The hardest hit: Scientists tackle the problem of athletes and concussions
As new rules try to protect players from concussions, scientists are racing to better diagnose and understand head injuries to athletes
Christian Lezzer has no regrets.
He played hard and hit harder — his high school football highlight reel shows that much. If that kind of play led to five concussions, he says, then so be it.
The Boston College sophomore knew what he was getting into. He knew the risks.
“If you’re playing football,” he said, “you know what could happen, you know what’s going to happen, you know it’s a violent game, you know you’re going to get hit every given play. If you’re worried about getting hit, it’s probably not the sport for you.”
Lezzer’s first three concussions came in high school. Only one forced him to sit out, because that was the only one the coaches and trainers noticed.
“The two other ones, looking back, I kind of knew something was wrong at the time, but I didn’t necessarily know that they were concussions,” Lezzer said. “Something was definitely wrong and I should have reported it. But I wanted to play.”
Football is a violent game, and impacts to players’ heads occur often. Those blows —from another player, from hitting the ground or from simply changing direction too quickly — can jar the brain and damage it.
The Centers for Disease Control and Prevention defines a traumatic brain injury, or concussion, as a blow to the head that “disrupts the normal function of the brain.”
Over the past five years, the issue of concussions has been at the forefront of discussions in
the National Football League. The league was called to testify before Congress on the dangers of concussions and the way it has or has not dealt with them.
In response, the NFL has invested in education and research. It has also implemented rule changes in an attempt to curb head injuries, including a rule that prohibits and fines defensive players from leading with their heads and hitting offensive players above the neck. There is some evidence that the NFL has been successful in cutting back on the injuries, too. According to Frontline, the PBS public affairs documentary show, which has been following the issue, the number of reported concussions in the NFL has gone from 171 in 2012 to 108 after 11 weeks of the season this year.
Similarly, the National Collegiate Athletic Association has recognized the need for more education, protection and research into the issue of concussions.
The governing body introduced the “targeting penalty” in 2008, a rule that flagged players for hitting other players above the shoulders. It carries a 15-yard automatic penalty. In 2013, the rule was strengthened. Now, along with the yardage penalty, if a player is called for targeting, he is automatically ejected from the game.
Dr. Susan Saliba, a professor of kinesiology at the University of Virginia who has done research on concussions, said the NCAA, however, is not logistically equipped to treat concussed players in a uniform manner.
“When you look at what happened with the NFL, they were definitely kind of turning their head and denying a lot of things that were actually happening,” Saliba said. “So, I think the NCAA wants to be proactive in making sure that they’re covered, so to speak, from a legal standpoint.”
She said the NCAA could create a set of safety parameters for athletes, “but what actually happens in terms of their treatment, they can’t dictate that.”
In the NFL, a protocol outlines a procedure to be followed by all 32 teams on game day and in practice when a player sustains a concussion. Although some NCAA teams have implemented similar procedures, they vary from school to school. The variance is largely due to financial constraints that the NCAA had to consider when it adopted its legislation.
Saliba explained: “From an NCAA standpoint, they can say at minimum that according to the laws of the state and the medical laws, a certain person can be able to assess and diagnose and make those return-to-play guidelines. But they can’t say that you need a specific test. Because if that school is not able to provide the resources for that, what are they going to say? You can’t compete in the NCAA?”
In January, the so-called Power Five conferences – the Big Ten, Big 12, Pac-12, Atlantic Coast Conference and Southeastern Conference – adopted their own “concussion safety protocol legislation.” The legislation requires the conferences’ 65 member universities to draw up concussion protocols, or plans of action, to detect, diagnose, treat and report concussions.
The protocols require that players be educated about concussions and their symptoms prior to the season. They establish policies for removing a possibly concussed player from a game and for evaluating him or her. They forbid an athlete to return to play on the same day of a concussion, and they require a doctor to clear the athlete before he or she can play again.
Under the protocols, “student- athletes must acknowledge that ... they have a responsibility to report concussion-related injuries and illnesses to a medical staff member.” All athletes sign forms at the beginning of the season acknowledging that they understand their responsibility.
Lezzer is used to dealing with concussion symptoms.
He felt nauseated and vomited after one of his concussions in high school, but he was able to hide his injury from his coaches at Clearfield High School in Central Pennsylvania. He knew they would force him to sit if they found out.
“Everyone has gotten their bell rung a couple of times and you don’t really think anything of it,” Lezzer said. “You just keep playing, and that’s what I did. A couple years later, it came back to bite me.”
The fourth concussion came during the 2015 pre-season training camp at Boston College. As Lezzer, a defensive back, tackled a running back during a drill, their heads collided. The symptoms lasted two weeks.
The fifth concussion came in September. After the Golden Eagles’ 14-0 loss to Florida State, the team was practicing for the game against Northern Illinois. Lezzer was going through a routine drill, just as he had done countless times, when his head collided with a teammate’s head.
It was an unremarkable football play — nothing too violent, nothing out of the ordinary. But this time he knew things were different.
Immediately after the collision, Lezzer felt woozy and “didn’t know where I was at.”
The protocol was followed to the letter: The player recognized the possibility of a concussion. The coach pulled him out of practice. The concussion was diagnosed. The training staff led Lezzer through the stages of recovery.
The problem, Lezzer said, was that the symptoms lasted four weeks. That was when he knew this was serious — something that might end his career.
The universities’ protocols range from as few as four pages to as many as 66, from a bare outline to a catalog of definitions and procedures.
The standard, at least for now, is a step-by-step guide to what a player needs to do to return to athletics and another guide to get back to the classroom. These are called return- to-play and return-to-learn.
Saliba said the return-to-learn guidelines are more important, because everyone has to get back to academics eventually. But there is variance from university to university even on this point. Some universities, like Virginia, have detailed guidelines; other universities take a case-by-case approach.
Saliba would like to see a standard set for athletes to get back into the classroom at a reasonable pace and in the right way. But, she acknowledges it’s not easy to make that happen.
“When you think about the reality of the big-money sports like football and basketball, whether or not they’re going to adhere to that, nobody’s really going to be able to tell,” Saliba said.
Curtis Cruz, who has studied concussions for years, said that the university-to-university variance is part of the problem of dealing with concussions.
As the president of Head Health Network, a company that partners with schools in research with special helmets that track hits to the head, Cruz is constantly looking at the different ways that concussions are identified and dealt with.
“You can go to five different schools, and while they’re all reading from the same textbook, the textbook is pretty vague,” Cruz said. “Basically we always say a concussion is a bag of symptoms, and if you have a couple of those symptoms, you can say you’ve got a concussion.”
As Texas Tech’s protocol states, there are “more than 42 consensus-based definitions of concussions.”
For example, North Carolina State University defines concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” At the University of Pittsburgh, a concussion is “an injury involving acceleration/ deceleration or rotational force imparted to the head that results in temporary alteration in mental status.”
Cruz has direct knowledge only of the three universities his organization has partnered with so far — Penn State, Louisiana State and Texas A&M. But, he said the lack of a unified definition of a concussion is a major challenge in diagnosing and treating the injury.
Right now, “the best thing that we can hope for is just finding better ways to care for and treat the injuries,” he said.
For players, the symptoms of a concussion can be hard to discern. According to a chart issued by the NCAA that is included in many of the team protocols, a symptom can be as mild as a headache or it can be as serious a loss of consciousness. However, as Cruz said, many symptoms – such as headaches, drowsiness and nausia – can be concussions or they can be something else.
In individual universities’ plans that list symptoms for coaches to look for, there are variances.
North Carolina State’s plan says that if a player states he “had his bell rung,” a coach should pull him out and have him tested.
Beneath the NCAA’s symptom chart, Northwestern’s plan states: “If you are having any of the signs or symptoms listed above, you should tell your athletic trainer, team physician, coach, teammate, or parents so you can get the help you need.”
For coaches, the NCAA fact sheet offers a warning in all capital letters at the bottom of the page: “IT’S BETTER THEY MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, SIT THEM OUT.”
But sometimes the signs are obvious. A nationally televised game in Ann Arbor, Michigan, on September 27, 2014, pushed concussions to the top of the NCAA’s agenda.
On a third-and-16 play in the fourth quarter, Michigan quarterback Shane Morris rolled out and fired a rushed pass as a Minnesota player was bearing down on him. While Morris’ pass fell incomplete, the crown of Theiren Cockran’s helmet hit the quarterback’s facemask right beneath the chin. Morris jolted backward and slammed to the turf.
Morris got up, walked toward the sideline and stumbled. He put his arm on the shoulder of a teammate to keep his balance. Other players motioned to the sideline for either a coach or trainer, but Morris waved them off.
Morris stayed in the game for the next play — an incompletion — and was then taken out.
Afterward, coach Brady Hoke said he had not realized Morris was injured when Cockran hit him.
Hoke said afterward, “I don’t know if he had a concussion or not... And Shane wanted to be the quarterback, and so, believe me, if he didn’t want to be, he would’ve come to the sideline or stayed down.”
Over the next week, Michigan students and fans called for Hoke’s job and commentators criticized the coach. University president Mark Schlissel said, “Despite having one of the finest levels of team medical expertise in the country, our system failed on Saturday.”
On the day after the game, Morris was diagnosed with a “mild, probable concussion.”
The problem, as Cruz sees it, is that each concussion is as different as each player.
“It would be nice if there was a way to clearly define when it’s considered a concussion and exactly what needs to be done to return to play,” Cruz said. “... It’s a hard injury to solve with a checklist.”
In July, the Big Ten announced that the conference would station independent medical spotters in the replay booth who could alert officials on the field of a possible injury.
Penn State’s head athletic trainer, Tim Bream, said that as of the halfway point of the 2015 season, no spotter in any Big Ten games had reported injuries.
Bream, a Penn State graduate, has been an athletic trainer in some capacity since 1986 at Syracuse.
He later worked for Vanderbilt and for the Chicago Bears of the NFL, and he arrived at Penn State in 2012.
After spending so much time diagnosing and treating so many injuries, Bream has seen research and technology develop right before his eyes.
The biggest improvement he has seen is in education – players are no longer afraid to speak up.
He said he didn’t think concussions “are underreported anymore, I really don’t.” Maybe 15 to 20 years ago, he said, “you could make that argument, but I think there’s so much education and so much awareness that everybody’s very alert and sensitive to head injury, including the players.”
Part of that awareness at Penn State can be traced to the relationship that Bream and his staff have with the players. The staff tries to become a support system — as Lezzer experienced at Boston College — so that student- athletes understand that whatever decisions are reached are in their best interest.
But Bream also recognizes the complexity of dealing with concussions. He said there are a lot of unanswered questions — questions of how and why certain impacts affect some players and not others.
Or, as Bream put it: “As long as there is going to be contact sports, there’s going to be risk of head injury. So how do we minimize that without diluting the competition?”
Head Health Network is trying to answer that question and more. Cruz said there will be a day when all that will be needed to diagnose a concussion is a finger.
“The most meaningful advancement that’s coming is somebody is going to figure out the blood study,” Cruz said. “If everything works out right, you would be able to prick your finger and see right away if you are positive for a blood marker that is consistent with a concussion.”
But, he said, that kind of test realistically is about a decade away. Head Health Network’s research helmets contain accelerometers to measure how hard the wearer is being impacted. They contain gyroscopes to record how fast a head is moving on impact. A third sensor, a “smart fabric” that lines the inside of a helmet, enables trainers to measure exactly where on the wearer’s head an impact has occurred.
This season, 24 Nittany Lions, representing nearly all positions, are wearing the special helmets in practice as Bream and his 12-member staff collect data.
The partnership with Head Health Network is not Penn State’s first step into concussions research.
Penn State Sports Medicine has a research lab that it runs in conjunction with the Center for Sport Concussion Research and Service within the College of Health and Human Development.
The lab is studying how concussions affect academic performance, the effects of anti- oxidant supplements on concussed brains, and genetic factors that may predict concussion outcome.
“The next step is just to continue to collect information to help form an educated opinion on what can be done,” Bream said. “Right now there’s just so much unknown because everybody’s brain is different. What might be a bad injury for one person may not be so bad for another.”
Football has been a part of Christian Lezzer’s life for as long as he can remember.
It was his favorite sport as he grew up, and he regularly attended Penn State’s games. His two uncles played football for the Nittany Lions.
When he got his own opportunity to play at the collegiate level, he didn’t pass on it.
But when it came time this fall for Lezzer to decide whether playing football was worth it, after all his concussions, his family roots helped him make the decision.
Concussions had forced one of his uncles to retire from the sport. Facing the same decision, Lezzer talked with his uncle.
He also had conversations with his immediate family, his coaches and the medical staff at Boston College.
They laid out the facts and made a list of the pros and cons.
He has fond memories of playing football. His favorite play was in his first season at Boston College. On Sept. 13, 2014, the Golden Eagles hosted the University of Southern California in a primetime game on ESPN.
On Lezzer’s first play at the collegiate level, he burst through the Trojan line and sacked star quarterback Cody Kessler.
Asked if he would do anything differently, Lezzer hesitated. He understands that medically speaking, he should have reported all five of his concussions to his coaches.
But, realistically, he doesn’t have regrets over the career he has had in the sport he loves.
“The biggest thing for me, why I was afraid to report and why I was afraid to retire from football, was that I was letting people down,” Lezzer said. “... You can’t think like that. Because in the end it’s your health and it’s your life.”
Lezzer recognized his symptoms and made his choice – before it was too late, before the next hit.
“I had to hang it up,” he said. “It isn’t what I wanted to do, but it’s for the best.”
About the Contributors
Senior / Print and Digital Journalism
Garrett is the editor in chief of the Daily Collegian student newspaper. He helped cover the 2016 Paralympic Games in Rio de Janeiro for the Associated Press through the John Curley Center for Sports Journalism. Garrett spent the summer of 2016 interning on the sports copy desk at The New York Times. He was born in Indianapolis, but grew up in Kentucky.