Concussions have clearly been an uncontrolled epidemic in football for decades. Epidemics are not instantly cured by simple solutions. They require complete strategies for risk reduction. The following outline provides a complete strategy.
BELIEVE IN PREVENTION
First and foremost, anyone involved in athletics should believe that prevention of neurological injury is of paramount importance. An undercurrent of “concussions are inevitable, we just have to manage them” permeates the sports world. Just because some concussions may still occur, this does not warrant an attitude of complete resignation towards preventing the injury. Prevention is possible. Prevention is critical.
IMPROVE UNDERSTANDING
The term concussion is inherently problematic, because it gives a vague sounding name to a tangible and dangerous injury. At Xenith we use the term concussive episode, as opposed to concussion, and invite others to join us. ‘Episode’ is a clinically useful term, describing something with a start and finish, and a variety of possible features and descriptors. With regard to concussive episodes, a long but generally accepted list of possible signs or symptoms may be included. Diagnosed concussions are included as concussive episodes. While the concussive episode may end, particular symptoms may linger indefinitely. The term concussive episode de-emphasizes “grading” a concussion (i.e. mild, moderate, severe) in favor of describing the episode’s features; who is to say what is mild, moderate, or severe?
The term concussive episode eliminates the need to “diagnose” the concussion to make it real. It ends the confusion over so-called “dings or bell-ringers,” or episodes of “seeing stars.” They are all included because they are all real. It is evident that players of all sports experience many more concussive episodes than are actually diagnosed as concussions, perhaps ten fold more. For more information in the incidence of concussive episodes in sports, read the position paper by the National Athletic Trainers Association and this paper by Scott Delaney.
The term concussive episode eliminates the need to “diagnose” the concussion to make it real. It ends the confusion over so-called “dings or bell-ringers,” or episodes of “seeing stars.” They are all included because they are all real. It is evident that players of all sports experience many more concussive episodes than are actually diagnosed as concussions, perhaps ten fold more. For more information in the incidence of concussive episodes in sports, read the position paper by the National Athletic Trainers Association and this paper by Scott Delaney.
IMPROVE THE CULTURE OF FOOTBALL
We must end the gladiator mentality that permeates football. Because of this mentality, big hits are rewarded, at least culturally, with cheering, highlight films, and awards with names like “Headhunter” and “Hammer.” Young players proudly show off the marks on their helmets. However, there is absolutely nothing in the National Federation of High Schools Football Rule Book that rewards hitting; nothing about being a gladiator. The “rewards” are entirely cultural, and the dangers entirely real.
It is critical to realize that football has always been popular, and will continue to be popular. The game can remain physical, fast, and entertaining, and will likely attract even more young athletes if it can become a safer activity. This is no longer about being a gladiator. It is about being an Enlightened Warrior.
It is critical to realize that football has always been popular, and will continue to be popular. The game can remain physical, fast, and entertaining, and will likely attract even more young athletes if it can become a safer activity. This is no longer about being a gladiator. It is about being an Enlightened Warrior.
IMPROVE THE GAME OF FOOTBALL
Football rules and techniques must be thoroughly examined, with the goal of eliminating neurological injuries. The most effective rules and techniques will be geared towards eliminating the use of the head for contact. Coaches, leagues and officials should take a zero tolerance policy towards this practice. Eliminating head first contact will not only minimize concussive episodes, it will minimize other more severe injuries, including spinal cord injuries. For more information on the danger of head-down, head-first contact, read this position paper by the National Athletic Trainers’ Association:
It is entirely possible, and preferable, to tackle without using one’s head. Xenith sponsors a very effective tackle training technique, coached by Bobby Hosea, called “Dip n’ Rip”. This technique has players deliver an upward thrust, with contact made across the chest and shoulders. This technique drives the runner upright, while the head remains out of the impact. Players make sound tackles with the focus on stopping forward progress.
It is entirely possible, and preferable, to tackle without using one’s head. Xenith sponsors a very effective tackle training technique, coached by Bobby Hosea, called “Dip n’ Rip”. This technique has players deliver an upward thrust, with contact made across the chest and shoulders. This technique drives the runner upright, while the head remains out of the impact. Players make sound tackles with the focus on stopping forward progress.
REDUCE EXPOSURES
One of the factors that must be addressed is the number of exposures that athletes are subjected to. An exposure is an activity that subjects the athlete to potential for injury. This may be a practice, a game, or an extended drill. Simply put, the more you play, the more exposures you have. Extended seasons, double or triple sessions, spring practices, or long practices with “live” contact will increase the player’s risk of injury. Teams would greatly improve safety by considering the number of exposures players are subjected to. This would of course reduce the risk of all other injuries as well.
IMPROVE PROTECTIVE EQUIPMENT
Protective equipment receives a tremendous amount of attention, both positive and negative, with regard to injury prevention. Some may blindly look for technology solutions, perhaps only after the problem has reached significant magnitude, at which point it is likely too late. Others believe that protective equipment cannot help, or they perceive that protective equipment leads players to take more risks, thereby making the problem worse.
In reality, protective equipment can play an important role when applied in the proper context. Protective equipment that minimizes the sudden movement of the head will reduce the risk of brain injury. However, no responsible equipment manufacturer believes that equipment alone can completely solve the problem of concussive episodes. No responsible equipment manufacturer wants their equipment to create a false sense of security. No responsible equipment manufacturer wants their equipment used as a weapon. However, better equipment is clearly a piece of the risk reduction strategy.
In reality, protective equipment can play an important role when applied in the proper context. Protective equipment that minimizes the sudden movement of the head will reduce the risk of brain injury. However, no responsible equipment manufacturer believes that equipment alone can completely solve the problem of concussive episodes. No responsible equipment manufacturer wants their equipment to create a false sense of security. No responsible equipment manufacturer wants their equipment used as a weapon. However, better equipment is clearly a piece of the risk reduction strategy.
IMPROVE RECOGNITION
Arguably the biggest problem in football is “playing through” a concussive episode; this is an extreme thing to do, and dramatically increases the risk of further injury and increased disability. This is a result of the gladiator mentality, which mandates playing through pain. Players may come forward to reveal symptoms of a concussive episode, but it remains likely that players will work to stay on the field. It will be up to those around the players to recognize and report injuries.
Research demonstrates that players with previous concussions may be more likely to suffer future concussions. For more information on the effects of multiple concussions, read the NCAA concussion study, co-authored by Dr. Robert Cantu and Dr. Kevin Guskiewicz. In rare instances, multiple concussions within a short period of time may lead to a severe and life-threatening condition known as Second Impact Syndrome.
Certified athletic trainers are often closest to players regarding physical injuries, and are therefore in a logical position to spot concussive episodes, or elicit honest information from players. Efforts to increase or mandate the presence of athletic trainers are certainly likely to result in better injury recognition.
In the absence of certified athletic trainers, coaches, officials, parents, and players still have a role. One concept, promoted by Dr. Gerry Gioia of Children’s National Medical Center, is called “Carry the Clipboard.” The Centers for Disease Control (CDC) offers free materials, designed to attach to a clipboard, providing a helpful checklist for awareness and management of concussive episodes. Carry the Clipboard suggests that one adult at each sporting event be assigned to carry the CDC information on a clipboard, designating that adult as responsible for recognizing players who appear to be debilitated, and for contacting a local expert. Preparation for more serious or critical injuries is also strongly advised. For expert training in management of the critically injured athlete, visit: www.sportsmedicineconcepts.com.
Research demonstrates that players with previous concussions may be more likely to suffer future concussions. For more information on the effects of multiple concussions, read the NCAA concussion study, co-authored by Dr. Robert Cantu and Dr. Kevin Guskiewicz. In rare instances, multiple concussions within a short period of time may lead to a severe and life-threatening condition known as Second Impact Syndrome.
Certified athletic trainers are often closest to players regarding physical injuries, and are therefore in a logical position to spot concussive episodes, or elicit honest information from players. Efforts to increase or mandate the presence of athletic trainers are certainly likely to result in better injury recognition.
In the absence of certified athletic trainers, coaches, officials, parents, and players still have a role. One concept, promoted by Dr. Gerry Gioia of Children’s National Medical Center, is called “Carry the Clipboard.” The Centers for Disease Control (CDC) offers free materials, designed to attach to a clipboard, providing a helpful checklist for awareness and management of concussive episodes. Carry the Clipboard suggests that one adult at each sporting event be assigned to carry the CDC information on a clipboard, designating that adult as responsible for recognizing players who appear to be debilitated, and for contacting a local expert. Preparation for more serious or critical injuries is also strongly advised. For expert training in management of the critically injured athlete, visit: www.sportsmedicineconcepts.com.
IMPROVE MANAGEMENT AND RETURN TO PLAY
Once an injury is experienced, proper management under the care of an expert (or someone closely aligned with an expert) is imperative. Improper management, or no management, dramatically increases the chances for repeated injury, prolonged dysfunction, progressive disease, or fatality.
Modern standard of care for a concussive episode involves not just physical, but also mental rest. The metabolic dysfunction incurred during a concussive episode requires the brain to recalibrate itself, and physical or mental exertion may exacerbate symptoms during the period of recovery. Managed return to play involves resolution of symptoms, followed by progressively increasing activity over a period of time. There is no set timetable; each individual will vary.
One increasingly utilized tool is neuropsychological testing. This type of testing involves athletes performing a series of tests, in order to gauge their “baseline” level of cognitive function. These tests are then repeated after the injury and during the period of recovery. Some mistakenly perceive these tests as pass/fail. In reality, these tests are part of the overall management plan, and when utilized properly, will contribute to the overall clinical picture. For more information on how to implement neuropsychological testing, visit www.impacttest.com or www.headminder.com.
With an athlete claiming no symptoms, performing well on neuropsychological testing helps confirm that the athlete is recovering well. Performing poorly indicates that the athlete is not yet recovered, or may be attempting to hide symptoms in an effort to return to play. Engaging in these tests also increases the likelihood that the athlete is managed by an expert, or managed by someone with access to experts.
Return to play decisions are rarely clear cut, but the science is evolving rapidly, and conservative management is always warranted. A great rule of thumb is “when in doubt, sit them out.”
Modern standard of care for a concussive episode involves not just physical, but also mental rest. The metabolic dysfunction incurred during a concussive episode requires the brain to recalibrate itself, and physical or mental exertion may exacerbate symptoms during the period of recovery. Managed return to play involves resolution of symptoms, followed by progressively increasing activity over a period of time. There is no set timetable; each individual will vary.
One increasingly utilized tool is neuropsychological testing. This type of testing involves athletes performing a series of tests, in order to gauge their “baseline” level of cognitive function. These tests are then repeated after the injury and during the period of recovery. Some mistakenly perceive these tests as pass/fail. In reality, these tests are part of the overall management plan, and when utilized properly, will contribute to the overall clinical picture. For more information on how to implement neuropsychological testing, visit www.impacttest.com or www.headminder.com.
With an athlete claiming no symptoms, performing well on neuropsychological testing helps confirm that the athlete is recovering well. Performing poorly indicates that the athlete is not yet recovered, or may be attempting to hide symptoms in an effort to return to play. Engaging in these tests also increases the likelihood that the athlete is managed by an expert, or managed by someone with access to experts.
Return to play decisions are rarely clear cut, but the science is evolving rapidly, and conservative management is always warranted. A great rule of thumb is “when in doubt, sit them out.”
MANDATES
The epidemic of concussive episodes is a major public health issue. A role for legislation or mandates clearly exists. Several states have passed or are considering measures that require players to receive medical clearance before returning after a diagnosed concussion. This is a step in the right direction, but is relevant after the fact, and assumes a diagnosis was actually made; it is aimed at secondary prevention, and is not going to affect the vast majority of the injuries that go undiagnosed.
Primary prevention, the goal of preventing an injury from ever occurring, must be paramount. Legislation by the government, or mandates by institutions, aimed at educating anyone involved in overseeing athletic activities and minimizing exposures, would prevent countless injuries. If a youth football coach knew the dangers of concussive episodes, and was compelled to think about the practices he ran, the techniques he taught, and the behavior he rewarded, primary prevention would be a reality, and the gladiator mentality would die out. The Enlightened Warrior would be born.
Primary prevention, the goal of preventing an injury from ever occurring, must be paramount. Legislation by the government, or mandates by institutions, aimed at educating anyone involved in overseeing athletic activities and minimizing exposures, would prevent countless injuries. If a youth football coach knew the dangers of concussive episodes, and was compelled to think about the practices he ran, the techniques he taught, and the behavior he rewarded, primary prevention would be a reality, and the gladiator mentality would die out. The Enlightened Warrior would be born.
CONCLUSION
Concussive episodes in football have reached epidemic proportion, and a complete risk reduction strategy must be built. Football has evolved over decades into something it was not intended to be, and the sport is often played in an extreme way. The extreme form of football must be eliminated, so the benefits of the game, including teamwork, selflessness, overcoming adversity, and achieving goals, can be maximized.
After finishing double sessions or an early morning training session, everything else in life feels much easier. Coming from behind for a last second victory really does make you feel like anything is possible. Helping an opposing player up from the ground after you’ve tackled him is an excellent guide for how to compete in life. The game of football will become even more popular, and will influence other sports for the better. It is time for some enlightenment.
After finishing double sessions or an early morning training session, everything else in life feels much easier. Coming from behind for a last second victory really does make you feel like anything is possible. Helping an opposing player up from the ground after you’ve tackled him is an excellent guide for how to compete in life. The game of football will become even more popular, and will influence other sports for the better. It is time for some enlightenment.
