While by no means risk free, research suggests that limits on full-contact practices, education of  parents, athletes, athletic trainers and coaches about the signs and symptoms of concussion and the dangers of continuing to play with concussion, implementation of conservative removal from and return to play guidelines and technological advances in safety equipment can reduce the risk to athletes of long-term brain injury from concussion and repetitive head impacts.

As readers of MomsTEAM/SmartTeams and viewers of our PBS documentary, The Smartest Team, know, I have dedicated much of my time over the past two decades to promoting these safety measures.  As an important part of that effort, I have worked with youth and high school football programs across the country to equip players with the most technologically advanced football helmets and impact sensors. 

I have always come away impressed with the efforts of equipment manufacturers to make the sport safer, but I also know that increased safety comes at a cost, leaving many youth and high school programs – and the parents and booster clubs which support them – in a quandary: wondering on the one hand how they can afford to buy expensive new helmets and impact sensor systems for their players, and on the other, how they can afford not to.

I first encountered this dilemma twenty years ago when my son Spencer was playing football in middle school.  One day in the spring of his sixth-grade year, he brought home a letter from the coach stating that, because of cuts to the school’s budget, he would be unable to replace the 100 or so worn out helmets the team needed, so that the program would have to be cancelled for the coming fall season.  Spencer and his friends who anticipated playing in the middle school were devastated. I recall Spencer, close to tears, asking me if I could “talk to the coach to change his mind.”

Instead, I asked coach how much money he needed to save the program. He said he needed about $30,000 to cover the cost of 100 new helmets and repainting and reconditioning the helmets before the next two seasons. Remember: this was 1998, so in 2019 dollars, he would have needed between upwards of $60,000 for the same 100 helmets. And that’s only for the helmets.  These days, football programs are not only looking at the cost of expensive new helmets (such as the new Vicis Zero1 helmets (top-rated by the both the NFL  and Virginia Tech ), but impact sensors, such as the Prevent Head Impact Monitor, and the S.A.F.E. Clip – a little shock absorber to replace the plastic breakable clips that attach to the facemask to the helmet.

So I rolled up my sleeves and got to work on a fundraiser to come up with the money needed to save the middle school program.

Car Raffles: Proven Fundraisers

First and foremost, you need to have a pressing need for something safety related such as new helmets, impact sensors, etc.

Car raffles are the best way to raise a significant amount of money quickly.  People need cars.  Kids and their parents love the teamwork and enthusiasm raffles generate. Winning an expensive car for a $100 donation with great odds is unbeatable as a fundraiser.  I have run five car raffles, raising between $25,000 and $50,000 for each raffle within an eight-week time frame, all before the year 2000 and all without the help of technology. Here’s the blueprint I used which has worked with dozens of organizations I have shared it with.

Case Studies

• The first car raffle I ran was for my children’s preschool in Connecticut back in 1985. The school needed to raise funds to pay off the mortgage on their property. We raffled off 500 tickets at $100 apiece for a basic Mercedes Benz 190 (what they used to call a “baby” Benz). We raised $50,000 and netted $30,000 after paying the dealer $20,000 for the car.The raffle was a huge success and demand was high (we sold all 500 tickets within three weeks), so we added a second car to raffle immediately after. The Greenwich car dealership agreed to add a second car and to take a cut in their cost in exchange for the great publicity they were getting. Printing, fees and graphic design work were donated. We made a total of $60,000 for the school, tax free, all in six weeks, which paid off the mortgage on the school.
• The second raffle I ran was for the 100 middle school helmets for Spencer’s middle school program. We located a Jeep dealership close to our school in Massachusetts. They were willing to give us a Jeep Grand Cherokee at cost. I used the same blueprint: we sold 500 tickets for $100. We brought in $50,000 in six weeks. After expenses we had $27,000 to buy the helmets and donate them to the school. The program was saved!
• Two years later, son Spencer was in high school and the football team needed strength equipment and helmets. Again, I put together a team of six parents to help me and we duplicated the outcome of the first raffle I ran. We intended on running one raffle but ended up raffling two Jeep Grand Cherokees because the demand and interest was there three weeks into it. We made close to $60,000 for the football program that year.

Proven Blueprint

1. Read and understand your state or commonwealth’s raffle laws. Each has a different set of policies and procedures. How much are the filing fees if any? Do ticket sellers in your state need to be older than a certain age? Does the raffle need to be run through a 501(c)(3)? What are the taxes that need to be paid by the winner or can they be absorbed by the seller? Etc. It will be helpful to ask an attorney to join your group as an advisor. Tax attorneys can be most beneficial and most will work pro-bono.
2. Check your local municipalities policies, procedures and filing fees in the town where you will be running the raffle. Anyone, from Anytown, USA can buy raffle tickets, but you will be selling in one particular town/city that has their own set of rules. For example: some states won’t let you sell tickets on Sundays and holidays. Some won’t let you sell in front of places of worship, etc. Raffle laws are strictly enforced. I know of one group who had to stop selling tickets completely because they violated many of the easy-to-follow rules. It a real mess but they succeeded the next year.
3. Run the raffle through a non-profit organization. Most school booster and sports clubs are set up as 501(c)(3) so this is usually an easy requirement to meet. Before going any further, you will need to partner with one (local boosters club, churches, etc.) and you’ll also need to check with the school to determine if your funds can go to your designated sports program. Be forewarned that some schools prohibit groups from fundraising for a specific team. I address ways to get around this below.
4. Recruit a team. Enlist a task force of 6-8 adults (usually parents) who are determined and dedicated to raising the designated funds for a specific need. I found it invaluable to have people on my team with banking, legal, sales, design and public relations expertise. Each person should volunteer for about a ten-week time frame.
5. Calculate your needs and expenses. I will cover this below, you’ll need to have a solid understanding about any challenges early on. I hope by reading my article thoroughly there will be no surprises. During your first meeting have your team put together a list of people in your community who will help make the raffle a success. Identify folks such as the car dealership, media personalities, store owners (who can donate things like helium balloons, etc.) This will help defray all costs.
6. Set a very short time frame to sell the tickets. I think six weeks is ideal for selling the tickets. There needs to be an urgency declared; “First come first served – get your ticket(s) before they are all sold” should appear on all marketing materials. There are many people/companies who will buy 2, 3 or more tickets and there are others who go in together and ‘split’ the price with intent to sell the vehicle if they win. A good strategy for quick sales is to announce the raffle about a month before the start of sales so folks can start saving money for a ticket and can also be alerted to the need for volunteers to sell tickets.
7. Select a vehicle to raffle. One that is in high demand in your community. Pickup trucks, four-wheel drive, luxury cars, even motorcycles all work well as long as they are popular in your area. I knew of a group that tried to raffle a Mini-Cooper here in New England (think four-wheel drive Subaru country) and they could not sell enough tickets to hold the raffle. It was a disaster. Contact a number of area dealerships and set a time to talk with the owner. If you don’t have contacts with the owner ask to speak to the sales manager.
8. Ask the dealer to work with you. Ask them to let you keep the car at someone’s home who will move it around town and will park it in the town center on weekends when a person is selling raffle tickets next to it. Place balloons (with the school colors) on the car and drive it around each Saturday (or Sunday if the town allows it) to a new high traffic location. We have a quaint main street in my town and the police put blockades out on the street each night to save a parking spot for the car. Do not agree to buy the car outright from the dealer until it is sold, you will need to “borrow” it until it is raffled.
9. Design and print posters, newspaper ads, flyers and the tickets. Printing the actual tickets is a little tricky. You will need to find a printer who can print a two-part perforated ticket on heavy glossy stock, similar to a ticket for a pro sports game; with the number printed on the stub and the same number printed on the ticket portion. One color ink is all that is needed but it should look professional. If you can, add another color. This is a little sales technique that we learned as we watched high school student’s show off tickets their parents bought for “their new car.” Find a ‘letterpress’ printer if you can; they do a great job with small run tickets. Most local printers will give you a discount. Always ask.  
10. Recruit as many people as you can people for selling the tickets. At this point I will tell you that this is a great bonding experience for all parents. Each raffle I ever ran was incredibly rewarding and a fun way to get to know parents of your child’s teammates. The kids always loved seeing their parents work as a team. Each seller should be willing to stand in front of shopping malls (get permission from stores), at home games, etc. These sellers should be given only 3-5 tickets at a time by the Sales Task Leader (see below). If they get lost you will need to reprint with correct numbers and it takes time. Try to recruit many sellers so they are not overwhelmed. In many towns we have found that the same parents are actually happy to sell once a week for the duration of the raffle. Once the raffle sales got underway, we found it easier to recruit parents to volunteer and we always seemed to have more volunteers than we needed
11. Hold the Drawing! The grand finale of your fast-paced fundraiser. This is the fun part. Will your group select the end-of-year team banquet or a mid-season game, perhaps at homecoming? This will need to be sorted out by the task force before tickets are printed.

    

     

Volunteer Duties

Task Force Leader

This role needs to be filled by someone with great organizational skills who is popular in the community, is a strong communicator and has a good temperament and ability to work with many types of personalities. The ideal person should also have a child on the team and have a driving desire to raise the needed funds.

Duties:

• Organize all meetings and meeting venues; someone’s home works best; Skype is also convenient.
• Recruit a group of motivated parents and community leaders for the core task force
• This person is the cheerleader and keeps all members motivated and is great at troubleshooting any issues that come up.

Treasurer

This person has to have business experience and be familiar with basic bookkeeping and understand that this is a fast-moving fundraiser where he/she may need to dedicate an hour or two a day for six-eight weeks.

Duties:

• Open and maintain the checking account.
• Determine if a simple website with credit card capabilities can be created. TIP: PayPal is an excellent option for sales but should be used after the community has an initial period of time to purchase the tickets in person.
• Be the keeper of all tickets (in a safe deposit box), and issue tickets to the sellers. TIP: entrust the task force with 5 tickets to sell as they wish.
• Collect money for all tickets sold
• Keep a ledger of who sold the ticket and the buyers contact information. TIP: Ask each buyer for the best phone number on the day of the drawing.
• Pay all bills
• Open a mail box for sixth months to collect checks. Local postmasters may donate one.
• Close out the account at end of raffle

Clerk

This person will have basic computer skills and need to know how to set up meetings and send out all group emails.

Duties:

• Take notes during the meetings and sending a recap to the task force. Notes (minutes of the meeting) may be required by the IRS at some point.
• Set up an email account to keep track of all correspondence separate from other accounts. Gmail works well.
• Help the Task Force Leader to set up all meetings.
• Doodle is an online calendar tool for time management, and coordinating meetings. Secure a meeting places for the group to meet.
• Set up and manage a Skype account
• Work closely with the treasurer to keep the journal of people who have bought tickets

Publicist

The ideal person for this role is someone who knows how to work with local media: TV, Radio and newspapers. Media outlets are more than happy to share the news about the raffle. This person also knows how to get things printed quickly and should have a working knowledge of Microsoft publisher or other program to create designs for the materials.

Duties:

• Negotiate best price for printing of posters, flyers, and the tickets.
• Create the designs and share with the task force for input and editing prior to going to the printer.
• Create a press release and distribute to the media
• Network with folks in town to see who knows media who will help with ad placement including in the various sports team printed programs
• Send a letter to every parent on the team to alert them of the upcoming fundraiser

 Sales manager

This team member should have strong computer and organizational skills and will need more time to spend on the fundraiser than other members.

Duties:

• Establish on-site locations where the volunteer sales force will sell tickets on a regular basis. Contact store managers for their approval. Think about places where Girl Scout cookies are sold and Salvation Army Holiday bell ringers stand. These are the spots you want to sell tickets at.
• Contact three or four local businesses where people can purchase a ticket. Keep these businesses supplied with 5 tickets at all times.
• Determine best spots around town to park the vehicle. There should be one or two dedicated ticket sellers next to the vehicle at all times.
• Contact all sports team parents by email to let them know you are raising money for equipment and you are looking for ticket seller volunteers. Two sellers per location always work best. Keep a spread sheet of volunteers contact info and times, dates, and locations where they will be.
• You will be the person heading up the sellers and providing them with tickets. As they run out you will need to float around to resupply the sellers.
• TIP: Best to issue only 3 to 5 tickets maximum to each seller at a time. Tickets are like money if they get lost.

Drawing organizer:

This person will be responsible for determining when and where the drawing will occur and the logistics around a successful event.

Duties:

• securing of the venue for the raffle and coordinate with the homecoming, end of season awards dinner banquet, and any other committees who will host the actual raffle
• securing of any and all permits and police details needed during the event
• renting or borrowing a container to drop all ticket stubs into for the drawing
• determine who will pick the winner. Perhaps the Police Chief, Fire Chief or school superintendent.
• Prior to the drawing the person doing the drawing should count all 500 stubs with the task force, the day before and together they should put them in a sealed container with the signatures of all task force members in black marker ink. Accountability and transparency is pivotal at all times.

Expenses

Most of your expenses can be negotiated or donated by townsfolk. Here is a list of what you will need to budget for:

• Raffle filing fees at the State and local levels
• Taxes – most of the time the winner will need to pay taxes. TIP: Have a good understanding about this to be able to address questions. There are various legal ways to avoid paying the tax by donating, etc.
• Printing materials. TIP: Ask the printer if you can add their logo to the back of the ticket in exchange for the printing charges
• Radio Ads – these may be donated. You will want to solicit and get ticket buyers from listeners from other towns
• Balloons for the car and sales spots

FAQ’s

Q: What can we do if some schools prohibit groups from fundraising for a specific team?

A: Find a community non-profit organization (church, synagogue, etc.) who will run the event and can make the donation of actual helmets, impact sensors, pads or other equipment will go to the team in need.

Q: What is most difficult about this fundraiser?

A: Sometimes raffles start slow and the task force begins to doubt themselves. The best way to overcome this hurdle is to set a short time frame for selling the tickets.  Set goals for yourselves. For example, know the minimum amount of tickets you need to hold the raffle and pay expenses. We always told buyers we would refund their money if we could not sell all 500 tickets. This was a tactic needed to ensure that all tickets got sold. If you follow the blueprint you will sell them all.

Q: How about if we want to sell more than 500, say, 1000 tickets at once?

A: It is better to try to raffle two cars with 500 tickets each. People like the odds better.

Q: How about if we raffle a vacation week or a years’ worth of groceries?

A: Great ideas, I think but experience has shown that they don’t get the kids as excited and you really want the kids helping to talk up the raffle.

Have a question: Please send me your questions and tips and I will it add it to this article. delench@MomsTeam.com

Brooke de Lench is the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), the Producer of the documentary, “The Smartest Team: Making High School Football Safer (PBS) and the founding Executive Director of MomsTeam Institute.

Follow Brooke on Twitter @BrookedeLench.

The disparate RTP criteria prompted the authors to recommend that, in the absence of a more objective definition of sport-related concussion and a consensus regarding a set of reliable measures of RTP readiness, a multimodal approach be used to promote consistent study design in SRC research and uniform and safe applications of RTP strategies in clinical practice.

Symptom resolution most common recovery measure

The study identified a variety of measures used to make the RTP decision, with eight conducting follow-up exams to validate the return to sport decision:

Symptom resolution or return to baseline: All 43 studies reported using some version of a symptom assessment to determine return to play readiness. Of those 31 used either the Post-Concussion Symptom Scale (which is part of the SCAT) or the symptom checklist from ImPACT. 

Basing return to play readiness solely on symptom resolution, they noted, presented clinicians with four challenges.

1. Symptom reports are not specific to concussions. 
2. Symptom resolution may not coincide with brain recovery, since physiological abnormalities – such as impaired cerebral blood flow and abnormalities seen using sophisticated brain imaging – persisting beyond reported symptom resolution have been reported in multiple studies of sport-related concussion (3)
3. While resolution of symptoms is recognized as a critical part of recovery, symptom reporting alone is problematic because athletes often under-report symptoms.
4. Symptom recovery is not consistently defined as an ‘asymptomatic state’, with 7 studies using a cut-off of a minimal symptom score (less than 7 out of a maximum of 132); 14 studies using a cut-off of ‘symptom free’ (symptom score of zero); 10 studies using ‘return to baseline symptoms’ as their recovery measure – the measure used by the most widely accepted guidelines for return to sport (the Concussion in Sport Group guidelines most recently promulgated after the Berlin Fifth International Conference on Concussion in Sport)(“CSG guidelines”)(1) ; and the remaining 12 either failing to specify what qualified as a normal level of symptoms or using a symptom checklist which did not measure severity on a 7-point (Lykert) scale.

Cognitive recovery or return to baseline (100%): The second most common measure used by researchers in determining return to play readiness (used in 27 of the studies) was return to baseline using neurocognitive testing, usually with a computer test like ImPACT, which assesses symptoms and aspects of cognition including visual memory, verbal memory, visual motor speed and reaction time that can be compared with individual pre-injury or age-normative values. Numerous studies, however, have noted limitations in using these tests in terms of test-retest reliability.

No exacerbation of symptoms with physical exertion (86%) :   Consistent with the CSG guidelines, which recommend completion of a graduated return to sport strategy without exacerbation of symptoms, the principal of return to normal exercise tolerance was used in 21 studies to establish physiological recovery from concussion. Seventeen used a non-specific definition of provocative exercise to test for exacerbation of symptoms.  Three evaluated exercise tolerance after concussion using the Buffalo Concussion Treadmill Test (BCTT)(all from the institution where the test was developed), which establishes physiological recovery from concussion in adolescents by measuring cerebral blood flow during exercise, and, the authors claim, is the “only functional test that has been shown to safely and reliably diagnose and establish recovery from exercise intolerance after SRC.^*  One clearly described the return to sport protocol from the 2012 CSG guidelines.

Normalization of balance (30%): Because persisting and untreated balance problems could lead to future injuries on the playing field, thirteen used normalization of balance to measure return to sport. Of those, eleven used the BESS (Balanced Error Scoring System) test, which is part of the SCAT, one used the Sensory Organization Test, and one did not specify how balance was assessed.

Normal specialized physical examination (12%): Vestibular and visual dysfunction, including accommodation disorder, symptoms with vestibular ocular reflex (VOR) testing, or receded near point of convergence, are common following concussion and have been associated with prolonged concussion symptomatology. Five studies measured recovery through vestibular-ocular examination. 

Successful return to school (5%): 

No exacerbation of symptoms with physical exertion (2%)

Normalization of cerebral blood flow (2%)

Minority of studies used multiple measures of recovery

Of the studies that used multiple criteria to assess return to sport readiness, the breakdown was as follows:

• 11:  symptoms and cognitive performance;
• 10: symptoms, cognitive performance, and physical exertion test;
• 5:   symptoms, cognitive performance, and balance;
• 4:   symptoms and physical exertion test;
• 4:   symptoms, cognitive performance, balance and physical exertion test;
• 2:   symptoms, cognitive performance, balance and return to learn;
• 1:    symptoms and cognitive exercise test;
• 1:    symptoms, cognitive performance, physical exertion test and cerebral blood flow;
• 1:    symptoms, cognitive performance, physical exertion test, special physical exam and return to learn; and
• 1:    symptoms, balance, and physical exertion test.

Weekly multimodal testing recommended

The authors encouraged researchers and clinicians to use standardized multiple criteria to establish recovery from a sport-related concussion, and suggested that testing on a weekly basis for up to 1 month following SRC (including general health questionnaires, symptoms, neurocognitive and balance testing and exertion testing) may be the best approach for determining recovery from concussion in young athletes.

* The authors, it should be noted, were the developers of the BCTT.

1. McCrory P , Meeuwisse W , Dvořák J , et al  Consensus statement on concussion in sport-the 5th International conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838–47.doi:10.1136/bjsports-2017-097699
2. Haider MN, Leddy JJ, Pavlesen S, et al. A systematic review of criteria used to define recovery from sport-related concussion in youth athletes. Br. J. Sports Med 2018;52:1179-1190.  
3. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review.  Br. J. Sports Med 2017;51:935-40.

For further reading:

Concussion Signs and Symptoms

Return to Play After Concussion Is Step-By-Step Process

Return to Learn Just As Important As Return to Play, AAP Says

Return to Learn After Concussion: Modify School Environment To Avoid Triggering Athlete’s Symptoms

Parents Play Important Role in Child’s Recovery From Concussion

Are Athletes Being Returned To Play While Still Cognitively Impaired?

In one corner are those who argue that playing tackle football at an early age comes with such an unacceptably high risk of developing the debilitating neurodegenerative disease, chronic traumatic encephalopathy or CTE, that the time has come to deny parents any say in the matter through an outright ban. 

In the other corner are those who see the game of tackle football being made safer, almost by the day, who believe that those in the anti-football camp, aided and abetted by many in the mainstream media, have built their arguments on questionable science and on fear. They argue that, despite football’s risks – a risk of CTE which at this point cannot be quantified with any degree of certainty and likely depends on a multitude of factors – it should be up to parents to decide whether to allow their child to play, and, if so, at what age.

From its title alone, the new book by former NFL player and ESPN commentator, Merril Hoge, and Boston University forensic neuropathologist Peter Cummings, M.D., Brainwashed: The Bad Science Behind CTE and the Plot to Destroy Football, leaves no doubt as to the corner the authors are in. (Which is perhaps why some of the “reviews” I have read suggest that the reviewer didn’t even bother to crack the book)

The authors acknowledge up front that, in questioning the football causes CTE and CTE leads to suicide memes, they expect to be labeled as “CTE deniers” by the so-called experts who dominate the news cycle. But, says Hoge, “I’m not a CTE denier. [Rather,] I’m a bad science denier. A lie denier. A hysteria denier.”

To his credit, Hoge makes it clear, over and over, that he’s not saying it’s good to take repeated impacts to the head, or that he is denying that there are former NFL players who have psychological and neurological problems which can be attributed to playing football.

But, he argues,

[S]cience done right is a slow process.  Because we favor information that confirms our biases, millions of doctors, athletes, parents, coaches, and journalists are making up their minds based on an incomplete picture painted by headlines that are far ahead of the science. That’s leading to conclusions that are harmful and wrong. It’s time we stopped calling people ‘deniers’ and had an open, candid conversation about what’s true.

I couldn’t agree more. (And, in doing so, I fully expect that I will, like Hoge and Cummings, take some pretty savage hits on social media from those who believe that any organization that fails to join the call for an immediate end to youth tackle football as we know it in America is, by definition, their sworn enemy).

Much of Brainwashed will undoubtedly be familiar to those who have followed the discussion of CTE in the media for the past twelve or so years since it first burst into the public consciousness on the pages of the New York Times in January 2007, and especially to those who have read my numerous blog posts on the subject of CTE and tackle football over the years on MomsTEAM, the Huffington Post, and Medium.com, and the articles by MomsTEAM Senior Editor Lindsey Straus in which she has attempted to shed light on the state of the science on CTE. (I would be lying if I didn’t find it gratifying to have been listed by the authors as one of eleven “significant players” in the tackle football debate (the only journalist and one without an M.D. or Ph.D, after their name), or that the book includes several long quotations from Lindsey’s articles.)

It will also come as no surprise to anyone with at least a passing interest in the debate over CTE that Hoge and Cummings single out for particular criticism the outsized role the BU CTE Center, its celebrity pathologist, Dr. Ann McKee, the BU-affiliated Concussion Legacy Foundation, and their media mouthpiece, The New York Times, have played in shaping the narrative about CTE.

But what I found informative and new in the book, and made it worth reading, even for one as steeped in the subject of head injuries in football as I have been for the past eighteen years, was the middle section of the book in which Hoge – with the invaluable assistance of Dr. Cummings – debunks the myth that CTE is settled science, and that football is its cause.

In so doing, they raise serious questions worthy of discussion about the validity of a lot of BU’s CTE research, including the degree to which it is marred by selection bias, by what they see as critical flaws in the theory that head trauma inevitably leads to CTE, by the lengths to which BU appears to have gone to maintain control over the CTE=football and CTE=suicide narratives, the degree to which the criteria for diagnosing CTE has largely been determined by BU (especially enlightening was a lengthy section of the book raising the question of whether stage 1 CTE is even a real disease), and the apparent willingness of researchers to conclude that CTE, and CTE alone, is responsible for behavioral changes in athletes found after death to have suffered from CTE, without accounting for, or at least revealing, the existence of other factors that could cause or increase the likelihood of the results they claim are due to CTE.

Hoge and Cummings take pains to point out in Brainwashed, as I have for many years, that, if parents decide to let their child play youth football – a decision that is theirs, and not the government’s, to make, they need to be sure beforehand that the program puts their child’s safety first by, among other things, educating coaches, parents, and players about concussions, supplying players properly reconditioned and fitted helmets, teaching players how to tackle without using those helmets, minimizing the amount of full-contract practice time, creating an environment in which players feel safe in honestly reporting concussion symptoms, ensuring that concussions, when they do occur, are managed properly, and prohibiting players from returning to practice and play until a doctor with concussion expertise decides in the exercise of good clinical judgment that their growing brains have been given all the time they need – and then some – to heal.

The challenge I face – that all those of us who love, not just the game of football, but all sports and are dedicated to making them safer – is having our message heard. For the most part, as Hoge and Cummings once again remind us, the national media doesn’t seem interested in reporting good news – that there are steps being taken to make football and contact and collision sports such as soccer, lacrosse, and hockey, safer – or in engaging in a discussion of the nuances of the science about head injuries, because it is bad news, scary news, sensational news, black and white news, that sells, and that some depend for their very livelihood on promoting.

From my vantage point, having spent countless hours working with youth football communities around the country, from talking with parents, coaches, administrators, athletic trainers, clinicians and academicians, and from becoming educated about the actual facts about the safety of football, I believe that, not only is football a sport worth saving, and that it can be saved, but that those who call for it to simply be abolished represent a minority, albeit an extremely vocal one, which is not above using smear tactics such as bullying, intimidation, and outright defamation in an attempt to get its way.

Brainwashed is not without its flaws. In making the pro-football case, the authors, who I have spent time meeting and talking with both before and after the book’s publication, can’t resist the temptation in some instances to respond to the hyperbole on the part of the kill tackle football cabal with hyperbole of their own, and to rely in some cases on questionable research data of their own, which is unfortunate.  Purple prose doesn’t help anyone make a reasoned decision on the basis of the facts. But, given the myths which so many in the kill football camp have been perpetrating and perpetuating, it’s no wonder Hoge and Cummings feel like they sometimes have to shout as well.

In the end, however, I don’t believe it will be those who scream the loudest, the trolls on social media engaging in the politics of emotion and innuendo, who will prevail. It will be those who discuss the risks and benefits of sports calmly, rationally, and objectively, who work tirelessly to make sports safer, based on science, who will win out.

One of the ways I have long believed contact and collision sports can be made safer is through the use of impact sensors – most of which are small, highly sophisticated electronic devices embedded in mouth guards, chin straps, skull caps, ear buds, skin patches, or attached to the interior or exterior of helmets which transmit data via Blue Tooth connection on the number and force of head impacts athletes sustain during games or practices to a dedicated monitor, iPhone, iPad or laptop on the sports sideline.  

About six or seven years ago, I started to hear about companies which were bringing to market impact sensors for use at the youth, high school, and college level; sensors that, while not as sophisticated as the ones used for research – which cost upwards of $1,000 per player – could be used to alert sideline personnel to athletes who sustained hits hard enough to cause concussion so they could be evaluated for concussion, and to identify athletes whose poor technique caused them to sustain an unusually large number of subconcussive impacts, the cumulative effect of which research has increasingly linked with a greater risk the athlete will develop a chronic, degenerative neurological disease such as chronic traumatic encephalopathy (CTE).

In 2012, when I was asked by the high school football program in Newcastle, Oklahoma for help in implementing an evidence-based concussion risk management program, I saw a perfect opportunity to beta test two of the new impact sensors, which the manufacturers, Impact Protective and i1 Biometrics, donated for installation in some of the Newcastle players’ helmets.

My experience during the filming of MomsTEAM’s PBS documentary, The Smartest Team: Making High School Football Safer, convinced me that they had value as a technological end run around the chronic problem of under-reporting by athletes of concussion symptoms.  From talking candidly with the players after a duck-hunting trip (next to playing football, their favorite activity), I learned that they actually wanted to wear the sensors. Why? Because they knew that, if they took a heavy hit, it would register on the iPad the athletic trainer or his assistant was holding on the sideline.  Knowing that they would be checked out if the sensor alerted sideline personnel to a blow with the potential to cause a concussion, they felt more comfortable, if they began experiencing concussion symptoms, reporting symptoms to the AT without fear of being labeled a wimp by their teammates or the coach.

As the Executive Director of MomsTEAM Institute of Youth Sports Safety, I was honored to be among the select group of external reviewers the CDC asked to provide feedback on the proposed report content and review drafts. The final report is culmination of that collaborative, three-year effort for which the distinguished authors and my fellow reviewers can be justifiably proud and stands as a stellar example of what can be accomplished when the public and private sector work together.

Our understanding of TBI has come a long way since MomsTEAM launched its pioneering Concussion Safety Center in 2001. But the work of educating sports stakeholders about the management of TBI in children and adolescents, and ways to minimize the risk of brain injury in sports is, by its very nature, a never-ending and ongoing process.

I am immensely proud that, for the past eighteen years, grants from organizations such as the NCAA and DoD, and contributions from corporate underwriters and individuals, have allowed MomsTEAM to provide comprehensive head injury safety information to sports parents, coaches, athletic trainers, and athletes on our legacy website, MomsTEAM.com, and via our SmartTeams Head Injury Safety Center, completely free of charge.

A tax-deductible contribution to MomsTEAM in any amount will help us to continue to be a leader in head injury safety education. In return for a generous contribution corporate donors will receive a banner ad placement on an article of their choice on MomsTEAM and inclusion as an underwriter on SmartTeams.

Won’t you consider making a donation today? Thanks in advance for your help in keeping kids safe.

Just as predictably, a review of articles on the study which come up in after a brief Google search discloses that most simply reported the study’s findings without asking scientists not involved in the study to comment.  None examined the study’s methodological soundness, and only one discussed its limitations, even those acknowledged by the study’s authors.

In the interest of balanced and objective reporting, we asked a number of researchers and clinicians to review and comment on the study.  Here’s what they told us.

Self-selection bias

The authors acknowledged that the study cohort, because it was a convenience sample of self-selected participants, “could potentially lead to bias effects, especially if age of first exposure (AFE) play[ed] a role in selection.”   

While the potential self-selection bias was mentioned as a limitation in articles on the study by The Boston Globe and Time, and highlighted by the Globe’s scientific publication, STAT (which, to its credit, even went to the point of pointing out that the study had limitations in the article headline), it received no mention in The New York Times article.

The scientists and researchers to whom we spoke viewed the potential self-selection bias as a significant concern.

Findings based on the results of a survey of “a convenience sample of self-selected participants could introduce bias effects if participants are familiar with the investigators work and media [coverage], where the consensus seems to be that playing football leads to long-term consequences,” said Summer Ott, a sports neuropsychologist at the McGovern Medical School at UTHealth-Houston and director of the concussion program at the Memorial Herman IRONMAN Sports Medicine Institute. “Individuals who suspect they are experiencing difficulties as a result of sports participation or who are fearful of long-term issues may be more likely to participate,” Ott noted.

Echoing Ott’s concern, but going one step further, was sports neurologist Jeffrey Kutcher, National Director of The Sports Neurology Clinic at The CORE Institute in Ann Arbor, Michigan.  Kutcher viewed the failure of the authors to disclose when the data for their study was collected as rendering all other scientific criticisms of the study essentially “moot.”  

If, as was almost certainly the case, the data for the study was collected after the publication during Super Bowl Week in 2015* of the BU group’s earlier study (2) – one which also linked tackle football before age 12 and later life cognitive impairment – Kutcher believed that the chances were “pretty low” that the current study excluded people who had heard about, and were likely influenced by that study.  As a result, the study subjects “were self-selected to be more likely to have more [behavioral and cognitive] problems,” Kutcher contended.

“From a commonsense standpoint, it totally makes sense to try to reduce the potential risk for brain injury in young children,” said Uzma Samadani, a professor in the Department of Neurosurgery at the University of Minnesota and Chair for Traumatic Brain Injury Research at the Hennepin County (MN) Medical Center. “But this study, like most of the work that has come out of the Boston University CTE group, is plagued by [a self-selection] bias.”  She likened the study’s methodology to an emergency room doctor writing a paper saying that, among the patients who came into the emergency room with their tibia at right angles to their fibia, “there was an increased likelihood of having [suffered] childhood trauma.  In other words, if you look for correlations in only a sick population rather than understanding them in a larger demographic you will likely find associations that are not generalizable.”

Lack of control group

None of the media articles we reviewed addressed the lack of a control group as a study limitation, but the researchers we talked to all thought its absence was significant. 

Not having one was “absolutely a problem,” said Kutcher.  “Sure, they compared two groups within the collected population. However, these people were self-selected to be more likely to be having problems.”

The fact that the study did not include a control group of age-matched participants who played other contact sports associated with repetitive head impacts, such as soccer and boxing, and did not address it as a potential limitation “suggests that the authors are concerned primarily about football and not the generalized implication of pre-adolescent exposure to contact sports,” said Ott.  “The findings of the study would have been strengthened if results could be replicated with a randomized group and include participants who played other contact sports. With the cohort at hand, the results are suggestive, at best,” she said.

Neurosurgeon Scott Zuckerman, Co-Director for Research of the Vanderbilt Sports Concussion Center Research Group, observed that, while the study only included athletes whose only sport was football, it is rare for athletically gifted athletes to only play one sport in middle school and high school, so he wondered “are we really isolating the effect of football” on long-term neuropsychiatric and cognitive outcomes.  “Why not compare football players to control athletes rather than to normative data?” he wondered.

Using age 12 as cutoff

None of the media reports on the study we reviewed, except for a WBUR report containing excerpts of a “Here and Now” interview with one of the co-authors, Robert Stern, questioned whether comparing a group of football athletes who started before age 12 to the group whose AFE was later was arbitrary. Nor did any point out that 2016 study in American Journal of Sports Medicine (3), which found no association between AFE and later life neurocognitive impairment, considered age as a variable, not an absolute.

Using a cut-off of age 12 is still “somewhat arbitrary,” said Zuckerman, a co-author of the 2016 AJSM study.  Treating AFE as a continuous variable, Zuckerman argued, was often preferred over dichotomizing into two groups, where data can be lost.  While the authors of the current study cited thirteen studies in the neurodevelopmental literature in support of using age 12 as the ideal cut-off, he noted that few specifically mentioned that specific age.

Controlling for variables

In terms of discussing controlling for potential variables which could cloud the study’s findings, the best article we read – by a wide margin – was from WBUR (coincidentally, the NPR station at Boston University), no doubt due to the fact that it was based largely on an on-air interview with study co-author, Dr. Robert Stern, in which he explained how the study attempted to statistically control for a number of variables, including age, education, number of years playing football, and learning disabilities (based on criticisms that the results of the BU group’s earlier study might have been due to the fact that more athletes in the AFE before age 12 group had learning disabilities, and thus had brains which may have already been uniquely vulnerable to repetitive head impacts brains). 

Dr. Zuckerman, however, questioned the assertion that including a history of learning disability (LD) as a covariate had a “minimal influence” on the finding of a “robust relationship between AFE and long-term clinical dysfunction.” Given that 2 of the 4 significant differences were lost when controlling for LD, the effect of LD was likely more than “minimal.”

While the authors discussed and accounted for learning disabilities, noted Ott, there was no mention of ADHD, occupational and psychosocial (i.e. childhood and divorce) history, or other conditions associated with depression, apathy, and executive function deficits that could affect participant self-reporting and performance on cognitive testing. “Given the potential adverse and confounding effects of these factors on reported outcomes, more information on inclusionary and exclusionary criteria is needed to determine if these variables were included, not reported, or both.”

Zuckerman wondered what comorbid medical and psychiatric conditions existed in the sample, noting that in the earlier BU study there was a significant overlap of medical and psychiatric conditions.

Limited reliability of telephone interviews and on-line testing

The study’s authors candidly admitted to a host of limitations in their use of a telephone test of cognition (the Brief Test of Adult Cognition By Telephone or BTACT) and online testing of executive function and depressive symptoms and apathy.

They acknowledged that, while the BTACT was a valid, convenient, and cost-effective, telephone assessment of cognition, it was “not ideal,” did not provide a comprehensive assessment of cognition; might not be sensitive to cognitive impairment in such a relatively young sample (average age of 50 years), and the global score used might not have captured the “diverse, and at times subtle, deficits associated with repetitive head impact exposure.” 

Further, the authors admitted that the use of telephone and online testing instruments precluded the ability to observe the participant’s concentration and engagement in testing, particularly in the context of symptoms of depression and apathy, and called for future investigation of the relationship between AFE to football and cognition to use comprehensive neuropsychological testing.

Despite such admissions, only the STAT article mentioned that gathering data via telephone interviews was not as reliable as face-to-face neuropsychological examinations. The Globe and Times mentioned that the results were based on phone and online surveys, but not that such methodology was less reliable than in-person interviews. None focused on these limitations in depth or pointed out that the earlier BU study by the same group did do in-person interviews.

Not surprisingly, all of the researchers we contacted for this article pointed to these limitations as significant.  Kutcher said the use of phone survey “greatly limited the overall value of the findings.”  While there were many reasons, the “biggest here,” he said, “is that you’re asking 50-year-olds what year they started playing a sport four decades ago. There’s a good bit of guesswork that would go into answering that.”  The bottom line for Kutcher: “Having age at onset as a clinically predictive variable in this case was incredibly unprecise.”

Evaluating cognition on the phone and via online testing is “not ideal,” said Ott, “in that participants cannot be observed during testing nor can test administrators be sure if the former athlete completed the self-reported measures alone or with assistance. Because the authors did not report any measures that were employed to guard against malingering or suboptimal effort, it is difficult to assess whether these issues factored into the results as well.”

Noting that the BU group’s 2015 study used three objective neurocognitive measures, Zuckerman wondered “why now [the study] only used one objective neuropsychological test?”

No association between AFE to football and cognition

Surprisingly, none of the media reports we reviewed reported, much less considered the significance of, the fact that the study found no association between AFE to football and cognition as measured by the BTACT (Brief Test of Adult Cognition By Telephone).  Such omission was all the more surprising, considering that the authors themselves admitted that the finding was “unexpected,” given that they found in their 2015 study of former NFL football players that those who began playing football before age 12 exhibited worse neuropsychological test performance on episodic memory and executive function at mid-life compared with those who began playing football at 12 or older.

To Ott, the lack of a significant association between the online, self-reported measures (which found rates of impairment >40%) and the objective measure provided by the BTACT (which found only 7% of participants clinically impaired) “highlighted the potential degree of discrepancy between a patient’s perception of everyday functioning and his neurocognitive ability” and suggested that “self-reported measures may not measure the same constructs as the objective measure.”

Like the authors, Zuckerman said one possible explanation for the lack of an effect of AFE to football the study reported on the objective neurocognitive test (the BTACT) but positive effects on self-reported neurocognitive measures was to attribute the results on the subjective measures to their self-report nature, particularly as the convenience sample of self-selected participants may have been more likely to participate because of perceived clinical symptoms.

Number of years playing

Many of the articles pointed out that those who started playing football before age 12 but went on to play in high school, college or the pros were not found to be more likely to be at increased risk for apathy and behavioral regulation and depression based on the number of years of football played, but none questioned whether this was consistent with research suggesting that later-life neurocognitive or behavioral problems are dose-related. 

“If this is a dose response process,” said Kutcher, “one would have expected that if there was a difference between 11 and 12, there should also be one for 10-11, 9-10, etc.  It seems that they were just searching for an effect at the 12-year cutoff.”  

Proceed with caution

“While this study examines an interesting relationship between youth football and its clinical implications,” says Ott, “it is difficult to make a claim that exposure to contact football at a young age results in long-term cognitive and emotional problems” because any “causal effect is confounded by lack of a control group and failure to control and identify factors such as psychological and medical history, ADHD, and psychiatric illness.”  

While noting that the authors cautioned against using their findings to inform safety and/or policy decisions regarding youth football (a caution absent from any of the media reports we reviewed for this article, save the Globe’s), and recommended that decisions about participation take into account the “important health and psychosocial benefits of participating in athletics and team sports during pre-adolescence” (noted in all of the media reports we reviewed), Ott was concerned that it was “unlikely that the findings and limitations of this study will be portrayed as such by the mainstream media. Rather, the headlines will focus on a cause-and-effect relationship instead of the association reported by the authors.”

Ott feared that, as a result, “parents may blame themselves for letting their children play football. Children playing football before the age of 12 may be led to believe that they are destined to encounter future problems.”

She noted that the mean age of participants in the study was 50, suggesting that some started playing over 40 years ago.  Since that time, football has evolved significantly to include improved tackling techniques, reduced number of contact practices, enhanced safety equipment, and protocols for diagnosis and management of concussions.” (developments mentioned in all the media reports reviewed for this article)  “Rather than relying solely on information by the media,” Ott said, “parents should form their decisions [about participation in youth football] after critically evaluating several sources and putting the findings into perspective.  Parents should also be encouraged to have a rational conversation with a concussion specialist who possesses both research and clinical expertise and is best qualified to explain both sides of the issue.”

“We don’t actually know if reducing tackling before age 12 will be better or worse for the general public health,” said Samadani. “It is possible that it would decrease the number of children who are obese from participating in sports at a very young age, which could potentially discourage them from participating later on, and increase their risk for all of the complications associated with sedentary lifestyle, such as hypertension, diabetes, obesity, cardiovascular disease, dementia, and thirteen different types of cancer.  In addition, it is possible that it may be safer to teach tackling at a younger age than an older one. (This is hypothesized to be one of the reasons why girls are more susceptible to brain injury – it is that they have never learned to fall or be in contact the way boys do from a very young age.)”

“Ultimately,” says Samadani, “we don’t know if children who play football from a very young age are more likely to have had the problems described in the BU study regardless of their football exposure.”

“The most dangerous aspect of most of the work done by the Boston CTE group is that they are constantly exploring the risks of brain injury from sport without at all accounting for potential benefits.  We barely understand the benefits of football, but we do know that exercise in the children who are most vulnerable to obesity and sedentary lifestyle has bigger benefits than seen in their lean counterparts.  In addition, the benefits of group risk-taking behaviors are poorly understood, but have implications for all adult occupations requiring risk. If our society does not allow our children to take risks, will we still be able to generate firefighters, policemen, surgeons, astronauts and other people with careers that involve individual and group risk?  These are not things we understand at all,” said Samadani.  “To draw blanket conclusions about football exposure risk from a single uncontrolled study that does not even consider benefit is scientifically irresponsible.”

** Timing the publication of the 2015 study for Super Bowl Week is nothing new for the BU group, which announced its long-since defunct “Hit Count” program just before the Super Bowl in 2012 and its long-since abandoned sensor certification program just before the Super Bowl in 2014 .   

This article was originally published in Medium.com on October 3, 2017.

1.     Alosco ML, Kasimis AB, Stamm JM, Chua AS, et al. Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes. Translational Psychiatry, 2017;7(9): e1236 DOI: 10.1038/tp.2017.197

2.     Stamm JM, Bourlas AP, Baugh CM, Fritts NG, Daneshvar DH, Martin BM et al. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology 2015;84: 1114-1120.

3.     Solomon GS, Kuhn AW, Zuckerman SL, Casson IR, Viano DC, Lovell MR et al. Participation in pre-high school football and neurological, neuroradiological, and neuropsychological findings in later life: a study of 45 retired National Football League players. Am J Sports Med 2016;

The prevailing media message, says Scottish neuropsychiatrist Alan Carson in a 2017 editorial commentary in a British medical journal, is that “concussion is a dangerous condition that causes” CTE, accompanied by mood change, irritability, and suicidal behavior which develops over time into a neurodegenerative disorder and death.” What follows is increasing alarm, accompanied by the suggestion that CTE is not just a disorder of elite athletes but a problem for youth sport and that even heading a soccer ball may cause dementia, “a terrifying prospect for parents trying to decide whether to allow their children to participate in sports.”

It thus may come as a surprise to many that, despite widespread media coverage and speculation regarding the late-life or post-retirement risks of cognitive impairment or neurodegenerative disease such as CTE in athletes who engaged in sports involving repetitive blows to the head and high concussion risk, and assertions that CTE causes them to be at high risk of suicide, there have been virtually no peer-reviewed, well-designed scientific studies that establish, much less quantify, such risks.

The problem is that, while some scientists who have in the past appeared most willing to push the envelope by arguing that such a cause-and-effect relationship exists in public, may be exercising more caution in reporting the results of their research in scientific journals, that caution is often be lost in translation when their research is reported by the mainstream media.

No consensus on causation

Rejecting the blanket conclusion that there is a definitive causal and effect connection between repetitive head trauma and CTE, most peer-reviewed scientific papers, including the most recent quadrennial international consensus statement on concussion in sport (“Berlin 2016”), caution that, while there is clearly a link between CTE and concussions and/or exposure to repetitive head trauma in contact and collision sports, the precise relationship is not yet known.

The conclusion by the head injury researchers in the Zurich 2012 statement put it succinctly: a “cause-and-effect relationship has not yet been demonstrated between CTE and [sports-related concussions] or exposure to contact sports. As such, the notion that repeated concussion or subconcussive impacts cause CTE remains unknown.”

The view that the football=dementia meme is scientifically premature has long been espoused by some researchers, including Christopher Randolph, PhD. a now retired professor at Loyola University in Chicago. In a 2013 study of retired NFL players — who largely comprise the highly limited, self-selected universe from which the case studies of brains showing the presence of CTE have been drawn (what scientists call a “convenience sample”), and who the media have widely reported as being at high risk of CTE — Randolph lamented that “the media attention to this issue continues to far outweigh any meaningful results from sound experimental science.”

Randolph found that, when compared with healthy controls and with non-athlete patients with a clinical diagnosis of mild cognitive impairment (MCI) commonly presumed to reflect the earliest stage of Alzheimer’s disease, the patterns of impairments of the retired NFL players in the study were virtually identical to those exhibited by non-athletes with MCI. The finding lead him and his colleagues to conclude that CTE might not be a distinct neurodegenerative disorder at all.

Randolph’s 2013 study appeared to lend support to his theory, first proposed in a 2009 paper, that a long history of repetitive head trauma in contact sports does not cause CTE, but might eventually result in a diminished cerebral reserve leading in some unknown percentage of cases to an earlier-than-normal expression of other common, age-related neurodegenerative diseases,such as Alzheimer’s Disease (AD) and Parkinson’s (PD). His theory was that the ways in which such diminished cerebral reserve would be expressed (e.g. mild cognitive impairment (MCI), AD, PD, ALS) would not differ from individuals with those diseases who lacked such a history of head trauma, which is precisely what his 2013 study suggests. A 2015 meta-analysis of 153 published cases of CTE, and a 2017 study by Canadian researchers (see discussion below) suggests much the same.

The first, published in 2012, compared the incidence of dementia, PD and ALS in 438 high school football players from Rochester, Minnesota who played the sport from 1946 to 1956 and 140 non-football playing male classmates. Researchers found that the football players were not at increased risk of later developing those neurodegenerative diseases.  

The results were consistent with those of a 1990 study of individuals with Alzheimer’s disease which also found no association between risk of disease and participation in contact sports, although, as noted in a 2013 paper, that study was limited by a small sample size.  

In the second, published in 2017, researchers, using the same methodology as in the earlier study, extended their investigation to another group of varsity high school players from the next era, 1956 to 1970, a time when the rules, regulations, equipment, and physical ability of the football players was evolving to mirror more closely those of the present era, but a time in which football-related concussions were still often minimized or dismissed as “getting your bell rung.”

Again, they found that individuals who played high school football between 1956 and 1970 did not have an overall increased risk of neurodegenerative outcomes or individual risks of dementia/mild cognitive impairment, parkinsonism, or ALS compared with their non-football playing classmates, this despite there being significantly more medically documented head trauma in football players.

Bigger, Faster, Stronger 

The Mayo Clinic researchers were careful to note in the two studies the many differences between today’s high school football players and those who played in earlier eras: while today’s players have better equipment, trainers and physicians who are more knowledgeable about concussions, play under rules which prohibit – at least in theory – leading with the head when blocking and tackling (spearing), and may be marginally more likely to report concussive symptoms than players from the two earlier eras, they also tend to be larger and quicker, increasing the force of impact, and wear helmets which, which, while “dramatically different from the marginally protective headgear of the earlier era, do not  eliminate concussions and may give them a false sense of protection.” 

As a consequence, they cautioned that the results of the two studies should not be interpreted as evidence that football-related head trauma is benign. “The literature on chronic traumatic encephalopathy in college and professional football players,” said the authors of the second study, “seems irrefutable,” but there may be a “gradient of risk, with low potential in high school players.”

Savica R, Parisi JE, Wold LE, Josephs KA, Ahlskog JE.  High School Football and Risk of Neurodegeneration: A Community-Based Study.  Mayo Clin Proc2012;87(14):335-340.

Pieter HHJ, Mandrekar J, Mielke MM, Ahlskog JE, Boeve BF, Josephs K, Savica R. High School Football and Late-Life Risk of Neurodegenerative Syndromes, 1956-1970. Mayo Clin Proc 2017;92(1):66-71.

Jordan BD, et al. Head trauma and participation in contact sports as risk factors for Alzheimer’s disease. Neurology1990;40:347.

Jordan BD. The clinical spectrum of sport-related traumatic brain injury. Nat Rev Neurol2013;9:227-30.

If your child plays a contact or collision sport, whether at the youth, middle school or high school level, chances are they will suffer a concussion at some point in their athletic career. How quickly they recover may depend on how soon after injury – if at all – their concussion is identified so they can be removed from practice or game action. The problem is that concussion signs – still the best way to identify a concussion – are difficult to spot, and athletes often hide their symptoms. The consequences of such unreported and undiagnosed concussions range from a longer recovery up to and including, in rare cases, catastrophic injury and death.

One way to improve the chances that an athlete’s brain injury is identified is for teams to employ a “buddy” system in which team members are assigned to watch for signs of concussion in designated teammates and, if they spot signs, or if their teammates tell them they are experiencing symptoms, are encouraged or required to immediately report the possible injury to the athletic trainer or the coach.

While I had been advocating the use of a buddy system for many years in every sport, it was not until five years ago, during the taping of our PBS documentary, “The Smartest Team: Making Football Safer,” in Newcastle, Oklahoma that I began to truly appreciate not just how culturally entrenched was an athlete’s reluctance to self-report concussion symptoms but also the part a buddy system could play in changing that culture.

At a players-only meeting at the beginning of pre-season, and in interviewing athletes in small group and one-on-one, nearly every football player I spoke to freely admitted that they would not self-report concussion symptoms.

“If I can get up and walk away from it, yeah, I’ll probably keep playing,” one said.

“You see some dots and they go away … so you just keep playing through it. It’s my senior year,” said another.

“As long as I can still see and keep my balance, as long as I’m not feeling dizzy, head injuries are all right,” acknowledged a third.

Typical was what one player told me: “There was a time that I’ve gotten a concussion. I didn’t think much of it, you know, just a headache, move on with it, keep playing. … Got hit pretty hard, helmet to helmet, couldn’t see, saw stars everywhere, just went back on the field, started playing again. Didn’t need to tell anyone. I mean it’s not like I was laying down, couldn’t get up or anything. But I thought I was fine.”

(He wasn’t, of course, and should have told someone and removed himself, or been removed, from the game)

My anecdotal experience in Newcastle was that instituting a buddy system – not just players watching teammates but cheerleaders keeping an eye out for players showing signs of concussion – helped, although it’s hard to say how much. One of the players recounted how he had noticed a teammate who seemed really “out of it” at practice one day. When he told the coach, his teammate “got really mad.” But he said he was undeterred, because he “knew it was going to help [his teammate] in the long run.”

Another player told me that, “As far as the buddy system goes, I know that we need to keep each other’s backs, like me and Justin have each other’s backs as far as like, if I get a concussion or he had gotten a concussion, then you know, make sure he’s OK. If he’s out of it, you know, can’t answer simple questions, go alert the coaches. He got mad at me, but I learned it was the right thing to do.”

One of the players recounted how he had noticed a teammate who seemed really “out of it” at practice one day. When he told the coach, his teammate “got really mad.” But he said he was undeterred, because he “knew it was going to help [his teammate] in the long run.”

Given my experience in Newcastle, I was not surprised when, three years later, a 2015 study suggested that a buddy system, while it does not remove the need for honest self-reporting by athletes themselves or place final responsibility on teammates for each other’s health behaviors, may be an important step towards creating a culture of concussion safety on sports teams.

What I learned from working with the Newcastle team, and with youth football programs across the country over the years is that traditional concussion education in which athletes, coaches, and parents are taught the signs and symptoms of concussion, and the health risks of concussion and repetitive head trauma, isn’t working to change the concussion reporting behavior of athletes. Between 40 and 60 percent of all concussions – and a much higher percentage of so-called “bell-ringer” events – still go unreported; indeed, a recent study found that four out of 10 athletes with concussion signs or symptoms return to play that same day. It has become increasingly clear that the problem isn’t a lack of knowledge. Rather, it is the attitudes and beliefs of athletes about concussion reporting, what they think might happen to them if they report, and what they think are negative attitudes of coaches, teammates, parents, and fans about concussion reporting which combine to create a climate which discourages reporting.

In the age of social media, such negative attitudes by teammates about honest self-reporting can take the form of cyber-bullying and shaming. “As health care providers dealing with concussions, we need to be aware that many concussed patients may be bullied or shamed on social media by friends or teammates who may not believe that they are experiencing concussion symptoms, or that those symptoms are lingering,” notes Mark Halstead, M.D., a sports medicine physician and Director of the Washington University Sports Concussion Clinic & Young Athlete Center.

The answer, then, is to work to change attitudes about concussion symptom reporting so that honest reporting is viewed as a valued team behavior and a hallmark of a good teammate. Like the Centers for Disease Control and an increasing number of concussion experts, I believe that the best way to increase the rate at which athletes report concussion symptoms, either their own or their teammates, is for coaches, parents, medical staff to work as a team to change reporting behavior – to reshape the culture around concussion reporting – by changing individual and team reporting attitudes and norms and by creating a climate in which athletes feel comfortable reporting their symptoms.

Available free of charge on MomsTEAM’s new SmartTeams concussion website, the #TeamUp4ConcussionSafety^TM program, developed by MomsTEAM Institute as part of its SmartTeams Play Safe^TM initiative with a Mind Matters Educational Challenge Grant from the National Collegiate Athletic Association and Department of Defense, is designed to do just that: to increase reporting by athletes of concussion symptoms by engaging coaches, athletes, parents, and health care providers in a season-long, indeed career-long program which emphasizes that immediate reporting of concussion symptoms – not just by athletes themselves but by their teammate “buddies” – not only reduces the risk the athlete will suffer a more serious brain injury – or, in rare cases, even death – but is actually helps the team’s chances of winning, not just in that game, but, by giving athletes the best chance to return as quickly as possible from concussion, the rest of the season, and by teaching that honest reporting is a valued team behavior and a hallmark of a good teammate.

The rate at which student-athletes immediately and honestly report experiencing concussion symptoms, both their own and their teammates, will only begin to increase if all stakeholders first understand how much they know about concussions, and about their own attitudes towards and beliefs about symptom reporting. Our five-part program begins by asking coaches, athletes, athletic trainers, and parents to take a series of quizzes designed to test their concussion knowledge, and, more importantly, whether they view concussion symptom reporting in a positive or negative light.

While knowledge and awareness of concussion has increased substantially over the seventeen years that MomsTEAM/SmartTeams^TMhas been engaged in concussion education, research shows that there are still important gaps that need to be filled. To fill them, coaches, parents, and athletes will be encouraged in Step Two in the #TeamUp4ConcussionSafety program to continue learning about concussions by taking our online concussion education course.

Because studies show that one-off concussion education isn’t enough to change concussion symptom reporting behavior, Step Three in the SmartTeams Play Safe^TM #TeamUp4 ConcussionSafety^TM game plan calls for coaches, athletes, athletic trainers, team doctors (and, at the youth and high school level, parents) to attend a mandatoryconcussion safety meeting before every sports season to learn in detail about the importance of immediate concussion symptom reporting, not just in minimizing the risks concussions pose to an athlete’s short- and long-term health, but in increasing the chances for individual and team success. (As I have learned from long experience with youth and high school sports programs, making attendance at a concussion safety meeting voluntary virtually guarantees a lot of no-shows.)

Anecdotal evidence from NCAA Division I football programs suggests that the signing by athletes of pledges acknowledging their responsibility to report concussion symptoms increases the rate of reporting by athletes, both of their own symptoms and those of teammates. Because improving concussion safety requires a team effort, we believe that all those with a stake in concussion safety should sign pledges, not just athletes. Step Four of our concussion safety game plan thus calls for athletes, coaches, parents, and medical staff to demonstrate in a tangible way their commitment to creating a culture in which immediate reporting of concussion symptoms by athletes is a valued team behavior and the sign of a good teammate by signing a concussion safety pledge at or shortly after the pre-season concussion safety meeting,

And, finally, because prevailing attitudes towards concussion symptom reporting and reporting behavior are deeply entrenched in our sports culture, we encourage, as Step Five, that coaches, athletes, athletic trainers, team doctors, and parents continue working over the course of the sports season to create and maintain an environment in which athletes feel safe in immediately reporting concussion symptoms (both their own and their teammates) by sharing and reinforcing positive messages about the importance of immediate concussion symptom reporting via social media, by maintaining open lines of communication and an ongoing dialog about concussion safety among and between and among coaches, athletes, medical staff and parents.

With consistent messaging and constant reinforcement of the value of immediate concussion reporting in achieving your team’s performance goals, and by making athletes feel comfortable in reporting, we believe that, not only will attitudes and beliefs about concussion reporting begin to change, but the concussion reporting behavior of your athletes will start to change as well, and that, over time, the culture of resistance to concussion symptom reporting will be replaced by a sports culture of concussion safety.

First published on Huffington Post on September 11, 2017 

Brooke de Lench is a pioneer in child athlete safeguards and rights, a risk reduction in sports and legal consultant.  She is Founding Executive Director of MomsTeam Institute, Inc., Producer/Director/Creator of the documentary, “The Smartest Team: Making High School Football Safer” (PBS). Director of Smart Teams Play Safe, Publisher of MomsTEAM.com, and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), and Brooke is also a founding member of the UN International Safeguards of Children in Sports global coalition.

She can be reached by email delench@MomsTeam.com, and you can follow her on Twitter @BrookedeLench.

When one recent email prompted me to pick up the phone to talk to one concerned mother, she told me that her son – who had suffered a concussion playing indoor lacrosse, but, seven months later, and after seeing a number of concussion specialists, was still experiencing symptoms – was giving up hope of ever getting better.  Most disturbingly, she said he had begun expressing the belief that he might be better off dead, because at least then he would no longer be a burden to his family and community and, if his brain ended up in a jar next to those of other athletes who also had CTE, perhaps might find a place in medical history.

My reaction was one of sadness, frustration, and worry: sadness that a young athlete simply assumed that he had CTE as a result of a single concussion and considered it to be a death sentence; frustration that, despite concerted efforts by researchers and clinicians, along with some in the media, to set the record straight on CTE, the prevailing media narrative continues to be that concussions or repetitive subconcussive blows “cause” CTE, that CTE “causes” former athletes to commit suicide, and that such causal links are proven scientific fact (they’re not); and, finally, worry: concern about the consequences of the football=dementia and CTE=suicide memes in the real world.

For the authors of a 2016 editorial in the British Journal of Sports Medicine the tragic case of a former NHL player, Todd Ewen, is Exhibit A of those real-world consequences.  Suffering from bouts of depression – which he was convinced were the result of CTE – and terrified at the thought of a future living with an untreatable neurodegenerative disease, Ewen committed suicide at age 49.  But before an autopsy could even be performed, the media’s verdict was in: his depression and suicide were most likely the result of a career in the NHL, repetitive head trauma, and the inevitable onset of CTE.  A subsequent autopsy, however, found no evidence of CTE. [November 2018 update: Two subsequent autopsies of Ewen’s brain, one by Dr. Ann McKee, the chief of neuropathology at the VA Boston Healthcare System and director of the Boston University C.T.E. Center, and the other at the Mayo Clinic, found evidence that Ewen had a less severe case of CTE].

How, asked the authors – three researchers at Vanderbilt and an epidemiologist at the University of North Carolina – Chapel Hill – did an athlete with treatable depression come to believe that he had an untreatable condition and commit suicide?  Because, they asserted, the media, ably aided and abetted by Dr. McKee, and the PBS series, Frontline, had for years been using the results of autopsies of the brains of a small, self-selected group of former athletes to create a “sensationalized state of fear” about CTE.

To make matters worse, they argued that many in the media – most especially, in my personal experience, those active in social media – not only ignore and/or severely criticize research findings that don’t fit the football = dementia and CTE=suicide narrative, but label anyone who dares to challenge that narrative or call for further study a ‘CTE denier’ or a ‘shill’ trying to advance their own vested interests,* confuse the public and conflate the issues, or all the above.

Are cases like Ewen outliers or do they represent an increasingly common and worrisome phenomenon?  Unfortunately, it appears to be the latter.  Every clinician who routinely treat athletes with post-concussion syndrome (i.e. patients whose symptoms after suffering a sports-related concussion persist for months or years) with whom I spoke for this article expressed variations of the same concern: that their patients, hearing media reports about athletes suffering symptoms associated with CTE (such as depression), were losing hope of a full recovery, to the point of considering suicide.

“As a clinician, I see patients that come to our clinic at months and years after they’ve been diagnosed with a concussion,” said Shannon Bauman, MD, director of the Concussion North Clinic in Barrie, Ontario, Canada.  It is “very concerning,” she said, “when my patients share their story and fears that they will not recover, and are being told by physicians and other health care providers that they trust that they will likely not get better and that living with lingering symptoms was likely to be their ‘new normal.  Without hope, patients begin to believe that they will not recover,” Bauman said. “For young athletes, this can be devastating.  Without hope, they begin to believe the messaging from media focusing on professional athletes who have died and been found to have CTE.  This takes a great toll on the mental health of a patient recovering from a prolonged concussion leading to increased anxiety and depression, and even thoughts of suicide.”

The problem, argues Bauman, is that too many media stories focus on professional athletes, CTE, and poor outcomes of prolonged concussion (or sports exposure to repetitive head traumas), and [there are] too few stories about athletes who make full recoveries and improve (even after years of concussion symptoms).  This unbalanced media coverage further fuels the mindset of the public and patients who are now believing that they, too, may not recover.  We need to restore hope and share positive stories of the many patients who do recover and the importance of having medical treatment and care provided by those who have an interest in managing cases of persistent symptoms.”

Likewise, in her practice, Elizabeth Pieroth, Ph.D., Associate Director of North Shore University Health System’s Sports Concussion Program, says she has seen a number of youth patients (athletes and non-athletes) who have sustained a concussion and believe they now have or are going to develop CTE.  “On too many occasions, I have had young people crying in my office that they were going to ‘die of CTE,’ even after just one concussion.”

As heartbreaking as such encounters are, said Dr. Pieroth, she saw a silver lining: at least they afforded her the opportunity to educate them on the current state of the science on concussions and CTE.  “What worries me,” said Dr. Pieroth, “are the countless people who have the same fear but are not being seen by healthcare professionals with the appropriate training and experience to adequately address this issue.”

The experience of Dr. Rosemarie Moser, Director of the Concussion Center of New Jersey, is much the same.  “In the past year, we’ve seen more young athletes at our Center who are overly anxious and worried about CTE,” she said. “This worry has become irrational to the point that they are afraid to engage in normal activities for fear of further brain damage, even when it is clear to us that they have recovered.  It’s as if they have equated the diagnosis of concussion with doom and a sentence of irrevocable brain damage.” She pointed to one patient, a high school athlete, who had clearly recovered from his concussion – to the point that he was performing in the superior range on neuropsychological testing and getting As in school – who was nevertheless so worried, anxious, and paranoid about hurting his head again that he thought he’d suffered another concussion when he happened to turn his head quickly from side to side! She wondered whether the media frenzy over CTE was creating a new medical condition she dubbed “Concussion Anxiety Syndrome.”

Like Dr. Pieroth, she said that it was the responsibility of concussion specialists to directly address the emotional component of concussions and undo the myths to which athletes and their parents have been exposed as result of the “media hype” about CTE.  “It’s not always easy undoing the misinformation out there.  Now, it is my job not only to help manage the concussion and facilitate recovery, but to challenge the myths and educate athletes and parents about the facts.  We still do not have clear, medical, scientific data that indicates that concussion leads to CTE.  We still don’t know enough about it.  We do know that most concussions resolve, that we should expect concussions to resolve, and that there are plenty of athletes who have had multiple concussions who do not have the emotional disturbance, brain damage, and suicidality that may be portrayed in the media

Media reports on the finding by Dr. McKee and her colleagues in a new study reported in the Journal of the American Medical Association that 110 of 111 deceased NFL players her group had autopsied had CTE will undoubtedly take the level of fear among sports parents and present and former athletes in all contact and collision sports alike to even more frenzied heights.  While I was encouraged by the amount of push-back from scientists, clinicians, and researchers objecting to the way in which the media has covered the story, and cautioning that the facts about CTE are far more nuanced and uncertain that many in the media would have the public believe, I am concerned that their voices aren’t being heard.  For every article by a scientist calling for an end to the “media and public hysteria,” and for both sides to “stop campaigning for their agenda and to let science take the lead, there are one hundred, or even one thousand, which will do nothing more than repeat the study’s top-line finding: that 99% of those who played in the NFL had CTE.

I worry that lost amidst the hoopla about the new CTE study is the fact that not every football player whose brain was donated to the CTE Center for pathological scrutiny was found to have the disease, and, that it was not detected in either the brains donated by the families of football players who died before they got to high school, and in only three of fourteen of high school players (and, in those, the disease had not progressed beyond the “mild” stage).

What I found most surprising was, that as far as The New York Times was concerned, her study didn’t add to the debate about the football=dementia narrative; it ended it. According to the Times – which is widely acknowledged to have originated the football=CTE and CTE=suicide narrative in a January 18, 2007 article) – all that was left for scientists to figure out was “how many blows to the head, and at what levels, must occur for C.T.E. to take hold.”  Not only was that assertion completely at odds with the uncertain state of the existing science, but it was contradicted by the study itself, in which Dr. McKee and her colleagues acknowledged that several other factors, besides prior participation in football, may influence CTE risk and disease severity, including factors other than cumulative hits to the head, and, even more importantly, admitted that it not even clear what the relative roles concussions and repetitive subconcussive hits play in CTE risk, disease severity, and progression.

That the Times didn’t report these findings, much less bother to interview anyone for the article other than Dr. McKee, wasn’t at all surprising to me (and, I’m sure, to many scientists) for one simple reason: such uncertainty didn’t fit the Times’ 10-year football=CTE meme.

Educating sports parents and athletes about head injury safety is tough enough without the media’s sensationalistic reporting, but it does come with its rewards.  Recently, I received an email from a mother asking for help for her son, an ice hockey player, who was struggling with post-concussion syndrome to the point he was suicidal.  I reached out to the clinicians on our organization’s Head Injury Advisory Board to see if anyone could help.  One of our members responded immediately, and working with the athlete and his family, developed and implemented a treatment plan that put him on the road to recovery.  I would like to think that I played a part, however, small in possibly saving his life.

Being able to share what I have learned from my nineteen years as the youth sports safety educator has been extremely gratifying.  Now, if only the media could focus its energies on educating the public instead of sensationalizing head injuries in sports, perhaps we could stop creating such a climate of fear that athletes end up literally being scared to death.

Have a story to share? Send it to me at delench@MomsTEAM.com

*  In the interest of full disclosure, neither I nor MomsTeam Institute, the non-profit of which I am the Founding Executive Director, has ever accepted any donations from the NFL, USA Football, Pop Warner, or any equipment manufacturer.  In order to remain fully independent and objective, this has always been our policy.

Updated January 23, 2019