The best cure for brain injury is prevention. It is one of the first things I learned as I began my advocacy in this field and is one of the often repeated missions of the Brain Injury Association. Yet, life causes brain injury and one does not give up living because it comes with risks of injury. Thus, as we reflect on the public issues of concussion and death in sport, I want to think out loud as I articulate some philosophies about “living” and “brain injury prevention.”
Let’s start with the simplest example. Our brains were not designed to travel at speeds above 60 mph, even in a car. While the skull and the protective mechanisms around our brain do an adequate job of protecting us from primitive and medieval forces, evolution has not had time to adapt to the intense acceleration/deceleration forces involved in motor vehicle accidents. Our world and our brains would be safer if we didn’t drive automobiles. But we would all starve. Cost benefit analysis: make cars safer but accept that there are some brains will be injured when cars crash into each other.
I am a football fan. I am the kind of football fan who watches pre-season games and knows how many regular season touchdowns a certain former Packer has thrown in his career. If you were to tell me that each time a Packer quarterback got hit on a pass, we had to pull him out of the game to determine if he had suffered a concussion, then I would tell you I couldn’t stand to watch the sport anymore. That obviously would be too extreme.
Even if you told me that my team’s quarterback couldn’t start the week after he suffered a Grade Two concussion, because he was still symptomatic after 15 minutes, I would be extremely frustrated about it.
I use the 7 day example because the American Academy of Neurology’s Sport and Concussion Guidelines, as originally published, required an asymptomatic period of 7 days from any concussion that was symptomatic longer than 15 minutes. So if you got hurt in a 12 noon game one Sunday, you couldn’t play in the next weeks game if still symptomatic after 15 minutes if the game was at noon.
For this reason I have preferred the NFL’s slightly more flexible approach to return to play considerations, even though I do comprehend that there is some risk (cost) involved. The reason, there is an overall benefit to returning an NFL quarterback to play (millions of dollars, millions of fans’ need to see their team play competitively).
In contrast, I am a firm believer that scholastic and true amateur athletes should never return to play after a concussion until they have passed rigorous and sensitive medical tests. There is just not a sufficient “benefit” to justify the “cost”. No amateur’s return to play should be so important to justify any risk of further injury, especially when dealing with young athletes who may be more susceptible to the impact of a second or third concussion. Yet, I am likewise not a believer in a strict three month (or not in that season) rule as then the disincentive to report the concussion, for both the team and the player, would be so great that we might do far more harm from underreporting.
In all sport safety issues, the leagues, the organizations, the teams must take responsibility to make rules to protect the athletes, because the competitive nature of sport virtually ensures an unsafe environment without them. The athletes themselves will almost always choose wrong on the cost/benefit curve. For example – in
snowboarding,
luge,
NASCAR – the competitor’s will to win virtually ensures that they will take unsafe risks. In football, the harder and more recklessly you hit your opponent, the more likely you will stop them. If there are no rules and no safety measures in these sports, they might as well be contests to the death, because that is what the consequences could be.
As I look at the cost/benefit analysis of risk versus winning in sport, I first ask myself, what is the purpose of this sport. If the purpose is to harm your opponent, such as boxing, I believe that any societal need this sport provides is strictly appealing to the blood thirst in us, and does not justify any risk. Boxing and other unarmed combat should be banned for the same reason we do not have gladiators and Christians versus the lions.
In contrast, if it is a sport like skiing, snowboarding, luge, then the mandate is for safety rules and guidelines. The sport governing authorities must define the limits of what risk it allows for its athletes. It cannot be left up to the athlete. It is really no different than steroids in baseball players. The entertainment value of the sport benefits from steroids, yet we ban them because of the danger to the athlete. Yet we know that if we do not ban them, the competitive pressures on the athlete will induce a high percentage of them to use them.
In the last month, we have seen some tremendous institutional progress towards making brain’s safer in sport. What the NFL has done, not only for the safety of its own players but the safety of all who play the sport is admirable and meaningful change. And Congress’s role in motivating the NFL is also to be congratulated. See our blog at
http://www.tbilaw.com/blog/2010/01/good-year-for-concussion-advocacy.html In contrast, what NASCAR did in allowing more contact to increase ratings is deplorable. See our blog at
http://www.tbilaw.com/blog/2010/01/nascar-vows-to-return-to-roots-as.html If the luge death at the Winter Olympics turns out to be as a result of negligent or reckless design of the luge run, then that is even more outrageous. As far as snow boarding, the governing body needs to ban the most dangerous of stunts. It cannot be left to the athletes discretion. See our blog at
http://www.subtlebraininjury.com/blog/2010/02/snowboarder-pearces-head-injuries-dont.html
