Every year, millions of the athletes in the U.S. suffer concussions. And it’s not just the professionals who are at risk of head injury. Emergency rooms treat 173,000 kids for sports-related traumatic brain injuries per year, according to the CDC, a statistic that has risen 60 percent over the last decade.
You can get a concussion from doing most things—biking is leading cause of concussion-related emergency department visits, for instance. In professional football, though, players can get hit in the head up to 1,500 times a season. Dialogue surrounding the risks of concussions has, for the past few years, thus largely focused on the National Football League, an organization that has downplayed the risks head injuries pose to players.
Only a few weeks ago, the NFL reached a $765 million settlement in a lawsuit from former players who alleged that the NFL deliberately misled them on the risks of concussions. One of the main cruxes of the lawsuit involved allegations that the NFL’s Mild Traumatic Brain Injury committee ignored the medical evidence for links between concussions and neurodegenerative problems.
In 2010, the NFL renamed the advisory group the Head, Neck and Spine committee and brought on two new chairmen, Hunt Batjer and Rich Ellenbogen. Both—unlike former committee head Elliot Pellman, a rheumatologist—are neurosurgeons working in the field. Popular Science spoke to Ellenbogen, a professor and chair of the department of neurological surgery at the University of Washington, about the NFL’s efforts to make football safer, the future of concussion research, and the technology that will get us there.
Popular Science: So first off, can you tell me a little bit about what being a chairman for the NFL Head, Neck and Spine committee entails?
Rich Ellenbogen: Hunt Batjer and I are co-chairmen for this committee. What we do is we advise the NFL—specifically the commissioner of the NFL, Roger Goodell; the executive vice president, Jeff Pash; and the executive vice president of health and safety, Jeff Miller—on ideas to make the game safer at the professional level, all the way down to helping youth athletes. So this entails a multitude of things, looking at longitudinal or long-term effects of concussion. It means to come up with new rules and regulations to protect players, to come up with new tools to diagnose players, to do education and advocacy all over the country, such as the Zack Lystedt law to protect youth athletes and professional athletes from repetitive injury, and then to come up with new equipment and protective gear that might help.
Has anything major changed about how the NFL approached head injuries since you became chairman in 2010?
We made huu-uge changes. We’ve come up with posters: Now we have close to a million posters in junior high schools and elementary schools around the country, educating kids on the dangers of concussion and how to diagnose and report it. That poster was taken from the one we did for the NFL. We have a sidelines exam that we came up with and instituted several years ago. We put unaffiliated neurosurgeons on the sidelines of every football game. There are spotters in the media box, who are watching the game from above, from eight camera angles, who can call down to the team physician and let them know if they see anything suspicious. We’ve worked with the competition committee in testing new rules and regulations that would protect the athletes.
Then, of course, from the education and advocacy [standpoint], the NFL has been instrumental in getting 49 states to pass the Zack Lystedt law, which has been enormous. It does three things. It says every kid, every parent, needs to understand what a concussion is, how to diagnose it, what the risks [are]. Number two, we’ve set the bar high. “If in doubt, you sit them out.” Any kid suspected of having a concussion is sat out, not to return to practice or a game until they’re cleared by–number three, you can’t get back into playing a sport unless you’re cleared by a concussion expert.
‘Since we get no money for doing this, we’re in the most enviable position of all, which is we can tell the NFL and the commissioner the truth, all the time, every day.’
So imagine, when we started, we only had a few states that had passed the Zack Lystedt law, Washington state in particular. Now, I thought it’d take decades to get done. Now within two, three years, with the force of the NFL, we have 49 states and the District of Columbia. So it’s been pretty amazing.
What is the one state that hasn’t?
Mississippi.
What do you think are the next steps you think we need to take to make football safer?
Well, you see, I think this is the misnomer. I probably, to be frank with you, wouldn’t do this job if it was just about football. I mean I love football–I’m like every other American. I love on Sunday watching football. But there’s a trickle down effect that occurs. If you do it in one of the most watched, exciting sports—like football, or hockey—it trickles down to the kids. So there might be three million kids playing football in America, but there are 300 million playing soccer around the world. Remember, kids get concussions from riding bicycles. Making this just a football issue is only important in that it serves as a role model.
I think in the future, we’ll come up with better equipment. In the pros, we’re thinking about putting sensors in either the helmet or the mouthpiece. They already exist at the college level at some schools, where they’re measuring the amount of impact the skull takes during a game. Then I think there’s a lot of research to be done. This used to be a subject that people didn’t understand. I think it’s evolved significantly because of the perfect storm that has occurred–everybody’s interested in athletics, in football and hockey and so on, and then the war in Afghanistan and Iraq has given so many of our beloved soldiers traumatic brain injury and post-traumatic stress disorder. It’s now front and center in everybody’s consciousness.
**Do you think the research is clear at this point that repeated head injuries are causing the major cognitive impairments and behavior issues and suicides seen in former football players? **
Well I don’t think it’s clear at all. I think we know that repetitive head injury isn’t good, and we know there are long-term effects of traumatic brain injury. But to correlate it directly with a particular event has been elusive for us. So we need to understand more about this. We know hitting your head is not good. We know the soldiers that are exposed to multiple IEDs, day after day, have long-term effects. We don’t know how that occurs, we don’t know how some people get no sequela (no effect) and other people, after relatively minor injury, get terrible effects. So unfortunately, because we don’t have the n, we don’t know what the incidence or prevalence of the long-term effects [are] based on the people that have been exposed.
‘We know that repetitive head injury isn’t good, and we know there are long-term effects of traumatic brain injury. But to correlate it directly with a particular event has been elusive.’
What do you see the NFL’s role being in traumatic brain injury research?
[The NFL’s] mantra has been, you know, safety first. I think you’ve seen in all the new rules, with all the new research that they’re funding, that this is the direction that is most important to them. That the game is competitive and it does what it’s supposed to do, but also that the players are well-protected and safety becomes the primary aspect of what they do.
I should note, neither Hunt Batjer or I, and no member of our committee, is paid. We have no conflict of interest, we declare this at the National Institutes of Health every time we apply for a grant. Since we get no money for doing this, we’re in the most enviable position of all, which is we can tell the NFL and the commissioner the truth, all the time, every day. And we do. We tell him things that are sometimes very challenging.
One of the tough decisions he had to make this year was that the player’s association wanted these unaffiliated neurotrauma experts on the sidelines. The NFL wanted to do it a little different. But in the end the commissioner made the decision that we’re going to do this, we’re going to put unaffiliated neurotrauma experts on the sidelines to be available for the team physicians in consultation, and get the players to the hospital quickly. Which is exactly what’s happened. Initially it may not have been a very popular decision with everybody, but it was the right decision.
**Have there been any recommendations you’ve made that the NFL has not implemented? **
You know, in general, almost all the recommendations we’ve made have gone forth. There have been some that have been slower to go forward, and there are some that happen quicker—like this unaffiliated sidelines [rule]. We had made a recommendation to study it and work towards that, and the commissioner made the decision at the Super Bowl and he said, ‘We’re going to do this. This is what’s going to happen and I want your committee to roll it out this year.’ So he sped up the timeline significantly.
For the most part he’s never said, ‘No, we’re not going to do this.’ He might change the way we do it. He and the NFL executives now, they’re a very mission-oriented sort of group of people. They’re probably one of the most data-driven groups of people. They look at the data, they do statistical analysis, and if they find a portion of the game where there’s more injuries than there should be, they immediately attack that and figure out how to make it safer.
But there have been criticisms of the NFL, like the recent lawsuits from players who say they weren’t educated about the risks of head injuries, or ESPN pulling out of a documentary on head injuries due to NFL pressure. Do you find that the NFL is willing to take risks into accounts?
I guess I have a different perspective, because I’m not paid by the NFL and I wasn’t here before 2010. I don’t know what they did. I mean, I don’t really care what they did before then. I mean I do, but I don’t have any personal knowledge, so I can just take ownership for the stuff from 2010 on with my committee.
‘So am I satisfied? I’m never satisfied that we’re doing enough.’
The lawsuit we were not involved with. They really put us in a silo and told us to keep moving forward and working on safety plans, and research, and education and advocacy. And that’s what we did. And at the end, I agree that you can never do enough for these players. There was a settlement, I’ll leave that to the lawyers, enough said.
But from my perspective, I’m a patient advocate, so whatever you can do for the student athlete or player, it’s all good to me. So I don’t know. I mean, you’re asking me if the criticism is warranted—you know, I really don’t care who’s to blame, if it’s this group of people or that group of people. At the end, we just have to move the science forward and take care of the players. You’ve got to put the patients first, number one, and number two, I’ve got to push the research forward. The beauty about my job, being a non-paying job, is I don’t have to get involved in the politics or the legalities of lawsuits and settlements.
People have a right to criticize what was done, but from my perspective, we’re moving pretty quickly and we’re pretty aggressive. So am I satisfied? I’m never satisfied that we’re doing enough. But I can tell you I’m doing more with this committee than I daresay any other organized sport organization in the country is doing, and there’s more money being applied to it as well. So I’d just look at the facts. I just rolled off a few of the things we’ve done. Has it been enough? Has it been the right thing? I think so. I think there’s more stuff to come.
Do you happen to have any data about how all of these changes have affected the players? Are the numbers of brain injuries going down?
The number of concussions a year, initially, as you know, in late 2008, ’09, ’10 went up, because we were better at diagnosing it. But the concussion rate went down in certain things. Let me give you a specific example: The competition committee, which is made up of football players and coaches and owners—really knowledgeable football people—decided that they were going to move kick off 5 yards. Well, that one thing for the last two years has dropped the concussion rate 40 percent on the kickoff. Because what’s happening is the players are now catching the ball in the endzone, and calling a touchback and not running it out to the frequency they used to run it out. So everything they do, every time they put a new regulation out, you can drop the concussion rate of the specific move you’re trying to prevent.
Since we passed the Zach Lystedt law in Washington state, to give you an example, protecting youth athletes from not going in after they’ve had a concussion/traumatic brain injury, I don’t know of one patient in the last year that we’ve lost on the athletic field in Washington state. We used to lose one or two or more every year. Hasn’t happened anymore.
Is there any promising helmet technology you think is really going to make a difference?
There are two GE challenges: One is, can you come up with better tools to diagnose concussion? GE challenge number two is, can you come up with better protective gear? I think they’re going to blow the roof off of this. I think there are companies and geniuses out there coming up with better helmets better biomaterials, better padding, better chin straps. I think in the next year, what’s going to be exciting is what comes out of the GE challenge number two, in terms of technologies. There are going to be some really neat technological advances making making all sports safer. You’d better believe there are going to be some brilliant people out, coming up with novel ideas we’ve never heard of or seen that are going to be transformative. That’s my prediction, and I stand by it.
