Explore This Issue
ACEP Now: Vol 36 – No 02 – February 2017ILLUSTRATION: Chris Whissen & shutterstock.com; Auerbach photo: Mark Tuschman
From peewee leagues to the NFL, football is a national obsession in the United States. However, recent research into football-related injuries is starting to illuminate the grave neurologic toll the sport can take on its players.
Paul S. Auerbach, MD, MS, FACEP, MFAWM, FAAEM, Redlich Family Professor in the department of emergency medicine at Stanford University School of Medicine in California, and coauthor William Waggoner decided to combine the current research on sports-related concussions with their knowledge of football to suggest a series of rule changes that could help protect players’ brains.1
ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Auerbach to discuss what inspired him to write this opinion piece and what he hopes football organizations will take away from it. Here are some highlights from that discussion.
KK: Let’s talk about your very provocative, interesting, and forward-thinking editorial about concussions that came out Sept. 27, 2016. What prompted you to write this?
PA: I got interested in this largely because of my experience as a team physician for a local high school and observing a lot of concussions in football players. I also want to give credit to my coauthor, Bill Waggoner. He was a high school coach and an outstanding collegiate player.
A few years ago, I was involved in a study to look at a noninvasive device to diagnose concussions. We discovered that it took a minimum of four to six weeks for the concussed players to get back to a baseline measurement. I discussed this finding with other investigators in the field who had used other methods to diagnose concussions and who had found the same result. That flew in the face of what commonly occurs with players, who get returned to play anywhere from 24 hours to about a week. That exposes them to what is commonly referred to as second-impact injury, which most people believe is far worse than the initial injury.
Tom Talavage, PhD, at Purdue University and other investigators have highlighted the fact that, with objective MRI techniques, subconcussive injuries—meaning injuries in which players don’t become clinically symptomatic in the same way that do persons who have an acute injury altered enough to be recognized at that moment—are prevalent. There is an enormous number, reasonably in the range of 10 to 20 percent, of players who are being injured.
KK: I love the quote from your article, “With orthopedic injuries, athletes, players, and coaches readily accept a four- to six-week recovery period. It is astonishing that they show so much less respect for the brain.” Do you have some statistics regarding football and concussions that you can share with readers?
PA: Yes. There is beginning to be a bit of a surge of a response. I’ve gotten communications from the National Collegiate Athletic Association (NCAA), from independent writers, and from researchers who are interested in this field, and the consensus is that commentaries like we published will hopefully ignite activity to prevent these injuries. I’ve also received responses from parents citing their distress at what’s going on with children.
There are statistics that I’ve seen from the years 2002 to 2012; there was a 200 percent increase in the number of emergency department visits for concussions among 8- to 13-year-olds and the number of reported concussions of children 14 to 19 years old. In 2012, emergency departments treated 325,000 teens for concussion. That is just the tip of the iceberg because those are the patients that seek care. The Centers for Disease Control and Prevention published statistics on the number of children who take part in some sports in the United States, and we’re talking about tens of millions of adolescents.
KK: The 325,000 number I heard a little bit differently, and this caught my attention. In 2012, those 325,000 who came into the emergency department for concussions equaled about 40 an hour. That put it in context for me.
Do you think there is a specific age group that is more at risk than others?
PA: What I’ve read suggests to me that youth players, meaning children under high school age, are more prone to these injuries than are other players. So this starts in the youth leagues, and it’s cumulative. They start injuring themselves the minute they start banging heads, and given what we know about concussions and what happens down the road, in my opinion, that’s unconscionable.
KK: What is your perspective on the current return-to-play recommendations?
PA: The current return-to-play recommendations are not adequate. Subjective tests, written tests, and the combination of motor skills that are used for evaluation can be manipulated by the players. They very likely underestimate the brain health of the player. The concept that the players should be cleared by a knowledgeable health care provider is certainly a step in the right direction, but it doesn’t go far enough because, in many cases, those health care providers aren’t fully aware of the duration of time it takes to heal from a concussion.
KK: I think it’s going to be hard for people to adopt these recommendations.
PA: Well, I didn’t expect the football establishment in this country to say, “Thank you. We will do exactly what you said.” But I think the conversation had to start somewhere, emphasizing the fact that my goal isn’t to abolish the sport—it is to get the people who have reasonable data to step forward and say we need to do something. I fully expect the NFL to be the most resistant. Colleges will be less resistant, and youth football will be most amendable to make these changes because of enlightened parents and coaches.
KK: Tell me about the reception you’ve gotten for the article, especially from the football establishment—have you gotten season tickets anywhere?
PA: No season tickets. The people I’ve heard from have offered an overwhelmingly positive response. They’ve said, “We agree that something needs to be done.” I made a very important point at the end of the article about why critics might protest. They wouldn’t want to change because it would change the game in an unacceptable way and it wouldn’t be football any more. I wanted to make it clear that we live in a free society and people can make individual choices, but that change would eventually come about because of necessary rule changes. Parents have contacted me about how to get their coaches and, in some cases, family members to accept and adopt this approach. I’ve heard from folks who want to spread the word through their organizations and a group of ex-NFL players who want me to talk to them about what I’m proposing.
KK: You mentioned the rules, and the name of your article is “It’s Time to Change the Rules.” What are you proposing?
PA: The rule changes we propose were based on our best understanding of how concussions occur. Based on the work of others, we know that down linemen hit each other in the head innumerable times in practice and games, and they sustain the subconcussive injuries that only on occasion turn into acute clinical manifestations that would pull someone off the field. We know that these linemen have been studied and their brains are affected in a bad way. The most common time they hit heads is at the snap of the ball. Why can’t they be hands-on-knees in an upright position and not firing off and hitting heads? In addition, I think it’s fairly obvious that if someone leads with the top of their head to tackle, that’s a bad thing. We did our best to define what that meant and create a rules infraction if they did it.
The next rule is no forearm shivers to the head, which happen every time that someone comes up with their forearm and smacks somebody in the head. That’s like boxing in football—just get rid of that. It should be noted that the Ivy League is experimenting with no-contact practices. Next, in terms of concussions and return to play, there are many physicians who are not aware of the fact that there is a four- to six-week minimum time for recovery. What we tried to do was pick a number that was sensible in terms of combining safety and all the reasons why people want to return to play. For kids, there’s just no reason why youth football players should be hitting heads ever; there’s just no reason. Tackle football should be abolished at that level.
KK: Don’t you also think that the presence of a helmet gives a false sense of confidence?
PA: One of the first responses I received from someone who read the article was his opinion that the way to solve the problem with football was to take the helmets away. If you take the helmets away, you’ll see the head injuries go away. What we recall is that the reason helmets were put in the game and why they added face masks was to prevent head and face injuries. Although, as you said, helmets provide a false sense of security because they aren’t designed to prevent concussions. They actually encourage players to strike heads with greater force, and the deceleration injury is not prevented by a helmet.
Reference
- Auerbach PS, Waggoner WH 2nd. It’s time to change the rules. JAMA. 2016;316(12):1260-1261.
Pages: 1 2 3 4 | Multi-Page
No Responses to “Emergency Physician Suggests Rule Changes to Combat Football-Related Concussions, Head Injuries”