Opening on an overhead shot of the Pittsburgh Steelers’ yellow-and-black stadium, the trailer for the 2015 biographical sports drama “Concussion” wastes no time before showing its hand.
Somber piano music interweaves with the lilting Nigerian accent of neuropathologist Dr. Bennet Omalu, portrayed by a sanctimonious Will Smith, as he uncovers a degenerative brain disease caused by repeated blows to the head. Discovered in 2002 while autopsying former professional football players, the disease — which Omalu names chronic traumatic encephalopathy — severely and permanently damages the brain, causing symptoms ranging from memory loss to social instability to impeded speech.
Forty seconds into the trailer, Omalu’s wife Prema Mutiso — played by Gugu Mbatha-Raw — voices the film’s central conflict:
“If you don’t speak for them, who will?”
Fourteen years after the events in “Concussion” took place, that question still lacks a definitive answer. Despite increased awareness and research funding, traumatic brain injuries remain among the most contentious and misunderstood topics in modern medicine.
But one set of institutions has recently begun to step up: college athletic conferences. In the last decade, concussion prevention education in American universities has expanded dramatically, overhauling safety regulations and creating new opportunities for collaborative research. With the strictest safety regulations in all of Division I athletics and a multimillion-dollar promise to continue research, Yale and the rest of the Ivy League are poised to take the lead on one of the most vexing problems facing modern sports.
THE MOST SERIOUS OF ALL INJURIES
Danielle Krzyszczyk arrived at Harvard University already having suffered from multiple concussions. Recruited to play ice hockey, Krzyszczyk had already been concussed three times — the last of which occurred in her final game as a senior in high school — while playing for the St. Mary’s Flames in Winnipeg, Canada, her hometown.
Just two months into her freshman year, Krzyszczyk was diagnosed with another concussion. Krzyszczyk returned to the ice for her sophomore season, but in the first game of the year, sustained another hit to the head. Suffering through a three-month headache, she struggled to complete her coursework, even dropping a class. Today, six months after being diagnosed with her fifth concussion, she said she is still experiencing symptoms and has not yet been cleared to skate again.
Krzyszczyk’s story, while extreme, is very common. According to a study conducted by the Centers for Disease Control and Prevention, an estimated 3.8 million Americans sustain concussions during athletic or recreational activity each year.
A concussion — also known as a mild traumatic brain injury or mild head injury — occurs when an impact or impulsive force acts on the brain, jarring or shaking it. While impact forces, including blunt trauma, are commonly associated with concussions, impulsive forces, such as whiplash, can cause similar effects. And after analyzing more than 100,000 impacts over five years of football practice, neurology researchers from the University of North Carolina argued that the magnitude of impact does not clearly correspond to symptom severity or cognitive function. Essentially, almost any type of blow to the head can cause a concussion, regardless of amount, location or magnitude of force applied.
“It is a tough injury because no one can see if you are in pain, because there is no visible bruise or cast. It’s just all about your description of what you are feeling,” Krzyszczyk said. “It truly becomes a mind game of whether or not you tell the truth, or hide it and keep playing.”
Sustaining a single traumatic brain injury leaves an individual more susceptible to additional damage. Concussions operate on a negative progressive cycle: after a person has suffered a traumatic brain injury, smaller impacts can lead to more severe symptoms. These effects can build on one another, as a group of researchers based out of the biomedical research Roskamp Institute discovered, and repetitive injuries produce behavioral and pathological changes that last even longer.
Size does not even matter: the term “minor concussion” is oxymoronic, the American Association of Neurological Surgeons stresses, as its formal medical definition of the injury is designated by “immediate and transient alteration in brain function … resulting from mechanical force or trauma.” Research has demonstrated that the physiological changes accompanying a minor traumatic brain injury sometimes last for months, even years.
But none of this was known until around 30 years ago, and as a result, concussion protocol throughout much of the 20th century was scant, at best. In 1933, the Spokane Daily News ran a series by Dr. Morris Fishbein, the then-editor of the Journal of the American Medical Association, titled “How to Stay in the Game.” In his final article, Fishbein identifies damage to the brain and skull as the “most serious of all injuries.”
“The first sign of such injury is loss of memory for recent events,” he writes. “The least important sign is a slight dizziness … The first thing to do in any such accident is to put the player immediately at rest, to determine extent of the injury. When a player has had a head injury, he should be put into a reclining position, questioned as to headache and the dizziness, and given the test as to his memory for recent events.”
Despite the dangers inherent in early football, the sport’s flagrant brutality did nothing to improve concussion awareness. Though the occasional student death would appear in a newspaper (although sometimes, as in 1905, when 18 people died playing football, it was more than occasional), it was the game — not the medical treatment — that underwent a reformation. Many of these major changes came from New Haven, where “father of American football” Walter Camp, class of 1880, played and returned to coach in the late 19th century.
And even after the introduction of helmets, as well as rules banning some of the more dangerous plays, concussions remained a significant challenge for an evolving medical community. With little physiological evidence and brain imaging still decades away, doctors resorted to treatment modalities predicated on cognitive and physical rest, the reduction of sensory stimulation and management of symptoms.
Even the Ivy League’s concussion policy, conservative for its time, relied on rest. According to Director of Sports Medicine Christopher Pecora, in the mid-’80s, the League mandated that any student-athlete suffering from a concussion sit out 10 days, regardless of injury severity.
“Coaches used to dislike this rule,” Pecora explained, “because in the ’80s, all the opposing teams would know the rule. So if someone got hurt, the next team [Yale played] would know he would be out. Then the research came in, and said you don’t have to have this arbitrary 10-day rule. People began to treat each specific concussion rather than use a blanket rule.”
During the following decade, Pecora added, protocols improved and treatment became further personalized as the medical community amassed information. Thanks in part to the concurrent advent of computerized axial tomography and magnetic resonance imaging — more commonly known as CAT scans and MRIs — doctors and researchers could examine detailed images of the brain in various states.
Though concussions still existed in a murky area, Yale athletics began to take them more seriously. The football team began tackling head injuries with new vigor, to mixed reviews from the student-athletes. (In 1986, the News quoted linebacker John Quinn ’87, who was frustrated that he was not able to “hit like [he] wants to.”)
Yale has “always been very cautious with head injuries,” said Pecora, who has been with Yale’s athletics administration for the past 32 years.
“The whole time I’ve been here, we’ve always been lucky to have team physicians that felt that it was important to be really versed in treatment of concussions,” he said. “I’ve always felt like we’ve been ahead of the curve in treatment of athletes.”
STOPPING THE BRAIN DRAIN
But not all institutions were as conscious as the Ivy League. Professional leagues, particularly the NFL and NHL, have a long history of either denying or failing to fund concussion research. As recently as March, the same month the NFL’s top health and safety official admitted there was a link between playing football and CTE, the NFL was accused by The New York Times of altering numbers in its seminal 1996–2001 concussion study. Two months later, Sen. Richard Blumenthal LAW ’73 sent a public letter to NHL Commissioner Gary Bettman challenging the league’s stance on concussions.
“While hockey and football are certainly different, both are full-contact sports that likely present risks to their participants,” Blumenthal’s letter read. “As the premier professional hockey league in the world, the NHL has an obligation not only to ensure the safety of your players, but to also engage in a productive dialogue about the safety of your sport at all levels — from youth to professional.”
Since 2010, the Ivy League has quietly been conducting its own dialogue about concussive hits in full-contact sports, a list that includes men’s lacrosse, football and ice hockey. That year, the League established the Ivy League Concussion Committee, an ad hoc body meant to reduce concussive hits in football. Chaired by Jim Yong Kim and David J. Skorton, the then-presidents of Dartmouth and Cornell who both have medical degrees, the committee recommended imposing practice limitations, encouraging referees to be more cautious and increasing athletes’ awareness of concussion symptoms and treatment. The committee also singled out ice hockey, lacrosse and soccer — in that order — as the next sports to re-examine, and months later established the Multi-Sport Concussion Review Committee to do just that. Wrestling and rugby, neither of which are varsity sports at Yale, have also undergone review.
In 2010, the National Collegiate Athletic Association came out with its own series of best practices for concussion management. While the committee deemed the NCAA’s guidelines “reasonable and appropriate,” the group’s final report also noted that “the recommended best practices go further than prior NCAA guidance and are also reasonable and appropriate.”
This pattern is not unusual: athletic conferences are not allowed to unilaterally make up their own rules, but are allowed to create rules stricter than the NCAA’s. The Ivy League has taken advantage of this on multiple occasions, most recently in June, when the NCAA sanctioned the League’s implementation of an experimental rule meant to minimize contact in kickoff plays, which are known to be particularly brutal. Until this year, Harvard’s head athletic trainer Brant Berkstresser chaired the NCAA’s Committee on Competitive Safeguards and Medical Aspects of Sports — the same committee responsible for this rule’s passage. The NCAA did not respond to a request for comment on the process of sanctioning the Ivy League’s rule and on concussion prevention in general.
Ivy League Executive Director Robin Harris lauded the change, pointing out that it represents “another example of the Ivy League leading the nation in concussion prevention.”
Games are not the only place where concussions occur. Practice, particularly for impact sports, also poses a significant danger. Dartmouth football head coach Buddy Teevens realized this in 2010, and banned full contact in practice. Six years later, he estimated that the annual number of concussions sustained during practice has decreased, from around 20 to just a handful.
Other Ivy League football programs similarly limited hitting in practice; so this May, when the coaches discussed eliminating to-the-ground tackling during regular season practice, the resolution to do so passed without objection.
“There’s a grow-or-die philosophy, and I’m proud to be a part of it,” Yale football head coach Tony Reno said. “It’s forced us to be innovative in practice, and to get smarter on the types of drills we run in practice. Yale football, for example, uses rugby equipment to teach tackling.”
Reno said the rule would require just a “minor change” for the team’s training, as the Bulldogs tried to limit themselves to 10 to 15 minutes of full-contact practice each week during the 2015 season.
The tackling ban does not represent the first time the League has changed practice rules to limit head and neck injuries. As adjusting practice guidelines does not require NCAA preapproval, the concussion review committees have implemented several changes, including an increased emphasis on neck strengthening, requiring coaches to devote a certain amount of time to proper stick-checking and heading technique for women’s lacrosse and soccer, respectively, and expanding concussion awareness.
“Collegiate conferences are mandated to abide by the NCAA’s concussion policy. The NCAA is a member-driven organization, meaning that any legislative changes (such as its concussion policy) must be voted on by the membership,” Christine Baugh, a doctoral student in health policy at Harvard who specializes in concussion policy, wrote in an email. “Because of this, change at the league level can take time. Because the NCAA rules set the minimum acceptable standard, conferences which are smaller and can act independently are able to go above and beyond to protect the health of collegiate athletes.”
But there are certain built-in advantages for the Ivy League — for instance, the structure of its football season. With a shorter preseason and just 10 games (as opposed to the normal 12-game season, plus any postseason or bowl games), Yale and its fellow Ancient Eight teams play fewer minutes than other Division I football programs.
Despite the focus on concussion prevention, the number of concussions has remained about the same over the last five years, while severity has lessened, according to Pecora. And, he added, as treatments improve, Yale has become more sensitive to concussions’ long-term effects. This sensitivity is paralleled by the student-athletes themselves, many of whom enter Yale already aware of concussions, their symptoms and the dangers they pose, Pecora said.
Still, the issue of underreporting remains germane. Although student-athletes might be more aware of what a concussion is, they often consciously ignore it in an effort to remain with their teams, Krzyszczyk said. Calling it “a self-assessment kind of injury,” Krzyszczyk questioned whether or not concussion education effectively taught student-athletes the importance of accurately reporting their symptoms.
Though three athletes at Yale expressed similar concerns, others pointed out the effectiveness of the University’s concussion awareness campaign.
“Every year we watch an NCAA video about concussions that encourages us, ‘Don’t hide it, report it, take time to recover,’” women’s soccer captain Colleen McCormack ’17 said. “Our trainers also take it very seriously, so it’s almost a given that we all take care of each other regarding concussions — meaning we would encourage a teammate to report it and ensure they’d make the best decisions to properly recover.”
Krzyszczyk, now a junior at Harvard studying cognitive neuroscience and evolutionary psychology, has become somewhat of a spokeswoman for concussed student-athletes. In July, she, alongside five other student-athletes, participated in a panel at the fourth annual Big Ten/Ivy League TBI Summit to discuss what concussions mean to them.
Announced in June 2012, the Big Ten/Ivy League Traumatic Brain Injury Research Collaboration unites 23 schools from the Northeast and Midwest in a research consortium that will use data from more than 17,000 student-athletes to better prevent, detect and treat concussions.
The 17,000 students represent a myriad of sports, a significant change from earlier major concussion studies, which largely drew data from football.
Baugh, who spoke about athlete symptom reporting and collaborative research opportunities at the TBI Summit in July, emphasized the need to look beyond football in concussion research and awareness.
“Don’t get me wrong, the repetitive brain trauma inherent in the game of football is an important area of inquiry,” she wrote in an email. “However, in focusing research and media attention on football, we are not addressing the issues particular to male athletes in other sports, and female athletes overall.”
The 17,000-person sample size alone places the collaboration among the all-time most significant studies undertaken by American universities, but with more than 500 researchers and 600 team physicians or trainers, its manpower further distinguishes it as one of the most concerted information-collecting efforts.
Furthermore, eight of the 23 participating universities boast medical schools that rank in the top 20 nationwide, according to U.S. News & World Report. This provided the impetus for the collaboration: According to Pecora, the Big Ten originally reached out to the Ivy League because it believed the medical schools in both leagues could effectively work together to pool information.
Director of Athletics Tom Beckett was enthusiastic about the collaboration, highlighting its benefits for student-athletes.
The medical schools’ partnerships crisscross the conferences, as each university dedicates resources to a particular set of projects or research focus. For example, a seven-university team that includes Dartmouth and Princeton has taken on biomarkers and recovery in sports-related concussions, while six Big Ten schools are working on concussion neuroimaging.
At the annual TBI Summits, representatives from the schools come together to update one another on projects, share abstracts and hear from speakers. This year’s summit, held in Philadelphia in July, featured keynote speaker John York, current San Francisco 49ers co-chairman and the chair of the NFL Health & Safety Advisory Committee.
The collaboration first addresses the information gap arising when an issue has only recently come under scrutiny.
“The first thing to do is to accumulate enough data to start to see trends,” Pecora said. “As the data develops, you can see trends and adjust treatment or change rules. For example, failing to penalize helmet-to-helmet hits may spike a trend in concussions in football.”
While some of this data is easily gleaned, other research undertakings rely on subjects. This topic is one that Krzyszczyk and her five fellow panelists took on at this summer’s student panel at the TBI Summit.
“We all agreed that understanding how much pain we are truly in and little energy we have is key,” Krzyszczyk said. “Having a concussion and trying to maintain your academics while trying to heal for your athletics definitely takes a toll on you. Adding extra hours for research will be difficult, but necessary, and should definitely be thought of when preparing to conduct research.”
Although she praised Harvard’s concussion education, she again cautioned against underestimating the frequency at which underreporting occurs.
Krzyszczyk ended by apologizing for any grammatical or syntactical errors.
“I am still kind of affected cognitively by this concussion and don’t necessarily notice my mistakes,” she said.
WHAT COMES NEXT?
As the Big Ten/Ivy League collaboration is open-ended, research will continue to pour in. But the consortium opens up a question with no clear response: What is — and what ought to be — the role of a college athletic conference?
This is a difficult question to answer, given the wide variety that exists even between Division I conferences. Other than NCAA guidelines, there is very little that binds athletic conferences together, and leagues have made varying use of the individual autonomy they are granted. College athletics occupy a strange no man’s land between recreational and professional sports, and since most conferences drift toward one end of the spectrum or the other, it is nearly impossible to make a sweeping generalization about them.
Additionally, athletics and American universities are inextricably linked — although student-athletes are not paid, they are a vehicle by which many schools bring in money. The financial interest in preserving the status quo cannot be ignored. The tension between a safe playing environment and contact sports’ inherent brutality will only deepen as conferences seek to balance the safety of student-athletes with the revenue they bring in.
Until recently, the NCAA granted significant autonomy to conferences, allowing them to dictate rules about concussion protocol and when student-athletes can return to their teams. As a result, college sports’ governing body has been less proactive than the Ivy League and other member conferences in combating concussions, and none of the organization’s seven core values directly address safety.
But a class-action lawsuit, filed in a Chicago U.S. District Court in 2011 and resolved three years later, is perhaps more indicative of how public opinion will lead the NCAA on this issue. The settlement required the NCAA to bookmark $70 million for concussion testing and diagnosis of current and former student-athletes, plus $5 million for research, the implementation of return-to-play guidelines and the establishment of new educational initiatives. The results of this arrangement will likely not pay off for several years, but the settlement represents a new — or renewed — commitment to student-athlete safety by the NCAA.
It is unclear if the Ivy League is leading athletics toward a safer future — perhaps, as snarky online commentators suggest, it is only leading toward a dumbed-down game that will eventually become unrecognizable as America’s favorite head-bashing pastime. But Yale promises to set its student-athletes up for the long-term, and for a future in which their degree will be an asset. With this goal in mind, do Yale and the Ivy League have a special responsibility to protect their athletes? Perhaps suggesting such is Ivy League exceptionalism at its finest, but Ivy League Executive Director Robin Harris maintains the League’s goal is simple, if optimistic.
“We’re not trying to change the nature of the game,” she said. “We’re just trying to make it safer.”