Running head: THE CONCUSSION CONUNDRUM

1
The Concussion Conundrum: An in Depth Look at Concussion

Regulation in NCAA and Professional Sports

Seth Halman

The First Colonial High School Legal Studies Academy,

1272 Mill Dam Rd, Virginia Beach, VA 23454

THE CONCUSSION CONUNDRUM 2

Abstract

This paper The Concussion Conundrum: An in Depth Look at Concussion

Regulation in NCAA and Professional Sports, is a breakdown of a pressing modern topic

concussions. Giving a brief overview of what a concussion is and the impacts that they can have.

The author explains the necessity of protocols and procedures for the management of

concussions and the recovery process. Going over some of the legal issues that the NCAA and

professional sports organizations have faced. Along with their individual policies and procedures

for dealing with concussions. The Author ends with a breakdown of legislation that is important

to the topic and a brief summary.

THE CONCUSSION CONUNDRUM 3

The Concussion Conundrum: An in depth look at concussion

regulation in NCAA and Professional sports

A concussion is a bruise to the brain no matter how major or minor; received during

some sort of athletic competition or practice. They are caused by some sort of impact to the head

or neck region, causing the brain to rattle or bounce against the side of the skull. This results in a

bruise on the brain, otherwise known as a concussion, which will cause symptoms such as

affected memory, reflexes, speech judgement, balance, and motor skills. Concussions can also

leave the affected athlete in a groggy state or a fog which can make it hard to pay attention or

process information. The reason I chose concussions as my topic of research and discussion is

the want to learn more about something that has deeply affected me on a personal level. Having

multiple concussions in my athletic career I know how they can affect a person. Receiving my

first concussion wrestling at the Junior Olympics my Sophomore year of highschool, I woke up

lying flat on the mat with trainers around me asking me questions about where I was and what

day it was. Mean while I was in a fog not knowing where I was. It took me almost a month to

recover before I was able to work back into practicing and participating again. Although I was

highly fortunate in having a highly qualified doctor and well run training staff at my school

during my recovery. Having other concussions since then it gives me a greater understanding of

how important the recovery process is in terms of long term health. Emphasis needs to be put on

the recovery process in terms of protocols and legislation. Due to the danger that is attached to

improper management of recovery from a concussion, such a second impact syndrome and CTE.

What is a Concussion
THE CONCUSSION CONUNDRUM 4
Concussions are an injury to the brain that result in a slow down of normal brain function

usually coming as a result of a blow to the head. The blow or impact causes the brain to move

back and forth inside of the skull forming a bruise on the brain, damaging brain cells, and

causing chemical imbalances in the brain. With concussions resulting in affected memory,

reflexes, speech judgement, balance, and motor skills ("American Association of Neurological

Surgeons ," n.d.). While a direct impact to the head is the most common cause of concussion in

athletics, there is also what is known as a rotational concussion. This is when the head is jolted or

there is a sort whiplash involved. This causes the brain to move rapidly inside the skull and hit

against the inside of the skull. This has all of the negative impacts that are associated with a

concussion caused by impact ("Concussion Facts | Sports Concussion Institute," n.d.).

Concussions in Sports

Annually there are 300,000 concussions in High School and Collegiate athletics, now the

second highest cause of traumatic brain injuries behind automobile accident (Gessel, Fields,

Collins, Dick, & Comstock, 2007). With a youth athlete suffering a sports related concussion

once every three minutes as the national average. Although it is not just football where these

injuries are occurring. Concussions also occur in not contact sports that are not generally

suspected. With the rate of concussions also being higher in girls versus boys when you compare

a sport that both genders play. In basketball 11.5 percent of girls who played suffered from a

concussion compared to 7.2 percent in boys. The same statistics are found when looking at youth

soccer with 17.1 percent of girls suffering from concussions compared to 12.4 percent of boys.

There is no known connection that gives explanation to why girls are at a higher risk of suffering

a sports related concussion than guys are ("Concussion Care Belongs at the Top of Every Youth
THE CONCUSSION CONUNDRUM 5
Sports Playbook," n.d.). In high school athletics concussions make up fifteen percent of all

injuries reported to athletic trainers.

Once an athlete has suffered their first concussion, it is even more important that they are

not only informed but strictly adhere to concussion protocols. Due to the fact that once an athlete

has a concussion, they are up to three times more likely to receive a second one ("Statistics,"

n.d.).

Concussions Long Term Effects

One of the biggest long term affects to receiving too many concussions during a given

athletic career is CTE, Which is a degenerative disease that causes a progressive breakdown in

the brain.It has long term effects that mirror dementia with the full list of symptoms including:

memory loss, confusion, impaired judgement, trouble controlling impulses, aggression, and

depression ("What Is CTE? CTE Center | Boston University," n.d.). CTE is related to the a

protein called Tau. Tau starts to form inside the brain after repetitive trauma, and the protein

starts to eat away at the brain cells. This is a process that may not begin until an extensive period

of time from the last suffered trauma or concussion. There are some cases of professional

athletes who have developed CTE multiple decades after they have stopped playing ("What Is

CTE?," 2016).

Although CTE can lead to many horrible effects on the brain long term, it is not the most

severe impact that a concussion can have upon an individual. Second impact syndrome poses the

biggest threat to an individual's health. Second impact syndrome occurs when an individual

sustains a concussion and does not report the symptoms or is not given a proper evaluation. The

individual returns to athletic participation and receives a second concussive blow. This can cause

the brain to begin to swell inside the skull without room for the said expansion to occur. Second
THE CONCUSSION CONUNDRUM 6
impact syndrome can cause brain damage and death (Bey & Ostick, 2009). In cases where

second impact syndrome has been reported, death has occurred fifty percent of the time

("Statistics," n.d.).

Return To Play Protocol

Return to play protocol is important when dealing with concussions on all levels of

athletics. They allow for athletes to gradually be eased back into participation allowing for their

brain to fully heal. As an athlete's long term health is the most important issue when dealing with

the recovery from a concussion (M. Midkiff, Personal communication, November 10, 2016).

The CDC recommends that all return to play progressions take a minimum of five steps.

All progressions follow the same basic guideline of light activity, moderate activity, non contact

sports drills, full speed practice, with a return to play coming as a result of the completion of the

progression as the fifth step. It is also important to note if an athlete is to begin having any signs

or symptoms while working through a specific stage of the progression. They should stop for the

day and return back to the previous step on their progression chart. All athletes should also have

a baseline cognitive test so the same examination can be done after a concussion occurs and the

results can be compared ("Managing Return to Activities," 2016).

It is highly important for all athletes who sustain a concussion to go through a return to

play protocol. The standards need to be higher for the return of a youth athlete. This is due to the

fact that the brain of an adult can heal faster than an adolescents can. Youth athletes needing to

pass their cognitive test before they begin their progression instead of after the progression

before they return to play. It is also important that the progression is spaced out for a youth

athlete, with every step of the progression occurring on a separate day allowing for an increased

period of time for the brain to heal. Since a concussion can cause an extended leave in relatively
THE CONCUSSION CONUNDRUM 7
shorter high school athletic season, the athletes return should be supervised by an athletic trainer

instead of a coach. This removes the possibility of a coach being put into a situation where they

must choose between what is potentially best for the team and an individual's long term health.

Along with having the process required to be supervised by an individual that is qualified to

oversee it along with having a medical background (M. Midkiff, Personal communication,

November 10, 2016).

Concussions in the NCAA

The NCAA and various athletic conferences, such as the SEC, are receiving lawsuits

from former players who suffer from chronic issues related to concussions sustained during their

playing time. Issues are related to suffering concussive and subconcussive blows during their

playing times at their respective schools due to the fact that the players played before the NCAA

held a sufficient return to play policy (Morales, 2016). It is necessary to monitor the recovery of

a player and prevent them from competing in contact sports while still displaying concussive

symptoms. In addition to smaller lawsuits, the NCAA has recently settled a major seventy five

million dollar class action lawsuit in July 2016. With the money being put into two different

causes, seventy million dollars worth will be used to set up, and run a medical monitoring system

that will make medical screening and Medical Evaluations available to all current and former

NCAA student-athletes regardless of when they played, what sport they played, for how long

they played, in which state they played or reside, or their age (Sports, 2016). The other five

million dollars will be put into funding concussion research, with the research being focused

upon the prevention, treatment, and/or effects of concussions (Sports, 2016).

Return to Play
THE CONCUSSION CONUNDRUM 8
The NCAA holds a high standard for concussion regulations requiring each school to

have a concussion management plan. With each plan having preset standards for return to

activity, return to play, and return to academics, allowing for every athlete to be eased back into

participation in each individual area. It is also necessary for collegiate athletic programs to make

their plan readily available for viewing. This will make sure that all athletes, coaches, or other

involved parties are educated about all procedures and standards ("Concussion Management and

Diagnosis Best Practices," 2016).

Every concussion management plan has four key components that must be followed by

the schools. All athletes, coaches, medical staff, and individuals directly involved in an athletic

program must receive adequate medical information every year. Along with a returned signed

acknowledgment of receiving the necessary information, showing that the school has covered

their obligation to inform the students. Baseline concussion testing must also be performed

before and athlete is allowed to participate in NCAA sanctioned athletics. With testing including

the following: brain injury/concussion history, a symptom evaluation, a cognitive assessment of

the athlete, and a balance evaluation. All of the testing should be completed by an approved team

doctor. The team doctor also possess the ability to have additional testing done on the athlete if

they feel it is necessary ("Concussion Management and Diagnosis Best Practices," 2016).

All athletes that exhibit signs or symptoms of a concussion must be removed from any

athletic activity immediately and be evaluated by an approved athletic trainer or doctor. The

athlete is checked for all of the signs of concussion, along with being given tests for cognitive

function and balance. With athletes who exhibit any signs being removed from athletic

participation immediately and entered into the concussion protocol. The exact protocol for

handling return to play is as follows:

THE CONCUSSION CONUNDRUM 9
Once a student-athlete has returned to his/her baseline, the return-to-play decision is

based on a protocol of a stepwise increase in physical activity that includes both an

incremental increase in physical demands and contact risk supervised by a physician or

physician-designee.12 Most return-to-play protocols are similar to those in the Consensus

Statement on Concussion in Sport guidelines,2 which outline a progressive increase in

physical activity if the individual is at baseline before starting the protocol and remains at

baseline throughout each step of the protocol. It is noteworthy that all return-to-play

guidelines are consensus-based and have not been validated by evidence-based studies.14-
15
McCrea and colleagues16 have reported that a symptom-free waiting period is not

predictive of either clinical recovery or risk of a repeat concussion. Further, student-

athletes have variable understanding of the importance of reporting possible concussion

symptoms.8-9 In summary, it should be recognized that current return-to-play guidelines

are based on expert consensus. ("Concussion Management and Diagnosis Best Practices,"

2016)

With the actual six step progression being listed as follows: light anaerobic exercise, moderate

resistance training, activity specific to the athlete's sport, non contact drills, full contact practice,

and finally a return to play. If an athlete becomes affected by any concussions symptoms while

working through their progression activity is to be stopped and they are to return to the previous

step ("Concussion Management and Diagnosis Best Practices," 2016).

Along with a protocol for returning to play, the NCAA also has set rules and regulations

to help an athlete in their return to academics. This is due to the fact that cognitive activity

requires more use of the brain then when compared to physical activity. However, the procedures

for return to academics are not as strict as the procedures set forth to outline return to play. This
THE CONCUSSION CONUNDRUM 10
is due to the fact that academics can become challenging to an athlete suffering from a

concussion. They do not pose the same threat of increased injury that physical activity does. The

first step to returning to academics is very similar to that of returning to athletics: rest. This is the

removal of all cognitive stressors not just school work. The list includes: school work, reading,

texting, playing video games, watching television, and anything else that will put stress on the

brain. While the NCAA expressly states that a break from academics should be a minimum of the

rest of the day on which the concussion occurred. Every situation is unique and the student

athlete should discuss with the trainer to build a more individual time table for initial rest. The

return to academics not beginning until the student athlete can complete basic activities that

require cognitive function without displaying concussion symptoms. The student athlete should

make a gradual return to the classroom once they are able to break that threshold. Student

athletes whose symptoms are persisting past two weeks should contact the disability services

office to have special accommodations made ("Concussion Management and Diagnosis Best

Practices," 2016).

Concussions in Professional Sports

The National Football League is the professional sports league most troubled by the long

term impacts of concussions. With players suing the league for the effects of long term

degenerative diseases connected to concussions sustained during their playing time. This can be

best displayed in a settlement between the NFL and The NFL Players Association from 2014.

The case Re National Football League Players Concussion Injury Litigation involves the

litigation between the NFL and the NFL Players Association, regarding to the long term effects

that concussive and subconcussive blows have had on former players. This includes CTE and

other degenerative diseases that can be connected to concussions. The 650 million dollar
THE CONCUSSION CONUNDRUM 11
settlement set aside money to compensate former players who suffer from degenerative diseases,

along with providing for better safety measures for current players, and concussion education.

(In re NATIONAL FOOTBALL LEAGUE PLAYERS' CONCUSSION INJURY LITIGATION.)

As more information starts to come in about players having adverse effects from

concussions sustained during their playing time, the NFL has attempted to raise safety standards

with player safety becoming the biggest concern in the game today. New rule changes to the

concussion protocol call for an independent neurotrauma specialist to check out players if they

are suspected of sustaining a concussion while playing. This removes any pressure that was

previously put on team doctors to clear key players to return into games when it was unsafe for

them to do so. Along with medical trainor's that now watch games to specifically look for players

who are taking big hits on the field, or displaying possible signs of a concussion if a player is

spotted the medical staff has the power to stop the game to allow for the player to be removed

from the field and for an evaluation to begin (Associated Press, 2016). The NFL has also placed

an emphasis upon concussion research and improvement of medical practices. With the League

starting a one hundred million dollar concussion initiative in September 2016. Money will be

spent mainly on medical and neuroscience research with a goal of better understanding how

concussions affect the brain, along with improving upon safety procedures and treatment for

once a concussion has been sustained (Scutti, 2016).

Return to Play

The NFL has a return to play policy that is centered upon giving providing players with

the best circumstances for a safe recovery. With the steps listed below being put into place to

allow players to be able to progress through their recovery while being monitored by medical

professionals.
 THE CONCUSSION CONUNDRUM 12
1. Rest and recovery: Until a player returns to the "baseline level of signs and symptoms and

neurological examination," only limited stretching and balance activities are recommended.

Electronics, social media and team meetings are all to be avoided.

2. Light aerobic exercise: The NFL recommends 10-20 minutes on a stationary bike or treadmill

without resistance training or weight training. The cardiovascular activity is monitored by an

athletic trainer to "determine if there are any recurrent concussion signs or symptoms."
3. Continued aerobic exercise and introduction of strength training: Increased duration and intensity

of aerobic exercise with strength training added. An athletic trainer will supervise to watch for

recurrent concussions signs or symptoms.

4. Football specific activities: The cognitive load of playing football will be added and players will

participate in non-contact activities for the typical duration of a full practice.

5. Full football activity/clearance: A player returns to full participation in practice, including

contact without restriction (Stites, 2016).

Legislation

As concussions become a more prevalent issue in sports from little kids playing their first

season of tackle football all the way up to the professional level where findings on long term

impacts are being published and drawing large amounts of attention, the passage of more

advanced legislation is something that is naturally starting to come forward. Most recently

through the Concussion Awareness and Education Act of 2015 which amends the Public

Health Service Act. Now Requiring the CDC to have more oversight in the regulation of

concussions, specifically in the age group of five to twenty-one. Along with making the

collection of the following data mandatory: the demographics of injured individuals, pre-existing

conditions of affected individuals, the use of involved protective equipment, the medical

qualifications of athletic staff diagnosing concussions, along with the cause and severity of the

concussion received by the involved party. This legislation also sets standards for future
THE CONCUSSION CONUNDRUM 13
concussion research with an emphasis on research towards the long term effects of concussions.

With the bill gaining its sponsorship from Joyce Beatty a Democrat from Ohio, the bill is

currently in committee awaiting a vote by the House of Representatives ("Countable," n.d.).

Forty nine out of the fifty states currently have individual laws regarding concussion

regulation in youth sports. With Wyoming being the only state without legislation on the books

although the state is currently in the process of passing laws on the matter ("Concussion

Legislation in the USA," n.d.).

Conclusion

Concussions are one of the biggest injury concerns in sports today from little kids, high

school athletes, the collegiate level, and all the way up into professional sports. With the truth

coming out about what all of the possible side effects are. It is becoming increasingly important

to for all individuals from the coaching staffs to the actual athletes themselves to be informed

about the proper procedures and safety regulations. Along with their being an increased emphasis

upon concussion research. Allowing for the improvement of diagnosis, treatment, and the

equipment that is used to keep athletes safe. Along with actual safety improvements legislation

and court cases are changing the ways that concussions are being viewed. With all of these steps

being followed the chance for increased brain health has a positive outlook for the future.
THE CONCUSSION CONUNDRUM 14

References

American Association of Neurological Surgeons. (n.d.). Retrieved from

http://www.aans.org/patient%20information/conditions%20and

%20treatments/concussion.aspx

Associated Press. (2016, October 20). N.F.L.s concussion protocol gets a change.

Retrieved from http://www.nytimes.com/2016/10/20/sports/nfls-concussion-protocol-

gets-a-change.html

Bey, T., & Ostick, B. (2009, February). Second impact syndrome. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672291/

Can just one concussion change the brain [Interview by I. Flatow]. (2013, March 15).

Retrieved from http://www.npr.org/2013/03/15/174409382/can-just-one-concussion-

change-the-brain

Concussion and sports. (n.d.). Retrieved from

http://www.brainline.org/content/2008/12/concussion-and-sports.html

Concussion care belongs at the top of every youth sports playbook. (n.d.). Retrieved from

http://www.nsc.org/learn/safety-knowledge/Pages/Sports-Concussions.aspx

Concussion facts | sports concussion institute. (n.d.). Retrieved from

http://www.concussiontreatment.com/concussionfacts.html
THE CONCUSSION CONUNDRUM 15
Concussion legislation in the USA. (n.d.). Retrieved from

http://www.knowconcussion.org/resource/concussion-legislation-map/

Concussion management and diagnosis best practices. (2016, November 23). Retrieved

from http://www.ncaa.org/sport-science-institute/concussion-management-and-diagnosis-

best-practices

Concussions in Sports. (n.d.). Retrieved from

http://www.nationwidechildrens.org/concussions-in-sports

Countable. (n.d.). Retrieved December 10, 2016, from

https://www.countable.us/bills/hr1271-114-concussion-awareness-and-education-act-of-

2015

Gessel, L. M., Fields, S. K., Collins, C. L., Dick, R. W., & Comstock, R. D. (2007).

Concussions Among United States High School and Collegiate Athletes. Journal of

Athletic Training, 42(4), 495-503. Retrieved November 9, 2016, from Family Health

Database; ProQuest Central K-12.

Gessel, L. M., Fields, S. K., Collins, C. L., Dick, R. W., & Comstock, R. D. (2007).

Concussions Among United States High School and Collegiate Athletes. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140075/

In re NATIONAL FOOTBALL LEAGUE PLAYERS' CONCUSSION INJURY

LITIGATION. (January 14, 2014).

Managing return to activities. (2016, February 08). Retrieved from

https://www.cdc.gov/headsup/providers/return_to_activities.html

McGrath, B. (2015, March 27). Does Football Have a Future? Retrieved from

http://www.newyorker.com/magazine/2011/01/31/does-football-have-a-future
THE CONCUSSION CONUNDRUM 16
Midkiff, M. (2016, November 10). Concussion interview with trainers on return to play

protocol [Personal interview].

Morales, A. (2016, October 06). Ex-Ole Miss, MSU players suing SEC over concussions.

Retrieved from http://www.clarionledger.com/story/sports/college/ole-

miss/2016/10/06/former-ole-miss-msu-players-suing-ncaa-sec/91658572/

Schnyer, M. F. (n.d.). Farrell and schnyer: Concussions in sports merits urgent attention.

Retrieved from http://www.houstonchronicle.com/opinion/outlook/article/Farrell-and-

Schnyer-Concussions-in-sports-merits-10811895.php

Scutti, S. (2016, September 14). NFL announces $100 million concussion initiative.

Retrieved from http://www.cnn.com/2016/09/14/health/nfl-concussion-safety-initiative/

Sports, S. B. (2016, July 14). Judge oks $75M class-action concussions settlement against

NCAA. Retrieved from http://www.usatoday.com/story/sports/ncaaf/2016/07/14/college-

football-concussions-lawsuit-ncaa/87097982/

Statistics. (n.d.). Retrieved from http://www.swata.org/statistics/

Stites, A. (2016, September 18). Explaining the NFL's concussion protocol. Retrieved

from http://www.sbnation.com/nfl/2016/9/18/12940926/nfl-concussion-protocol-

explained

What is CTE? CTE Center | Boston University. (n.d.). Retrieved from

https://www.bu.edu/cte/about/what-is-cte/

What is CTE? (2016, November 10). Retrieved from

http://concussionfoundation.org/learning-center/what-is-cte
 THE CONCUSSION CONUNDRUM 17
Grading Rubric for Almost Final Graded Draft

Criterion 4 -- Advanced 3 Above 2 Proficient 1 -- Emerging

Average
Mechanics, Zero to very few A few errors Several errors Many errors inhibit

Grammar, errors the reading of the

Spelling, text

Sentence

Structure, etc
Academic Voice Academic Academic Academic language Paper lacks
language used
language used through most of used for some of academic
paper
throughout paper paper language

informal

throughout

Law Law is a major Law is present Lacking law No law

presence

Title, Abstract, All present and All present All present need Missing pieces
to fix several errors
Body, Reference correct needs to fix a few or somewhat
incomplete
errors didnt

quite make it to

15 pages

especially after

you remove the

big quote

Uniform LSA Scoring convention

16 = 100 12 = 88 8 = 76 4 = 64
THE CONCUSSION CONUNDRUM 18
15 = 97 11 = 85 7 = 73 No submission = no

score

14 = 94 10 = 82 6 = 70

13 = 91 9 = 79 5 = 67

Please do the following for final: Just scroll through and fix what is marked.