The Devastating Trend of Concussions in American Football

From a lecture series presented by The Great Courses

Concussions in American football have occurred at an alarming rate, unleashing a devastating impact. About 3.8 million traumatic brain injuries occur yearly in the United States—these are mostly so-called “mild” injuries, like concussions, and up to 5.3 million Americans are living with disabilities related to these injuries.

College football player having senior doctor review his concussion injury.

What Happens after a Concussion?

There are both immediate and delayed effects of concussion. Which symptoms occur depends on which cells are affected most.

In the immediate sense, a concussion is accompanied by a change in brain functioning. This change in functioning could be a complete loss of consciousness, or more typically a period of confusion or delirium, or trouble walking or remembering things.

Essentially, any brain function could be affected, from balance to eyesight to knowing how to take your football helmet off. The usual definition of a concussion requires that there be some immediate symptoms, but if these symptoms are subtle, they can be overlooked.

And then, what happens next? Brain cells can usually heal, given time and rest.

But the brain remains especially vulnerable after a concussion, while brain cells are already requiring lots of extra energy to heal. This healing time is an especially dangerous time for players to return to the field.

Learn more about the science of concussions

The Dangerous Aftermath of a Concussion

In a high school football game in 2006, 17-year-old Cody Lehe took a helmet-to-helmet hit. No one noticed it much at the time, though later his mother said that both of the players, quote, “had their bells rung.”

Cody kept playing in the game, though the next week he continued to have headaches. One was bad enough that he asked to be taken to the doctor, which is something tough-guy Cody wouldn’t typically do.

A CT scan of his brain was normal. Although Cody continued to experience a bad headache, he returned to playing football.

This is a transcript from the video series The Skeptic’s Guide to Health, Medicine, and the Media. Watch it now, on The Great Courses Plus.

During the next practice, Cody took a shoulder hit-—by all accounts, a fairly routine blow. But he collapsed, and nearly died on the way to the hospital, where he spent almost 2 months in the Intensive Care Unit.

Cody survived, but he can no longer walk and has significant memory problems.

What happened is called the “second impact syndrome,” a second brain injury that occurs before the brain has recovered from a first concussion. It can be especially devastating for teenagers, who may be more vulnerable because of their still-developing anatomy.

Though Cody survived, second impact syndrome has a 90 percent mortality rate.

Important to note, second impact syndrome is not common. It captures headlines, but well-documented cases probably occur just a few times a year.

Concussions: A Widespread American Phenomenon

But widespread occurrences of concussions are very common. About 3.8 million traumatic brain injuries occur yearly in the United States—they are mostly “so-called mild” injuries like concussions. Up to 5.3 million Americans are living with disabilities related to these injuries.

An estimated one in 14 high school football players suffers a concussion during each football season.

Any player with any neurological symptoms following a hit during the game has received a concussion and needs to come out of the game or practice to be evaluated and treated. It is important to remember that other direct hits besides a direct blow to the head can cause a concussion. It is the change in the speed of the head’s movement that results in a concussion.

A stylized depiction of a man receiving a traumatic head injury or concussion.
A sudden hit to the head can change the speed of the head’s movement and damage the brain, resulting in a concussion.

Remember, the brain is in the skull, the skull is in the head, and the head is attached to the rest of an athlete’s body. A sudden hit anywhere that changes the direction and speed of the head’s movement can damage the brain and result in concussion, even if the head didn’t take a direct hit.

Why Aren’t Concussions Being Taken More Seriously?

Though there has been more media attention to concussions lately, in some ways, these stories don’t seem to be getting through to the people who need to hear it most: the athletes, and especially the young athletes.

College football players, who really ought to know better, report that they’ve had six suspected concussions and 21 “dings” for every concussion that’s been diagnosed. Getting a “ding,” “getting your bell rung:” these are all, well, euphemisms for concussion. They perpetuate the idea that an athlete should just keep playing.

After all, it’s just a “ding.” It’s clear that the vast majority of these injuries are not being evaluated, treated, or even tracked. And as we’ll see, it’s the long-term effects of these mostly missed concussions that can have the most serious consequences.

In the days and weeks after a concussion, symptoms depend on which area of the brain was damaged. Again, none of this damage can be seen on a typical MRI or CT scan—this is damage on a microscopic, cellular level.

Depending on which cells are damaged, symptoms after a concussion can include problems with balance, trouble concentrating, difficulty sleeping, headaches, anxiety, or depression. And sometimes these symptoms can linger for weeks or even months.

Risk Factors for Concussions

Certain athletes are more at-risk for concussions. American football is the number one cause, with a 60 percent higher rate than the number two sport, lacrosse.

This high risk is occurring despite the fact that women rarely play football. Females, we know, are more prone to concussion, or at least more prone to reporting a concussion.

One theory about this is that women are more honest than men when it comes to self-diagnosis and reporting. When you look at high school soccer, which is played by both boys and girls, it’s the girls who lead the way in reported concussions, with a reported rate twice that of boys.

An injured soccer player goes to the doctors office for help
Female players tend to report concussion more than male players.

People with certain underlying medical conditions also seem to be at higher risk, including people with a history of migraine headaches or depression.   

But the greatest single factor predicting future concussions in an athlete is whether the athlete has had previous concussions. There are multiple reasons for this.

Some people are genetically more vulnerable to concussion, and some, because of personality, education, or increased self-awareness of symptoms, are more likely to report concussion.

Different athletes may have different styles of play, perhaps putting the more aggressive, physical players at greater risk.

And past concussions, even if the symptoms have completely resolved, may leave some damage behind, predisposing the brain to more easily being damaged again.

Learn more about concussions and the future of football

Downplaying the Impact of Concussions

So concussions, themselves, are a big deal—they can cause prolonged symptoms and disability. But until relatively recently, there really wasn’t much media attention on sports concussions at all. Yet brain injuries and concussions had been a part of sports, specifically football, since the game was invented.

In 1905, President Theodore Roosevelt, a big sports fan, summoned the coaches of the largest college football teams to the White House to discuss the brutality and serious injuries that plagued the game. That year, there had been 19 deaths during games, and there was far less football played back then compared to now.

American football concussion protocol concept with a brain wearing a football helmet for protection

Though many reforms were put in place, football remained a physical and dangerous sport. However, the National Football League tried for many years to minimize the impact of concussions on the game.

In 1994, Dr. Elliot Pellman, who had recently been appointed as the chair of the National Football League’s new Mild Traumatic Brain Injury Committee, characterized concussions as no big deal, as an “occupational risk” of football.

Dr. Pellman, actually, had no experience with brain injury—he was a rheumatologist. But his viewpoint reinforced the boys-will-be-boys acceptance of brain injury as a normal part of sports.

From the lecture series The Skeptic’s Guide to Health, Medicine, and the Media, taught by Professor Roy Benaroch, M.D.

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