Contact in football often leads to injury.
One blow to the head can be a problem, but additional blows increase the risk of catastrophic head injury, long-term neurological disability, and permanent brain damage.
Undetected and untreated, concussion and other kinds of traumatic brain injury (TBI) can be fatal.
The Centers for Disease Control and Prevention (CDC) started the "Heads Up" project in 2003 to raise awareness and provide training about TBI and concussion. In 10 years, they distributed more than 6 million copies of their materials, and trained over 1.5 million coaches online.
But concerns remain.
What is concussion?
Concussion can result from a direct blow to the head or an indirect blow to the body. It affects the way the brain functions.
The American Association of Neurological Surgeons (AANS) describe it as: "A clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma."
- 1 in 3 concussions happen during practice, and 1 in 5 high school athletes will have a concussion during the season
- 1 in 3 high school athletes who report a sports concussion have at least one more within the year
- Some 5.3 million people live with a TBI-related disability in the U.S.
- 9 out of 10 concussions do not involve a loss of consciousness.
The skull contains cerebral spinal fluid. This fluid supports the brain, acting in a similar way to a shock absorber if a person receives a minor blow.
In concussion, the brain moves too quickly inside the skull. If there is a direct blow to the head, the brain may strike the inside of the skull. When the head stops moving, the brain hits the other side of the skull. These blows are known as the coup and the contrecoup.
A rotational concussion happens when the head rotates quickly from one side to another, causing the brain tissues to shear and strain.
Both motions can damage the delicate neural pathways in the brain, causing neurological damage, including problems with memory, judgment, reflexes, speech, balance, and muscle coordination.
Hazards that have been linked to concussion and TBI include an increased likelihood of dying from a subsequent unintentional injury, possibly due to changes in cognition and balance, and a tripling or quadrupling of the risk of suicide.
Mouse studies have suggested that young women who experience concussion could be more susceptible to alcohol abuse as adults.
Recovery is normally possible without intervention, but a second concussion increases the risk of permanent damage by 39 percent.
Concussion in football
In the U.S., concussion occurs more often in football than in any other sport. Some 47 percent of sports concussions happen during high school football activities.
Statistics indicate that the incidence of concussion among footballers is 64-76.8 per 100,000 participants.
In boy's ice hockey, the incidence is 54 per 100,000.
Girls are most at risk of concussion when playing soccer, with 33 cases per 100,000. For cheerleaders, the rate is 11.5-14 per 100,000.
Given the number of players in the U.S., Dr. Paul Auerbach, of the Department of Emergency Medicine at Stanford University School of Medicine in Stanford, CA, a former team doctor, describes football as a "colossally greater cause of significant injuries than boxing."
Signs and symptoms of concussion in football players
The CDC's "Heads up" project lists the signs and symptoms for coaches and players to be aware of.
The athlete may experience:
- Headache or "pressure" in the head
- Nausea or vomiting
- Balance problems or dizziness
- Double or blurry vision
- Sensitivity to light or noise
- Feeling sluggish, hazy, foggy, or groggy
- Concentration or memory problems
- Just not "feeling right" or "feeling down."
A blow to the head can leave a player dazed or stunned.
To others, the player may appear:
- Dazed or stunned
- Confused about an assignment or position
- Forgetful about an instruction
- Unsure of the game, score, or opponent
- Clumsy in movement
- Slow to answer questions
- Lose consciousness, even momentarily
- Show mood, behavior, or personality changes
- Be unable to remember what happened before or after the hit or fall.
If concussion is suspected, the CDC recommend:
- Removing the athlete from play
- Keeping them out of play for the rest of the day
- Obtaining permission from an appropriate healthcare professional stating that the athlete can return to play.
Dr. Auerbach points out that after a concussion, a person can feel normal in less than a week, but that the injury incurred may take at least 4-6 weeks to heal. However, athletes often return to the field before they have fully recovered, often within 7-10 days.
This puts them at risk of serious damage.
Since 2009, "Return-to-Play" laws have been introduced to give athletes enough time to recover before putting themselves at further risk.
Footballers are prone to repeated head trauma.
In 2009, a 13-year-old footballer, Zackery Lystedt, sustained a concussion during play. He returned 15 minutes later, but he then spent 9 months in a coma. He survived, but he is still in a wheelchair.
As a result, Washington passed the first "Return-to-Play" Law. By 2014, all 50 states and the District of Columbia had established such laws.
The Washington law, also known as the Zackery Lystedt law, requires that:
- Schools and activities institutions develop concussion guidelines and educational programs
- Parents and players sign a concussion and head injury information sheet every year
- Players are immediately removed from play if they may have concussion
- Players only return to play when they have written clearance from a specially trained healthcare provider.
Details vary according to the state. Texas and Arizona additionally allow parents to remove their child from play if they suspect concussion.
Do the Return-to-Play laws go far enough?
Some experts believe the laws do not offer sufficient protection.
Earlier this year, Dr. Auerbach and co-authors published an opinion article entitled "It's time to change the rules." The article, published in JAMA, calls for further action to prevent concussion in football before it happens.
Dr. Auerbach told Medical News Today:
"Return-to-Play laws are a step in the right direction, but do not go far enough. Based on evolving knowledge, allowing an athlete to return to play after a concussion after only 24 hours does not take into account that the healing process, even in the absence of ongoing clinical manifestations, may require 4 weeks or longer. The health professional that gives permission for an athlete to return to play should be an expert in concussions with a fund of knowledge comparable to that of a skilled neurologist."
Dr. Auerbach sees rest and recovery as a good step forward, but he calls for a more far-reaching solution.
He proposes changing the game from within.
Suggestions for doing this include:
- There should be no "down linemen" in direct opposition at the line of scrimmage. Opposing linemen must be in an upright position
- There should be no tackling of the opponent or intentionally striking an opponent's body with the top part of the helmet, above the face mask. It could be marked with a different color. Penalty 1 could be 15 yards from the infraction and loss of down. Penalty 2 would be ejection from the current and the next game
- No forearm blows, or "shivers," to the head at the line of scrimmage or while blocking or tackling. Penalties should be as above
- There should be a maximum of 2 days' full contact practice per calendar week. A practice day should involve a maximum of 20 plays per player with full contact
- If symptoms, a physical exam, or testing suggest concussion, a player should not play for at least 4 weeks. Before full play, they must progressively return to full contact
- Any coach that allows an athlete to participate with symptoms of concussion will be suspended for three games. A repeat infraction would lead to suspension for the rest of the season.
Other proposals include a ban on tackling or intentional head blows at youth level.
Asked why he thinks more radical changes to prevent concussion are not being actively pursued, Dr. Auerbach told MNT:
"Owners, sponsors, coaches, parents, and players may not be aware of the clinical manifestations, pathophysiology, natural course, and seriousness of concussions. If they are aware and have a conflict of interest, be that emotional, philosophical, or economic, they may continue to put players at risk by having the game continue in a manner that maintains the current number of traumatic brain injuries."
Dr. Auerbach recognizes that these changes might not be popular, but he argues that rather than detracting from the game, they could make it not only safer, but faster and more nimble.
Where is football headed?
We asked Dr. Auerbach whether he expects football and other sports to become more aggressive in time.
He told us: "I expect football and other games to become less aggressive in time, as data reveal the risks of traumatic brain injuries. In response, intelligent and caring proponents of safety in sports will hopefully make rules changes and enforce responses to injuries, such as appropriate return-to-play recommendations, to lessen the risks and improve outcomes. These interventions should be made immediately at the youth level."
Dr. Auerbach is not alone. The CDC are keen to raise awareness of the issue of TBI and concussion, and the public health burden it represents. They call for additional surveillance to help tackle the problem.
Without change, Dr. Auerbach predicts that participation will decline at youth level, as parents will become less accepting of this type of injury. This could be damaging to the sport.
"If more safety rules are not made and enforced, we will continue to have the current rates of concussions and other traumatic brain injuries. I expect that parents of youth players will be less tolerant of these injuries, so participation will decline. Educational institutions that sponsor football teams have a responsibility for the health and welfare of the athletes and will recognize the moral and legal imperative of making rules changes that preserve the game while better protecting the players."
Dr. Paul Auerbach
"If the youth, high school and university programs that feed into professional leagues make good decisions," adds Dr. Auerbach, "the professionals will follow. If they do not, football at that level will remain a dangerous sport."