Less contact offers the most impact limiting concussions 


February 7, 2021

Two weeks ago, based upon the removal of two high-profile quarterbacks from crucial playoff games, the headline in this space read, “NFL heading in right direction with concussion protocol.”

Against that backdrop, though, came word last week that Marty Schottenheimer, 77, had been placed in hospice due to worsening Alzheimer’s disease that was first diagnosed in 2014. You may remember him for his 21 seasons as an NFL head coach. His last was in 2006, when his San Diego Chargers posted a 14-2 regular season record, before a first round playoff loss prompted his termination.

However, prior to becoming an NFL assistant coach with the Giants in 1975, he had been a linebacker for the Buffalo Bills and New England Patriots over the course of six seasons, after having played collegiately for the University of Pittsburgh. One can’t help but wonder if all the hits to the head that came with all those years of playing contributed to Schottenheimer’s current condition.

With former players such as Schottenheimer serving as motivation, the NFL Players Association and the league have agreed over the last two decades to adopt multiple rule changes, with improved brain health as the goal.

One is the concussion protocol — updated at the start of the current season — that mandated the removal of Patrick Mahomes and Lamar Jackson from their respective divisional round games and prevented their same-day returns.

Throngs of maskless fans took to Tampa’s streets to celebrate Super Bowl win

Another is the nine-year-old edict that limits teams to 14 full contact practices over the course of a 17-week regular season. According to a commentary published last week in the online edition of JAMA Neurology, that change has drastically reduced concussions in practice to the point that they now account for only 18% of those that occur in an NFL season.

The commentary was authored by Dr. Chris Nowinski and neurosurgeon Dr. Robert Cantu, both of the Concussion Legacy Foundation, which is affiliated with Boston University and is responsible for much of the research in the last decade on sports related head trauma.

The article accompanied the publication of a nationwide study of the frequency of concussions and head impact exposures (HIE) among college football players. Its release clearly timed to coincide with Super Bowl week, the investigation’s results offered further evidence of my claim from two weeks ago, that the NFL is making progress addressing head trauma but, of late, major college football is not.

Among the 18 authors were Dr. Thomas McAllister, the chairman of the Department of Psychiatry at the Indiana University School of Medicine in Indianapolis, and Dr. Jaroslaw Harezlak, a professor in the Department of Epidemiology and Biostatistics at Indiana University in Bloomington.

The group looked at six NCAA Division I football teams across the 2015-19 football seasons, measuring the HIE experienced by 658 players whose helmets were outfitted with the Head Impact Telemetry System (HITS) developed by Illinois-based helmet manufacturer Riddell. The use of HITS by researchers at Purdue University was first outlined in this space nearly a decade ago.

Back then, the scientists in West Lafayette found that high school football players averaged just over 600 hits to the head per season. Similar research at the time discovered similar numbers at the collegiate level.

Consequently, the news from this most recent study — that the players averaged 415 head impacts per season — could be viewed as progress. Clearly, across all levels of football, an effort has been made this century to reduce the frequency of head contact in football.

Yet, according to McAllister, Harezlak, and their colleagues, the progress at the collegiate level has been insufficient. During the course of their study, they recorded 68 concussions, 33 before a game was ever played. “In total, 48.5% of concussions occurred during preseason training,” they reported, “despite preseason representing only 20.8% of the football season.”

They also discovered that 72% of concussions and 66.9% of HIE took place during practices. “These data point to a powerful opportunity for policy, education, and other prevention strategies to make the greatest overall reduction in concussion incidence and HIE in college football,” they concluded, “particularly during preseason training and football practices throughout the season, without major modification to game play.”

Nowinski and Cantu were more blunt.

“As a former college football player (Nowinski, at Harvard) and former team physician, respectively, we find this situation inexcusable,” they wrote. “Concussions in games are inevitable, but concussions in practice are preventable. Practices are controlled situations where coaches have almost complete authority over the HIE risks taken by players.”

As reported in this space on numerous occasions, development of Chronic Traumatic Encephalopathy is associated not with number of concussions but with cumulative HIE.

“Some might argue that non-professional athletes need more full-contact instruction to learn how to play safely,” Nowinski and Cantu continued. “That argument is inconsistent with data from high school football. Nearly 40 states now have full-contact limits in high school football. In 2014, the Michigan High School Athletic Association instituted contact practice limits that resulted in one high school football team experiencing 53% fewer head impacts in practice. Practices went from accounting for 61% of HIE during the 2013 season to 49%.

“A 2019 rule further strengthened contact limits, moving from 90 minutes allowed per week to 30 minutes. High school reforms have been driven by oversight from state athletic associations, state governments, advocates, and educators responsible for the health and safety of minors. In the NFL, reforms have been driven by the players, who can legally organize and collectively bargain. College football players exist in a regulatory no-man’s land.”

The NCAA partially funded the JAMA Neurology study. One would expect the organization will now heed the advice for which it paid.

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