Trickle-Down Safety: Sports Concussions

New protocols, more societal recognition and advances in understanding and managing concussion have improved safety at all levels of sports.
Jason Socrates Bardi, Editor

(Inside Science) -- Memory. It's what keeps sports fans going during the poor seasons and what energizes them during rich playoff runs. We don't just rack up wins -- we build memories. That throw. That catch. That move. There is something universal, timeless and even beautiful about human bodies in motion. Athletes -- sports -- competition. At times, it's most impressive.

But in every sport at every level, we know there is more on the line than just a match. No game, no season, no team and no tradition really matter when stacked against human suffering. Where lives are at stake, it's no longer about sports, but safety. Fans know that. Coaches know that. Officials know that. Leagues know that. Players know that. And athletes, parents and loved ones definitely know that.

How do we as a society recognize, manage, treat and prevent head injuries like concussions? To begin to answer this question, Inside Science sought answers from two neurosurgeons at a conference in Los Angeles earlier this year.

"What I’ve noticed in my years of serving on the medical staff for the Pittsburgh Steelers is a sea change in the viewpoint of the players, the coaches and the organization," said David Okonkwo, clinical director at the UPMC Brain Trauma Research Center.

"What I’ve seen is the players now taking this issue as seriously as everybody else, and I have personally been involved in situations of a player coming off the field saying, 'Hey, I just got hit. Can you check me out and make sure I’m OK?' That didn't happen 10 years ago. That was not a part of the game in the 1980s. But it's a part of the game now," said Okonkwo.

"I think all the focus on concussion is very protective for the players," said Mark Proctor, neurosurgeon-in-chief at the Boston Children's Hospital.

"The National Football League has taken this issue very seriously and has worked very hard over the last decade to create what is often called a concussion protocol where the athletes are identified during the course of the game's play, pulled off the field, and put through a very specific set of evaluations. And there is a very high threshold to return an athlete to play on the same day if there has been any form of suspicion of a concussion," said Okonkwo.

"The public attention and focus on the issue of concussion, which really has its roots in the issue of concussion in professional football, has triggered an enormous elevation in the safety of the game for patients -- for athletes at the professional level with a broad trickle-down effect on youth sports in general from coast to coast," said Okonkwo.

This has impacted sports of all levels across our country, as new policies and procedures have been put in place governing concussion. "The trickle-down effect has impacted not just football, but soccer, lacrosse, etc. It allows for new sports leagues to copy or mimic what is happening at the higher levels of the sport because there's a framework in place for people to understand that this is what the best subject matter experts in the field have concluded is the proper way to do this. This has introduced a tremendous amount of safety into recreational sports in the United States that simply didn't exist a quarter-century ago," said Okonkwo.

Dealing with a concussion starts with protocols established to prevent a player who has sustained a concussion from making the injury worse by returning to play and risking further head injury.

"It tends to be something you see in teenagers. It can lead to this cascade of brain swelling that is fatal in 50 percent of the patients," said Proctor. Safety also starts with training officials.

"In youth sports in the United States, whether it's soccer, lacrosse, football or other sports, almost every coach has to go through a certification process," said Okonkwo.

"Most states would say that if a school district is not following the concussion laws, they can't use public lands. And there needs to be an educational program aimed at the athletes, the family, and the coaches and trainers," said Proctor. At some levels, such as in professional football, even the evaluators are evaluated.

"There is in fact a system in place to evaluate the performance of the medical staff just as much as there is a system in place to evaluate the performance of officials referring games, etc. The issue is taken very seriously. The data is reviewed in a continuous fashion, and the expectations are in place that medical staffs for each of the franchises in the National Football League will adhere to the standards put in place for the evaluation of an athlete with a possible concussion," said Okonkwo.

Parallel to what sports leagues have done, local governments have also acted in the past few years. State by state new laws have been added to the code, collectively known as the Lystedt laws.

"So, Zachary Lystedt was a teenager in Washington state who suffered that severe complication of a second concussion before he recovered from the first nearly fatal outcome. Thanks to excellent medical care, he survived, but with a lot of disability. That led to the first of the concussion laws in Washington state, thanks to the interventions of medical professionals, and frankly, sports professionals as well. The NFL took it on as a major project. Every state now has a concussion set of laws. And usually what these laws say is that any athlete who's symptomatic can't go back," said Proctor.

If the advent of Lystedt laws has added iron to the glove by forcing players who may have sustained a concussion from the field of play, rule changes have also added to safety by helping to prevent concussions in the first place.

"We know that there are protections that are put in place for the quarterback. We know that there are protections put in place for blindside hits. There are a number of plays that used to be highlight reel plays that are now viewed as plays that do not have a place in the game of football.

"There is a direct drive to eliminate those dangerous plays from the game. We've seen college football introduce the opportunity to eject a player from the game with just one single infraction of targeting, as an example,” said Okonkwo.

"Next low-hanging fruit is probably going to be continued rule changes, taking hits out of the practice arena, because most football coaches now have really realized that, well, hitting in practice doesn't really improve the effectiveness of the player in competition. And that's really been led by a group in Dartmouth College and their coach Buddy Teevens, who's really focused on that," said Proctor. This has trickled down to other sports.

"When you look at the numbers, the absolute numbers of concussions in youth sports are actually higher in multiple sports other than football. Girls' soccer, lacrosse has higher rates of and absolute numbers of concussions on an annual basis than kids playing football," said Okonkwo.

"There is a very deep conversation happening in youth soccer about whether heading the ball should be allowed in youth soccer. There appear to be some clear indications that, again, athletes who are under the age of 14 who do not have a sufficiently mature neck musculature, are at higher risk for a consequence if they are heading the ball in soccer," said Okonkwo.

In addition to changes in the rules, advances in the clinic may have broad impact in coming years -- more personalized treatment and promising new diagnostic research, like MRIs that will be able to show the brain alterations after a concussion.

"I think as you look into the decade ahead, you're going to start to see a lot of the medical realities catching up to what the regulatory interventions-- on the treatment side-- we have already seen tremendous advances in the capacity to parse out the different forms of concussion and start targeting rehabilitation and treatment strategies to patients who have vestibular problems, or who have vision manifestations of their concussions, etc. Beyond that, the next phase will be even more powerful treatments for those very specific types of brain injuries and concussions that occur," said Okonkwo.

"I think we're really going to start to see biomarkers. So, let's say for a soldier on the field, they were around a blast. Literally you'll be able to do a prick of the finger and see if they've suffered a head injury. And if they have, then you obviously treat them differently than if they haven't," said Proctor.

"I think that we are at the dawn of wonderful, fabulous things that are happening in the field of traumatic brain injury and in the field of concussion and in the field of sports-related concussion," concluded Okonkwo.

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Jason Socrates Bardi is the former News Director of the American Institute of Physics and a longtime science writer.