02/26/2013 08:21 am ET Updated Apr 28, 2013

Is Brain Injury Winning?

Flipping through the channels last month, I witnessed an NFL playoff game just at the moment to see a player tackled so hard that his headgear went flying through the air! This, along with the ongoing media attention on head injury, made me want to revisit the topic of helmet safety and head trauma. Recently published findings in the scientific journal, Brain, amplified the correlation between repetitive mild traumatic brain injury and the development of chronic traumatic encephalopathy (CTE), a progressive degenerative and incurable disease whose symptoms can include memory loss, depression and dementia.

In a New York Times article, it was suggested that there may be brain damage even when a player does not appear hurt and reported that in a group of 85 people, 80 percent (68 men) -- nearly all of whom played sports -- showed evidence of CTE. In a survey conducted on 125 former football players last August, 70 percent claimed they were in fear of losing their mind. These findings insinuate that the risks associated with even minor head trauma may be being dismissed inappropriately and that the dangers of head trauma are under appreciated.

The brain is a soft tissue organ surrounded by thin layers of tissues and encased in a boney skull. Contrary to popular belief, a concussion is not just a bruising of the brain. Often there is no swelling or outward damage detectable on imaging examinations. Concussions are caused by the head being swung rapidly causing a de-acceleration of the brain which can jar the brain and the soft tissue envelope within the skull. Depending on the severity, the brain may also impact against the hard shell of the skull. What we are learning is that trauma of this sort causes the brain cells to become depolarized and fire neurotransmitters all at once in an unhealthy rush, flooding the brain with chemicals and deadening certain receptors linked to learning and memory; this insult may be responsible for confusion, blurred vision, memory loss, nausea and possibly unconsciousness. These types of head-whipping occurrences are seen during a typical football game. Neurologists report that once a person suffers a concussion, a second one is as much as four times more likely. Moreover, after several concussions, the brain becomes more sensitive and it takes less of a blow to cause an injury, and more time is required to recover.

During the 2011-12 school year, head and facial injuries were most likely to occur in high school athletes, with nearly 309,000 estimated incidents, according to a study done by High School RIO (Reporting Information Online).

Football players are role models for male youngsters and project how "real men" should behave. Children and their parents need to understand what emulating their favorite sports stars means and have appropriate information to make informed decisions on personal safety. This is not dissimilar to the way smoking was portrayed in the 1940s when many movie actors and actresses smoked and it was the in "hot" look and sanctioned by parents and youngsters, despite concern that it might not be healthy. That said, how much longer are dangerous conditions that can cause permanent head injury going to be tolerated on the playing field?

The NFL, football team owners, equipment manufacturers, stadium owners, players and sponsors should not be allowed to look the other way and ignore safety. Ignoring safety is not tolerated in our society in other fields such as healthcare, airline industry, food products, etc., so why should it be tolerated and even sanctioned in sports? In the defense of the NFL, in 2009, team owners enacted four player safety rules for the following season to eliminate blindside helmet-to-helmet blocks. The rules state that:

  • 1. The initial force of a blindside block cannot be delivered by a helmet, forearm or shoulder to an opponent's head or neck. An illegal blindside block will bring a 15-yard penalty;
  • 2. initial contact to the head of a defenseless receiver will draw a 15-yard penalty;
  • 3. on kickoffs, no blocking wedge of more than two players will be allowed and;
  • 4. the kicking team cannot have more than five players bunched together pursuing an onside kick.

Adjusting player regulations, however, does not change the fact that the game is inherently dangerous and it is that very danger that makes the game profitable. In 2011, the NFL concussion statistics continued to climb with another 162 head injuries reported last year. That is roughly a 72 percent chance of a concussion or injury occurring in each NFL game.

Recognizing sports-related head trauma is not new. The National Football Head and Neck Surgery Registry began collecting data related to head and neck injuries occurring during tackle football in 1971 (see footnote 1). The data showed that headgear is not as protective as one would think and in some respects deceives the player into thinking they can use their head like a battering ram e.g., spear tackling which was outlawed in High School Football in 1976. From the 1960s to present, the football helmet has not significantly changed. The current headgear used is outdated. Although, there is new fancy equipment, these devices do not actually minimize impact. Take for instance, the impact indicator chinstrap, which is simply a sensor designed to tell the player that they have been hit, hard. While designing a better helmet may be a step towards safety, we are learning that the helmet does not protect the brain adequately from the risk of a concussion.

As of August 2012, over 3,000 former NFL players have been involved in lawsuits against the NFL and Riddell, the makers of NFL helmets, concerning head injuries. Many of the lawsuits revolve around new evidence that the NFL was withholding critical information about the nature of head trauma. Former players are stating that the NFL downplayed the risks of repetitive head injury, and were misleading concerning the long term effects, however, the projected outcome of the lawsuit is unfortunately not expected until 2018.

By and large, we need widespread awareness of the risks, both immediate as well as long term.


Head injuries are occurring in football and other sports. The understanding of how a concussion can occur -- is defined and how it is diagnosed -- is becoming clearer along with the recognition of long term consequences. Scientific evidence is mounting that repeated head trauma can lead to permanent sequelae. Action is needed to promote safety. The fans can be a voice against the profiteers and help protect the game they embrace. The fans need to realize that they can be effective in what's "ok" on the field and what's not. The era of the coliseum, where you either win or die, e.g., the Christians against the Lions or the Gladiators against the slaves, should not be tolerated. Winning should not mean death and/or destruction to the opposing team or any team player(s). The fans can help protect the players, make the game safe or ban football. Tough choices? Not really.

1.Torg JS Truex R, Quedenfeld TC, Burstein A, Spealman A, Nichols C. The National Football Head and Neck Registry: report and concur decision 1978. JAMA 1979; 241: 1477-1479

For more by Helene Pavlov, M.D., click here.

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