Concussions in Pro Sports: Overview

Introduction

Professional athletes—particularly boxers, football players, hockey players, race-car drivers, and professional wrestlers—risk concussions and concussion-related brain damage from participation in their respective sports. While concussions have always been part of professional sports as a vague “sports-related injury,” the growing incidence of concussions and the increasing understanding of their long-term effects and severity have ignited an intense debate regarding how professional sports organizations should handle these injuries. The discussion has become complicated by the financial stakes for pro-sports leagues, the balancing of medical consequences for athletes and the pressure and corporate culture of winning, and fan investment and loyalty.

Concussions are a common form of traumatic brain injury resulting from blunt force trauma to the head, which may be caused by a fall or by being struck in the head. Also known as minor head trauma, mild head injury, or mild traumatic brain injury (mTBI), a concussion is associated with a temporary lapse or loss of brain function and related physical and mental symptoms. Professional sports leagues have handled concussions in a variety of ways, though a consensus has been developing regarding a standard practice once a concussion is identified.

Once sustained, a concussion should be evaluated by a physician or medical team, initially using brief neuropsychological tests such as the Maddocks questions and the Standard Assessment of Concussion (SAC), then later with more extensive neuropsychological testing and neuroimaging. Athletes who experience concussions during sports are medically advised to rest and to avoid contact sports and any other strenuous cognitive or physical activity until symptoms are gone and the athlete has completed a gradual return-to-play progression of increased activity, which often takes seven to ten days but may take several weeks or even months. Any athlete suffering a concussion should be monitored for sleepiness, head pain, dizziness, confusion, incoherence, or nausea, which may signify complications such as hemorrhaging or brain swelling.

Understanding the Discussion

Concussion: A common form of traumatic brain injury characterized by structural injury to the brain and/or disruption of brain function from blunt trauma or acceleration or deceleration forces.

Dementia pugilistica: A form of dementia that often affects professional boxers, associated with repeated concussions and blows to the head. Symptoms of dementia pugilistica mimic those of Alzheimer’s disease, making a proper diagnosis difficult.

Post-concussion syndrome: A medical syndrome, also referred to as shell-shock syndrome, that affects individuals for weeks or months after they experience a concussion or mild traumatic brain injury. Symptoms include headaches, emotional irritability, and unpredictability.

Second-impact syndrome: An often-fatal medical condition in which a second concussion occurs before the brain has healed from the first concussion, causing the brain to swell. Individuals may be at risk for second-impact syndrome if they receive a second concussion or traumatic brain injury before fully recovering from their first concussion.

History

Since the mid-twentieth century, major professional sports leagues have responded in different and evolving ways to the issue of concussions and traumatic brain injuries in athletes. Initially, precaution existed only in the form of protective sports equipment and gear, widely required in many professional sports beginning in the 1950s. However, only in 1979, for example, did professional hockey require the mandatory wearing of protective helmets, and only as recently as 2002 did an equipment manufacturer for pro football release a helmet designed to reduce or lessen concussion effects. By 2017, padded helmets were required in professional baseball (when batting or catching), football, hockey, and Formula One and NASCAR racing.

Simply acknowledging the link between concussions and severe long-term damage to the brain has also been a slow process. The National Football League (NFL), for example, was routinely taken to task for a disability system that denied benefits to retired players suffering the effects of multiple concussions, an issue that prompted a congressional warning in 2007. Only as more cases came to light—such as the one involving former NFL player Andre Waters, who died in 2006 of a self-inflicted gunshot at age forty-four and whose autopsy revealed a brain similar to that of an eighty-five-year-old—did the need for a culture change in sports definitively materialize.

In the late 1990s, professional sports leagues began the process of developing player concussion policies to address the growing concerns about long-term health effects for players experiencing multiple concussion-related injuries. In fact, of the “Big Four”—the North American leagues of Major League Baseball (MLB), the NFL, the National Basketball Association (NBA), and the National Hockey League (NHL)—only the NBA lacked a concussion policy until the 2011–12 season, when a policy was implemented for the first time.

Despite some technical variations, the leadership and concussion policies of major sports leagues generally agree that players experiencing a game-related concussion should not return to play if they experience a loss of consciousness, confusion, incoherence, dizziness, nausea, vomiting, or headache.

The NHL is widely considered to be the first professional sports league to adopt a concussion policy, having done so in 1997. An updated policy was instituted in 2011. The policy states that injured players are required to go to a quiet area for a fifteen-minute neuropsychological evaluation. After the examination, the team doctor is authorized to make a return-to-play decision for the player. The team doctor is also authorized to make the decision about when a player who has been sidelined due to significant concussion-related injury is fit and sufficiently symptom-free to return for future games. While trained concussion spotters hired by teams had long attended games, a protocol change for the 2016–17 season saw the addition of a central group of independent concussion spotters who monitored players via television and had the authority to pull them from play.

The NFL implemented its first concussion policy in 2007 and updated it in 2009. It also calls for an examination by team medical staff immediately following the injury and, if a concussion is diagnosed, subsequent approval from the medical staff and independent medical professionals for return to play.

MLB also implemented its first concussion policy in 2007. The policy was updated in 2011. It states that team medical personnel must evaluate the injured player in a quiet location. After the examination, the team medical staff is authorized to make a return-to-play decision for the player. If a concussion is diagnosed, the league's neurologist decides when an athlete is fit and sufficiently symptom-free to return for future games. The 2011 update also established a seven-day disabled list (DL) policy for concussions.

According to the NBA concussion policy, all players must take a baseline neurocognitive exam prior to each season. A player suspected of sustaining a concussion during play is evaluated by team medical staff in a quiet area. If diagnosed with concussion, the player will not be allowed to return to play until all symptoms are gone and a subsequent neurocognitive exam provides results that correspond with preseason baseline readings.

Other professional sports leagues that have implemented player and team policies for concussions include Major League Soccer (MLS), the World Professional Boxing Federation, and NASCAR. MLS developed its first concussion policy in 2011. Their policy aligns with the policies enacted by the other pro leagues, with an immediate examination by team medical staff and, if a concussion is diagnosed, a follow-up with the team medical staff and an independent physician.

The World Professional Boxing Federation and the United States Boxing Council have issued medical and safety guidelines that specify knockout and post-bout medical exam procedures. Boxers who experience a knockout (KO) or technical knockout (TKO) due to a blow to the head are given a 30-day medical suspension; two KOs or TKOs due to head blows within six months result in a 180-day suspension, and three within one year lead to a suspension lasting one year. Boxers may be reinstated after the suspension period is over and the player has passed a comprehensive physical examination.

NASCAR developed its first concussion policy in 2003. It is similar to the other concussion policies developed by other major sports organizations. Starting in the 2014 season, the organization began to mandate preseason baseline testing as well, and in 2017 protocol changes included a standardization of the screening test used.

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The long-term concussion-related health effects for professional athletes have been strongly debated by the international medical community and pro sports management. The international medical community—as represented by the American Academy of Neurology, the American Association of Neurological Surgeons, the British Medical Association, the Australian Medical Association, the American Academy of Family Physicians, the American College of Sports Medicine, the American Medical Society for Sports Medicine, and others—has come to a consensus on concussion evaluation and treatment.

According to the medical consensus statements from the 5th International Conference on Concussion in Sport, held in Berlin in October 2016, medical evidence suggests that multiple concussions result in lasting brain damage scenarios such as degenerative dementia pugilistica, post-concussion syndrome, or second-impact syndrome. These consensus statements include recommendations on proper concussion evaluation in pro sport settings, on-field or side-line evaluation of acute concussions, concussion grading and management, graduated return-to-play protocol, concussion rehabilitation, and ongoing monitoring of mental and psychological issues associated with concussions.

The medical community has criticized pro sports leadership and management for minimizing the importance of concussion in professional sports. While the majority of major sports leagues have developed more formal concussion policies since the turn of the twenty-first century, critics have found fault with the leniency of the return-to-play guidelines, the potential for conflict of interest when allowing team physicians to make return-to-play decisions, and the frequency with which these guidelines are evaded and injuries are hidden by the players themselves. In addition, medical organizations such as the British Medical Association and the Australian Medical Association have gone so far as to call for a ban on professional boxing due to the concussion- and head-injury-related risks and trauma associated with the sport.

In 2011, the issue of concussions in professional sports spilled over into both the political arena and popular culture. In March of that year, a US member of Congress called upon the House Judiciary Committee to organize hearings on concussions and head injuries in professional sports. The committee previously held an initial hearing regarding head injuries in professional football following widespread criticism of the NFL and its handling of hits to the head, which prompted a change in NFL policy. A popular video game, Madden NFL 12, also nominally addressed the severity of concussions in professional sports by including a game-play feature that requires virtual football players suffering head injuries to be virtually sidelined for the remainder of the game.

Also in 2011, a lawsuit was filed against the NFL on behalf of seven former players due to long-term medical effects they suffered as a result of concussions sustained while playing; numerous other lawsuits were filed, ultimately representing more than 4,500 former players. The lawsuits were settled in 2013 for $765 million, a sum that has been criticized as insufficient to cover the more than twenty thousand former players affected by the ruling while representing only a fraction of the NFL’s annual profits. Following on the heels of the NFL settlement, in November 2013, ten former pro hockey players filed a similar suit against the NHL for negligence. In 2015, the NHL helped fund a British study on concussions in sports. The NHL suit was settled in 2018 with an agreement to provide up to $75,000 for medical treatment for the roughly 300 former players involved in the suit, which was compared unfavorably to the NFL settlement.

Concussions in Pro Sports Today

For many, concussions in pro sports continued to be a crisis spanning all professional leagues. The evidence remained mixed whether the incidence of concussions, or at least the proper acknowledgement thereof, was on the rise in professional sports.

In addition to ATC spotters and improved concussion policies in pro sports, the development of blood tests that could objectively and reliably detect concussions could potentially reduce the conflict of interest faced by professional athletes and league medical personnel in the diagnosis of concussions. In February 2018 the Food and Drug Administration (FDA) authorized the Banyan Brain Trauma Indicator for marketing after a six-month review process. The review was part of the FDA's Breakthrough Devices Program. The Banyan indicator is the first blood test for evaluating concussion in adults. The test helps diagnosticians determine which patients with suspected mild traumatic brain injuries need computed tomography (CT) scans. In subsequent years, researchers worked to develop a blood test instrument for concussions that would be faster and portable.

Athletic equipment manufacturers have developed new devices to help protect athletes from mTBI. In February 2021, the FDA approved the Q-Collar, a C-shaped device designed for athletes ages thirteen and older to wear around the neck for protection against injuries caused by repetitive sub-concussive head impacts. The Q-Collar decreases the brain's movement within the cranium during head impacts.

The NFL revised its concussion protocol in the fall of 2022 after Miami Dolphins quarterback Tua Tagovailoa was injured during a Week 3 incurred a concussion the following week during a "Thursday Night Football" game versus the Cincinnati Bengals, prompting an outcry over whether the Dolphins had followed the league's concussion protocol. The NFL and NFL Players Association (NFLPA) investigated these allegations and found that although the Dolphins had followed protocol, the protocol itself needed to change to include ataxia, poor muscle control, as a "no-go" symptom. The NFLPA also fired the independent neurologist who had cleared Tagovailoa to play. By Week 5, the NFL and NFLPA approved and implemented the Tua Rule, adding ataxia to the protocol's list of no-go symptoms.

In 2024, the NFL released injury data for the 2023 season, including the preseason and regular season. The data showed an increase in diagnosed concussions between 2021 and 2022 (from 187 to 213) that had stayed around the same in 2023 at 219. The league did note that during the 2023 season, 43 percent of diagnosed concussions had a self-reporting element, underscoring a growing trend in players reporting concussion symptoms themselves. Also in 2024, the NFL announced that following a trial in certain positions during training camp that had reportedly seen a 50 percent reduction in concussions, players would have the option starting in the 2024 regular season of wearing Guardian Caps, or specially designed helmet covers. At the same time, the league had continued to conduct regular evaluations of available helmet models and offer more claimed to better reduce the risk of concussion.

These essays and any opinions, information or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

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