Football players at both the college and professional levels have the reputation for being some of the toughest people in the world, able to endure pain that would reduce most people to tears while still performing at a high level.
For years, when a football player was shaken up after a hard hit, he was sent right back into the game. Dallas Cowboys quarterback Troy Aikman was renowned for continually playing with post-concussion symptoms.
"In Troy Aikman's category, he had very well diagnosed concussions with memory loss, difficulty regaining memory and things like that, yet he continued to play," Head University physician and President of the American College of Sports Medicine Dr. James Moriarty said. "It was estimated he was playing every game with some concussive symptoms."
However, recently sports medicine has begun to focus more on the devastating effects repeat concussions can have on all athletes.
"That's where sports medicine comes into play … I think it is a good thing that we are much more sensitive to head injuries now then we were 10 or 20 years ago," University physician Dr. Rich Jacobs said. "Certainly there is a recognition that certain sports put you at a higher risk for dramatic brain injuries or concussions."
Jacobs said concussions are common in high impact sports played by many Notre Dame athletes, including soccer, lacrosse and football. Players are routinely checked for concussions on the sidelines, he said.
"On the very first play of the game against Washington, we had a player who was blindsided," he said. "When he got up he was confused enough to be going to the opposite sideline … It was quite clear that he was not thinking clearly … so he watched the rest of the game on the sideline."
Jacobs said before an athlete is cleared to play, all of the symptoms of a concussion, such as nausea, dizziness, memory loss and headaches, should have faded.
"Before that person is cleared to go back to play, all the symptoms need to be resolved — no more headaches, no more nausea, no more feeling confused," he said.
The increased interest in concussions has come after reports of retired college and professional players reporting higher instances of dementia. According to a Sept. 29 New York Times article, a recent National Football League study found Alzheimer's disease or similar memory-related disorders appear at a rate of 19 times the normal rate in football players aged 30 through 49.
"That's in NFL football players," Moriarty said. "But what is the percentage of NFL players in the population? NFL players are at risk because of what they do. You would expect in a high risk pool to have a higher concussion rate and dementia rate based upon their exposure."
Moriarty said the real impact of the study will be on the new NFL collective bargaining agreement, but the rate of concussions among even high school football players has been high.
"There's about 1.5 million kids that play football in high school. They think that the incidence of concussion per year is somewhere in between 10 and 20 percent," he said. "So you can do the math — there are a lot of concussions."
Moriarty said the real danger with concussions is if they go untreated. If a player is put on a field after recently sustaining a concussion, he could be affected by second impact syndrome.
According to an Aug. 25 New York Times report, at least four high school players have died after suffering head injuries on the field, most from second impact syndrome.
Moriarty said interest in second impact syndrome rose after a high school player in Colorado died in the 1990s "from a relatively minor concussion."
However, second impact syndrome can sometimes be difficult to prevent because concussions are so difficult to diagnose.
"It is very difficult to define a concussion. It is actually a constellation of symptoms," Moriarty said. "There's a lot of efforts to identify a concussion … in people exhibiting unusual symptoms during a game where there is contact going on."
Moriarty said the difficulty in diagnosing concussion has made gathering reliable data harder.
"Those efforts resulted in a lot of new data in, for example, how many kids had symptoms of concussions during games, which is not the same thing as how many kids have concussion during a game," he said. "We know what the denominator is in terms of how many people play football or soccer. What we don't know is the number that truly have concussions."
Jacobs said those players who sustain one concussion sometimes are at a greater risk for future, more serious concussions.
"People that have multiple concussions oftentimes will have a lower threshold for trauma that causes their subsequent concussions," he said. "The other problem you see in a person that has had multiple concussions is they don't clear up."
Moriarty said he knew of two studies that differed on whether those who sustain one concussion are at an elevated risk.
"The fear has been that once you have a concussion, you're going to get more and more and more, and that is possible but it is by no means certain," he said. "If you continue to play high risk sports, then your chance of having a second concussion is pretty high, but that doesn't mean it comes from less and less trauma."
Moriarty said one famous case he knew quite well was Florida quarterback Tim Tebow, who was knocked out of a game two weeks ago after sustaining a severe concussion. Tebow was examined by a former Notre Dame sports medicine fellow.
Many fans saw Tebow vomiting on the sidelines before he was taken to the locker room, and some members of the sports media criticized Florida coach Urban Meyer's decision to allow him to play last Saturday.
"I happen to know it was extremely well managed," Moriarty said. "There is very well laid out criteria in terms of when you return someone to competition. They have to go through a series of steps and they have to meet each of the goals along the way."
Moriarty said a "shotgun statistic" was that it took 80 percent of people five to seven days to recover, 15 percent took two to three weeks and five to 10 percent of people took two to three months.
"Everybody's different, so somebody might be able to take a hit better than someone else," Jacobs said.
Moriarty said despite the vigilance of the sports medicine staff, some players that sustain concussions are never examined.
"Are there people that have probably had dings and minor concussions after a game that we don't know about? Yes absolutely there is," he said.
Moreover, Moriarty stressed many things in everyday life put people at risk for concussions.
"Is the numerator of the number of people that have problems long-term in [football] greater than the average population? Probably so, and by a small percentage," he said. "But, everybody has exposure to automobile accidents, ski trauma, skateboarding — we're at risk for a lot of things."
But Moriarty said the impact a concussion or series of concussions could have can be serious.
"It only takes one serious concussion to have long-term effects," he said. "It depends one what area of the brain and how much."
In addition, Moriarty said college and high school athletes could be at a much greater risk of developing long-term disorders due to concussions because of the brain is not fully developed.
"We don't really know if it is not more problematic in a younger person because the brain is still developing," he said. "The younger you are, it may be that there is increased risk."
Both Moriarty and Jacobs said they have had to tell Notre Dame athletes that their careers were over due to concussions.
"We are very much interested in that athlete that has multiple concussions," Jacobs said. "And in fact, last year, one of our football players was not allowed to continue because he had multiple concussion over the years."
Jacobs said the threats from concussions must be taken seriously because sometimes effects can be seen "even a year or two years down the road."
Jacobs compared the effects with a child who falls out of a tree and is "just never the same again." He said he could imagine a Notre Dame graduate who suddenly finds themselves unable to focus or developing learning disorders.
"Now, somebody graduates from Notre Dame … and here's someone that was a good student and is on top of the world, but now they're having difficulty," he said. "It's not just sports, it's life."
Jacobs said the game of football is constantly evolving, and improved equipment and some rule changes, such as the anti-spearing rule, have been effective in decreasing the number of concussions.
"There was an immediate improvement and lessening of head injuries [after the anti-spearing rule was instituted in the 1970s]," he said.
Both Moriarty and Jacobs said there is still a lot to learn about the long-term effects of concussions.
"We're just kind of scratching the surface trying to figure out all there is to know," Jacobs said.
