Will findings lead to more effective prevention strategies?

Concussion incidence and head impact exposure (HIE) among college football players were both disproportionately higher in the preseason than regular season, and most occurred during practices, an observational cohort study found.

“These data point to a powerful opportunity for policy, education, and other prevention strategies to make the greatest overall reduction in concussion incidence and HIE in college football, particularly during preseason training and football practices throughout the season, without major modification to game play,” wrote Michael McCrea, PhD, of the Medical College of Wisconsin, Milwaukee, and co-authors, in JAMA Neurology.

McCrea and colleagues analyzed helmet sensor data from six NCAA Division I football programs participating in the CARE Consortium, comparing concussions and HIE during preseason versus the regular season, as well as injuries in practice versus games. The researchers prioritized impact monitoring to starting players over those who played less predictably.

Over five seasons spanning 2015-2019, a total of 528,684 head impacts were recorded from 658 players. Median age of players was 19, and median head impacts per season were 415.

About half (48.5%) of concussions occurred during preseason training, even though the preseason period represented only 20.8% of the overall football season (0.059 preseason vs 0.016 regular-season concussions per team per day; mean difference 0.042, 95% CI, 0.020-0.060, P=0.001).

Total preseason HIE occurred at twice the rate of the regular season (324.9 vs 162.4 impacts per team per day; mean difference 162.6, 95% CI 110.9-214.3; P<0.001). For all five seasons, HIE per player was highest in August with median 146 impacts, and lowest in Nov. with median 80 impacts.

In both pre- and regular season sessions, 72% of concussions and 67% of HIE occurred during practice. During the regular season, total HIE in practices (median 175 impacts per player per season) was 84.2% higher than in games (median 95 impacts per player per season).

“As a former college football player and a former team physician, respectively, we find this situation inexcusable,” wrote Christopher Nowinski, PhD, and Robert Cantu, MD, both of the Concussion Legacy Foundation in Boston, in an accompanying editorial.

“Concussions in games are inevitable, but concussions in practice are preventable,” they wrote. “Practices are controlled situations where coaches have almost complete authority over the HIE risks taken by players.”

From 2005 to 2010, studies on college football showed about two-thirds of head impacts occurred in practice, the editorialists said. “We cited this data in 2010 when we proposed to the National Football League Players Association that the most effective way to reduce the risks of negative neurological outcomes was to reduce hitting in practice,” Nowinski and Cantu noted. “They agreed, and in 2011 the National Football League Players Association collectively bargained for severe contact limits in practice, with 14 full-contact practices allowed during the 17-week season.” Since then, only 18% of National Football League (NFL) concussions have occurred in practice.

“In 2014, the Michigan High School Athletic Association instituted contact practice limits that resulted in one high school football team experiencing 53% fewer head impacts in practice,” they added. “Practices went from accounting for 61% of HIE during the 2013 season to 49%. A 2019 rule further strengthened contact limits, moving from 90 minutes allowed per week to 30 minutes.”

At the high school level, reforms have been driven by oversight from state athletic associations, state governments, advocates, and educators responsible for the health and safety of minors, the editorialists pointed out. “In the NFL, reforms have been driven by the players, who can legally organize and collectively bargain,” they wrote.

“College football players exist in a regulatory no-man’s land,” they said. “They have no mechanism through which to organize, they are no longer minors, and they seem to exist outside the influence of professional educators.”

To date, NCAA policy changes have had a limited effect in reducing preseason concussion incidence and HIE, McCrea and co-authors noted.

“The most effective prevention strategies will require a multidimensional approach that extends beyond singularly focused policy and will require buy-in from all key stakeholders, including sport governing bodies, institutional athletic administration, coaches, and athletes themselves,” the researchers wrote. “Football practice reform to reduce exposure and risk of concussion will undoubtedly require engagement from coaches, who ultimately design and implement drill-specific practice activities.”

Limitations of the research include non-systematic representation of athletes who played less frequently. Additionally, the study did not involve live or video surveillance to independently verify recorded head impacts, McCrea and colleagues said.

The football community has “known for more than a decade that reforming practice could reduce both concussions and HIE by approximately half,” Nowinski and Cantu noted.

The NCAA was founded in 1906 to protect the health of athletes, but it is “now unwilling to provide the oversight on which it was founded,” they added. “After an NCAA football player died of a brain injury that occurred in practice, NCAA lawyers defense to the surviving family’s lawsuit was ’the NCAA denies that it has a legal duty to protect student-athletes,’” they wrote.

“Ultimately, whether college football players experience preventable concussions in practice or preventable degenerative brain diseases is in the hands of football coaches, football conferences, schools, and the NCAA, none of whom have done enough to reform college football practice, which leads us to ask: who will protect the brains of college football players?”

  1. Concussion incidence and head impact exposure (HIE) among college football players were disproportionately higher in the preseason than regular season, and most occurred during practices, an observational cohort study found.

  2. High school players have been protected as minors and professional players have demanded change, but college players “exist in a regulatory no-man’s land,” the editorialists pointed out.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Research was supported by the Grand Alliance Concussion Assessment, Research, and Education (CARE) Consortium, funded in part by the NCAA and the U.S. Department of Defense.

McCrea reported grants from the NIH, CDC, Abbott Laboratories, and the National Research Brief Report Opportunities for Prevention of Concussion and Repetitive Head Impact Exposure in College Football Players.

Nowinski reports nonfinancial support from National Football League Players Association as a member of the Mackey-White Health and Safety Committee and serves as a volunteer adviser to the Ivy League outside the submitted work. Cantu reports personal fees from National Football League (consultant), National Operating Committee on Standards for Athletic Equipment (consultant), National Collegiate Athletic Association (legal expert opinion), National Hockey League (legal expert opinion), and National Collegiate Athletic Association Student-Athlete Concussion Injury Litigation (paid member of Medical Science Committee) outside the submitted work.

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