While there is no way to make football, or any contact or collision sport, completely concussion-risk free or completely eliminate the repetitive head contact that a growing body of research suggests may lead to more cognitive and emotional problems later in an athlete’s life, there are at least eight steps programs – and parents – can take to minimize the risk of concussion and the effect of repetitive head trauma on an athlete’s long-term brain health:
1. Requiring comprehensive sports physicals
All athletes should undergo a pre-participation physical evaluation (PPE) before every season to identify those who, because of a history of concussions (all brain injuries, not just those sustained during sports) or other pre-existing medical conditions – such as chronic migraines, ADHD, learning disabilities, or sleep disorders – should be advised against playing contact or collision sports or to consider retirement from such sports (Pillar Six). It is particularly important that the PPE include the taking of a detailed concussion history;
2. Ensuring that players wear properly fitted protective equipment
Helmets in any helmeted sport such as football, lacrosse, and hockey need to fit properly before the season, and proper fit must be maintained over the course of the season (which is especially important for newer football helmets with air-bladder systems, because helmet fit may be compromised, either because air leaks from the bladder or because players intentionally let the air out for a more comfortable fit). After the season, helmets must be properly reconditioned, or replaced if they have reached the end of their useful life.
Three important caveats about protective equipment:
- Although biomechanical studies have shown that helmets and other protective equipment may reduce some impact forces to the brain, there is no evidence that such equipment reduces, much less prevents concussion, nor is there field data (as opposed to tests conducted under controlled conditions in a laboratory, such as are presented in Virginia Tech’s STAR helmet rating system) showing that one type of helmet is superior to another kind of helmet in reducing concussion risk. Indeed, several studies and a recent research paper suggest that older helmets, as long as they have been properly reconditioned, do just as good a job of protecting against concussion as new helmets);
- The evidence does suggest, however, that an improperly fitted helmet can increase risk of concussion, especially if the helmet comes off during play (one of the two concussions suffered by Newcastle players during the 2012 season during the filming of The Smartest Team occurred after an opposing player intentionally shoved his helmet off);
- There continues to be no compelling evidence that mouth guards protect athletes from concussion, but they nevertheless an important piece of safety equipment because of their role in preventing dental and orofacial injuries.
3. Teaching players proper tackling, blocking, and body-checking techniques, and keep their head up to brace for contact
- All football players, regardless of position, need to learn how to tackle in a way that minimizes helmet-to-helmet contact.
- Lacrosse and hockey players need to be taught how to body check an opponent without using their head;
- Players on the offensive and defensive line in football should learn how to avoid using their helmets as the initial point of contact with opponents on the line of scrimmage. Despite being technically illegal since 1976 and a point of emphasis in recent years in rules enforcement at the high school level, such helmet-to-helmet contact continues to be a widespread practice during line play, with players being rarely penalized; and
- Players in all contact and collision sports should keep their heads up and aware of their surroundings so that when they see a hit coming they can brace for the blow. A study of hockey players shows that bracing for a body check reduces of the risk of concussion.
How important is it that football players learn and employ proper technique in block and tackling? Very. And it isn’t just to reduce the number of concussions, but also because it can reduce both the number of subconcussive hits, particularly to the top and front of the head.
In a groundbreaking 2010 study researchers at Purdue found short-term neurocognitive effects among high school football players who sustained a high number of subconcussive hits during the course of a season. In an April 2011 interview with PBS’s Frontline, Tom Talavage, Ph.D., an associate professor of electrical and computer engineering at Purdue, co-director of the Purdue MRI facility, and the lead author of the study, observed that at least 50 percent of the subconcussive blows were the function of poor technique.
“Some of the players … [didn’t] have very good technique, to be quite honest. What we found was they will launch into a play and they will lead with their helmet. Other players will more correctly keep their head up, try to get their arms up as a blocking technique, or when they’re rushing, they will try to get their arms up as a means to push the offensive lineman out of the way. Those technique differences lead to a very large difference in the total number of blows experienced and where those blows are experienced on the head.”
Talavage told Frontline that one of the players involved in the study, an offensive lineman who was among a group the researchers found after one season to have suffered a short-term functional impairment from repeated subconcussive blows to the top front of the head (the area of the brain responsible for visual memory) changed his technique so much that he not only drastically reduced the number of blows he experienced to the top front of his head and had a moderate reduction in the total number of hits he experienced, but “his neurocognitive testing never detected any deficits.”
Moreover, Talavage said, when the researchers had a chance to monitor a second local football team, they observed a “dramatic difference” in technique. Whereas the team they had principally studying (the one with the players who were functionally impaired as a result of sustaining a high number of subconcussive blows), had a “large number of players who lead with their helmet and experienced a large number of blows with their helmet, the second team had a much greater tendency to get arms up for blocking, and tended to, at least from observation, to take many fewer blows to the head. And we think that has a potential effect on their neurological health.”
“We need to really get back to emphasizing proper tackling technique,” said Talavage.
While the research is limited, and has generated considerable controversy, one recent study does appear to show that teaching heads up tackling, at least when combined with strict limits on full-contact practice time, reduces the concussion rate in youth football.
4. Encouraging players to strengthen their neck muscles
Emerging evidence suggests that stronger neck muscles may help players better withstand the linear and rotational forces that cause concussion. Players should also maintain peak overall physical condition all year round, which reduces the overall risk of injury, not just of concussion.
5. Strictly enforcing existing rules against helmet-to-helmet contact and defenseless players
Rules designed to protect players against contact that increases risk of concussion and serious, and potentially fatal, head/neck/spine injuries, must be more strictly enforced. But such rules are only as protective as the officials charged with enforcing them. While recent years have seen greater emphasis on efforts to penalize illegal hits at all levels of football, as well as in other contact and collision sports, such as lacrosse, hockey, soccer, and basketball, some suggest that, if an official is unsure whether an illegal hit has occurred, they should err on the side of caution by calling a penalty.
We really need to “reinforce the spearing rules [in football], particularly at the high school level, where spearing basically happens on every play, but the referees don’t call it, because they don’t want to call a penalty on every play. We need to get them to do that,” says Purdue’s Talavage.
If they did, predicts Dr. Frederick Mueller, former Director of the National Center for Catastrophic Sports Injury Research, the number of concussions and catastrophic injuries might be reduced because “Coaches would no longer teach improper techniques and players would no longer use their helmeted heads if they know a penalty will be called or if they were subject to a game disqualification.”
6. Adopting new rules where there is strong evidence that a particular aspect of play increases injury risk
One suggested rule, adopted by NFL owners in March 2013, penalizes with a 15-yard penalty a runner or a tackler who initiates forcible contact by delivering a blow with the top/crown of his helmet against an opponent in the open field (when both players clearly are outside the tackle box (an area extending from tackle to tackle and from three yards beyond the line of scrimmage to the offensive team’s end line). The rule warrants adoption by the National Federation of High School Associations (NFHS) and its member high school athletic associations as soon as possible. The Smartest Team includes an interview with a Newcastle player who suffered multiple concussions as a result of what he admits was a “bad habit” as running back of lowering his head and exposing the crown of his helmet. A recent study published in the journal Pediatrics suggests that rule or coaching changes that reduce collisions after long closing distances (such as occur on kickoffs and punt returns) should be considered.
7. Working to reduce total brain trauma
While medical science works to find the thus far elusive threshold beyond which repetitive brain trauma significantly increases risk of concussion and permanent brain damage, common sense and intuitively attractive steps are being taken to reduce and/or limit the number of impacts players sustain over the course of a season or career, including reducing or eliminating off-season practices at the high school level, and reducing the number of full-contact practices during the season – as has been done in the National Football League, many youth football programs, the Ivy League and Pac-12, as recommended by the NCAA, and now mandated by law or by state high school athletic association rules in all but a few states – should be taken now. The long term goal should be to find such thresholds, at which point “hit counts,” similar to pitch limits instituted in youth baseball, might be considered.
There is, as of yet, little research to show a direct link between the implementation of limits on full-contact practices and a reduced concussion rate, although a research paper presented at the 2015 American Academy of Pediatrics National Conference and Exhibition did find a significant reduction in concussion risk after rules limiting the number and duration of full-contact practices were put into place for high school football in Wisconsin.
Some experts believe that one way to reduce the number of concussions and hits to the head in sports suffered by youth athletes in sports such as soccer and football is to prohibit heading in soccer until age 14 and delay the introduction of tackle football until age 14.
While intuitively attractive, such recommendations are not, thus far at least, supported by the kind of longitudinal studies needed to establish that the introduction of heading before the age of 14 or playing tackle football before high school is associated with increased risk of chronic traumatic encephalopathy or long-term cognitive impairment.
A much-publicized 2015 study found that former National Football League players who began playing tackle football before the age of twelve were more statistically more likely to experience long-term neurocognitive impairment, but a more recent study – which received virtually no attention from the media – was unable to replicate its findings, finding no association between pre-high school football and neuroradiological, neurological, or neurophysiological outcome measures.
Sources:
McCrory P, et. al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013: 47:250-258.
Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)
McGuine T, Brooks A, Hetzel S, Rasmussen J, McCrea M. “The Association of the Type of Football Helmet and Mouth Guard With the Incidence of Sport-Related Concussion in High School Football Players.” Presentation Paper AOSSM, July 13, 2013.
Mihalik JP, Blackburn JT, Greenwald RM, Cantu RC, Marshall SW,Guskiewicz KM. Collision type and player anticipation affect head impact severity among youth ice hockey players. Pediatrics. 2010;125:1394-1401.
Gregory S. “Neck Strength Predicts Concussion Risk, Study Says” (http://keepingscore.blogs.time.com/2013/02/21/study-neck-strength-predicts-concussion-risk/)(accessed February 22, 2013), citing Comstock R.D. High School Sports-Related Injury: Recent Trends and Research Findings. Presented at the National Youth Sports Safety Summit, Washington, D.C., February 5, 2013.
Talavage T, Nauman E, Breedlove E, et. al. Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion. J Neurotrauma. 2010; DOI: 10.1089/neu.2010.1512.
Mueller, F, Colgate B. Annual Survey of Football Injury Research 1931-2011, National Center for Catastrophic Sports Injury Research; February 2013. (accessed at http://www.unc.edu/depts/nccsi/2012FBInj.pdf)
Collins CL, Fletcher EN, Fields SK, Kluchurosky L, Rohrkemper MK, Comstock RD, Cantu RC. Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports. J Primary Prevent. 2014; DOI:10.1007/s10935-014-03555-2 (published online ahead of print June 15, 2014)
Meehan WP, Landry GL. Council on Sports Medicine and Fitness Pediatrics. Tackling in Youth Football. Pediatrics 2015;136(5). doi: 10.1542/peds.2015-3282 (accessed at http://pediatrics.aappublications.org/content/early/2015/10/20/peds.2015…
Research paper, “Effect of New Rule Limiting Full Contact Practice on Incidence of Sport Related Concussion in High School Football Players.” McGuine TA, Hetzel S, Brooks MA. Presented at American Academy of Pediatrics National Conference and Exhibition. October 24-27, 2015, Washington, D.C.
Stamm JM, Bourlas AP, Baugh CM, et al. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology 2015;84(11):1114-1120.
Solomon GS, Kuhn AW, Zuckerman SL, et al. Participation in Pre-High School Football and Neurological, Neuroradiological, and Neuropsychological Findings in Later Life. Am J Sports Med. 2016;20(10). doi:10.11777/0363546515626164.
