In the wake of the NFL's settlement of the first class action concussion lawsuit brought by former players over brain trauma, much has been declared and yet little has been clarified for those seeking to determine the concussion risks of playing sports. In May 2012, Kurt Warner went on record as saying that he wasn't sure he'd want his sons to play football. The hailstorm of criticism he faced from colleagues was at once shocking and predictable. That former players like Merril Hoge would be so conditioned to defend the NFL that they accused Warner of throwing "the game that has been so good to him under the bus" is heartbreaking.
The NFL has reacted to the entire concussion issue in typical 800-pound gorilla fashion: circling the wagons and using their mountainous funds in the courts to achieve a settlement amount that is little more than a pinprick compared to the $25 billion per year that the NFL expects to be earning within 15 years. That the football mega-business has chosen this path indicates their fear of increased financial liability, uncomfortable fans and diminishing talent pools. If parents indeed ultimately choose to bar their children from participating in football, this fear could be made manifest and the next generation of NFL players will come entirely from the ranks of the desperate poor.
Sooner or later, parents are also going to understand that any sport can cause a concussion including basketball, soccer, hockey and even bike riding and roller-skating. The bottom line is that falling off a sidewalk curb can cause a concussion, whether one hits one's head or not. Lost in the NFL hype is the fact that impact is not necessary to sustain a concussion.
Concussions are the result of a rapid deceleration in which the brain bangs up against the inside of one's skull. Sudden rotational force can cause a concussion just as effectively as a blow, fall or collision. This is why helmets cannot prevent concussions. Helmets are extremely successful in protecting the athlete from skull fracture, which is what they were originally designed to do.
In his defense of football, Mr. Hoge went on to assert that the foremost danger to America's youth is not sports--it's obesity. He pointed out that sports are probably less harmful than letting one's child "sit on the couch, play [video games] and eat a donut."
Mark Verstegen, President and Founder of Athletes' Performance and Core Performance, is at the forefront of the NFL Players' Association's efforts to reduce concussions and improve the cognitive and physical health of the players. The athletes' most significant "win" in the new Collective Bargaining Agreement was the elimination of back-to-back contact practice sessions. The new rules not only reduce the number of collisions, they also force a recovery period between contact practices. Mr. Verstegen estimates that this could save players 10-15,000 hits to the head per season, resulting in 40,000 fewer impacts over the average career. If adapted at the college, high school and youth levels, this principle could greatly increase a young player's chances of avoiding brain injury.
Another dramatic improvement in sports training is AP's use of a virtual regimen created by Axon Sports, which eliminates the risk of head injury entirely by providing as many as 300 simulated snaps (or pitches or basketball plays) via computer in 12-15 minutes. Athletes can accumulate many of the 10,000 hours of practice necessary for mastery of their position through cognitive repetitions, not risking collisions that could cause concussion.
In physical training, athletes are being taught how to use their bodies in ways that better prevent rapid deceleration of their brains. The more generally fit one is, the higher the likelihood of being able to decelerate one's entire body, spreading the force over a larger area than inside the skull. This is part of the new emphasis at all levels of football against any movement that leads with the head. The NFL is also adapting both baseline testing and a buddy system. The idea is that if a player is tempted to disguise symptoms in order to return to the field, their "buddy" on the team can recognize when something is not right with a teammate he knows well.
Athletes' Performance has recently partnered with the Mayo Clinic to promote research, treatment, medical/training techniques and best practices that strive to improve the health of the Mayo Clinic's patients, AP's athletes and to take that knowledge to the public at large in a mission to improve America's health. While that may sound like a sweeping fairy tale dream, the plan is grounded in science, technology, nutrition, therapies and inspirational dedication that can make this dream a reality.
In this partnership, Mayo Clinic patients can be referred to Athletes' Performance for physical therapy, "pre-hab" (injury prevention training) and overall wellness programs that help them get back to optimal performance (in sports or life) and AP clients have access to the Clinic's world-class medical services.
The Mayo Clinic's concussion initiative, led by neurologist Dr. David Dodick, is a broad-based approach dedicated to improving how we care for concussions, how we educate the public on brain injuries and how we research the brain. The Clinic's research is focused on understanding concussion at the cellular level. If we know exactly what changes occur in the brain and the body between normal brain function and the injured brain, we would not only be able to objectively identify the presence of a concussion but also establish a "biology of recovery" to track the patient's healing and determine when they are unequivocally ready to return to their sport. There are exciting indications that researchers will be able to identify biomarkers (even something as seemingly simple as blood pressure changes) that prove the presence of a concussion even in the absence of symptoms.
As has been famously discussed during the NFL concussion debate, the single tallest hurdle in protecting a player's cognitive health is accurate diagnosis when a concussion occurs. This is because existing diagnostic techniques are subjective. The current best practice is to establish a pre-sport brain function baseline and compare it to how an athlete performs on the same cognitive test after any event that may have caused a concussion.
The NFL, NHL, NCAA, the Olympics and the U.S. military services require pre-participation baseline testing. According to Dr. Dodick, 49 states mandate clearance by a "licensed healthcare professional" (not including a cognitive examination) prior to joining school sports. This system has many flaws including intentionally poor initial testing by athletes and inaccurate in-game assessment.
When asked whether the professional sports leagues were supportive of the new concussion research, Dr. Dodick pauses. "I approached the NFL two years ago about establishing a system for a completely independent neurologist to be on the sidelines of every game. They were not interested." Concussion protocols still vary in professional football. Each team has a "concussion expert" and players are entitled to a second opinion by a non-team medical professional before returning to play after a concussion. Dodick believes that truly independent neurologists must be volunteers. He advocates a group of doctors who would work games in their area for no compensation. One wonders how the NFL would view such a suggestion today.
Life in the National Football League has changed when it comes to head injuries. The ownership is diligently taking steps to improve the rules for player protection. As Dr. Dodick says, "When it takes place in the NFL, it's the highest level and everyone else has to take it seriously."
Mark Verstegen brings his boundless optimism to bear on this issue: "Concussion awareness is structurally a part of the new CBA and a part of the game. [This emphasis on safety] will continue on as we transparently work together in the players' best interest."
Dr. Dodick is determined to establish tools for concussion identification that are "reliable, non-invasive, rapid and cost-effective" for everyone from Pop Warner to the NHL. The only sure way to determine the presence of a concussion is with imaging--hardly practical during a two-minute drive or on a junior high school hockey field.
The Mayo Clinic is beta-testing a device that may be able to provide access to expert neurological diagnosis literally from the sidelines. VGo is a robot. Yes, as in R2D2 hovering around next to the bench. VGo is a joint venture between the Clinic and Northern Arizona University. It has a remotely controlled camera system linking the football team's trainers and players with neurologists. Dr. Bert Vargas, Mayo Clinic neurologist, heads the trial and hopes that such a system can be used in isolated areas to provide accurate concussion diagnosis within the physical and environmental settings of athletic events.
The Mayo Clinic has also made baseline testing available to anyone, free of charge. The Clinic's cognitive test gives a healthcare provider an "objective snapshot" of an athlete's "Before" brain function. You can go onto the site, take the test, save it in a password-protected format and print it out. If you sustain a concussion you can also take a post-injury test and take them both to your doctor. The testing site location is: http://www.mayoclinic.org/concussion-testing/.
The Clinic is also developing new protocols for post-injury care. If you are having difficulty recovering from a concussion you can make an appointment. They will help you make pre-appointment arrangements and you will be evaluated by their neurologists. The evaluation is followed by concussion-focused post-injury testing and referral to a neurological expert trained to your area of difficulty: balance, memory, sleep disturbances, etc. You will receive treatment and rehabilitation designed specifically for your situation. Dr. Dodick stresses that patients should "not just wait" for things to improve.
The truth is that there is no way to prevent concussions in sports and young athletes are more vulnerable to long-term impairment than adults. Better equipment helps. Better training and conditioning helps. Rule changes that protect the athletes help. But physical activity carries the risk of injury.
When asked what steps a parent could take to ensure that their child or teen is entering a sports situation that is dedicated to athlete safety, Dr. Dodick advised:
- Adopt a healthy lifestyle where fitness, conditioning and safety awareness are ingrained
- Find out the state and local school district requirements for pre-athletic clearance, equipment standards, coaching certifications
- Research the sports program's credentials such as Heads Up Football and Safe Football http://usafootball.com/headsup http://safefootball.org/
- Talk to the coaches and the trainers.
- Do they do baseline testing?
- What tackling/contact techniques do they teach? How do they practice to dissipate the impact forces on contact?
- What is the concussion protocol?
- Who is watching out for the safety of the players on a constant basis? Trainer? Safety Consultant?
- What position will they be playing? Positions with routine collisions (offensive line, hockey forward) can have adverse effects from cumulative blows to the head even if there has never been an actual concussion.
- What is the plan if a concussion is suspected? Above all things, what steps do they take to avoid "Second Impact Syndrome," in which a second concussion occurs before the first is healed?
Sports participation has helped millions of young people develop into healthy, responsible adults. Sports promote a level of physical fitness fast disappearing in America. Sports teach discipline, leadership, the ability to work together as a team. Sports connect people and form bonds. Sports build self-confidence, shape characters and challenge spirits.
Those of us who love football do not want it to disappear. We want to be able to support it wholeheartedly, knowing that the risks have become manageable to the point where we, and Kurt Warner, would not hesitate to let our children play this spectacular game.
With thanks to Mark Verstegen and Leigh Dow of Athletes' Performance and Dr. David Dodick of The Mayo Clinic.