPORTER: Correct, after the game or in the days following.

JEFF MILLER:  I don’t know the answer to that question.  Dr. Heyer, have you had any experiences with that?

ROBERT HEYER: I think there have been a few.  I speak without exact knowledge, but that’s an excellent question.  Looking at the UNC data and the concussion data should be able to find out that number.  It would not surprise me if there was a case here and there, because concussions sometimes, their symptoms do develop over a period of time sometimes.

JEFF MILLER:  I think we’d have to do a little further digging to answer your question.  So let me do that and get back to you.

REPORTER’S QUESTION: You mentioned the athletic trainers in the booth who stop the clock for player evaluation when there is suspected injury.  Do you have a report on the times the referees may have stopped to the clock to have a player evaluated?

JEFF MILLER:  Where an official escorted a player off the field?  You can think of the Tyrod Taylor hit in the Buffalo game where I think Ed Hochuli took him off the field.

QUESTION: Right.

JEFF MILLER:  That was a point of emphasis with the officials as well and has been for a couple of years around identifying players they perceive need some assistance.  Again, that’s not asking the official to diagnose anything, that’s not his or her job.  But to identify a player that they think needs some medical attention.

So through the Competition Committee specifically, we’ll go back and look at those instances.  We would deem officials looking at players and identify them as needing medical attention as a positive thing.  But I don’t have any numbers to offer you at this point.

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