New Rules for Football Concussions

NFL issues new rules about when players can return to the game after a concussion.

Reviewed by Louise Chang, MD on December 04, 2009
From the WebMD Archives

In late October, Philadelphia Eagles star running back Brian Westbrook suffered a concussion in a game against the Washington Redskins. He sat on the sidelines for two weeks, recovering -- but when he returned to play on Nov. 15 against the San Diego Chargers, Westbrook suffered yet another concussion, putting his season and possibly his career in doubt.

Westbrook's immediate re-injury raises the question: should he have been playing at all? And just how many football players are returning to play too soon after concussions, or not having the seriousness of their injuries recognized?

On Dec. 3, in the wake of much debate over the long-term damage concussions do to players, the National Football League (NFL) announced new rules governing concussion management. Players who've had a concussion will now only be allowed to return to the field after being cleared by an independent neurologist.

But concussion is not just an issue for the NFL. A study from the National Center for Injury Prevention found that 47% of high school football players say they suffer a concussion each season, with 37% of those reporting multiple concussions in a season. But according to the American College of Sports Medicine, some 85% of sports-related concussions go undiagnosed.

And even when they are diagnosed, more often than not, concussions in football and other sports aren't being managed properly. Guidelines from the American Academy of Neurology say that, for example, if an athlete's symptoms after a concussion -- such as dizziness or nausea -- last longer than 15 minutes, he should be benched until he's been symptom-free for a week. But a three-year study of play in 100 U.S. high schools found that nearly 41% of athletes were back on the field too soon.

Long-Term Impact

It's pretty clear that all those concussions can have devastating long-term impact on NFL players. Many former players, still young, report persistent headaches, fatigue, difficulty paying attention, memory problems, mood swings, and personality changes. Even a study commissioned by the football league itself found a higher rate of dementia among retired players than in the general population -- about six times as high in players over 50 compared to other men in the same age group. A New York Times analysis bolstered those findings.

But much less is known about how repeat concussions, especially those that are not properly managed, affect high school and college athletes over the long term. "The long-term effects of a few concussions on the young athlete is an incomplete book," says Mark Lovell, PhD, founding director of the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program. "We're just starting to scratch the surface. We're starting to study kids as young as five and follow them throughout their lives, but that takes years to do; 90% of what we know about concussion, we've learned in the last five years."

The little information available is troubling. The Center for the Study of Traumatic Encephalopathy (CSTE), a program at Boston University School of Medicine that studies long-term brain damage from injuries like concussions, recently found the beginnings of chronic traumatic brain disease in the brain of an 18-year-old high school multi-sport athlete who had suffered multiple concussions.

"This is very worrisome, suggesting that this kind of long-term damage can be starting in your teens," says CSTE co-director Robert Cantu, MD, clinical professor of neurosurgery at Boston University School of Medicine and co-director of the Neurological Sports Injury Center at Brigham and Women's Hospital. "Another individual we studied, a former college athlete, also showed significant changes to the brain as well as clinical symptoms that occurred toward the end of his life. That demonstrates that the trauma you get in your teen years and a college career, without any professional play, can be enough to produce chronic traumatic encephalopathy in susceptible individuals."

In Cantu's study, 11 out of 11 of deceased NFL athletes -- all of whom showed symptoms of brain damage toward the end of their lives --had significant changes to their brains. A number of them, who died relatively young, had tangles in their brain tissue resembling what you might see in the brain of a 75-year-old with Alzheimer's disease.

Dangers to Young Brains

A major problem for young athletes, says Anthony Alessi, MD, who co-chairs the American Academy of Neurology's sports neurology section, is that high school and even some college programs lack the resources necessary to protect their players from concussion. "At the professional and, to a lesser extent, the collegiate level, everybody's trying to protect these athletes from getting hurt," he says. "But at the lower level, it's not managed as well."

"There's not usually a doctor on the sidelines at a high school football game to evaluate an athlete after a concussion," Lovell says. "And most high school football teams don't have athletic trainers."

"Many high schools say they can't afford to have an athletic trainer. I say that means you can't afford to have a program," Alessi says. "The presence of a certified athletic trainer makes your program safer by every measure, and if you can't afford to make the program safe, then you should be closing it up. Where we're getting into trouble is with programs where there are no trainers and no medical personnel who understand what happens to the brain in a concussion."

What does happen to the brain in a concussion? The brain is shaken so forcefully that it hits the inside of the skull, damaging blood vessels and nerve cells and even leaving bruising. If a player is left unconscious for more than a few minutes, the concussion is clearly serious; but sometimes even mild-appearing concussions can do grave damage. "A minor hit on the field can take a long time to recover," Lovell says.

And there's no magic number of concussions that constitutes "too many."

"It's not as simple as how many concussions someone's had -- it's total brain trauma," Cantu says. "Linemen who've had almost no concussions have the majority of cases of chronic traumatic encephalopathy, because on every play they get their brains rattled, trying to block with their head."

Having an Impact on Concussion

Every high school and college football program -- as well as those for other high-contact sports -- should have a concussion management program, Lovell says. Among his recommendations:

  • Put people on the field who understand the injury. This means trained physicians and a certified athletic trainer. Alessi suggests that high school teams call local neurologists to see if they will contribute their time. "Even if they charge, they're the cheapest thing you're going to pay for compared to hospital visits, scans, and EEGs."
  • Use a standardized test to determine if a player is ready to return. The Immediate Post Concussion Assessment and Cognitive (ImPACT) test, developed by Lovell, measures factors such as attention span, working memory, sustained and selective attention time, response variability, nonverbal problem solving, and reaction time. "Athletes will tell you they're fine. Kids think they're invincible. If all you're doing is asking them whether their headache's gone, you're letting a teenager manage his own brain injury."
  • Develop a graduated program for returning the injured athlete to play -- a "stress test for the brain." "Just because they don't have a headache, it doesn't mean you can go ahead and put them back on the field," Alessi says. "Your athletic trainer needs to put together a program, first having them walk at a certain pace, then run, then do wind sprints, bike, and lift weights, to see if the player can do those things without a headache or other symptoms."
  • Monitor players who've had concussions long-term. "Especially for those who've had multiple concussions, be alert for signs that they're getting injured more easily and with less provocation, or that symptoms are lasting longer and are more severe," Lovell says. This may be a sign of chronic injury.

Football itself also needs to change, experts say. "The head needs to never be allowed to be the point of contact in blocking and tackling," Cantu says. "Those rules are on the books, but they're just never called. We need to call the rules correctly, and for officials who don't call them correctly, replace them or at least sit them out a few games."

The NFL has improved their handling of such penalties, Cantu says. "For example, if you carry out a crack-back block, where you hit somebody behind you, and hit their shoulder pads or head, you get a 15-yard penalty. And the officials get scored and graded every week."

That needs to happen at the high school and college level as well, he says. "Most colleges and even many high schools have game videotape. You don't have to review the tape simultaneously with the game, but review it later to determine if flagrant problems like head hits are being missed."

Knowing what he knows about the game, would Lovell let his son play football? "Yes -- but only if there were a good monitoring system in place. If he went to a school where I didn't think they paid attention to this, I wouldn't let him play," Lovell says. "If they had an athletic trainer on the field and other elements of a good system, I'd let him play. But I'd still be concerned, just like any other parent."

Show Sources


Robert Cantu, MD, clinical professor of neurosurgery, Boston University School of Medicine; co-director, Neurological Sports Injury Center, Brigham and Women's Hospital, Boston.

Anthony Alessi, MD, co-chair,  American Academy of Neurology section on sports neurology; chief of neurology, the William W. Backus Hospital, Norwich, Ct.

Mark Lovell, PhD, founding director, University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program, Pittsburgh.

American College of Sports Medicine.


Yard, E. Brain Injury; 2009; vol 23: pp 888-898.

The New York Times.

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