Even more alarming was a study that extended those results to younger athletes. That study also monitored head impacts, this time on a high school football team through the entire 2009 season. What stunned the researchers wasn’t what they found in the concussed players, but rather what they found in a control group of eight teammates with no reported concussions or observable symptoms. Four of the eight controls surprisingly demonstrated cognitive deficits (on neuropsych tests) and neurophysiological impairments (on functional MRI scans); what’s more, the most impairment was found not in the three concussed players, but rather in nonconcussed linemen who’d absorbed numerous hits below the concussion-causing threshold of 80 g’s. By designating a new category of athletes who are functionally but not observably impaired, the researchers from Purdue University underscored the value of monitoring the number of hits sustained by players at every level.
With 58 percent of all documented college football concussions occurring on the practice field, Guskiewicz began spending his weekday afternoons using the HITS technology to monitor severe impacts that might otherwise go unnoticed as well as unreported. He used it to identify dangerous techniques and then teach at-risk players safer ones to protect their brains; like a coach breaking down games films, he would show a player 3-D computer images diagramming hits to the top of the head and correlate them with replays of the perilous plays in question. Based on Guskiewicz’s research, UNC head coach Butch Davis cut back on full-contact practices, hoping to reduce the toll on players’ brains.
UNC was not alone. At Virginia Tech, which pioneered the HITS technology in 2003, the team physician, Dr. Gunnar Brolinson, had long turned the practice field into a virtual lab. His head-impact data convinced the coaching staff to do away with the universal training camp ritual of two-a-day practices and to limit the time spent on certain drills that HITS showed to be most dangerous to the brain.
In theory as well as in practice, the impact-sensing helmets made perfect sense. In reality, the cost—up to $1,000 per helmet—proved prohibitive for most colleges and virtually all high schools. If high schools couldn’t afford to hire a certified athletic trainer—only 42 percent of them have access to one—and if they wouldn’t invest $500 for neuropsychological testing software like ImPACT, then they certainly weren’t about to pony up $60,000 to buy helmets with sensors.
Even among those schools that did employ such software, a recent study showed that an alarming number of athletic trainers were administering the tests incorrectly, misinterpreting the results, or flat-out ignoring them. The 2009 study of ImPACT usage found that only half of high school and college trainers bothered to make sure that athletes hadn’t purposely scored low on baseline tests; those skewed results would make it impossible to accurately interpret cognitive status after a concussion and evaluate when it might be safe to return an athlete to play. Most troubling, 10 percent of trainers reported that they would clear a concussed athlete who scored below baseline, and another 4 percent said they might return such a player if the game was really important. While nearly all of the trainers administered baseline tests to football teams, only two-thirds did so for soccer and basketball.
Some school districts were using the potential misuse of neuropsychological tests as an excuse for not including them as part of a comprehensive concussion-management protocol. Even in the state of Washington, where the adoption of the Zackery Lystedt Law set the standard of care for the rest of the nation, at least one school district rebuffed calls to implement neuropsych tests in large part because its insurance provider did not recommend them, citing the liability opened up by the potential for improper or inconsistent use.
Another loophole in the Lystedt Law was that it did not require emergency or medical personnel to be at games. With only 34 percent of Washington high schools having access to a certified athletic trainer—less even than the national average of 42 percent—it’s clear that cost considerations could trump safety concerns even in the state deemed the most enlightened on the concussion issue. “The best advice I can give is to have appropriate medical personnel in place,” says Guskiewicz, the leading concussion expert among certified athletic trainers. “Trust me, this is not self-serving; it’s just what we know. If you have a certified athletic trainer who understands the signs and symptoms, that person can help the team—from the coaches to the players to the parents—better understand brain trauma. If you can’t have that, then you might want to give strong consideration as to whether or not your school should offer contact sports.”
Of course, not even the presence of trainers can assure safe management when so few of them follow proper procedures. Guskiewicz, the lead author of the National Athletic Trainers’ Association position statement on concussion management, had been dismayed to discover that only 3 percent of the certified athletic trainers he surveyed for a 2005 study were complying with the organization’s guidelines advocating the use of symptom checklists, neuropsych tests, and balance exams for managing sports-related concussions.
After the NFL reversed field and became a leading voice on the issue of concussion management, the lower levels did exactly what Cantu and Goodell had predicted—they followed suit. The NCAA, the National Federation of State High School Associations, and USA Football all beefed up their return-to-play guidelines. The NCAA and the NFHS, for example, each instituted a new policy mandating that players with any concussion symptoms be held out for the remainder of the game.
Unfortunately, the new policies, like the emerging science, remained way ahead of the culture. No sooner had the 2010 college football season kicked off than fans were treated to this nationally televised spectacle: a head coach berating his team physician on the sideline for refusing to let a star player return to the same game in which he’d been knocked unconscious. As soon as Dr. Sam Haraldson diagnosed a concussion based on loss of consciousness as well as problems with balance and memory, Texas Christian University running back Ed Wesley should have been sidelined automatically per the new NCAA policy. But Haraldson found himself debating the return-to-play issue with TCU coach Gary Patterson in full view of ESPN’s cameras. “I was literally verbally accosted by the coach, screaming at me insanely at the top of his lungs that he doesn’t think [Wesley] has a concussion and what right do I have to hold him out,” Haraldson said later.
Such inconsistent use of mandated policies and management protocols meant that the quickest fix to the urgent concussion crisis remained the most fundamental: changing the way the game was played. USA Football did just that in 2010 by toughening its rules against head hits, penalizing the use of the shoulder or forearm—not just the helmet—to make contact with an opposing player above the shoulder. And in the other collision sport where hits were intrinsic to the game and concussions long ago reached epidemic proportions, USA Hockey continued to set a standard for vigilance.
At a Mayo Clinic concussion conference in the fall of 2010, a group of 250 doctors, researchers, and hockey officials formally recommended that head contact be banned at every level, urging the NHL and its minor leagues to follow the example set by all the amateur organizations that had already done so. The NHL was not ready to sign on for such revolutionary change. Having just instituted a rule penalizing blindside hits to the head and bodychecks targeting the head, the league immediately dismissed any suggestion of penalizing head-on checks and even distributed an explanatory video showing what it termed “an example of a legal shoulder check to the head”—the very type of jarring hit responsible for 60 percent of its seventy-five concussions per season. Kerry Fraser, who had just retired after refereeing an NHL-record 2,165 games over thirty years, responded to the league’s recalcitrance by calling for a complete ban on head hits. “Really, what it takes is this,” he said as he brandished a silver referee’s whistle. “You need to blow the whistle, call the penalties, and get everybody on the same page. The culture will change very quickly.”
In the meantime, since the pros seemed too deeply entrenched to accept
a leadership role that would filter down to all the amateur levels, the Mayo Clinic conference focused on youth hockey, where the rate of concussion was surprisingly only slightly lower than in the NHL. The group of experts strongly urged hockey officials to delay the age at which bodychecking is introduced to thirteen, two years older than what the rules currently allow. They cited a new Canadian study showing that the concussion rate among eleven- and twelve-year-olds in Alberta, where bodychecking was allowed, to be four times higher than in Quebec, where it was prohibited. The study’s authors concluded that moving back the age in Alberta would reduce concussions among the nine thousand kids playing hockey there from seven hundred to three hundred per season.
As the conference came to a close, the concussion experts left hockey-crazed Minnesota determined to spread their message at other conferences and to other sports. “You can hear the sounds of change,” James Whitehead, executive vice president of the American College of Sports Medicine, observed. “Historic, game-changing, breakthrough change.”
Nowhere, of course, was that sound more audible than in the NFL. Sixteen years after forming its Mild Traumatic Brain Injury Committee to study concussions, the league had finally realized that there was no such thing as a “mild” traumatic brain injury and renamed it the Head, Neck and Spine Medical Committee. More significant, the NFL completely overhauled the committee, replacing the doctors who had been impediments to change from the inside with those who had been agents of change from the outside. The league even brought in as adviser one of the harshest and longest-standing critics of its concussion policies, Dr. Robert Cantu, a quarter century after he began preaching what eventually became a mantra throughout the medical community: “When in doubt, sit them out.”
• • •
The opening of the 2010 NFL season brought the promise of a new era of enlightenment. Posters papering locker room walls preached the league’s newfound gospel warning players about the dangers of concussions. Players had been drilled on the recent policy changes designed to treat concussions more seriously than ever before. And now, all eyes were watching the NFL to see how the sea change would play out on the field. They didn’t have to wait long.
On the very first Sunday of the season, Philadelphia Eagles linebacker Stewart Bradley was attempting to make a diving headfirst tackle when his helmet slammed directly into a teammate’s hip. He woozily tried to rise, stumbled to his feet, staggered a few steps on rubbery legs, and then collapsed back to the turf. His teammates frantically waved for medical assistance and then watched in concerned silence as he was being attended to and helped off the field.
More than twenty-eight million viewers across America saw all this live on TV. More than sixty-nine thousand Eagles fans witnessed it in person at Lincoln Financial Field. The only people who didn’t see it, apparently, were the medical personnel on the Eagles sideline.
As a national TV audience watched slow-motion and real-time replays of the episode, the Fox broadcasters narrated the scene with concern in their voices. “Clearly confused and dazed,” observed the color commentator, Troy Aikman. “It’s hard to imagine him coming back into the game, with all the attention paid to head injuries.”
Less than four minutes later, Bradley was sent back onto the field. “That surprises me,” Aikman told viewers. His play-by-play partner, Joe Buck, agreed and added that Bradley must have passed the standard sideline assessment tests so he was “OK to return.” Neither Buck nor Aikman, the Hall of Fame quarterback whose own concussion history had prematurely ended his career and brought the problem to fans’ attention a decade earlier, raised the question of how it was possible that an obviously concussed player had been cleared to return to play and put back into the game with just three minutes left in the first half.
At halftime, Bradley was examined, diagnosed with a concussion, and pulled from the rest of the game. For all the NFL’s strong words about how far the league had come on concussion safety, the incident spoke volumes about how much farther it still had to go. The Eagles tried to rationalize away their failure to adhere to new, stricter concussion policies prohibiting any player from being returned to the very game in which he was concussed. They insisted that none of their medical personnel had seen the collision or the subsequent collapse. And more importantly, they said their three-minute sideline exam revealed no concussion—an explanation that boggled the minds of brain injury experts across the nation, and in the NFL itself.
“I doubt they did any kind of neurologic, thorough assessment,” Cantu declared, noting that sideline evaluations require at least fifteen minutes. “You just can’t do it that fast. You need to assess the player both at rest and then after exertion.” Cantu shook his head. “It’s a shame it was seen on national TV,” he said, “but it points out needed work to be done.”
It also raised frightening questions for every parent of a sports-playing child: If a concussion this obvious could be missed by the well-trained medical staffs that populate NFL sidelines, what about high school and youth league games where there are no team physicians or athletic trainers? And if a concussion this glaring could go unnoticed under the NFL’s spotlight and microscope, how many go unnoticed on high school fields, youth league fields, and playgrounds across America?
Epilogue
Seven years after post-concussion syndrome forced him to drop out of Rutgers, Dave Showalter went back to college. He was tentative at first, signing up for just one course to see if he could handle the work. But by fall of 2008, he was back at Rutgers full-time, enthusiastically pursuing a degree in anthropology. School was different this time. Some of the concussion damage had been permanent, and learning didn’t come as easily as it once had. Before the brain injuries, he had needed only to attend lectures to get a good grade, often skipping reading and homework assignments. Now if he wanted to do well, he needed to read every word from the assigned books, sometimes more than once, and could never skip a homework assignment. This time, though, he was excited about his major and happy to put in all the extra work, maintaining nearly a 4.0 GPA in the classes he took since his return. By the spring of 2010, he had a diploma in hand and an open door to new dreams that included graduate school, perhaps even a career as a professor.
Showalter was philosophical about the years he took off from school. He wasn’t sure he would have been as motivated if he had tried to come back sooner. One thing he was sure of was that he had spent too long assuming that his cognitive abilities would never return. No one had told him that he could retrain his brain by plugging away at the tasks that had become so difficult for him. Among the most important lessons he learned from his first class back was that the brain could be rehabbed just like any muscle in the body. The more he read, the easier it got. The more he expressed himself, the more fluidly he wrote and spoke. He still read more slowly than he did when he started college back in 1998 and occasionally found himself fumbling for words, but he learned that he could still excel in the classroom. He accepted the fact that his brain didn’t work as well as it once had. He was happy that it seemed to be working well enough to take him where he wanted to go. He started rewriting his old concussion speeches in his head. Now he wanted to tell all the high school and college students whose lives had been derailed by concussions that they needed to keep at it and push themselves to reclaim the skills stolen by brain injury. He hoped that nowadays fewer kids would need to hear this advice, that the sports world had finally gotten the message that concussions were serious injuries.
As he watched games during the first few weeks of the 2010 NFL season, Showalter was amazed to see what Roger Goodell had managed in just a few short months. Players were actually being pulled from games because of concussions. Though the changes meant the sport might have fewer of the exhilarating big hits, he figured a little less excitement was a small price to pay to protect players’ brains.
Not everyone felt the same way.
• • •
As the 2010 season swung into high gear
, so did the violence. Despite warnings from league officials that certain types of brain-rattling head hits would be harshly punished, playing styles hadn’t changed one bit. In fact, it seemed like this season was even more brutal than previous ones. By mid-October, there had already been at least fifty-three concussions. And then came a Sunday that instantly became famous for its level of brutality: violent head hits sent one player to the hospital on a backboard and knocked four others out of games. Overnight, Goodell upped the ante, threatening suspensions in addition to fines for offenders. Ultimately, the commissioner decided to mete out only fines this time, but he sent a memo to every team warning that there would be an immediate crackdown and that from now on players who delivered illegal blows to the head and neck would receive suspensions as well as hefty fines.
The crackdown wasn’t popular with the players or their union. The most notorious of the three fined players, James Harrison of the Pittsburgh Steelers, threatened to pick up his football and go home. “How can I continue to play this game the way that I’ve been taught to play this game since I was ten years old?” said the hard-hitting All-Pro linebacker. “And now you’re telling me that everything they’ve taught me from that time on for the last twenty-plus years is not the way you’re supposed to play the game anymore. If that’s the case, I can’t play by those rules. You’re handicapping me.”
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