# Lentis/Football and Concussions
## Introduction

Football has become an integral part of American culture. In 2014 the NFL will take in over $9 billion. The presence of dementia, depression and memory loss in many retired football players led to the discovery of Chronic Traumatic Encephalothopy (CTE). Each season, approximately 4% of football participants experience a concussion, and without proper treatment the consequences can be long term. “Premature return to play by a symptomatic athlete places that athlete at greater risk for subsequent concussion and cumulative brain injury”. Evolving helmet technology, rule changes and legislation have affected the culture surrounding traumatic brain injury in football. A combination of cultural shifts and improved helmet technology may be necessary to find a solution to traumatic brain injury.

## History of Football Culture
### Warrior Culture in American Football

Organized competitive sports have long played a part in shaping gender expectations in Western culture and football has been central to the construction of masculinity in the United States. Risk-taking is prominent in sports because it offers stress relief, physiological rewards, and affective benefits. Athletes are likely to take risks on the field due to the pressures of fame, career security, and team loyalty. This player mindset along with fan encouragment and the media fashioned the way that football is played today.
The media has encouraged risk-taking in players "raised on a warrior culture". ESPN, perhaps the most popular medium for sports news in America, included a popular segment titled "Jacked Up" from 2003 to 2006. The segment showed the five hardest hits of the week, perpetuating football violence and glorifying players for sacrificing their personal safety. Media have traditionally supported the masculine warrior narrative over player health, partially because sports journalists want to enhance their own machismo through reporting.
While people of all walks of life follow football, it's no surprise that men make up about 63% of football's fan base. As with gladiators fights in Ancient Rome, spectators are intrigued by football because of its violent nature. Large audiences would tune in to watch the biggest hits on "Jacked Up" during its stint on ESPN, and many would contend that football would be less popular without the violent aspects of the game.
The sacrificial tendencies of players for the sake of athletic glory illustrate the emphasis on a masculine status. Football players, especially professional, are almost unanimously big, fast, and strong. Increased competitiveness warrants self-sacrifice in order to stay in the game, or players risk losing their careers. The long-standing expectation for injured players to continue playing is described by Seattle corner-back Richard Sherman; "The next time I get hit in the head and I can’t see straight, if I can, I’ll get back up and pretend like nothing happened.". This philosophy is common among players dedicated to the sport.

### Helmet Improvements

Football evolved from rugby and soccer-like games in the late 1800's. Padding quickly became necessary, although the helmet did not become essential until a 1939 NCAA rule required leather helmets. Increasingly violent play peaked during a 1893 game between Harvard and Yale, deemed the Hampden Park Blood Bath. This almost led to football's banning across American campuses and made minimum protection necessary. Helmets evolved over the next three decades to include hard plastic shells and face masks.
Protective equipment may influence the user to act more aggressively, increasing the potential for serious injuries. This assertion reflects the theory of risk compensation with helmets giving the players a false sense of security, causing them to take more chances. The affect of helmets for football players can be compared to that of gloves for boxers. Though gloves protect the boxer's hands, the protection gave them the confidence to throw stronger punches.
The National Operating Committee on Standards for Athletic Equipment (NOCSAE) is the regulatory agency in charge of inspecting new and reconditioned helmets. Improvements in helmet technology directly affect the regulations established by NOCSAE on helmet manufacture. Critics cite that NOCSAE tests focused extensively on preventing skull fractures, which helmets do effectively, but no standards addressed mitigating concussions. NOCSAE counters that to prevent concussions helmets would need to be rated approximately four times better than the standard, and to do this would require increasing the size and padding. Enlarging the helmets would increase the weight, and the resulting neck fatigue could cause players to drop their head down, leaving them more vulnerable to both concussions and neck injury.

## Concussions and Traumatic Brain Injury
### What is a concussion?

A concussion is a head injury characterized by "alteration of mental status" resulting from a blow to the head or brusing of the brain inside the skull. Recurring impacts, especially without proper recovery time, can increase the likelihood and magnitude of concussive consequences, particularly depression.

### Discovery of CTE in Football

In 2002, Dr. Bennet Omalu was the first to identify football-related brain injury in NFL player Mike Webster’s brain tissue through tau protein buildup similar to that of Alzheimer’s sufferers. Webster's post-retirement life was unusual and erratic. He became aggressive and forgetful, and was for a time homeless and addicted to Ritalin. Within the ten years following Webster's death, the brains of five other retired NFL players who had died or committed suicide were found to have evidence of long term brain damage. In 2014, 76 of 79 analyzed players brains showed the presence of CTE. The neurodegenerative disease was named chronic traumatic encephalopathy (CTE), and had most commonly been found in the brains of boxers. Symptoms can include depression, paranoia, aggression, memory loss, poor eyesight, dementia, irritability, and reduced concentration.

### NFL Reaction

The NFL, NOCSAE, and helmet manufacturers historically formed an iron triangle that disguised the dangers of brain trauma in football. These institutions are interested in preserving the business of football and Americans’ love for the sport. The NFL’s Mild Traumatic Brain Injury (MTBI) committee denied Omalu's initial findings of CTE in retired players and manipulated their own research, which increased the perceived safety of football. Riddell, manufacturer of the official helmet of the NFL, introduced the Revolution helmet in 2002. Though the company claimed “the helmet was designed to protect players from concussions,” much of the supporting research was fraudulent.

## Changing Culture

The discovery of Chronic Traumatic Encephalopathy has spurred increased interest in traumatic brain injury relating to football. Helmet-to-helmet hits and concussions continue to afflict more players each week, with an average of 7.7% of all players suffering at least one concussion per year. As more information regarding traumatic brain injury is discovered, social groups put pressure on football's governing bodies to fight for player safety.

### Player Safety

In 2013 retired players sued the NFL for concealing the dangers of concussions and agreed to a settlement of $765 million to cover the costs of concussive brain injuries. The settlement awards $3 million to players with dementia and $4 million to families of players that are posthumously diagnosed with CTE. Despite prior attempts to cover up the dangers of concussions, NFL Commissioner Roger Goodell stated it was time to "do the right thing for the game and the men who played it." In 2012, 25 year old Chiefs linebacker murdered his girlfriend before shooting himself outside team practice facilities. In 2014, ESPN's Outside the Lines reported Belcher's autopsy showed strong a presence of Chronic Traumatic Encephopathy. Belcher's case is the first known instance of CTE effecting an active player. The development of serious health issues among many of the game's greats has caused current players to think twice about the occupational hazards of football.

### Rule Changes

The NFL has instituted various rule changes outlawing excessively violent hits. The kickoff has been moved up in attempt to remove one of the most deadly plays in the game, and spearing and head to head contact now results in heavier fines. Repeat offenders can even be fined for unnecessary roughness. The NFL has also developed more rigorous return to play standards for players that are suspected of being concussed. Independent concussion experts watch each game to ensure team doctors are not allowing concussed players to wrongfully return to play. These changes have filtered down from the NFL to high school and youth leagues. Washington state adopted strict return to play legislation inspired by catastrophic injury experienced by Zackery Lystedt. The legislation calls for immediate removal of players with suspected concussions and requires a doctors written consent to return to play. To combat risky plays, youth organizations have begun educating players on safer tackling. Coaches and parents hope that teaching players proper form at a young age will decrease concussions at the upper levels.

### Player Culture

For years macho aggression has dominated football culture. Former NFL player Mark Schlereth stated, "We glorify these hits. We make money on these hits. That's what we do, and the NFL profits on that.". Scientific breakthroughs on the dangers of CTE and traumatic brain injury have caused a culture shift in the NFL. Several former NFL stars, including future Hall of Fame quarterback Brett Favre, have said that they would not let their children play football. Many offensive players, such as quarterback Aaron Rodgers and tight end Todd Heap are instead speaking out in favor of the new enforcement, arguing that players' health should be protected and dangerous plays should be outlawed. Public concern has grown as fans have watched their childhood heroes become debilitated by various brain diseases, causing segments such as ESPN's "Jacked Up" to no longer air. Helmet researchers have started addressing the issue of head acceleration after years of focusing purely on impact. However not all players react the same way to the new health developments. Richard Sherman is an active opponent of changing the game, stating that he understands and accepts the risks involved with his occupation. Steelers linebacker James Harrison even threatened to retire after being fined for unnecessary roughness multiple times. Despite some player resistance, a growing culture shift is visible in all levels of football.

## Conclusion

While there is ongoing research to develop helmets that will reduce the occurrence of concussions, the solution may require a social change to accompany these advances in equipment technology. For effective change, the gladiator-like culture behind football must be adjusted to accommodate increased concerns for player safety. Many current NFL players believe it is too late to reconstruct their playing mentality, as they have spent their lives fighting to play professionally. To eliminate the stigma of violence in football, the shift will likely come from the bottom-up, focusing on proper tackling techniques and injury detection in youth football. Further research could expand this claim and describe what modifications in youth leagues might trigger permanent social changes at all levels. This chapter is currently focused on football, but additional work could investigate similar cultural patterns in other sports including soccer, rugby, and hockey.

## References

* ↑ Burke, M. (2013, August 17). How The National Football League Can Reach $25 Billion In Annual Revenues. Retrieved December 1, 2014, from www.forbes.com
* ↑ Maroon, Joseph, Mark Lovell, John Norwig, Kenneth Podell, John Powell, and Roger Hartl. "Cerebral Concussion in Athletes: Evaluation and Neuropsychological Testing." Neurosurgery 47.3 (2000): n. pag. Neurosurgery. Web. 20 Nov. 2010.
* ↑ Kushner, David. "Concussion in Sports: Minimizing Risk for Complications." American Family Physician 64.6 (2001): n. pag. American Family Physician. Web. 26 Nov. 2010.
* ↑ Hargreaves, J. 1994. Sporting Females: Critical Issues in the History and Sociology and Women’s Sports. New York, NY: Routledge
* ↑ Messner, M. A. 2002. Taking the Field: Women, Men, and Sports. Minneapolis, MN: University of Minnesota Press.
* ↑ Castanier, C., Scanff, C. L., Woodman, T. (2010). Beyond sensation seeking: affect regulation as a framework for predicting risk-taking behaviors in high-risk sport. Journal of Sport and Exercise Psychology, 32(5), 731-738. PsycNET.
* ↑ Ellenbogen, R. G., Berger, M. S., Batjer, H. H. (2010). The National Football League and concussion: leading a culture change in contact sports. World Neurosurgery, 74(6), 560-565. 10.1016/j.wneu.2010.11.016
* 1 2 Thomas, Katie. (2010, October 21). N.F.L.’s Policy on Helmet-to-Helmet Hits Makes Highlights Distasteful. The New York Times. Available at http://www.nytimes.com/2010/10/22/sports/football/22hits.html?_r=2
* 1 2 Anderson, Eric, and Edward M. Kian. 2012. Examining media contestation of masculinity and head trauma in the national football league. Men and Masculinities 15, (2) (06): 152-173
* ↑ Scarborough, N. (2004, September 6). Get to know the NFL fan. Retrieved December 7, 2014, from http://www.sportsbusinessdaily.com
* 1 2 Sherman, R. (2013, October 23). We Chose This Profession. Retrieved December 7, 2014, from http://mmqb.si.com/2013/10/23/richard-sherman-seahawks-concussions-in-the-nfl/
* ↑ Riffenburgh, B. (1986) Official NFL Encyclopedia. New York City: New American Library
* 1 2 Watterson, J. (2000). College Football: History, Spectacle, Controversy. Baltimore: Johns Hopkins University Press.
* ↑ Hagel, B., & Meeuwisse, W. (2004). Risk Compensation: A “Side Effect” of Sport Injury Prevention? Clinical Journal of Sport Medicine, 14(4).
* ↑ Borden, Sam (September 20, 2012). "Despite Risks, N.F.L. Leaves Helmet Choices in Players' Hands". New York Times. Archived from the original on September 20, 2012.
* ↑ Albergotti, R., and Wang, S., (2009, November 11). Is It Time to Retire the Football Helmet?. Wall Street Journal Available at http://online.wsj.com/article/SB10001424052748704402404574527881984299454.html
* ↑ Concussion. (n.d.). American Association of Neurological Surgeons. http://www.aans.org/patientinformation/conditionsandtreatments/concussion.aspx.
* ↑ Guskiewicz, K. M., Marshall, S. W., Bailes, J., McCrea, M., Harding, H. P., Matthews, A., Mihalik, J. R., Cantu, R. C. (2007). Recurrent concussion and risk of depression in retired professional football players. Medicine and Science in Sports and Exercise, 39(6), 903-909. 10.1249/mss.0b013e3180383da5m
* 1 2 3 Fainaru-Wada, M., Fainaru, S. (2013). League of denial. NY: Three Rivers Press.
* ↑ Breslow, J. (2014, September 30). 76 of 79 Deceased NFL Players Found to Have Brain Disease. Retrieved November 21, 2014, from http://www.pbs.org
* ↑ McKee, A. C., Cantu, R. C., Nowinski, C. J., Hedley-Whyte, E. T., Gavett, B. E., Budson, A. E., Santini, V. E., Lee, H. S., Kubilus, C. A., Stern, R. A. (2009). Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. Journal of Neuropathology and Experimental Neurology, 68(7), 709-735. Web of Science
* 1 2 Pellman, E., J., Powell, J. W., Viano, D. C., Casson, I. R., Tucker, A. M., Feuer, H., Waeckerle, J. F., Robertson, D. W. (2004). Concussion in professional football: epidemiological features of game injuries and review of literature: part 3. Neurosurgery, 54(1), 81-94. Web of Science.
* ↑ Heitner, D. (2012, Jun 21). Why football helmet manufacturer Riddell should be very concerned about concussion litigation. Forbes. http://www.forbes.com/sites/
* ↑ NFL, ex-players agree to $765M settlement in concussions suit. (2013, August 29). Retrieved December 3, 2014, from www.nfl.com
* ↑ Delsohn, S. (2014, September 30). OTL: Belcher's brain had CTE signs. Retrieved October 13, 2014, from http://espn.go.com/espn/otl/
* ↑ New NFL rules designed to limit head injuries. (2010, August 6). Retrieved December 3, 2014, from www.nfl.com/news/
* ↑ NFL's 2013 protocol for players with concussions. (2013, October 1). Retrieved December 9, 2014, from http://www.nfl.com
* ↑ Bompadre, V., Jinguji, T. M., Yanez, N. D., Satchell, E. K., Gilbert, K., Burton, M., & ... Herring, S. A. (2014). Washington State's Lystedt Law in Concussion Documentation in Seattle Public High Schools. Journal Of Athletic Training (Allen Press), 49(4), 486-492. doi:10.4085/1062-6050-49.3.30
* ↑ Heads Up Football [USAFootball]. (2014, March 2) Heads Up Football | Overview | USA Football [Video File]. youtube.com
* ↑ Wilson, R. (2014, July 16). Brett Favre reiterates he wouldn't want son to play football. Cbssports.com
* ↑ NFLLabor. (2010, October 25). Players agree with stricter enforcement of rules against illegal hits. NFL Labor News. Available at http://nfllabor.com/2010/10/25/players-agree-with-stricter-enforcement-of-rules-against-illegal-hits-2/
* ↑ Foster, T. (2012, December 18). The Helmet That Can Save Football. Retrieved December 2, 2014, from http://www.popsci.com/science
* ↑ Battista, J. (2010, October 20). Defenders Criticize N.F.L. For Helmet-to-Helmet Fines. Retrieved December 5, 2014, from www.nytimes.com