Concussions and Sports

With the start of the American football season, and with hockey just around the corner, it is time for that new annual sports ritual: pontificating and equivocating on the implications of games that grievously injure brains.

In the context of sports such as football and hockey this ritual most often starts with questions about technology. Can’t we just come up with better helmets? Or better monitoring systems? Or better diagnostic tools? Or better brain science? The answer is mostly no – those things might help, but they won’t solve the problem of concussions in sports. Helmets can prevent the skull from fracturing, but they can’t prevent people throwing around their bodies in ways that cause violent impact between the delicate biochemical goop that is our brain and the rigid textured inner-wall of our skulls. Brain scans may be progressing to the point where they could give approximate estimates of cellular damage, but they can’t do the moral or even pragmatic calculus of how we accept the risk of accelerated senescence. The fact that the conversation around concussions tends to start with science and technology, while regularly neglecting society and culture, says something critical about how we think about sports.

I should admit up front that I am not a specialist on the science of concussions, but I’ve found the topic of much interest and use in teaching and scholarly conversations about the games we play. As an academic psychologist who draws heavily on sociology and cultural anthropology, I mostly identify as a determined advocate for contextualizing any type of science with interdisciplinary perspectives. The issue of brain injuries in sports screams out for such interdisciplinarity. While there is a growing body of scientific work on the technical challenges of preventing, diagnosing, and treating concussions, I’ve found much less work integrating the science with the social meanings of head trauma in sport.

Take, for example, an important report put out this year by the august National Research Council and Institute of Medicine, published by the National Academies Press as Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. This 356-page volume offers essential information about neuroscience, biomechanics, neuroimaging, biomarkers, neurology, and biostatistics. It’s an invaluable compendium of the latest natural science. But what makes the last clause of the title confusing is the almost complete absence in the report of any scholarly perspectives on the culture of youth sports. There is virtually nothing about the social space of sport and the complexities of actually changing a culture where children and parents regularly put brains at long-term risk for the temporal glory of a high school championship or a college scholarship. This omission strikes me as particularly notable given that in my own area of interdisciplinary scholarship, child and youth development, the National Academies had been at the forefront of promoting a multi-level approach. Their 2000 report titled From Neurons to Neighborhoods: The Science of Early Childhood Development offered both a catchy title and a substantive model for recognizing that healthy brains in any context depend upon both biology and society.

Why would the sports concussion problem require understanding brain trauma “from neurons and neighborhoods”? As just one example take the curious but serious finding that when comparing girls and boys playing essentially the same sport (e.g., soccer or basketball), girls tend to report significantly higher rates of concussions. The only thing we know for sure about this difference is that there is no one definitive explanation; instead, these gender differences are almost certainly based on a combination of factors that map nicely onto what I think of as the continuum ranging between neurobiology and society: head injuries in sport occur in the tissue and cells of the brain, which has some anatomical limits set by both nature and nurture, which are tested by socialization experiences and psychological dispositions, which are based on the social norms and environments in which we grow and play, which are shaped by the dynamic values and meanings of culture. The range of this continuum is clearly evident, for example, in a helpful and research-based summary of various possible explanations for gender-differences in concussion rates by Brooke de Lench at that can be easily organized and supplemented towards a multi-disciplinary layer cake:

• There may be differences at the level of basic neurology; average gender differences in hormones, metabolism, and cerebral blood flow could hypothetically influence brain injury.

• It may be that anatomy matters; on average girls have smaller head and neck mass, along with less developed musculature. But…

• Musculature and the biomechanics of sports performance may be shaped as much by social expectations and opportunities for strength training and sports-relevant experiences such as hitting and checking as they are by natural physiology.

• It may also be that psychologically coaches and trainers may pay more attention to girls’ injuries, and/or girls may be more likely to self-report injuries – leading to a potential for some of the reported gender differences to simply be a matter of social desirability. It may also be that female athletes actually take more physical risks, including risks with the head, as a sort of psychological adaptation against stereotypes of girls in sports – a possibility implied by journalists such as Michael Sokolove in his excellent book Warrior Girls but not directly tested in any scholarly research I’m aware of.

• And speaking of gender stereotypes, at a more sociological level it may be that parents, trainers, coaches, and doctors are quicker to recognize concussions in girls due to some perceived need to be extra protective, while boys may feel compelled to “play through” brain injuries to live up to imagined norms of masculinity – suffering but not reporting. Or it may just be that we have a broader sports culture that values “sacrifice for the game” more than concern for long-term health.

There is some recognition in the sports world that all of these multiple levels matter, and that concussions in sports are not just a technical problem. Some of the most promising trends, for example, have been legal and political moves to take decisions about playing sports with concussions out of the hands of invested individuals and make firm “Return to Play” laws – recognizing that the psychological pressures on coaches and athletes make them less than objective decision-makers when confronting head injury. It also strikes me that groups such as the “Safer Soccer Initiative,” which looks to ban heading in youth soccer, or those behind initiatives in youth hockey to de-incentivize violent body-checking are thinking like sociologists. They are looking towards systemic changes as much as technological innovation to address what is wrongly conceptualized as an individual problem.

Ultimately, however, both systemic change and technological intervention will need to be complemented by further humanistic reflection about sports culture. What does it mean that athletes and coaches are willing to risk young brains knowing technology won’t save them? What does it mean when over half of a sample of “standout” American high school football players say that “a good chance of playing in the NFL is worth a decent chance of permanent brain damage”? Or how can we make sense of the stories that I’ve been told of girls soccer teams agreeing, as a unit, to intentionally manipulate mandatory concussion testing protocols in order to avoid having to sit out any games due to head injury? Because concussions can only be diagnosed by proxy, most often through comparing pre-injury and post-injury functioning on tests of cognitive abilities (verbal memory, reaction time, etc.), some teams apparently plan together to intentionally under-perform on the baseline pre-test in ways that will make any post-injury tests look “normal.” This makes any poor performance due to actual brain injury all the more difficult to detect. Moreover, players who disguise their injuries in this way won’t have to wait the mandated time to heal. The important thing to them is to play their sport.

There may come a point where more sophisticated technology for testing and/or more careful systemic regulation of “return-to-play rules” can ferret out problems like the intentional manipulation of baseline cognitive testing. But the more fascinating and perplexing question to me is how we have a sports culture where athletes feel like this is all ok.