Buck Pierce’s concussion raises questions

The Blue Bombers may have their preferred starting quarterback under centre in Monday's clash against the Montreal Alouettes, but there are serious questions about if they should play him. Buck Pierce was remarkably effective in his return from a foot injury two weeks ago, and he played well against Toronto Saturday before being knocked out of the game with what was later diagnosed as a concussion. Thus, the point at issue isn't if he's the Bombers' best quarterback option at this point: that doesn't seem to be in serious dispute. The questions are really more about the team's handling of the initial situation, about if Pierce has had enough time to recover and about if the Bombers should consider another option this week to preserve his long-term health.

Before we get to the current situation, let's look at just what happened to Pierce in the first place. From Kirk Penton of The Winnipeg Sun:

Pierce took a helmet-to-helmet hit from Argos linebacker Brandon Isaac late in the first quarter of Saturday's 29-10 loss to Toronto. He left the game to get stitched up and have a concussion test, but he returned midway through the second quarter and guided the Bombers to 10 points.

Pierce started developing a headache late in the first half, however, so the team's training staff held him out of the second half. Pierce's headache persisted until Monday, but Burke wasn't sure why he ultimately failed the concussion test on Tuesday.

That's a significant problem. The headache and concussion diagnosis may have come after the initial hit on Pierce, but it seems highly likely that's what caused them. This is further proof that concussion tests are not infallible, something that's been stated by leading authorities. That doesn't necessarily mean the Blue Bombers or their medical staff did anything wrong by the book; concussion symptoms can take time to develop, and Pierce may not have exhibited any when he passed the test. It's even possible (if unlikely) that Pierce wasn't concussed by the Isaac hit, but by a later play. Hits to the head are hugely troubling regardless of their result, though, so it would be nice to see the league at least investigate the Isaac hit on Pierce and perhaps hand down some discipline to discourage players from doing this.

There's also something to be said for taking a more cautious approach to returning players to play following a head hit, even if they pass concussion tests. Yes, it's not required at the moment. Yes, it may result in holding some non-concussed players out. That's a small price to pay for preventing concussed players from returning to play, as they're far more vulnerable to a wide range of serious issues following a concussion, including the often-deadly second-impact syndrome. Fortunately, Pierce doesn't seem to have run into any of those.

Returning other concussed players to games could create dramatic problems, though, so it may well be worth it for teams and the league to take an even more cautious approach than they currently are. The current approach has its merits, and it's impressive once players are actually diagnosed with a concussion. However, it's worth pointing out that concussions are extremely difficult to diagnose, and even the most state-of-the-art tests don't catch them all. The Bombers' initial tests don't appear to have caught Pierce's concussion, and that's worth being concerned about.

There are also questions about how soon Winnipeg plans to return Pierce to action. Here's what head coach Tim Burke had to say about Pierce's injury:

Pierce was diagnosed with a mild concussion on Tuesday, but he is symptom free and could still be under centre on Monday in Montreal if he passes a standardized concussion assessment tool, or SCAT test, in the next couple of days.

"However long it takes for him to pass that test is when he can play," Bombers head coach Tim Burke said. "… He's very close to passing it."

One element that's interesting here is the declaration that Pierce is "symptom free," which seems in stark contrast to the information that he failed a concussion test Tuesday. We don't know exactly what that test is, as Jamie Dykstra, the CFL's director of communications, said the league and its teams use multiple tests to evaluate players. "To determine when and if a player who has been diagnosed with a concussion can return to play, our trainers use a number of different tests, including but not limited to the ImPACT test, Scat2, physician assessments, neurologist assessments (if deemed necessary by the treating physician)," Dysktra wrote by e-mail Wednesday. However, copies of the SCAT and SCAT2 tests can be viewed here (PDF) and here (PDF) thanks to Dr. Charles Tator's respected ThinkFirst organization, and although information on how exactly the pass or fail system works isn't provided on that sheet, it would appear difficult to fail with no symptoms of a concussion.

Now, perhaps that "symptom free" comment (which is not a direct quote: it's in Penton's words) means Pierce doesn't display physical symptoms such as a headache or neck pain. There are mental symptoms as well, though (such as difficulty concentrating or remembering). The SCAT tests looks like solid ones, as they look at elements like gait, eye movement, balance and so on as well as cognitive questions (the value of cognition tests alone has been questioned by some leading authorities), so they're a good thing to use here. Pierce's issues passing one of those or another test used by the league Tuesday suggest that he isn't entirely recovered yet.

Would Pierce be able to play Monday under the league's concussion protocol? Possibly. Here are the return-to-play guidelines included on the nationwide poster the CFL was involved with developing in 2011. A very similar six-step process is found at the bottom of the SCAT test:

Dykstra said the league's return-to-play standard follows a similar pattern. Quoting from the CFL's concussion policy, he said "Concussion return to play decisions are based on the completion of a graded, stepwise activity progression. The player is allowed to proceed to the next exercise level if he completes and is asymptomatic at the present level. The final step in return to play is clearance by a team physician." If that graded, stepwise activity process has the same steps as the above poster and the same 24-hour time period between each step, Pierce would be able to return for Monday's game under these steps if he's on step two by 1 p.m. Thursday (and doesn't experience any setbacks). However, he wouldn't be able to do non-contact training until Saturday and wouldn't be able to do contact training until Sunday. That's not a lot of practice time to get ready for Monday's game, and you wonder if the Bombers wouldn't be better off practicing with Joey Elliott all week and starting him, resting Pierce for the following week.

Unsurprisingly, Pierce wants to play. As Katie Miyazaki's case illustrates, most players always want to play, which is why it's a good thing the decisions are up to doctors. Still, you get the sense from Pierce's remarks that he's eager to get back on the field as soon as possible, perhaps even too much so:

"I fully understand every situation that I put myself into, and (the trainers and doctors) understand that, too," Pierce said. "If they felt I wasn't able to physically go out there and play or that it would be a risk for the club or for me going out there and playing, then they wouldn't do that. And I wouldn't do that."

As outlined above, this isn't necessarily a case where anything is violating league rules or established concussion protocols. If Pierce is able to pass that test by Thursday afternoon, he could be starting Monday while still following the six-step process outlined by the poster. Moreover, it's going to be medical personnel who make the call on whether Pierce is ready to go. Even if he is medically cleared, though, there's a case to be made that the Bombers shouldn't start him this week.

No matter how "mild" (a ridiculous term that many are trying to get rid of) Pierce's concussion is, concussions are serious business, and Pierce's injury history adds another layer to this. He refuses to talk about past concussions, but has admitted to at least one, and many CFL observers would expect the real number to be higher. Former CFL quarterback and current TSN analyst Matt Dunigan (who's candidly talked about how concussions suffered during his playing career affect him to this day) even called Pierce Monday to tell him to think about the big picture here. As we've previously seen, there can be legitimate concussion questions even when one isn't officially diagnosed. Granted, the Bombers are currently desperate, as they're 3-10 on the year and would need to go on quite the run over the last five games to make the playoffs. It's still debatable whether starting a quarterback with a history of head injuries who's coming off another concussion, and doing so after he received only minimal practice reps, is the best course of action for them.