Between 1.6 and 3.8 million Traumatic Brain Injuries (TBI) are diagnosed each year in the United States — mostly concussions.
Concussions are usually caused by a blow to the head and football is the leading sport for TBIs, according to the CDC. Consequently, prevention and treatment of concussions within the sport has reached a critical juncture.
"Football is a violent sport," said David LaMarre, head football coach for St. Francis Catholic High School in Gainesville. "Everybody says it's a contact sport. It's not a contact sport, it's a collision sport."
The size of players is another issue. “Athletes are bigger than they were in the past," said UF Health's Dr. Seth Smith. "When people are larger, forces get transmitted more violently.”
The speed of the athletes is also increasing. "Changing technology, changing genes, and a changing mindset" have allowed athletes to become faster than ever before, said sports science writer David Epstein during his TED Talk "Are athletes really getting faster, better, stronger?"
Larger athletes colliding with each other at faster speeds can result in increasingly disastrous consequences.
"The biggest thing is trying to educate folks," said Craig Damon, director of athletics for the Florida High School Athletic Association. Concussion education requires extensive knowledge of signs and symptoms, as well as accurate treatment methods.
Dr. Jason Zaremski and Smith are non-operative sports medicine physicians and co-directors for the University of Florida's High School Outreach Program. Their team pairs with certified athletic trainers and works with all but one of the high school football programs in Gainesville.
Some symptoms of concussions include headaches, confusion, dizziness, ringing in the ears, nausea and fatigue, according to the Mayo Clinic. Smith said most symptoms resolve themselves within 7-10 days. However, sometimes symptoms can persist for weeks or months. This is called Post-Concussive Syndrome. In some cases, players suffering from PCS also experience irritability, anxiety and insomnia.
"Not only are they having these symptoms," Zaremski said, "but these symptoms are affecting their everyday way of life." Difficulty concentrating in school can lead to poor grades and trouble getting into college.
Some doctors, including Smith, believe there is a relationship between repetitive, concussive blows to the head and Chronic Traumatic Encephalopathy (CTE) or Chronic Neurocognitive Impairment (CNI). However, this has not been proven. Smith also believes some athletes may have a genetic predisposition to these conditions.
CTE is a degenerative disease in the brain that can result in "memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, suicidality, parkinsonism and eventually progressive dementia," according to researchers at Boston University. CNI is a long-term condition in which concussive symptoms return years later, Smith said.
The FHSAA has adopted several new rules to address the concerns about concussions. The first rule introduces a penalty for targeting a player above the shoulders. The second rule changes the definition of a defenseless player to someone who is especially vulnerable to injury because of a physical position. For example, a receiver trying to catch a pass, kickers who haven't yet regained their balance and players already on the ground.
Still, athletes get hit; athletes get concussions; and those concussions can lead to further problems.
If you're an athlete, you're hiding your concussion," Zaremski said. He noted that up to 35-50 percent of individuals are hiding their concussions.
Melissa Goo, a Certified Athletic Trainer for St. Francis, blames this on what she calls the "Warrior Mentality." She said athletes often want to fight through the pain, but it can also be a leadership problem. She has seen coaches tell athletes to "suck it up."
In another case, a star player on the football team fractured his hand. If it were up to her, Goo said she would not have let him back in the game. The doctor working with the team at the time, however, said that the damage was already done so he may as well continue playing.
Zaremski said that this attitude in regards to concussions is especially worrisome.
"It’s one thing to sprain your ankle and return to play too early," he said. "What’s the worst that’s going to happen? You’re going to re-sprain your ankle.”
Concussions are not the same. They are brain injuries.
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Jennifer Scott's daughter Lexie is a senior on the St. Francis football team. Her husband is a neurosurgeon who has seen "the worst of the worst" when it comes to brain injuries. After their son's friend died as a result of a concussion sustained while playing flag football, Scott and her husband decided they needed to do something. They purchased new helmet technology for the entire team that added sensors to the existing helmets.
“These kids really have a fierce desire to play for their team even if they’re injured and the helmets would be a line of defense,” Scott said.
LaMarre had heard about the Riddell InSite helmet system, but wasn't sure when the team would be able to afford it.
"We've been very fortunate," LaMarre said. It cost about $150-200 to add sensors to each of the helmets they already had. "Her [sic] and her husband took care of it."
“It wasn’t cheap,” Scott said. “We try to support St. Francis in a lot of ways and that was just what we felt was incredibly important.”
The InSite system allows the team's certified athletic trainer to receive information on any impact the players receive to the helmet, including location, duration and strength.
Goo said the system has been incredibly helpful for her.
"Sometimes I might be stretching an athlete on the sideline, somebody gets hit and I don’t see it," she said.
With the automatic alerts, it is also much more difficult for players to hide their head injuries.
Scott McDaniel, Varsity Head Coach for Oak Hall School in Gainesville, whose team also got the InSite technology, said it can "save the kids from themselves."
Playing through injuries can cause further damage, Goo said. If you put a player back in the game, but they are unable to defend themselves due to disorientation from a concussion, they are more likely to sustain new injuries.
The technology can also be a coaching tool.
“We had one young man who's helmet alerted six times in one game," McDaniel said. If a player is setting off the sensors often, it likely means they are using their head too much when blocking or tackling. Coaches can then work on that player's individual technique.
Still, this technology is not cheap.
“Expensive. Very expensive. We spent close to $20,000," McDaniel said. “Because it values the football program, the school ponied up all of that money over the course of the next three years.” The money will come out of the athletic budget.
Schools that do not have these kinds of funds may not be able to provide their athletes with this system.
St. Francis and Oak Hall are the only two high schools in Gainesville to have the InSite technology. They are both private.
According to the FHSAA that is ok.
Damon said that as long as the gear is approved by the National Operating Committee on Standards for Athletic Equipment, parents are allowed to "spend a little bit more money to buy what has been marketed as a better helmet.”
But, how much does this really matter anyway?
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“We have to be really careful in making decisions based on what a marketing group would say," Smith said. "There's a lot of money to be made in concussions now."
Although helmets and mouth guards are marketed as tools to prevent concussions, neither do. The purpose of a helmet is to decrease the risk of skull and facial fractures. The purpose of a mouth guard is to decrease the risk of dental trauma. Not even proper tackling technique can prevent concussions, according to Smith. All that does is help decrease the risk of a cervical spine injury.
Hines Ward, a former Pittsburgh Steelers receiver, goes so far as to say that helmets do more harm than good. “When you put a helmet on you’re going to use it as a weapon, just like you use shoulder pads as a weapon," Ward said in a Boston Globe article.
“We also don’t know what each person's threshold is for number of hits,” Smith said. One athlete could take five hits without suffering any long-term side effects and another could experience a high level of brain trauma from a single impact.
What worries Zaremski and Smith the most are the "amount of contact or tackling or hitting" and the age at which kids start playing contact sports.
“Younger brains don’t handle contact or collisions as well as older brains do,” Smith said.
For some, though, these risks may be worth it.
McDaniel said all the negative attention on football frustrates him. He said he wishes there was more focus on the possibilities that sports and football offer.
"We’re going to run people away from the game when that might be their only opportunity to get out of whatever cycle that their family is in,” he said.
McDaniel said he has seen an 18-20 percent drop in the number of kids playing football over the last five to six years.
LaMarre has also seen the fear of trauma affect his team. One of his players incurred several concussions in middle school. After suffering another in high school, his parents told him he could no longer play football.
“Some kids you know why they get through high school?" McDaniel asked. "Sports. Football. If I want to play on Friday night I have to go to school Monday through Friday."
McDaniel coached a player at Santa Fe High School who came from a less privileged family situation. He went on to graduate from East Carolina University and earn a Master's degree in business.
“Football gave him a vehicle to get to college," McDaniel said.
So, the problem remains. Safety or football? Safety or education?