Brain cells are like sticks of chewing gum. They stretch and bend, but only up to a point. If you give them a short, sharp shock, they snap. That’s what happens in a concussion.
According to Dr Robert Cantu, one of the US’s leading concussion experts quoted in the book ‘Head Games: Football’s Concussion Crisis from the NFL to Youth Leagues’, a concussion is a brain injury that can damage thousands of neurons at a time.
After repeated hits to the head, the brain starts to lose its ability to recover. The broken neurons build up and tangle together. This is thought to be the cause of chronic traumatic encephalopathy (CTE), the degenerative brain disease that afflicts athletes in contact sports such as football and rugby.
Under a microscope, CTE is shocking: it looks like the brain has started to simply rot away. The symptoms of CTE are similar to Alzheimer’s disease or dementia and they’re being seen in more and more retired athletes.
One 2009 study conducted by University of Michigan and funded by the NFL found that retired players over the age of 50 were five times more likely than the normal population to be diagnosed with dementia, Alzheimer’s disease or other memory problems.
Concussion risk to children
CTE was brought squarely into the public eye by Dr Bennet Omalu, a Nigerian pathologist working in Pittsburgh. His story – which is told in the 2015 movie Concussion, starring Will Smith – starts with the autopsy of Mike Webster, a Pittsburgh Steelers’ player who had been behaving increasingly erratically before he died.
Omalu was shocked to discover that the brain of this supposedly healthy middle-aged man had shrunk to such an extent that it looked like it belonged to a 90-year-old dementia patient.
Since then, a growing number of sports have been drawn into the concussion debate. Rugby, hockey and soccer are all in the firing line, as it has emerged that even repeated lower-force impacts not strong enough to cause a concussion or any symptoms at the time could lead to cognitive problems later in life.
The research suggests that children are more susceptible to concussion and its lasting negative effects. This may be because their heads are bigger in proportion to their bodies, and their brains are still developing.
One study found that being exposed to a concussion or mild brain injury as a child was associated with an 18 to 52% increase in the risk of negative outcomes, including early death, low educational attainment, or being admitted to a psychiatric hospital.
Considering more than 300,000 American children were admitted to hospital in 2012 following a sport or recreation-related concussion or traumatic brain injury, this is a shocking revelation.
Falling participation levels
Professional players as well as parents are spooked. In 2015, San Francisco 49ers linebacker Chris Borland decided CTE was not a risk worth taking. He forfeited a contract worth at least $2.35m to retire from the sport after just one season, with the aim of preserving his mental health. “If there was no possibility of brain damage, I’d still be playing,” he said.
Participation levels are falling. A 2014 survey by Bloomberg found that 50% of Americans would not allow their children to play youth football, while Pop Warner – the largest youth football organization in the world – reported a 9.5% drop in participation between 2010 and 2012. With between 60 and 70% of NFL players getting their start in Pop Warner-run games, this has serious implications for the future of the sport.
The sports viewed most negatively were rugby (only 6% of parents said they would let their children play), hockey (12%), field hockey (16%), lacrosse (17%) football (18%) and wrestling (18%).
Pulling children out of athletic activity is not the answer. Even doctors and experts on concussion and traumatic brain injury have repeatedly called for parents not to do that.
“Simply put, turning our children into couch potatoes is not a cure for sports injuries,” wrote Dr Andrew Murray in a 2016 article for UK newspaper the Daily Mail.
“Imagine a present that adds an average seven years to life, increases happiness, can help prevent and treat more than 40 chronic diseases like type 2 diabetes, heart attacks, stroke, depression and dementia, and may even improve marks at school. Surely we would want that for our children, and that’s what physical activity and sport can bring.”
Tweaking the rules
In the short-term, rule changes could have the biggest impact. The NFL recognized that a significant number of concussions occurred when teams charged towards each other at kick-offs; by moving kick-offs back five yards, that figure reduced by 43% between 2010 and 2011.
Changes to tackling are another area with potential. Helmet-to-helmet hits are already banned in the NFL, which has pioneered a training program called ‘Heads-Up Tackling’. This teaches young players to use their shoulder, as in rugby.
World Rugby has brought in its own changes to the rules on tackling to try and protect players against concussion. US Soccer has banned heading the ball under the age of 13, in response to a class action lawsuit from parents.
New playing formats can also help. In the UK, children have played touch rugby – a form of the game with no tackling – for many years. The American 7s Football League has a similar offer – it’s a seven-a-side version of football where the players do not wear pads and helmets.
Dr Julian Bailes, chairman of neurosurgery at the North Shore Neurological Institute in Evanston, Illinois, whose research helped prove the link between head traumas and dementia in NFL players, is among those experts who believe helmets may encourage a false sense of security.
Players may be more reckless with their movements, thereby increasing the force of impacts, while helmets also increase the weight of the head as it moves around.
Now it’s not just thought to be about the brute force of an impact – instead, it is the acceleration and rotation of the head that is believed to have the biggest influence.
However, that is not the kind of movement helmets have traditionally been designed to prevent. “Helmets have never been designed primarily to reduce the risk of concussion,” says Glenn Beckmann, director of marketing communications at Schutt Sports.
“Football helmets do two things very well: they protect the skull from external injury and, in the case of Schutt helmets, they use D3O® liners to absorb linear force impact. Helmets are an unequivocal success at those two standards.”
Tougher performance standards
A shelf in the D3O lab is lined with ‘headforms’ of different shapes and sizes, filled with sensors to measure impact speed and g-force, and how it changes when different types of protective technology are used. New products are tested by dropping them onto a metal plate from a defined height to measure the force created by the linear impact.
However, the way helmets are currently tested may need to change if it is really to benefit athletes. The sports helmet certification committee NOCSAE (National Operating Committee for Standards of Athletic Equipment) announced in January 2017 that their new football helmet performance standard would incorporate rotational accelerations in the pass/fail specifications.
Instead of simple linear impact, the headforms will be mounted on a neck to provide a more realistic measure of the role helmets can play in reducing concussion. Manufacturers will be required to meet the new football helmet performance standard beginning in June 2018.
One approach being developed at Schutt in anticipation of the new standards is designed to reduce those rotational pressures and make sure that the weight of a helmet doesn’t simply carry the head along with it after an impact.
But, as Beckmann stresses, there’s a limit to how much new equipment technology can do. “There currently exists no scientifically viable test for preventing a concussion,” he says.
“If there were, we would certainly manufacture our helmets to meet and exceed that test – just as our current helmets are significantly better than current helmet testing standards. Scientists, medical researchers and doctors can only generally agree on what factors play key roles in causing concussions.”
It is, of course, unrealistic to expect sporting equipment – no matter how technologically advanced – to prevent every single case of concussion and head injury.
But with further research into the kind of impacts that cause concussion, continued innovation in impact protection technology and the new NOCSAE football test protocol, athletes of the future will generally be safer and better protected from the risk of head injury and CTE.