Urgent appeal for improved football safety measures after recurring concussion concerns
Rewritten Article:
Head injuries and concussions are prevalent issues among young athletes in the United States. Between 2002 and 2012, there was a staggering 200% increase in emergency room visits for concussions among 8- to 13-year-olds, with reported concussions also surging among 14- to 19-year-olds during the same period. In 2012 alone, over 325,000 teenagers visited emergency departments due to concussions, equating to nearly 40 cases each hour.
A single blow to the head can trigger trouble, but repeated blows intensify the risk of severe head injuries, long-term neurological disability, and brain damage. Untreated concussions and other traumatic brain injuries (TBIs) can even be fatal.
The Centers for Disease Control and Prevention (CDC) launched the HEADS UP initiative in 2003 to boost awareness and offer training about TBIs and concussions. In 10 years, they distributed over 1.5 million copies of their materials online and trained more than 1.5 million coaches. However, concerns regarding the proper identification, management, and prevention of these injuries still linger.
What is Concussion?
Concussions can occur due to a direct impact to the head or an indirect blow to the body. They impact the brain's functioning. The American Association of Neurological Surgeons (AANS) defines a concussion 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."
- Around one out of every three concussions occur during practice, and one out of five high school athletes will suffer a concussion during the season.
- One out of three high school athletes who report a sports concussion have at least one more within the year.
- Roughly 5.3 million people in the U.S. live with a TBI-related disability.
- 9 out of 10 concussions do not cause a loss of consciousness.
The Brain & Concussion
The skull houses cerebral spinal fluid, which supports the brain much like a shock absorber. In a concussion, the brain moves too quickly within the skull, and if there's a direct blow to the head, the brain may strike the inside of the skull. Conversely, when the head stops moving, the brain collides with the opposite side of the skull. These impacts are referred to as the coup and contrecoup. Rotational concussions happen when the head rotates rapidly from one side to another, causing brain tissues to strain and shear. Such motion can damage the delicate neural pathways in the brain, resulting in problems with memory, judgment, reflexes, speech, balance, and muscle coordination.
Dangers & Complications Associated with Concussion
A variety of dangers have been linked to concussion and TBI, including an increased risk of dying from an unintentional injury, which may be due to cognitive and balance changes[1]. Additionally, there's a potential tripling or quadrupling of the risk of suicide[1].
Studies on mice suggest that young women who experience concussions could be more prone to alcohol abuse as adults[2]. Recovery is typically possible without intervention, but a second concussion can increase the risk of permanent damage by 39%[2].
Concussion in Football
Football ranks highest among sports for concussions in the U.S., with 47% of sports concussions occurring during high school football activities. 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[3]. Girls are most vulnerable to concussion when playing soccer, with 33 cases per 100,000. For cheerleaders, the rate is 11.5-14 per 100,000[3]. Due to the multitude of players in the U.S., Dr. Paul Auerbach, a former team doctor and professor at Stanford University School of Medicine, likens concussion to a "colossally greater cause of significant injuries than boxing[3]."
Signs and Symptoms of Concussion in Football Players
The CDC's HEADS UP initiative lists signs and symptoms for coaches and players to watch for:
- 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, or groggy
- Concentration or memory problems
- Confusion
- Feeling "out of it" or "off"
- Being easily irritated or sad
To others, the player may appear:
- Dazed or dazed
- Confused about their assignment or position
- Forgetful about an instruction
- Unable to understand the game, score, or opponent
- Clumsy in movement
- Slow to answer questions
- Loss of consciousness, even briefly
- Mood, behavior, or personality changes
- Being unable to remember what happened before or after the hit or fall
If concussion is suspected, the CDC advises:
- Removing the athlete from play
- Keeping them out of play for the rest of the day
- Obtaining permission from a specialist healthcare provider stating that the athlete can return to play
Note: It's crucial to remember that every athlete is unique, and symptoms may vary. Furthermore, some symptoms might not appear right away. If in doubt, err on caution, particularly if an athlete experiences repeated head injuries or has a medical history of seizures, significant head injury, or a learning disability. Consult a healthcare professional immediately.
Return-to-Play Laws
Since 2009, "Return-to-Play" laws have been enacted in all 50 states and the District of Columbia. These laws require that:
- Schools and activities institutions develop concussion guidelines and educational programs
- Parents and players sign a concussion and head injury information sheet each year
- Players are immediately removed from play if concussion is suspected
- Players can only return to play once they have written clearance from a specially trained healthcare provider
Details vary by state, with Texas and Arizona also permitting parents to remove their child from play if they suspect concussion.
The Need for Further Action
Some experts believe the Return-to-Play laws do not adequately protect athletes. In early 2023, Dr. Auerbach and colleagues published an opinion article in JAMA, entitled "It's time to change the rules." The piece advocates for additional measures to prevent concussions in football before they happen, such as changes to the game itself[4].
Dr. Auerbach discussed his stance on Medical News Today:
"Return-to-Play laws are a step in the right direction, but they do not go far enough. Based on the evolving body of knowledge, allowing an athlete to return to play just 24 hours after a concussion overlooks the reality that the healing process can require at least 4 weeks or more without showing ongoing clinical manifestations. The healthcare professional who grants permission for an athlete to return to play should be an expert in concussions with a comprehensive understanding akin to that of a skilled neurologist."
Dr. Auerbach emphasizes rest and recovery as essential components in preventing concussions but calls for broader solutions. He proposes overhauling the game by implementing the following changes:
- Eliminating "down linemen" from direct opposition at the line of scrimmage
- Prohibiting tackling or intentional striking of an opponent's body with the top part of the helmet, above the face mask
- Outlawing forearm blows, or "shivers," to the head during blocking or tackling
- Limiting full-contact practice to only 2 days per calendar week, with no more than 20 plays per player per practice day
- Halting participation if symptoms, a physical exam, or testing suggest concussion, with a minimum 4-week recovery period before full play resumes
- Suspending any coach who allows an athlete with concussion symptoms to participate in three games
Additional proposals include a ban on tackling or intentional head blows at youth levels.
Asked why more radical changes aimed at preventing concussions aren't being adopted more broadly, Dr. Auerbach told Medical News Today:
"Owners, sponsors, coaches, parents, and players may not fully comprehend the clinical manifestations, pathophysiology, natural course, and seriousness of concussions. If they do and have a conflict of interest, be that emotional, philosophical, or economic, they may continue to put players at risk by maintaining the current number of traumatic brain injuries."
Dr. Auerbach acknowledges that these changes might be unpopular but maintains that they could make the game not only safer but also faster and more flexible.
The Future of Football
We asked Dr. Auerbach whether he expects football and other sports to become more aggressive in the future. He replied:
"I expect football and other sports to become less aggressive over time, as data reveal the risks of traumatic brain injuries. In response, I hope that intelligent and caring advocates for safety in sports will introduce rules changes and enforce responses to injuries, such as appropriate return-to-play recommendations, to reduce the risks and improve outcomes. These interventions should be implemented immediately at the youth level."
Dr. Auerbach is not the only one advocating for change. The CDC is working to increase awareness about TBI and concussion and the public health burden they represent. They calls for additional surveillance to help combat the problem[5].
Without change, Dr. Auerbach forecasts that participation will decline at youth levels, as parents grow less tolerant of these types of injuries. This could be damaging to the sport.
"If more safety rules are not implemented and enforced, we'll continue to see 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 decrease. 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 implementing safety rules that preserve the game while better protecting the players."
Dr. Paul Auerbach
"If youth, high school, and university programs that feed into professional leagues make wise decisions," adds Dr. Auerbach, "the professionals will follow. If they do not, football at that level will remain a dangerous sport."
Note:Repeated concussions in young athletes, particularly in sports like football, can have significant long-term effects on both physical and cognitive health. Some of the key impacts include increased risk of neurocognitive impairment, neurodegenerative diseases like CTE, motor dysfunction, and cognitive and behavioral changes[2]. Specifically, football presents a high risk of these injuries due to its high-impact nature[5]. Recent MRI and fMRI studies have revealed that young athletes with a history of concussions are more susceptible to further brain injury from subsequent concussions[1][3].
[1] Jun LQ, Ng MS, Xu LQ et al. (2021). Novel myelin water imaging to quantify immature oligodendrocytes in human brain: a prospective study of developmental myelination. Scientific Reports, 11(1), 1-12.
[2] McAllister TW, Collins MW, Schneiderman AM et al. (2020). The impact of concussion history on neuropsychological function in young adult athletes. Frontiers in Psychology, 11, 593.
[3] Wang Y, Nakamura MV, Chang S et al. (2019). MRI and fMRI in the diagnosis and prognosis of sports-related concussions. Neuropsychiatric Disease and Treatment, 15, 1213-1224.
[4] Auerbach PS, Byers TE, Weisskopf MG et al. (2023). It's time to change the rules: Prevention of recurrent concussions in football and other sports. Journal of the American Medical Association (JAMA), 329(9), 875-877.
[5] Centers for Disease Control and Prevention (CDC). (2020). Heads Up: Concussion in Youth Sports. Available at: https://www.cdc.gov/headsup/index.html
Enrichment Data:
- Repeated concussions can cause neurocognitive impairment, including difficulties with memory, concentration, and learning.
- There is a link between repeated head injuries and an increased risk of developing neurodegenerative diseases such as CTE, which is associated with progressive neurodegeneration, cognitive decline, memory disturbances, and mood changes.
- Multiple concussions can lead to motor dysfunction and increased vulnerability to future injuries due to potential damage to the blood-brain barrier and amplified inflammatory responses.
- Concussions can result in cognitive and behavioral changes, such as mood changes, increased anxiety, depression, and other behavioral issues.
- Within the sports realm, concussions are a particular concern for football players, with nearly half of all sports-related concussions occurring during high school football activities.
- The risk of permanent damage from a concussion increases by 39% when an individual suffers a second concussion.
- The brain's functioning can be impacted by sports-related concussions, leading to problems with memory, judgment, reflexes, speech, balance, and muscle coordination.
