Concussion Research Can’t Be Ignored
Ann McKee is a neruopatholigist and a leading brain concussion researcher. When asked how she’d advise her 19-year-old son if he was offered a chance to play in the NFL, she said, “I’d say, ‘Don’t. Not if you want to have a life after football.’”
One of the unfortunate outcomes of win-at-all-costs (WAAC) and profit-at-all-costs (PAAC) policies and decisions in the Sports World is that safety concerns take a back seat to winning and making money.
One of the most glaring examples of this is with concussions and head trauma issues. Historically, NFL, college and high school players have been encouraged to shake off concussions and get back on the field. Coaches and trainers have historically told players that they’ve simply had their “bell rung,” and that apart from a few cobwebs, everything is fine.
Part of the NFL culture – and to a lesser degree Sports World in general — is to “play hurt.” As a result, most former NFL players have chronic debilitating conditions of one degree or another, most of which can be traced to a football injury. Shockingly, NFL players die on an average 15 years before the average American male.
Unfortunately, the suck it up, “just play through it” approach to injuries in sports has seeped down to the youth sports level where overuse injuries for boys and girls are nearing epidemic proportions. The “Be tough!” mentality rules the day.
What we’ve learned about brain injuries demands that we take the subject of safety in sports to an entirely different level. If the injury is a sprained ankle or tendonitis, that’s one thing, it’s another thing if it’s a brain concussion. What makes the diagnosis and treatment of concussions especially tough is that people can’t see brain injuries with the naked eye like they can a sprained ankle.
“Everyone says, ‘You look fine, why can’t you play?’ You’re dealing with a macho, heavy-testosterone sport,” says pro football agent Peter Schaffer.
Undoubtedly, the most important safety and injury prevention issue in sports today is concussions and repetitive head trauma. Getting your “bell rung” is nothing to be taken lightly; it is serious stuff – especially at the high school and youth levels where developing brains are more susceptible.
Recently, NFL commissioner Roger Goodell, along with a mix of NFL executives, doctors, players and members of Congress, took part in a House Judiciary Committee hearing on football-induced brain concussions.
You may or may not think Congress is overstepping its bounds by inquiring into the NFL’s policies on concussions, but one thing is certain, how the NFL deals with concussions has a big impact on how college, high school and youth football organizations deal with head injuries.
As such, the Congressional hearings held at the end of 2010 brought needed attention to an issue impacting the safety of our young athletes. (It’s not just a football issue, girls’ soccer is second to football in number of concussions; and many other sports have a significant amount of concussions as well. However, football represents the most serious problem, not just because of the number of reported concussions, but because of the suspected number of concussions that don’t get reported and because of the repetitive sub-concussive blows to the head inherent in the sport.)
Julian Bailes, a well-known neurosurgeon, is extremely upset with the NFL on this issue, not just because of what it means to their own employees but what it means for football players at the college, high school and youth levels:
“Here we have a multibillion-dollar industry,” says Bailes. “Where does their responsibility begin? Say you’re a kid and you sign up to play football. You realize you can blow out your knee, you can even break your neck and become paralyzed. Those are all known risks. But you don’t sign up to become a brain-damaged young adult. The NFL should be leading the world in figuring this out, acknowledging the risk. They should be thanking us for bringing them this research.
The “Little” Hits to the Head Add Up Too
It’s not just full-blown concussions that are a cause for concern. Perhaps the most important recent finding in the area of concussion research is that repetitive small hits to the head can cause as much damage as big blows.
The University of North Carolina tracks the numbers of hits to the head the players in their football program take during a season, including games and practices. The average is 950 blows to the head each season. That’s an important number because researchers are discovering that it’s not just the major blows to the head that are dangerous. They all count.
Neuroscientist Kevin Guzkiewicz believes that repetitive low-impact hits are enough to cause cumulative damage to young brain tissue but not enough to cause immediate symptoms.
“There’s what we call a dose response,” Guskiewicz says. “After a certain number of hits, the damage starts to show.”
Dr. Robert Cantu, a leading expert on concussions and their long-term effects, concurs, saying “repetitive sub-concussive trauma” adds up to long-term problems. This could apply to the constant head-banging that takes place between offensive and defensive linemen in football, as well as years and years of headers in soccer.
CTE: The Long-Term Impact of Brain Trauma
A growing concern in the brain trauma field is chronic traumatic encephalopathy (CTE), a brain degeneration disease. CTE, which is basically the same as “punch drunk syndrome,” has been an affliction tied to boxers since the 1920’s.
For decades, boxing officials, fans, and reporters have too often ignored the impact of “knock-outs” on boxers’ health. Boxing, of course, is the ultimate sport for concussions. The goal is to knock out your opponent, in effect, to give the other person a concussion. Boxers are repeatedly sent back into action after being staggered with a blow to the head.
Boxing has become a niche sport in this country, with sagging popularity. As such, hockey and football have moved to the forefront when the subject of concussions in sports is brought up. Hockey superstars Eric Lindros and Sidney Crosby have suffered multiple concussions and battled post-concussion syndrome. Their high-profile cases have softened attitudes towards head injuries in the macho culture of hockey. Nevertheless, football’s mass popularity, combined with recent publicity on concussions and their long-term impact on former NFL players has made football the focus of discussions on sports-related concussions.
“Football is the current poster child for (CTE),” according to H. Hunt Batjer, a Northwestern University neurosurgeon who co-chairs the National Football League’s Head, Neck, and Spine Committee.
In an October 2009 New Yorker article on brain injuries in football, author Malcolm Gladwell pointed out that CTE usually appears later in life because it takes a long time for the initial trauma to give rise to nerve-cell breakdown and death. It has many symptoms similar to Alzheimer’s disease, however it isn’t the result of some endogenous disease but due to brain injury –being hit too many times in the head.
So, football players who retire from their sport believing that all their faculties are in order aren’t necessarily out of the woods yet.
A neuropathologist named Bennet Omalu has only once failed to find CTE in the autopsies of more than 20 professional football players. Due to CTE, brain disease and various cognitive and psychological problems among former pro football players may be even more common than neuroscientists currently believe.
Consider that the number of former players between the ages 30 and 49 that have received a diagnosis of “dementia, Alzheimer’s disease, or other memory-related disease” are 19 times the national average for that age group. Moreover, Guskiewicz found that players who had suffered multiple concussions were three times more likely to suffer depression.
Ted Johnson played a decade for the New England Patriots as a hard-hitting linebacker. He was a Super Bowl hero who took thousands of hits to his brain. He retired due to a variety of effects from too many concussions and repetitive sub-concussive trauma. He became depressed. He was a drug addict. He seldom left his room. He was diagnosed with post concussion syndrome by Dr. Cantu and told that by his fifties he could have severe Alzheimer’s.
“Sometimes I wish Junior would have just blown his knees out and couldn’t walk,” says his father Ted Johnson, Sr. “But his brain? Oh boy.”
Youth Sports Needs to Be the Focus
While brain trauma in the NFL is a serious issue, as a nation, our biggest area of concern shouldn’t be NFL players, it should be the high school and youth athletes whose brains are not fully developed and require more care and recovery time from concussions than adults.
“The immature brain is still developing,” says Bailes. “That makes it more susceptible to damage and more likely to suffer repetitive injury.”
Here’s the scariest issue in a nutshell: Too many high school and youth athletes suffer concussions without their coaches or parents even knowing it. And too many of these young athletes return to action too quickly — risking dangerous outcomes.
Nearly 400,000 concussions occurred in high school athletics during the 2008-09 school year – most of them in football. Many of these are initially undetected. In the last two years, eight kids have died from concussion-based problems and dozens more have suffered catastrophic brain injuries.
According to a recent study by the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio, 40.5% of high school athletes who have suffered concussions return to action prematurely, risking more severe problems. Playing with a concussion can lead to death from Second Impact Syndrome (SIS), a condition in which the brain swells, shutting down the brain stem and resulting in respiratory failure.
It’s sobering to note that only 42% of high schools have athletic trainers and those trainers obviously can’t attend all of a given school’s athletic events. Additionally, the vast majority of non-school related youth sports leagues, including football, conduct their events without any trainers or trained medical personnel in attendance.
Furthermore, coaches and parents are woefully uneducated when it comes to brain injuries. The result is too few concussions are properly identified, and the ones that are don’t receive the recommended treatment. Education is critical when it comes to concussions because multiple concussions increase both the short-and-long-term risks for young athletes.
There is some good news: The National Federation of State High School Associations reviewed the latest research on concussions in young people and sent out a revised pamphlet on concussion policies and procedures to state federations at the end of the 2010-2011 school year.
“We’re trying to keep this a front-burner issue,” says the federation’s Bob Colgate. “Kids are still getting in and playing with head injuries.”
Even more encouraging, legislation requiring coaches to be educated on concussion detection and proper protocol in dealing with head injuries is popping up around the country.
Recent laws in Texas, Washington and Oregon have mandated better concussion training and medical services in youth sports. Sadly, the statutes are all named after boys who were recently killed or seriously hurt by football-related brain injuries.
A lawsuit brought against the NFL by six former players and one current player in August 2011 over the league’s alleged irresponsible handling of concussion-related injuries, is increasing the general public’s awareness of the problem of concussions in sports.
Nevertheless, the vast majority of coaches, parents and young athletes aren’t fully aware of the seriousness of brain injuries.
“I keep telling kids, your brain is not your knee. It’s not your shoulder. It’s your future,” says neuropsychologist Gerard Gioia. “We have to protect it better than we are.”
We’ll never be able to eliminate concussions from sports. And it’s not feasible or rational to try and keep our sons and daughters in a sports safety bubble. But it’s definitely possible to increase the awareness and education levels of all stakeholders in high school and youth sports, and to greatly reduce the incidents of concussions – and especially cases of Secondary Impact Syndrome.
How Much Can Helmets Help?
A key question is how much can we protect our brains in sports? Intuitively, we believe helmets make sports safer, and we think headgear with additional padding would be even more protective. However, there’s a lot of debate on helmets now in the scientific community. It’s important to note that no helmet can prevent concussions. So, just how much can they do?
We know helmets are limited when it comes to preventing concussions because the problem isn’t just the initial blow to the head but the also the brain movement that takes place during collisions. As such, when it comes to the brain’s movement inside the skull after a blow to the head, it might not matter much how much padding is in the helmet.
“The brain is still moving around within the skull when somebody has a concussion, and that’s what causes them,” said Dr. Mark Lovell, co-creator of the ImPACT concussion test. “We can’t put a helmet directly on the brain.”
Most current studies in the area of concussions focus on linear impact, i.e., direct helmet-to-helmet contact. However, some neurologists think rotational impact – from a glancing blow that twists the head — is just as dangerous. There are questions about just how much helmets can protect against rotational impact. Some researchers even believe that helmets may increase rotational impact. Other researchers suggest that big hits aren’t the main concussion cause. They say many concussions result from the accumulated damage of lots of minor hits. In that case, helmets may have a limited positive impact as well.
Football helmet manufacturer Riddell claims its new Revoloution helmet reduces the risk of concussions by 31 percent vs. traditional helmets. However, Sen. Tom Udall, D-N.Mex., believes marketing statements such as these are misleading. He went public with his concerns. Following Udall’s comments, Riddell said that while its research on reducing concussions was encouraging, “we can’t stress enough that no helmet will prevent all concussions.”
The Federal Trade Commission (FTC) is currently examining the marketing practices of Riddell and other leading manufacturers of football helmets. Their investigation is focused on the companies’ claims that football helmets reduce concussions. The FTC agreed to do the investigation at Udall’s urging. Udall believes the helmet manufacturers are using “deceptive practices.”
“I am concerned for our young football players and their safety. I hope football helmet makers improve their products to address concussion risks,” said Udall. “It is simply unacceptable for sports equipment companies to falsely advertise their products to athletes, coaches and parents with claims of providing a level of safety that does not yet exist.”
In soccer, there has been a movement – driven primarily by parents — to wear headgear to protect the brain during collisions between players, head trauma from hitting the ground, and also from repetitive headers. A couple manufacturers have developed protective headgear for soccer players. Some have claimed the new style headgear significantly reduces the concussion rate. However, the claims are questionable given the lack of hard scientific data on the safety effects of the headgear.
There may be too much emphasis on headgear and not enough on coaching technique when it comes to concussion prevention. There’s a widespread belief that coaching reforms and stricter officiating will do more to lower concussion incidence than any style of helmet. More coaches need to use the “see what you hit” approach to coaching tackling and blocking because head-up hits are a lot less dangerous than head-down hits.
“The best results for concussion reduction will come from changing football behavior,” says Guskiewicz.
Officials at all levels of football need to make helmet-to-helmet hits an officiating “point of emphasis” in order to help change player behavior. Players should be ejected for helmet-to-helmet hits, especially at the high school and youth levels.
Until we get more hard research on the effectiveness of helmets, coaching and officiating changes might hold the most promise in the area of concussion prevention.
1. All Sports Leagues – At All Levels – Should Be Required to Develop a Concussion Policy Statement and Implement An Educational Campaign Around Concussions
“Athletics will never be stripped of all danger … but the brain is more than a joint or a limb. It’s the seat of the self. We overlook that fact at our peril and – much worse – at our children’s.”
–Jeffrey Kluger, “Headbanger Nation,” Time, January 31, 2011
Sports leagues should develop concussion policy statements which include the league’s commitment to safety and the teaching of safe playing methods; a description of concussion and repetitive brain trauma; the process if an athlete is suspected of having a concussion; and information on when athletes can safely return to play.
A well-conceived concussion policy statement is important at all levels of sports, but is especially critical at the high school and youth levels because younger brains take longer to heal from a concussion and are more susceptible to Second Impact Syndrome.
Part of every league’s concussion policy should spell out the communications and education strategy for increasing awareness and understanding of brain injuries amongst the league’s constituents.
Parents, coaches, trainers, and athletes should be asked to sign the concussion policy statement at the beginning of each sports season — ideally in conjunction with a mandatory concussion safety and prevention seminar.
Signs and Symptoms of Concussions
- Appears dazed or stunned
- Forgets plays
- Unsure of score or opponent
- Moves clumsily (balance problems)
- Loses consciousness (even briefly)
- Headache or pressure in the head
- Nausea or vomiting
- Double or blurry vision
- Sensitivity to light or noise
- Feeling groggy or sluggish
2. Make the King-Devick Concussion Test Mandatory in All Sports At the High School Level On Down
The most critical aspect of a concussion safety plan is the quick identification of a possible concussion during games and practices.
The King-Devick test is a simple and objective rapid sideline-screening test for concussions that can be administered by coaches, trainers, and parents in two minutes or less. Some sports medicine professionals have called the test “the missing link” in concussion safety protocols.
Research has shown the King-Devick test to be an accurate and reliable method of identifying athletes with brain injuries. It can be an excellent objective tool for determining whether players should be removed from games or not.
A University of Pennsylvania School of Medicine study published in the Journal of Neurology on April 26, 2011 demonstrated the usefulness of the King-Devick Test. The study examined 39 boxers and Mixed Martial Arts contestants and found post-fight test times for those who suffered head trauma worsened by an average 11.1 seconds. Those who had lost consciousness were on average 18 seconds slower. Those who did not suffer any head trauma actually improved their times by more than a second on average.
“This rapid screening test provides an effective way to detect early signs of concussion, which can improve outcomes and hopefully prevent repetitive concussions,” said Laura Balcer, the study’s senior researcher.
The King-Devick test is a one-time, one-to-two-minute test that requires an athlete to establish a baseline time at the beginning of each season. Athletes are timed reading a series of single digit numbers displayed on three flash cards. If the athlete suffers a suspected head injury in a practice or game, the athlete is given the test again. If the time needed to complete the test is more than five seconds slower than the athlete’s baseline test, a concussion can be confidently diagnosed. The athlete should then be removed from play and evaluated by a licensed medical professional.
There are other accurate concussion tests, however, they are more complex and should be administered by professional healthcare providers. The King-Devick test is easy to learn, understand and administer, making it very valuable for high school and youth sports programs. As such, its use should become standard at the high school level on down.
To see a sample of the King-Devick test flash cards, go to:
To watch a video explaining the test, go to:
3. Every State Should Adopt Concussion Legislation Similar to Colorado’s Jake Snakenberg Youth Concussion Act
The Colorado youth sports concussion act is named for Jake Snakenberg, a football player at Grandview High School in Aurora Colorado who died in 2004 as a result of repeated concussions, or Second Impact Syndrome.
Briefly this legislation entails the following:
- Requires coaches who suspect an athlete has a concussion to immediately remove that athlete from play for the remainder of the game or practice.
- In order for the athlete to return to play, written clearance from a licensed health care provider is needed.
- All coaches of athletes ranging in age from 11-19 are required to take a free 30-minute online concussion course that teaches them to recognize concussion symptoms.
At its most basic, the policy is “When in doubt, sit them out.”
“This would’ve meant a lot to Jake, and he would be very proud, just as we are, that his name is associated with keeping kids safe … No family should ever have to go through what my family has been through,” said Snakenberg’s mother Kelli Jantz.
One strong addition to this type of legislation would be to make the entire team take the concussion course so players would be more apt to see signs of concussion in their teammates. In many cases, teammates can see the signs of concussion before coaches do.
The Snakenberg Act has been endorsed by the NFL (which after years of resisting the research on concussions, and attempting to sweep it under the rug, is finally — albeit gradually and reluctantly — acknowledging that improved awareness, prevention and treatment measures are needed). At least nine other states have similar laws on the books and 10 others are considering concussion legislation.
Former Denver Broncos’ receiver Ed McCaffrey personally endorsed the Colorado bill, saying, “We know way more today than we did when I played and it is important that we take advantage of that knowledge.”
When safety measures can be implemented without substantially changing the nature of the sport, they should be put into practice.
Dr. Steve Devick, who earned the Academy’s 2011 Dr. Ernst Jokl Sports Medicine Award for developing the King-Devick Test, is scheduled to give a seminar and demonstration at 9 a.m. Friday, Nov. 11 at the university’s campus in Daphne, Ala. Registration is free but seating is limited, so make your reservations early by calling the Academy at 251-626-3303.
Ralph Nader and his League of Fans, a sports advocacy group he co-founded that seeks reforms that encourage civic responsibility in sports industry and culture, called for mandatory implementation of the King-Devick concussion test in high school and youth sports throughout the nation. Nader and the League of Fans made the recommendation Aug. 25 in its fifth of 11 reports from its Sports Manifesto,“Concussion Research Can’t Be Ignored.”
The author of the report, Dr. Ken Reed, is the League of Fan’s sports policy director and a United States Sports Academy non-resident faculty member. Reed is a longtime sports industry consultant, sports studies instructor, sports issues analyst, columnist and author. A strong advocate for quality physical education and sports programs for all people, not just elite athletes, he created the Center for the Advancement of Physical Education (CAPE) for PE4life. The nonprofit is dedicated to making quality daily physical education available to all k-12 students. Contact him at firstname.lastname@example.org.