Gathering storm of concussions has put high school football at a crossroads


Dylan Mathias’ first experience with a head injury came when he was 10 years old and the tree branch he was hanging from snapped, sending the boy hurtling to the ground. He fractured his skull. A few years later, his mother was understandably concerned when Mathias lobbied to play football at Analy High.

“But he’s good,” said his mother, Kelley McNeal. “And he loves it.”

So he played. Last year, as a junior, Mathias was shaken up twice on the field. The first time was, by all accounts, minor. He came out of a play dazed; there was no official diagnosis. The second time was more severe. Dylan was diagnosed with a concussion, an injury that sidelined the wide receiver/linebacker for three games.

“It was definitely a struggle making these decisions,” McNeal said. “In my head I’m thinking, ‘Is it OK? Should we let him keep playing?’ It was an internal struggle.”

McNeal is not alone in her confusion and anxiety. Throughout Sonoma County, and pretty much wherever high school football is played, families are reconsidering their commitment to the sport. They have been bombarded with media reports of rampant dementia among former NFL players, not to mention the suicides of prominent players like Junior Seau and Dave Duerson.

While the commentary has focused mostly on the NFL and the lawsuits filed by more than 2,000 former players, deep concern has spread to the high school level, where 1.1million students across the country play the game.

Certainly, there is research to justify those concerns. Studies in the past decade have shown that sports are second only to motor vehicle accidents as the leading cause of brain injury among people 15 to 24 years old; that 47 percent of all high school athletic concussions happen on the football field (just under 64,000 each year); that anywhere between 50 and 90 percent of concussions at this level go undiagnosed.

Though the science of concussions remains a bit murky, one thing is clear: High schoolers seem to be particularly vulnerable. Their brains are still rapidly developing, especially the frontal lobes, increasing the potential harm of head injuries. And fostered by loyalty to teammates and an ingrained tough-guy culture, high school athletes are notoriously unreliable in reporting symptoms.

Asked if she trusts her son to inform her of a head injury, Kelley McNeal answered bluntly: “No. He wants to get back in that game.”

High school-age players seem to be at greater risk than younger youth-football players, too, because they hit with more force. Jim Hanson, president of North Bay Youth Football and Cheer — the local equivalent of Pop Warner football — said before this season that his organization hasn’t seen a diagnosed concussion in five years.

It is the high schoolers who play at the intersection of youthful exuberance and grown-up muscle. It’s a dangerous intersection.

With that in mind, Gov. Jerry Brown signed Assembly Bill 25 last October, making California the 31st state to pass legislation ordering specific handling of high school concussions in all sports. (Since then, seven other states have joined the charge, and others have pending legislation.) AB 25, which took effect Jan. 1, requires same-day removal of any athlete suspected of sustaining a concussion, prohibits the athlete’s return without written clearance from a health-care provider and mandates that parents or guardians annually sign forms with information on the subject.

One problem with head injuries, though, is that there is no simple diagnosis. Concussions are caused by the brain slapping against the inside of the skull, but they have no obvious biological markers. The classic image is a football player out cold on the turf, but fewer than 5 percent of concussed high school athletes report loss of consciousness.

“There’s no blood test you can do. There’s no scan you can do,” said Dr. Robert Nied, a physician at Kaiser Permanente’s Santa Rosa Medical Center who specializes in family medicine and sports medicine.

Instead, diagnosing a concussion involves a complex interplay of physical observation, tests of balance and cognition, and self-reported symptoms.

One approach riding a wave of momentum is baseline testing. Several competing computer models exist, each involving healthy athletes taking online, rapid-fire quizzes that test memory, concentration and problem solving. If a player is suspected of suffering a concussion, retests can help determine his level of impairment.

“The nice thing is, it’s objective data,” said Dr. Ty Affleck, who heads Santa Rosa Sports and Family Medicine. “It looks at the visual side of the brain and measures reaction time and distractibility. If all of that’s working, you’ve got a pretty good idea that you’re looking at a healthy brain.”

Studies have shown that athletes who are subject to baseline testing tend to stay off the field or court longer than their counterparts, lessening the chance of repeat injuries.

One caveat: A survey in Current Sports Medicine Reports last year found that the false positive rate of the ImPACT program — the dominant baseline model, and the one Affleck has introduced at both Sonoma State University and Santa Rosa Junior College — comes in at 30 to 40 percent, “and the false negative rate may be comparable.”

The urge to find an objective measurement is understandable. There is strong pressure to get back on the field, especially from the athlete himself. But as has been learned in recent years, the risk is significant. A concussive event activates billions of brain cells, spontaneously releasing neurotransmitters and leaving the brain particularly fragile. Another blow to the head during the recovery period can result in a massive, and permanent, loss of neurons.

That’s why successive concussions are so much more damaging than the first.

There are strategies that lie outside the doctor’s office. The most established is teaching proper tackling technique — eyes up, head back, lead with the chest, not the helmet. Doing it right lessens the chance of direct head impacts, especially the dangerous helmet-to-helmet collisions.

Not surprisingly, those players most involved in tackling are most prone to concussive injuries, researchers say. On offense, that means running backs face the highest risk; on defense, it’s the linebackers.

Bad technique is one reason the college concussion rate is higher at the Division III level than it is in the FBS, formerly known as Division I.

Some analysts place their hopes in better equipment, especially helmets. Austin Nahmens might be their poster boy.

Nahmens, now a senior at Piner High School, suffered one concussion as a freshman and two as a sophomore, all on the football field. He doesn’t remember the latter two happening. The last one knocked him unconscious, and Nahmens wound up missing all but four games of his sophomore season. The next year, he bought a new helmet with more substantial padding.

“I felt like the one I had was part of the problem,” Nahmens said. “It was hard and old. Ever since, it’s been night and day.”

Helmet replacement has become a big priority at many schools. Thanks to alumni financial support, all varsity players at Casa Grande have helmets that are either brand new or a year old. Maria Carrillo coach Jay Higgins estimates his program has raised $20,000 over the past two years for new helmets.

But many doctors believe it isn’t the equipment that needs our attention as much as the rules that govern how it’s used. There is historical precedent. An increase in skull fractures among high school football players in the 1960s led to the formation of the National Operating Committee on Standards for Athletic Equipment and, by 1973, to new guidelines for helmets. Unfortunately, while those helmets do prevent skull fracture, they do little to avoid concussions, and in fact have heightened the risk by making the athletes feel more invulnerable.

The most basic step toward head safety? Education. In fact, word seems to be getting around. More schools are implementing baseline testing (from 26 percent in 2008-09 to 41 percent a year later), and pediatric emergency-room visits for head injury increased almost 100 percent from 1995 to 2007, seen as a sign of greater awareness.

“There’s this deal in football between hurt and injured,” Nied said. “Hurt is something you can play through. An injury is something you have to treat so it doesn’t shorten your career. And people are now accepting that a concussion is an injury that you need to treat appropriately.”

You can reach Staff Writer Phil Barber at 521-5263 or phil.barber [at] pressdemocrat [dot] com.