It has been a good two weeks for parents looking to make high school football safer, with a number of promising developments. But it is not time to declare victory, and many questions remain to be answered.
More Lystedt laws
First, on the legislative front, three more states (Tennessee, Georgia and Montana) enacted Lystedt concussion safety laws, bringing to 45* (plus the District of Columbia) the number now requiring that schools (and, in some cases, as with Georgia, independent youth sports organizations using public fields):
- educate youth athletes and their parents, and, in some cases, coaches, about the signs and symptoms of concussions, the dangers of continuing to play with concussion, and acknowledge receipt of a concussion information form as a condition for playing sports;
- remove from play any youth athlete suspected of having suffered a concussion and not allow them return to play that day; and
- require written clearance from a licensed health care professional trained in the evaluation and management of concussions before an athlete can return to play.
Two more states (South Carolina and West Virginia) are moving towards passage of Lystedt laws. [Update: Both states have since enacted Lystedt laws, bringing the number of states with such laws to 47, plus D.C.]
What about the remaining three states (Arkansas, Wyoming and Mississippi)?
In the case of Arkansas, its legislature recently appropriated $1 million for a pilot concussion management project, and, under guidelines issued by the Arkansas Activities Association, the state's governing body for high school sports, student-athletes suspected of having suffered a concussion must be removed from play immediately, cannot return to play within 24 hours after concussion, and only then after obtaining a written release from a medical professional current in concussion management clearing the athlete to begin a mandatory 5-day graduated return to play protocol.
Wyoming's youth sports concussion safety law (Chapter 190), signed into law in March 2011, requires the state Superintendent of Public Instruction to develop a model protocol and to assist school districts in developing protocols for addressing risks associated with concussions and other head injuries from school athletics, and that school districts adopt protocols to address risks associate with concussion and other head injuries, including providing training to coaches and trainers, restricting a student's participation in sports after suffering a concussion or head injury, and distributing educational information to students and parents, but does not, among other things, require removal of athletes from games or practices if they are suspected to have suffered a concussion, or require medical clearance before return to play.
That leaves Mississippi as the only state in the country without any legislation or athletic association rule on concussion safety, enacted or pending.
Effectiveness of laws remains to be seen
Simply passing laws, of course, won't be enough, by themselves, to improve the safety of contact and collision sports such as football, lacrosse, hockey and soccer. Such laws need to "be open to ongoing review and amendment as new scientific knowledge about sports concussions is discovered and the best and most effective ways to implement such laws are learnt." 
Limiting full-contact practices
Perhaps just as noteworthy, the last two weeks have seen the governing bodies for high school football in three states (Arizona, Washington, and Texas) move to limit contact practices. MomsTEAM has long been an advocate for sensible limits on full-contact practices, as part of a multi-pronged approach to comprehensive concussion risk management we call the Six Pillars featured in our new high school football documentary, The Smartest Team.
Intuitively at least (more about that point in a moment), it makes sense to limit the number of times football players are exposed to the kind of impact forces that can result in concussions or brain damage from the cumulative effect of impacts which, according to at least two recent studies,[3,4] may lead - emphasis on the word "may" - to short-term, and potentially long-term cognitive and emotional problems, or, in an unknown, but believed to be very small, percentage of cases, to degenerative neurological conditions such as chronic traumatic encephalopathy.
First up, Arizona, where the Executive Board of the Arizona Interscholastic Association voted on April 15, 2013 to limit contact practice (padded athletes in contact with each other) in the pre-season to no more than 1/2 of practices, and to no more than 1/3 of practice time in the regular season. In doing so, the state claims to be the first in the nation to reduce off-season and in-season contact practices. While I think it is right in making that claim with respect to in-season contact practices, it appears that Iowa beat Arizona to the punch on pre-season contact practices (a shout out to one of MomsTEAM's Facebook followers, Kevin Fleming, for alerting us to the action taken in the Hawkeye State), and that doesn't count the 19 states that already ban off-season full-contact practices altogether.
What can't be denied is that Arizona has been out front on concussion safety in a number of respects in recent years. In 2011, it became the first - and, as far as MomsTEAM is aware, the only - state in the country to require high school athletes to take and pass a concussion education course in order to play sports. According to the AIA, the course, called Brainbook, has been completed by more than 150,000 students.
Arizona was also the first to require that a player whose football helmet becomes dislodged during play to come out of the game to allow for a sideline concussion assessment and an inspection of the helmet to insure that it is fitting properly before being allowed to return to play. That rule served as a model for a similar rule enacted by the NFHS in 2012. (A properly fitted helmet, by the way, is one of the steps football programs can take to minimize concussion risk we feature in The Smartest Team, not because a properly fitted helmet necessarily reduces the risk of concussion, because, at this point at least, there are no peer-reviewed studies to prove that one does, [1,5,6] but because there is at least some evidence  that an improperly fitted helmet does put an athlete at increased risk of head injury). Arizona's Lydstedt law is also one of the few to allow parents to remove players from practice or game action in case of suspected concussion. (As The Smartest Team documentary demonstrates, and as I argue in my book, Home Team Advantage, it is often parents, especially mothers, who are most concerned about the safety, not just of their child, but every child on the team).
In announcing the limits on contact practices, Dr. Javier Cardenas, chair of the AIA Sports Medicine Advisory Committee, which recommended the new rule limiting contact practices, said, "I am proud of the leadership the AIA has demonstrated. By taking such unprecedented action, they are demonstrating the level of concern that exists to keep Arizona's kids safe. It makes me proud to be an Arizonian." You should be proud, Arizona!
Texas rule: sleeves off the coach's vest?
Next up, Texas. On April 21, the Medical Advisory Committee of the University Interscholastic League (UIL), which, despite its strange name, is the governing body for high school sports in Texas, unanimously recommended limiting football programs to 90 minutes of full-contact, game-speed practices (with tackling and blocking to the ground) per player per week during the regular season and playoffs.
According to news reports, the recommendation, which is expected to be approved by the UIL Legislative Council when it meets in June and must be signed by the Texas Commissioner of Education to become effective, was in response to a bill introduced in the Texas House that would have limited full-contact practices to one per week, and which was later amended to provide for 60 minutes of full-contact practice time per week. (That bill has now been withdrawn by its sponsor.)
The Medical Advisory Committee, however, was careful not to place similar restrictions on spring football or preseason practices, where the majority of teaching and instruction on blocking and tackling techniques takes place. As things stand, Texas currently allows 18 days of off-season football, among the most in the nation. It should come as no surprise that Mississippi, the only state without a concussion safety law, allows the most: an astounding three weeks!
Interviewed for the story by the Dallas Morning News, most coaches thought that the new rules would not drastically change what they were doing already because their players didn't tackle to the ground during in-season practices anyway. "I don't think there a whole lot of people that are full-contact, live game speed like that much anymore," said one. An article in another Texas newspaper reported much the same: that the new rules wouldn't result in much a change in current practice, which is to limit full-contact practice (as defined by the proposed rule) to about 15 minutes a week (although it is perhaps telling that the reason, said coaches, was to make sure that there were enough healthy starters come Friday night).
Some expressed concern that the rule would "open the door for more injuries," although it seemed that the concern - at least as far as I could tell from the comments to the articles online - was more about bureaucrats taking decision-making out of the hands of coaches, as reflected by the comment of one coach who grumbled in an interview with Lubbockonline.com, "I don't know what's wrong with the way it's been. The coaches are the commanders on the ground and they probably know more about what they need than someone in Austin who's been behind a textbook."
Washington State: No more camping out?
Last, came word on Monday, April 22, 2013 that the Washington Interscholastic Athletic Association had voted to limit high school football practices during the offseason, reducing to 10 the number of full-contact practices a team could hold after the end of spring sports and to 20 the total number of coach-supervised practices before pre-season football. According to the Belleville Reporter, common practice in the Seattle area had been for schools to engage in ten days of spring football, passing camps or seven-on-seven tournaments in the summer and a team camp at a local college which included controlled scrimmages with other schools. Seven-on-seven competitions and team camps are covered by the new 10 day limit.
"We'll have to get creative," one coach told the Reporter, admitting that the new rules would make it "harder to do a team camp and full spring ball," but that it would be far from the death-blow that some around the state were making it out to be.
Contact limits: throwing baby out with bathwater?
As many of MomsTEAM visitors and readers of this blog know, I spent a lot of time last year closely following a football team in Oklahoma for The Smartest Team, attending practices, scrimmages, and games. Among the experts who parachuted into Newcastle to help set up a comprehensive concussion risk management program was Coach Bobby Hosea, whose heads-up tackling technique is being implemented at all levels of the game. After watching Bobby spend a full day working with the players on learning how to tackle, and talking to players about limits on full-contact practices, I came away with mixed feelings about limiting the amount of days of tackling.
While I think, on balance, that the recent movement to limit full-contact practices will, in theory at least, make the game safer, there are a number of reasons why caution should be the byword.
First, as the authors of a March 2013 review of current risk-reduction strategies in the British Journal of Sports Medicine (1) caution, in enacting rules such as limits on full-contact practices, high school athletic associations and state legislatures "need to carefully consider potential injury 'trade-offs' associated with the implementation of injury-prevention strategies, because every change may have certain advantages and disadvantages. That is, by reducing one risk or danger, additional risks may be created."
In other words, could limits on full-contact practices create additional risk of injury to players because they haven't spent enough time practicing proper tackling? There are those who believe limits on full-contact practices, taken too far, could do just that, among them experts like Coach Hosea and Dr. Guskiewicz.
As Bobby and other coaches say about practice, "If you want to be better at playing an instrument, you need more practice, not less. A new lanquage? More not less. So, why are we limiting practice?" For his part, Dr. Guskiewicz believes that one of the principal reasons it is better for athletes to start playing tackle football before high school is in order to learn how to tackle, and that delaying the start of tackle football until age 14, as recommended by some experts, may perversely result in more head injuries at the high school level, not less. He argues that, while there are trade-offs, contact and collision sports are relatively safe for younger athletes as long as the coaching emphasis is on protective skill development. He notes that there are very few catastrophic injuries at the youth level, with most occurring among 16-17-18-year-olds who are playing contact and collision sports without having developed such protective skills. "We need to find ways to keep our kids physically active so they don't become couch potatoes," Guskiewicz says.
What do the players themselves think about limiting full-contact practices? Well, my completely unscientific survey of Newcastle players suggest that they are concerned that it might expose them to more, not less injuries. One told me that he felt that "if you went out at practices, didn't have contact, didn't have near the amounts of impacts you receive in the game, it would almost be a surprise to you when you got to Friday night."
It may be true, as Forbes magazine blogger Bob Cook argues in his story on the movement to limit full-contact practices during the off-season and in-season, that coaches who oppose such limits are old-school in that "none of [them] grew up during a time when anybody gave a rat's petute about concussions, [and] are going to have to adjust, for better or worse, to contact and practice restrictions in the name of saving their sport."
But, let's not go totally overboard here, folks, and end up throwing the baby out with the bathwater.
Concussion "holy grail": a long way off
Which brings me to my second note of caution, which is that medical science has not, despite throwing millions of dollars at the problem, thus far been able to come close to establishing a impact force threshold for concussions, [1,9] and is likely an even longer way off from establishing a threshold for the number of sub-concussive hits a player has to sustain before the risk of short-term, much less long-term, brain injury becomes unreasonably high.
I agree that it makes intuitive sense to reduce total brain trauma. It is hard to argue with that. But whether a headlong rush to limit contact is the best approach, and is backed up by the science, that's something else entirely.**
I will have more to say on this subject after completing a comprehensive review of the peer-reviewed medical literature on impact thresholds, and conducting a detailed critique and analysis of the arguments being advanced in support of imposing strict limits on the number of hits. But what I, and MomsTEAM's Senior Health and Safety Editor Lindsay Barton, have seen so far suggests that a cautious approach is indeed warranted.
Watch this space.
*Update: Since this blog post was written, two more states (South Carolina and West Virginia passed Lystedt laws, bringing the total to 47).
** Update: In a study published after this blog was written, by researchers at the University of Michigan agreed that caution in imposing limits on full-contact practices for precisely the reasons I have outlined. While finding that reducing result in an 18% to 40% reduction in head impacts respectively over the course of a high school football season, reports a new study, Concussion experts agreeLimiting or eliminating contact practices in football would  which says that, until the risk factors for chronic traumatic encephalopathy (CTE) are better defined, and research shows that reducing the time spent learning to tackle in practice will not lead to increased risk of concussions in games, policymakers should proceed with caution in imposing such limits.
While describing the goal of reducing the overall number of head impacts that high school football players sustain in a season as "logical" and "appealing," lead author, Steven P. Broglio, PhD, ATC, of Michigan NeuroSport and Director of the NeuroSport Research Laboratory at the University of Michigan, concluded that, "until the risk factors for CTE are better defined by carefully designed and controlled research," and research determines "what the advisable limit to head impact exposure should be," employing contact limits or establishing "hit counts" will remain "educated guesses, at best."
Brooke de Lench is Producer/Director of the new high school football documentary, "The Smartest Team," Founder/Publisher of MomsTEAM.com, and the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins)
1. Benson B, McIntosh A, Maddocks D, et. al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013;47:321-326.
2. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion legislation one year later - what we have learned: a descriptive pilot survey of youth soccer player associates. PM R 2012;4:427-435.
3. Talavage T, Nauman E, Breedlove E, et. al. Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion. J Neurotrauma 2010; DOI: 10.1089/neu.2010.1512.
4. March N, Bazarian JJ, Puvenna V, Janigro M, Ghosh C, et. al. Consequences of Repeated Blood-Brain Barrier Disruption in Football Players. PLoS ONE 2013;8(3): e56805. doi: 10.1371/journal.pone.0056805.
5. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.
6. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)(data is "insufficient to support or refute the superiority of one type of football helmet in preventing concussions).
7. Torg J, Boden B, Hirsch H, Fowler J, Gaughan J, Comstock RD, Tierney R, Kelly P. Athletic Induced mTBI and Catastrophic Intracranial Injuries: Determining Helmet Efficacy and Predisposing Injury Profiles. Presentation Paper OSSM 2012.
8. Alan Schwarz, "Teaching Young Players A Safer Way To Tackle." New York Times, December 25, 2010 (http://www.nytimes.com/2010/12/26/sports/football/26tackling.html?pagewa...)
9. Broglio SP, Martini D, Kasper L, Eckner JT, Kutcher JS. Estimation of Head Impact Exposure in High School Football: Implications for Regulating Contact Practices. Am J Sports Med 2013;20(10). DOI:10.1177/036354651302458 (epub September 3, 2013).
Updated September 25, 2013