Concussion! Friday Night Lights and Informed Consent—A Commentary

COMMENTARY Concussion! Friday Night Lights and Informed Consent—A Commentary

a b KATHY A. DEBARR, PhD MICHELE L. PETTIT, MPH, PhD, MCHES

Citation: DeBarr KA, Pettit ML. Concussion! Friday night lights and informed consent—a commentary. J Sch Health. 2019; 89: 341-344. DOI: 10.1111/josh.12744

Received on October 6, 2017 Accepted on August 21, 2018

ootball is a national pastime, and for many, an The US Centers for Disease Control and Prevention Fobsession. It also is an entertainment industry (CDC) has prioritized concussion, a medical condition tour de force with the National Football League (NFL) that requires a medical diagnosis and management, generating estimated revenues greater than $13 billion as an important public health issue with its online in 2016.1 The national culture of football perpetuated training module, Heads Up.7 According to the CDC: by the NFL trickles down to the state and local levels. ‘‘A concussion is a type of traumatic brain injury—or Inspired by this culture, roughly 3.5 million youth in TBI—caused by a bump, blow, or jolt to the head the United States play football and continue to play the or by a hit to the body that causes the head and game throughout high school.2 In fact, in cities and brain to move rapidly back and forth. This sudden small towns across the United States, autumn ushers movement can cause the brain to bounce around in the bright lights of Friday night high school football. or twist in the skull, stretching and damaging the Unfortunately, the excitement and thrill of the high brain cells and creating chemical changes in the school football season is not without consequence. brain.’’8 Aside from second impact syndrome (ie, a A growing number of studies3 have documented the condition whereby an athlete sustains a blow to the adverse consequences of repeated concussions from head after experiencing a concussion that has not high impact sports such as football. Whereas sports fully healed; second impact syndrome can result in like football predominantly are played by boys, high death or permanent disability),9 perhaps the most school girls appear to be at greater risk for persistent devastating consequence of repeated concussions is sequelae from concussion than high school boys.4 chronic traumatic encephalopathy (CTE). In fact, soccer, in particular, poses a high risk for CTE was discovered by Dr. Bennet Omalu whose concussion among high school girls.5 Because of the research was the focus of the ﬁlm Concussion.10 Dr. inherent risks associated with contact sports, students, Omalu, a neuropathologist, conducted autopsies on parents, legal guardians, coaches, and teachers must the brain of a retired Pittsburgh Steelers player who be aware of the potential risks of participation in such had completed suicide and uncovered signs of a sports in order to provide informed assent and consent. degenerative disease. CTE is marked by ‘‘memory Besides football and soccer, hockey, wrestling, loss, confusion, impaired judgment, impulse control rugby, and lacrosse pose a risk for ‘‘exposure to brain problems, aggression, depression, and, eventually, injury that ranges from asymptomatic subconcussive progressive dementia.’’11 blows to symptomatic concussion to more moderate For years, the NFL conducted its own studies or severe traumatic brain injury (TBI). In addition, regarding concussions and concluded that football military service and many other activities, including, players do not experience brain damage. Despite but not limited to, downhill skiing, martial arts, horse a conﬂict of interest, the research conducted by riding, parachuting, and other adventure sports have the NFL allowed the organization to deny that been associated with TBI.’’6(pS460) concussions were contributing factors to behavioral

aAssociate Professor, ([email protected]), Department of Public Health, University of Illinois Springfield, One University Plaza, PAC 332, Springfield, IL 62703-5407. bAssociate Professor, ([email protected]), Department of Health Education and Health Promotion, University of Wisconsin-La Crosse, 1725 State Street, 207 Mitchell Hall, La Crosse, WI 54601. Address correspondence to: Kathy A. DeBarr, Associate Professor, ([email protected]), Department of Public Health, University of Illinois Springfield, One University Plaza, PAC 332, Springfield, IL 62703-5407.

Journal of School Health • May 2019, Vol. 89, No. 5 • © 2019, American School Health Association • 341 and mood disorders and cognitive decline. The NFL’s question—‘‘What is the level of acceptable risk and approach to concussions was much like that of the the level of reasonable reform?’’ Pro football players tobacco industry, which bankrolled studies finding no have come to recognize that whereas the financial connection between their product and cancer.12 rewards are great, the costs in terms of CTE and According to Heffernan, both the NFL and the dementia are not worth the risks. Although not every tobacco industry were guilty of willful blindness, concussion results in CTE and a causal link has not a phenomenon whereby people could and should yet been established,4 an awareness of risks posed know about an issue, but refuse to acknowledge by high impact sports is imperative. The interna- its existence.13 Fortunately, the connection between tional consensus statement on concussion in sports concussions and CTE became apparent when 5000 held in Berlin in 2016 notes: ‘‘ ...there is much players filed suit against the NFL due to increased more to learn about the potential cause-and-effect rates of dementia and other long-term neurocognitive relationships of repetitive head-impact exposure and degenerative diseases. The NFL settled the case concussions. The potential for developing chronic and admitted in court that they expect one- traumatic encephalopathy (CTE) must be a consider- third of players to develop behavioral and mood ation, as this condition appears to represent a distinct disorders, cognitive decline, and other brain injury tauopathy with an unknown incidence in athletic related issues (eg, Alzheimer’s disease and other populations.’’4(p844) types of dementia, Parkinson’s disease, and Lou Increased recognition of CTE has sparked a Gehrig’s disease—amyotrophic lateral sclerosis) at an national interest in protecting youth from football- earlier age than the rest of the non-football-playing related concussions. To that end, many improvements population.14 Interestingly, researchers15 recently have been made in rules of play, equipment, and uncovered CTE in ‘‘110 of 111 former National recognition of concussions and subsequent care.23 Football League players (99%).’’(p360) For example, the National Federation of State High Despite all of the attention toward concussions School Associations has issued rules against illegal in the NFL, Barra16 contends that ‘‘America’s most helmet contact (eg, spearing)24 and all 50 states have dangerous football is in the Pee-Wee leagues, not the instituted concussion laws, some of which require NFL.’’ Influenced by parents and coaches, children baseline cognitive testing.25 increasingly are being exposed to contact sports like In addition to the aforementioned efforts, the 2017 football at young ages in an effort to be competitive.17 Concussion in Sport Group Consensus Statement Unfortunately, in accordance with Social Cognitive provides a number of tools (eg, the Concussion Theory,18 children tend to emulate the type of play Recognition Tool version 5, the Sports Concussion they see in the NFL, thus increasing their risks for Assessment Tool version 5 [SCATS], and the Child concussion. SCATS) and guidelines (eg, 6-step graduated return- The NFL recognizes that if children do not play to-sports strategy as well as a 4-step graduated return- football, the pipeline for future NFL players seriously to-school strategy) for dealing with sports-related will be compromised. It should be noted that the NFL concussions.4 is not alone in its quest for future players. In fact, some parents perceive scholarships for football and other IMPLICATIONS FOR SCHOOL HEALTH high impact sports as the key to paying for college.19 Alternatively, some parents place greater emphasis With the growing body of evidence linking repeated on sports participation than academics as a means of concussions to CTE, health educators have an attaining upward mobility.20 ethical responsibility to assist parents, legal guardians, In addition to opportunities for financing higher and students with making informed decisions about education, football offers many youth a sense of participating in high impact sports such as football. camaraderie, an opportunity to engage in physical Specifically, a call to action is needed for health activity, and a means for building teamwork and educators within the realms of education, research, leadership skills.21 Despite these benefits, the question and advocacy. To that end, we offer the following remains—How well-informed are children, youth, recommendations for health educators. parents, and legal guardians about the inherent risks of football? Moreover, can youth provide informed Education assent, and their parents and legal guardians informed consent, without being made fully aware of the • Develop programs to assure that students, parents, potentially devastating sequelae associated with legal guardians, teachers, and coaches recognize that: the sport? (1) concussion is a medical condition and requires As Bob Costas pointed out in the documentary, a medical diagnosis and management;4 (2) concus- Head Games,22 it is incumbent upon coaches, par- sions may occur without loss of consciousness;26 ents, legal guardians, and others to consider the (3) repeated head injuries, even those that are

342 • Journal of School Health • May 2019, Vol. 89, No. 5 • © 2019, American School Health Association subconcussive, pose a risk for serious sequelae Advocacy such as impaired long-term memory and learning, impaired concentration, second impact syndrome, • Collaborate with schools to create and enforce and increased risks for depression, dementia, CTE, concussion protocols where they are lacking. For as well as suicide.11,27,28 example, health educators need to assist schools • Create a social marketing plan for parents, legal with developing return-to-learn policies to support guardians, and athletes to recognize sports that student-athletes with their post-concussion learning pose the greatest risks for concussion. It should needs. Health educators also need to facilitate be noted that girls and young women are not training opportunities for parents, faculty, staff, and immune to concussions. In fact, girls’ soccer is administrators to better support student-athletes as notorious for posing increased risks for concussion.26 they transition back to school after sustaining a 28,32 As such, health educators should advocate for concussion. increased attention toward concussions among male • Advocate for evidence-based diagnosis and treat- and female athletes alike. ment methods for concussion. • Assist parents, legal guardians, and athletes with • Advocate for the presence of athletic trainers, 29 identifying the challenges posed by concussion. especially in urban schools where a disparity exists. For example, according to Scorza, Raleigh, and • Apprise lawmakers of ongoing needs for regulatory 30 O’Connor,28 there are no objective diagnostic mea- intervention. sures for concussion and no ‘‘well-documented,’’ • Work with parents, legal guardians, athletes, and effective treatments for concussion; there also is coaches to create a culture of safety surrounding 33 no universal definition for concussion. Moreover, sports participation. there are ‘‘limited empiric prospective data to guide • Advocate to change the manner in which games return-to-play decisions.’’(p123) like football are played. For example, eliminating • Develop strategies within the school district (eg, tackle football among those younger than 16 and discussion forums) for parents, legal guardians, and advocating for continued modifications to the game athletes to weigh the pros and cons of participation and equipment would be helpful in reducing the 34 in high impact sports such as football and to make incidence of concussion. informed decisions. • Serve as a resource person for parents, legal In conclusion, concussions occur in all contact guardians, and athletes by helping them to locate sports. The decision to engage in high impact information, both pro and con, to support their sports should be an informed one for children, decision to engage in sports with the potential for youth, high school students, parents, and college concussion. students alike. That said, health educators have an • Incorporate concussion education into school health ethical responsibility to create concussion awareness curricula as part of injury prevention units. Such among student athletes and their parents necessary education especially is needed in urban schools for informed assent and consent regarding sports where knowledge of concussion is lacking.29 participation. • Work with school boards and administrators to make concussion training required for all entities involved REFERENCES in sports including, but not limited to, players, parents, legal guardians, coaches, teachers, and team 1. Belzer J. Thanks to Roger Goodell, NFL revenues projected to medical providers.30 surpass $13 billion in 2016. Forbes. 2016. Available at: http:// www.forbes.com/sites/jasonbelzer/2016/02/29/thanks-to- roger-goodell-nfl-revenues-projected-to-surpass-13-billion- in-2016/#36d0c06f3278. Accessed June 3, 2018. Research 2. Wong RH, Wong AK, Bailes JE. 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