Decades Beyond the Three-Finger Test for Sports-Related Concussion

NFL Head, Neck, and Spine Committee Co-Chair Dr. Richard Ellenbogen talks about the NFL's more evolved sidelines test and the Madden Rule.

See all videos with Dr. Richard Ellenbogen.

The NFL sidelines test is an amalgam of other tests that have existed for a while, but the advantage of it is it's not a 2-second test, like years ago, the doc on the sideline might have said, "Can you see my 2 fingers? Great. If you can see them, you can go back into the game." That's what we all used to do decades ago, I suspect. But now, it's a little more rigorous, because concussions, the brain injury from concussions, can evolve over time. So, you might feel, you might come out of a game and feel perfectly fine, then a minute later you have a headache, then 2 minutes later you're confused. Five minutes later you're vomiting. So, this test takes about 8-10 minutes to do, and it is a thorough neurologic exam that you would get from a neurosurgeon or a neurologist in the doctor's office. It includes a cognitive test to test your thinking, a memory test to see if you can remember numbers and names. It includes a balance test which has actually been validated, which is an excellent test, which has you stand on 1 foot with your hands on your hip and your eyes closed, and what we find which is remarkable is that a concussed patient can't do that. They fall over, their equilibrium is off. Whereas somebody who is compos mentis or doing well, not having a concussion, can do that better. So, it's an amalgam collection of a lot of tests that we already perform, put in 1 tool. One toolbox that the doctor or the professional athletic trainer can do by the sidelines and make a pretty good assessment that that player, A, comes out or B, can go back in, and part of that exam are 6 disqualifying things. To give you an example, if you're knocked out on the field, and remember only 10% of concussions do you get knocked out, but if you're knocked out, you're out. That's what we call a 'no-go.' If you have a change in your neurologic exam, anything, if your eyes are not focused and you're seeing double, you're out. So, there are certain things, that you don't even have to do the whole test, you're automatically out. If you stumble off the field, you're out. So, it's really helpful to have 6 things that you know that, no matter how good their exam is, they will be disqualified from the rest of the day, and another part of that test that was, incidentally, added by John Madden, the famous coach and color commentator on TV, who's forgotten more football than most people ever knew, was, when we presented this to the NFL, and we presented it to the competition committee, which consists of professional coaches,players, owners, really, people that know the game of football, John Madden stood up, the most diehard football fan you could ever meet, and he said, "Hey doc, that's a great test but guess what? It doesn't go far enough." He says, "I think that if you're concussed, if one of my players is concussed, I want him pulled off the field. I want his helmet taken away, I want him in a quiet locker room where he can be examined by the doctor or the professional athletic trainer, and I want no chance that he can ever come back out on the field." And I said, "Well, coach, I can't make that rule. I can just suggest the exam." Well, he and the commissioner of football, Roger Goodell, made that rule with his committee, and so, now, this year you have something called The Madden Rule, which is, not only are you taken out of the game, but you're taken off the field, so there is absolutely no chance you can come back and also gives you an opportunity to examine the player in a quiet environment, and you can see if it evolves or, at least, he can get better away from the noise of the stadium. So, I think this is where the thought process is being changed in organized sports. Where we're going from one end of the pendulum, decades ago, where, you know, "Just go back into the game," because we didn't understand the injury, to now, not only can't you go back in the game, but you're taken off the field, out of the stadium, and you can't go back to practice until you see 2 doctors-- 1 independent and 1 working for your team to clear you, just to start practice up again. I think it's a remarkable transformation in our thinking.
Posted on BrainLine October 23, 2012.

Produced by Vicky Youcha, Ashley Gilleland, Justin Rhodes, and Erica Queen, BrainLine.