Head Bangers

How big a problem are brain injuries in high school football?

By Marcello Di Cintio

Tristan Rice didn’t remember the hit. He didn’t remember much of the rest of the game either, only that sometime in the third quarter one of his fellow offensive linemen asked him, “What the hell is up? You screwed up three plays in a row.” Rice figures the hit must have come in the first few minutes of the game, and that the “stud D-lineman” he’d been knocking helmets with all game probably delivered it. He couldn’t be sure, though. All he knew was that his team lost, and on the drive home something was different about passing cars’ headlights. “They were way brighter than usual and hurt my head a little,” he says. “It was weird.”

This was likely not Rice’s first concussion. He started playing tackle football as a 10-year-old Pee Wee, and bumped a lot of heads as he grew into a teenage O-lineman and football star with both the Centennial High School Coyotes and Calgary Colts. “I’m sure I’ve had a few other concussions that weren’t that bad, and I played through them,” he says. One can hardly fault Rice’s sense of invincibility—the 17-year-old stands 6’4″ and weighs 270 pounds—but even he could tell this concussion was different. He suffered headaches and occasional loss of balance for about two weeks. Bright lights and loud noises made him flinch.

Some consider Rice not merely the victim of a hit, but of an epidemic. The Government of Canada says football showed a greater than 40 per cent increase in reported head injury in youth and children between 2004 and 2014. The Canadian Institute for Health Information recorded 202 visits to Alberta emergency rooms by high-schoolers with football and rugby related concussions in 2014–2015, a more than 70 per cent increase over the previous four years.

Football is one of the sports sending the most concussed kids to the ER. A British Journal of Sports Medicine study showed a concussion incidence rate for youth football of 0.53 concussions per 1,000 games or practices. This number, though seemingly small, represents one of the highest concussion incidence rates among youth sports. Fact is, a lot of kids play a lot of football. Around 5,800 teenagers play football on 150 high school teams each autumn in Alberta. They compete in six regular season games, plus playoffs if they do well, and attend upwards of 60 practices.

Hockey consistently tops the concussion rate rankings: twice as many young athletes suffer brain injuries on the ice as on the gridiron. But hockey isn’t part of the Alberta Schools’ Athletic Association. Kids don’t play hockey at school. A 2016 article in the American Journal of Bioethics argued public schools should ban football outright. Football, the author claimed, cannot be made safe. With concussion fears mounting, a rising number of parents, educators and doctors question whether schools should be offering—and therefore endorsing—football at all.

When University of Calgary neuropsychologist Keith Yeates, a leading authority on youth brain injuries, began his clinical research 25 years ago, conventional medical opinion was that concussions in children were essentially benign. “We thought we didn’t have to worry,” he says. Now, further research and high-profile media stories have swung the pendulum. While heightened awareness is obviously positive, and likely responsible for the increased concussion diagnoses, Yeates is “concerned by the over-concern.” He and many of his colleagues feel concussion fears have crossed into the realm of paranoia.

Current research, he says, does not support sweeping statements about concussions. The science of traumatic brain injuries, or TBIs, has too many unanswered questions. “Even the definition of a concussion is a bone of contention,” Yeates says. Generally, a concussion occurs when the transmission of physical force, or some sort of mechanical trauma, causes the jelly-like brain to bounce around inside the skull. The rattled brain sets off a metabolic cascade that can lead to the sort of symptoms Tristan Rice endured. Doctors diagnose concussions based on symptoms alone. There’s no other way. Concussions rarely show up on brain scans, and no known bodily markers signal a person is concussed. “People are trying to find a tool that can objectively identify a concussion,” Yeates says, “but we don’t have one at this point.”

Rice’s 2016 concussion was typical: a blow to the head followed by symptoms that resemble a flu without a fever, with headaches, light and sound sensitivity, nausea and general fogginess. Rice’s recovery was typical too. Following his doctor’s instructions, he stayed home from school for three days and did his teenaged best to avoid his phone and television. “I mostly chilled in my room and slept.” Rice’s doctor cleared him to return to football practice after two weeks.

With most concussions, symptoms usually peak in the first week, followed by substantial improvement over the next three weeks. Yeates expects most kids to fully recover within four weeks. About a quarter remain symptomatic after a month, and only 10–15 per cent suffer symptoms after three months. “And an unfortunate even smaller percentage show persistent symptoms a year or more later,” Yeates says. “It’s a real problem that needs to be taken seriously.”

Research shows teens may take longer to recover from concussions than adults. Whereas the plasticity of the teenage brain helps following localized injuries such as strokes, a concussion affects the entire brain. “Plasticity can’t help you if everything is injured,” Yeates says. Further, concussions might impede the rapid development of behaviour control, especially in relation to risk and judgment. In healthy teenage brains, the allure of dangerous behaviours such as reckless driving and substance abuse declines as the ability to assess such dangers grows. Wildness eases as brains mature. Research suggests concussions disrupt and delay this critical rebalancing.

Scientists are also trying to learn why certain athletes suffer more concussions than others. Yeates suspects some might be born with concussion-prone brains, like the boxer with a “glass jaw,” and thinks researchers will eventually identify a genetic marker for this vulnerability. Recent evidence also suggests kids with pre-existing psychological disorders such as ADHD face greater risks of concussions.

The long-term effects of concussions remain the most compelling and controversial mystery. Studies linking concussions to chronic traumatic encephalopathy (CTE), a terrifying degenerative brain disease, have received intense media attention. Many scientists, though, remain unconvinced. Research hasn’t established a clear cause-and-effect relationship between head trauma and CTE, and no research links youth participation in contact sports with CTE risk. “The scientific community [is] hesitant to accept the speculation out there about CTE,” says Martin Mrazik, a neuropsychologist from the University of Alberta.

High-profile work has been done on the post-mortem brains of NFL players without a significant control group from the regular population. “If you’re saying that all these hits to the head cause CTE, we have to know this isn’t happening in other populations. That data is just not out there,” Mrazik says. At least not yet. “We’re in the process of collecting longitudinal data where we have a 13-year-old and follow him for a long period of time. Then we can better tell you what’s going to happen.”

Other studies claim an array of potential long-term consequences of concussions other than CTE. A Canadian Medical Association Journal study, for example, linked concussions to increased long-term risks of suicide. Another suggested concussions literally shrink the brains of college-aged athletes and reduce brain blood flow. According to Yeates, though, none of these studies are flawless. “It’s easy to cherry-pick studies that show bad outcomes, or those that show good outcomes. But it’s the cumulative weight of evidence that matters,” he says.

Rice, for his part, seems to have made peace with long-term risks—regardless of whether or not they actually exist. “I know in the future there’s going to be side effects,” he says. “Earlier onset of Alzheimer’s, or that CTE or whatever it is. I know it’s coming.”

The scientific community publishes around 2,000 concussion-related studies each year, and the boom in research has led to an evolution in concussion treatment. Older protocols prescribed strict bed rest—no books, phones or screens—until a patient showed no symptoms. Such bedroom prison sentences can cripple a teenager’s academic, athletic and social life. “The new research says bed rest is a bad thing,” Yeates says. Just like Rice, patients need to rest for the first vulnerable days following their injury, “but pretty quick we want to get kids back to their regular life. Get back to school. Begin more activity. Much earlier than what we originally thought.”

The return to school offers its own challenges for a concussed teen. In addition to headaches, nausea and light sensitivity, these students can suffer concentration issues. Their processing speed slackens and they have difficulty remembering new information. The slowness of their shaken brains causes intense stress in some students, especially those who were high achievers before their injuries. “All of a sudden, it takes twice as long to do a math equation,” says Danelle Spence, a Calgary-based psychologist and school counsellor who helps concussed teens with their return to regular life. “They feel the pressure to go back to school because we live in a high-pressure society.” Students worry about their grades, their friendships and—in the case of football players—getting back on the field. “They don’t want to miss out, and this anxiety perpetuates more anxiety.”

Teachers play a vital role in reintegrating concussed students. Rice’s didn’t assign him much work when he first returned to school, and allowed him to leave the classroom whenever his head started pounding. A teacher might allow a student like Rice to wear sunglasses if lights bother him. He might be instructed to answer only every second question on an assignment, say, or to skip optional modules. This not only rests a battered brain, but allows a student to rebuild a sense of competency. Some concussed teens also suffer from what Spence calls “anticipatory anxiety”: fear that the injury could reoccur. They benefit from trauma counselling. “We want kids to get their confidence back,” Spence says, and this requires a flexible “wrap around” effort by psychologists, teachers and parents.

Some argue public schools should ban football outright —that football cannot be made safe.

Getting back onto the football field, on the other hand, requires a more specific and regimented protocol. In 2010 Football Canada published its “return to play” guidelines. Concussed players must first refrain from all physical activity until symptom free. After being cleared by a physician, athletes slowly increase their activity, starting from supervised light aerobic exercise before moving on to football-specific drills without body contact. The player must be medically cleared a second time before they can resume hitting. If the player remains symptom-free throughout the protocol, they can get back into game play in as few as six days.

No one polices these rules, however. According to the post-concussion protocols, Rice’s Colts coach put him back in too soon. Only five days after returning to practice—game day—he was back on the Colts’ O-line protecting his quarterback. “I wasn’t quite symptom free, but my symptoms were light,” Rice says. “Sometimes a hit felt a little more rough than it normally would.”

The St. Francis Browns, clad in black-and-white practice jerseys, gather on the cleat-scarred field behind the school. The cool air carries the teenage growls of quarterbacks calling out plays, and the shouted instructions of coaches on the sidelines armed with vinyl binders. Spiralling footballs find the chests of intended receivers with satisfying whumps. But there’s no crack of helmet on helmet or of pads against pads. At St. Francis, as in most Calgary high schools, football teams don’t hit much in practice anymore.

David Diluzio played for the Browns in the early 1990s before taking a linebacker position for the University of Calgary Dinos. He left the team before his final year of eligibility when offered a student teaching job. (“Of course, the Dinos won the Vanier Cup that year,” he sighs.) Diluzio coached football at St. Francis during his practicum year before landing a job at Francis’s chief gridiron rival, Notre Dame. In all, Diluzio has been coaching high school football for over 20 years. “I have the best job in the world,” he says.

Diluzio has a broad view of the efforts to make high school football safer for young brains. He remembers laying blindside hits on opponents during his time as a Brown. “Back in the day, if you’d have a receiver coming across the middle, you’d just shitcan him. You’d wipe him out,” Diluzio says. “You can’t do that anymore.” Stricter officiating—from kids’ leagues all the way up to the NFL—now focuses on preventing head injuries. Collisions will always be a part of football, but referees now penalize players who lay out their opponents away from the play. They also throw out anyone who shows an intent to injure.

“Reality is, if moms and dads aren’t letting their kids play, we’re not going to have football. We have to make it safe.”

The most dramatic innovations are found on the practice field. In 2015 Football Canada required amateur football coaches to take a Safe Contact training course, which emphasizes protecting the heads of young players. The course became mandatory for all coaches in March 2017. Diluzio started teaching the course in Calgary last year. The program “isn’t revolutionary,” Diluzio says, and many coaches have already incorporated similar changes. “Essentially, you cannot hit with your head.”

The course shows coaches how to identify possible concussions, outlines the “return to play” guidelines, and urges coaches to communicate with players about concussions. “As coaches, we talk about ‘sucking it up,’ and ‘playing through soreness,’” Diluzio says. “But don’t mess with your head. If you’re feeling any head issues, you tell the coach right away. You don’t suck up that.”

Practices must change too. When Diluzio started coaching, the sound of bodies slamming into each other scored the nightly drills. “We used to hit a lot more. Bring guys to the ground,” Diluzio says. “Everything was full-contact.” The Safe Contact guidelines suggest heavy contact be taken out of practice altogether. The reasoning is simple math: The fewer hits a player takes, whether on the practice field or in a game, the less their chance of suffering a concussion. Diluzio doesn’t believe taking hitting out of practice leaves players unprepared for games. “You can get enough good work done practising against a bag or against another guy without equipment on,” he says.

Tackling itself has also changed. Until recently, players were taught to bring their head across their opponent’s body and put their face into the football. “For years I was saying ‘Bite the ball! Bite the ball!’” Diluzio says. “Football Canada doesn’t want me to say that anymore.” The Safe Contact guidelines urge coaches to teach players to tackle with their shoulders. Football purists don’t like to admit it, but many of these “new” techniques come from rugby. “It’s bad for a football coach to say that rugby has it right, but rugby has it right,” Diluzio says. “They have so many collisions. They’re smashing each other. But not hits to the head. Everybody gets up.”

Football remains a violent sport, of course. Mrazik points to the physical differences between young players. “You’re going to see some 6’2″ kid who’s shaving already taking on some 5’1″ kid,” Mrazik says. “How does a 14-year-old who hasn’t had his growth spurt yet respond to the constant physical demands of football—especially if it involves hits to the head?” Still, Mrazik credits the new guidelines for making football safer. Coaches can recognize possible concussions and they know better than to simply ask players “How many fingers am I holding up?” before shoving them back into the game. The evolution of protocols regulating a concussed student’s return both to the field and the classroom also reassures Mrazik.

But in the frenzied kinetics of a football game, with 24 players in motion at any given time, coaches and trainers aren’t going to notice every potential concussion-causing hit. The responsibility to report injuries rests largely with athletes themselves. Unsurprisingly, many hesitate. A 2004 study of high school football players in Wisconsin showed that less than half who sustained concussions reported their injuries to coaches or trainers. Mrazik co-authored a comparable study in 2015 with Alberta teen and preteen hockey players. While nearly all knew what they “should” do when concussed, one-third didn’t follow these recommendations. Players won’t report on teammates, either. “We usually don’t rat out each other,” Rice says. In 2013 Ernest Manning High School’s football team wore high-tech helmets that lit up the trainer’s iPad whenever someone received a heavy hit. Many players, frustrated by being pulled off the field, simply reached back and unplugged the sensors.

In addition, not all coaches have bought in to the new safety philosophies. Even some younger coaches adhere to old-school ideas. Rice says his coach at Centennial High School runs full-contact practices almost every day. Rice approves. “I definitely think you should be hitting in practice,” he says. “Obviously you’re not going to go 110 per cent in practice, but you’re still going to tackle each other. You’re not going to win games if you don’t know how to hit.” The fact that St. Francis won both the city and provincial championships last year without much hitting in practice does not convince Rice otherwise. “Francis has unreal players,” he says.

Many of these highly experienced players still “bite the ball.” Rice has been using his head to take down his opponents for seven years. He’s not going to change now. “You can teach a new way to hit in practice, but it’s completely different in the game,” he says. Rice is too focused on the play at hand to consider the safe tackling techniques he only recently learned. “All I’m thinking about is what I’m going to do to stop the guy across from me from getting to the quarterback.” Tristan and many of his teammates scoff at the new tackling methods. “Me and my buddies all feel the exact same: This [new] hitting is bullshit. It might be safer but it’s not going to work. You’d rather win a game.”

Rice, though, might represent the last generation who grew up tackling the old way. Kids entering the sport now will only learn the new, safer techniques. Diluzio believes that even reluctant coaches will eventually adopt the new philosophies designed to make football safer. The future of the sport may rely on this. “The reality is, if moms and dads aren’t letting their young kids play, we’re not going to have football. We have to make it safe for them,” he says. If Notre Dame is any indication, parents have reason to be reassured. Diluzio says he usually sees only one or two concussed players each season, and that last year Notre Dame football was completely concussion free.

Knowing what they know about concussion research and the new protocols, both Yeates and Mrazik would allow their own children to play high school football. (As it turns out, both have teenaged daughters who play other sports.) They would, however, reconsider if their child endured multiple concussions. Neither believes football should be banned from Alberta public schools. According to Yeates, the decision to allow children to play football is a philosophical question rather than a medical one. “Parents and kids have a decision to make about what risks they want to take,” Yeates says. “And it’s incumbent on the sport to do all it can to prevent and minimize the injury and treat it quickly and appropriately when it occurs.” The risks of any sport must be balanced against the physical and psychological benefits—especially when youth inactivity causes far more health problems than concussions.

As with the vast majority of concussion patients, Rice’s symptoms haven’t returned. He’s looking forward to beginning his first season on the Dinos O-line this fall. Rice admits the chance of getting concussed again worries him, and he’s already discussed with his parents the possibility of finding another sport, however reluctantly, if he suffers more serious concussions. “It’s always in the back of my head,” he says, “but I like playing the game and hitting other kids.”

Marcello Di Cintio is a former high school and collegiate athlete. He lives and writes in Calgary.


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