Recommendations by the National Federation of State High School Associations (NFHS) that members adopt limits on full-contact practices in high school football have been gaining traction, with an increasing number of state associations adopting them, in whole or in part, or in some cases, pro-actively implementing risk reduction measures beyond those recommended by the organization.
The recommendations, contained in a position paper [1] issued in July 2014 by a 24-member Concussion Summit Task Force including medical doctors, athletic trainers, high school coaches, and key national leaders in high school sports, and subsequently approved by the NFHS Sports Medicine Advisory Committee (SMAC) and the NFHS Board of Directors identified nine steps for minimizing head impact exposure and concussion risk in football [2]:
1. Limit full contact practices, both regular and off-season: Full-contact should be limited during the regular season, as well as during activity outside of the traditional fall football season. For purposes of these recommendations and guidelines, full-contact consists of both "Thud" and "Live Action" using the USA Football definitions of Levels of Contact.
Rationale: By definition, "Thud" involves initiation of contact at, or up to, full speed with no pre-determined winner and no take-down to the ground. Accordingly, the task force supports that initial contact, particularly with linemen, is just as violent with "Thud" as with "Live Action." However, the task force also recognizes that "Live Action" likely carries a higher risk for other injuries to the body than does "Thud." The USA Football Levels of Contact "Air," "Bags," and "Control" are considered no- or light-contact, and thus no limitations are placed on their use.
2. Consider variety of options in limiting contact.
Rationale: The task force acknowledges that there are insufficient data to specify with certainty a research-validated "best practices" standard for contact limitations. Several states (Alabama, Arizona, Maryland, and Texas) adopted varying limitations on contact prior to the 2013 football season. Preliminary High School RIO injury surveillance data suggest these states have seen a statistically significant decrease in concussion rates during practices, with no increase in concussion or other injuries during games.
3. Allow more full-contact practices in pre-season: Pre-season practices may require more full-contact time than practices occurring later in the regular season, to allow for teaching fundamentals with sufficient repetition.
A. Pre-season heat acclimatization protocols [3] take precedence and should always be followed.
B. While total full-contact practice days and time limitations may be increased during the pre- season, the emphasis should focus on the proper principles of tackling and blocking during the first several practices, before progressing to "Thud" and "Live Contact."
Rationale: The task force acknowledges regular season practice limitations may need to be revised during the pre-season. This should be done in a specific and systematic manner to allow coaches to spend sufficient time teaching proper tackling and blocking techniques.
Emphasis should be placed on teaching inexperienced players, as they slowly work through tackling and blocking progressions with "Air," "Bags," and "Control" using the USA Football definitions of "Levels of Contact."
4. Only one full-contact practice during two-a-days: During pre-season twice-daily practices, only one session per day should include full contact.
Rationale: The adolescent brain needs sufficient recovery time following full-contact practices. In addition, concussion signs and/or symptoms [4] may not develop for several hours after the initial injury (delayed symptom onset is more common among children and adolescents).
5. Review game action time: Each member state association should review its current policies regarding total quarters or games played during a one-week time frame.
Rationale: High School RIO injury surveillance data consistently show that competition presents the highest risk for concussion. The task force is concerned that participation in games at multiple levels of competition during a single week increases risk for head injury and unnecessarily increases head impact exposure. In addition, games played on consecutive days or those scheduled on the same day (Freshman and Junior Varsity games or Junior Varsity and Varsity games) may not allow the brain an opportunity to adequately recover.
Consideration should be given to moderating these situations as much as possible.
6. Modify policies regarding off-season football. Consistent with efforts to minimize total exposure to full-contact, head impact exposure, and concussion risk, member state associations with jurisdiction over football outside of the traditional fall football season should review their current policies to assess if those policies stand in alignment with the Fundamentals discussed within this report and, if needed, modify the policies accordingly.
Rationale: Football played outside of the traditional fall football season presents an opportunity for learning, physical activity, and skill development. However, athletes are at further risk for head impact exposure and concussion during any full-contact activity.
Consideration should be given to significantly limiting the total time of full contact. Other factors to consider include time elapsed since the previous football season and whether individual athletes have recently been, or are currently, participating in other contact/collision sports (e.g., Ice Hockey, Lacrosse, Soccer and Wrestling).
7. Develop coaching education programs integrating all levels of game. Each member state association should reach out to its respective state coaches' association on designing and implementing a coach education program that appropriately integrates youth, middle school, and high school football programs in every community. USA Football and the NFHS Fundamentals of Coaching courses should be the primary education resources for all coaches. Education for coaches should also include the proper fitting [5] and care of helmets.
Rationale: The game of football continues to evolve and proper coaching technique at each level is fundamental to keeping the game safe and enjoyable. A properly fitted helmet may help decrease, but not eliminate concussion risk.
8. Schools should have concussion management protocols: Each member state association should regularly educate its schools on current state concussion law and policies [6] and encourage schools to have a written Concussion Management Protocol. Schools should also be encouraged to share this information with coaches, parents, and students annually.
Rationale: Many schools experience frequent turnover of Athletic Directors and coaches. Frequent "refreshers" on state concussion laws and policies as well as sample concussion management protocols should be made available to ensure all schools are current on, and prepared for, safe and effective concussion management.
9. An Emergency Action Plan (EAP) [7] [7]with clearly defined written and practiced protocols should be developed and in place at every high school. When possible, an athletic trainer should be present at all practices and games [8].
Rationale: An effective EAP should be in place, as a prompt and appropriate response to any emergency situation can save a life. The EAP should be designed and practiced to address all teams (Freshman, Junior Varsity, and Varsity) and all practice and game sites. An athletic trainer is a key component in any strategy to minimize injury risk and optimize safety for all participants.
"The primary concern of the NFHS Concussion Summit Task Force was to limit head impact exposures and try to minimize the long-term, cumulative negative effects related to non-concussive blows to the head and body," said Dr. William Heinz, chair of the committee in a September 2015 NFHS press release [9]. "We were also very cognizant of trying to avoid any unintended consequences of increased injury rates related to not having the players adequately prepared for game situations. We feel the recommendations achieve a good balance between the two goals."
The recommendations were designed to allow flexibility for state associations that collectively oversee the more than 15,000 high schools across the country that have football programs.
The teams fielded by these schools may vary tremendously in the number of available players. Team size dictates numerous variables that may affect an athlete's potential head impact exposure. Those variables cannot be easily accounted for by stringent guidelines.
For example:
Based on what is currently known, the guiding principles in developing the report for young athletes and those who oversee, support and administer high school football programs were to reasonably limit overall exposure to multiple blows to the head and body (head impact exposure) and minimize concussion risk, while maintaining the integrity of the game and attempting to avoid unintended consequences.
As additional evidence emerges, NFHS said that its guidelines will evolve, and may become more or less restrictive. While the current level of knowledge kept the task force from making proposals that are specific and rigid, there is consensus that lessening the frequency of contact (and thus head impact exposure) is likely beneficial to overall brain health.
The task force also recognized that multiple contributing factors that affect head impact exposure and the parallel effects on an individual football player's brain, including:
*Note: This contributing factor was added to the document by the NFHS SMAC.
It is very likely that each athlete has a unique level of resilience or susceptibility to concussion and further brain injury. While there is currently no definitive way to measure or quantify this resilience or susceptibility, the task force recommended reasonably limiting head impact exposure through the Fundamentals. Individual risk factors that are modifiable, such as position played, total time spent on field, and sport technique, must be also considered when implementing contact limitations, it said.
The Concussion Summit was the latest effort by the NFHS to minimize risk for the almost 7.8 million student participants in high school sports. In 2008, the SMAC advocated that a concussed athlete be removed from play and not allowed to play on the same day (a rule adopted as law by nearly every state since May 2009, at least at the high school level).
For the past six years, all NFHS rules publications have contained guidelines for the management of a student exhibiting signs, symptoms or behaviors consistent with a concussion [4]. In 2010, the NFHS developed on online course - "Concussion in Sports - What You Need to Know" [11] - and about 2 million individuals have taken the course through the NFHS Coach Education Program.Some states had already adopted similar limitations in previous years.
In 2013, Texas began limiting its players to 90 minutes of full-contact practice per week during the regular season and postseason. Preliminary High School RIO injury surveillance data suggest that the new policy resulted in a statistically significant decrease in concussion rates during practices, and similar results were seen in Arizona, Maryland and Alabama after comparable changes were made to practice rules in those states.
The task force designed its recommendations to be flexible for state associations as they adopted their own requirements. In the months leading up to the 2015 fall season, some state associations adopted the recommendations exactly, while others altered them to more closely fit the needs of their member schools:
"Our committee was able to adjust some things so the recommendations would be a better fit for our schedule," said Mark Lentz, assistant executive director and administrator for football at the Kansas State High School Activities Association (KSHSAA).
The KSHSAA has been one of many state associations to make changes to its football rules that went beyond the recommendations of the task force. For example, players in Kansas will no longer be able to participate in "Live Action" the day after a game. And, effective with the 2016 season, they will not be allowed to participate in games on consecutive days. That change was made to address the issue of student-athletes playing a varsity game followed by a junior varsity game the next day, Lentz said.
Many states have also enacted rules changes establishing a progression up to full-contact in preseason practices, similar to the heat acclimatization schedules [3] integrated into preseason workouts in recent years. In Illinois for example, the Illinois High School Association (IHSA) limits equipment to helmets only during the first two days of practice, helmets and shoulder pads the next three days, with full pads being allowed on the sixth day of the acclimatization period. Similar progressions have also been adopted in Alabama, Minnesota and Kansas, among others.
Interestingly, a recent study [12] by Purdue researchers provides support for such a progression. it found that cerebrovascular reactivity (CVR), a measure of the ability of blood vessels in the brain to dilate to compensate for increased levels of carbon dioxide in the blood, such as occurring during exercise, was significantly reduced in almost all football athletes during the first six weeks of the contact season, findings which the researchers viewed as demonstrating that the onset of subconcussive blows had "at least a transient effect on the brain, but also suggest[ing] that the brain can adapt to [the contact] with an eventual return to baseline."
The researchers expressed concern that athletes may be at risk of incurring symptomatic injury during period their brains were trying to adapt to contact at the beginning of the season. Noting that. in most states football teams typically switch from limited contact levels prior to the season to two practices a day, at least one of which includes contact, they expressed concern that, based on their findings, "the brain may not be able to adjust quickly to this change, leaving players at increased risk for injury" at the beginning of the football season. They thus suggested that it might be better for teams to increase the amount of contact more gradually to allow players' brains to adapt so as to reduce the risk of serious injury. This is exactly what the new rules in Illinois, Alabama, Minnesota, and Kansas appear to address.
Another key recommendation from the task force was that each member state association review its policies concerning offseason football. In states such as Ohio and Illinois, there were already rules in place to limit contact during the offseason, with teams prevented from participating in full gear or in full-contact practices. Other states that previously had no restrictions in place for offseason football have begun to adhere to the task force's guidelines as well.
"The information from the NFHS Concussion Summit was very beneficial as we developed these new policies," said Kevin Merkle, associate director of the Minnesota State High School League (MSHSL). The MSHSL now limits its coaches to 11 contact days during the summer, with full-contact - "Thud" and "Live Action" - being limited to four of those days.
Although the new rules being enacted for the 2015 football season varied among the states, there has been one constant: the overwhelmingly positive response from coaches. Because of the increased focus on student-athlete safety in recent years, there has been little pushback, said Beau Rugg, assistant commissioner and administrator for football at the Ohio High School Athletic Association (OHSAA).
"Our coaches like the new regulations because they understand they help make football safer for our students," Rugg said. "Some coaches have even responded saying that the new limitations are keeping their teams fresher for the upcoming season."
Rugg's feedback in Ohio has been mirrored in Kansas, according to Lentz.
"Our coaches were part of the process to implement these recommendations, so they completely understand why it was time to make some changes," Lentz said.
As for future changes, there are still a few important topics to be discussed for upcoming seasons. Continuing to emphasize proper techniques and adjusting to the new rules for targeting and unnecessary contact are chief among them, Merkle says.
"We are making the rules changes a major focus for our game officials, as it is imperative that they call those penalties to keep the game as safe as possible."
Other recommendations from the NFHS task force involved implementing coach education programs, as well as having a written Concussion Management Protocol and Emergency Action Plan [13] in each school.
"We continue to emphasize the concussion issue with our schools, not just in football but in all sports," Merkle said. "It is vital that we do our best to provide them with the most recent information."
"Looking at the big picture going forward, it is all about continuing to change the football culture across the country and minimizing risk for all who participate in the sport," said Bob Colgate, NFHS director of sports and sports medicine.
For a pdf of the NFHS's "Recommendations and Guidelines for Minimizing Head Impact Exposure and Concussion Risk in Football" position paper, click here [1].
Source: National Federation of State High School Associations
Resources:
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Breedlove EL, Robinson M, Talavage TM, Morigaki KE, Yoruk U, O'Keefe K, King J, Leverenz LJ, Gilger JW, Nauman EA. Biomechanical correlates of symptomatic and asymptomatic neurophysiological impairment in high school football. J Biomech. 2012 Apr 30;45(7):1265-72.
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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 Dec;41(12):2877-84.
Broglio SP, Eckner JT, Martini D, Sosnoff JJ, Kutcher JS, Randolph C. Cumulative head impact burden in high school football. J Neurotrauma. 2011 Oct;28(10):2069-78.
Davenport EM, Whitlow CT, Urban JE, Espeland MA, Jung Y, Rosenbaum DA, Gioia GA, Powers AK, Stitzel JD, Maldjian JA. Abnormal White Matter Integrity Related to Head Impact Exposure in a Season of High School Varsity Football. J Neurotrauma. 2014 Jul 14. [Epub ahead of print].
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Head impact exposure in youth football: high school ages 14 to 18 years and cumulative impact analysis. Ann Biomed .Eng 2013 Dec;41(12):2474-87.
Posted November 12, 2014. Most recently updated October 22, 2015
Links:
[1] http://www.nfhs.org/media/1014079/2014-nfhs-recommendations-and-guidelines-for-minimizing-head-impact-final-october-2014.pdf
[2] https://momsteam.com/health-safety/seven-ways-to-reduce-risk-of-brain-trauma-in-contact-and-collision-sports
[3] https://momsteam.com/health-safety/pre-season-heat-acclimatization-guidelines
[4] https://momsteam.com/health-safety/concussion-signs-and-symptoms-physical-cognitive-emotional-sleep-related
[5] https://momsteam.com/health-safety/football-helmets-new-guidelines-issued-ensuring-proper-fit
[6] https://momsteam.com/health-safety/every-state-has-youth-sports-concussion-safety-law
[7] http://www.momsteaminstitute.org/article/emergency-action-plan-needed-every-youth-sports-program
[8] https://momsteam.com/team-of-experts/athletic-trainer-AT-every-school-should-have-one
[9] https://www.nfhs.org/articles/states-adopt-plans-to-limit-contact-in-football/
[10] https://momsteam.com/health-safety/concussion-safety/multiple-concussion-history-important-factor-in-concussion-management
[11] http://nfhslearn.com/courses/38000
[12] https://momsteam.com/purdue-studies-show-repetitive-head-impacts-in-high-school-football-damage-brain
[13] https://momsteam.com/health-safety/general-safety/emergency-medical-plan-essential-for-youth-sports-safety
[14] https://momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports
[15] https://momsteam.com/repetitive-brain-trauma-and-chronic-traumatic-encephalopathy-CTE-cause-and-effect-relationship-scientifically-premature
[16] https://momsteam.com/alzheimers/cte-media-narrative-ahead-science-say-researchers
[17] https://momsteam.com/health-safety/cte-what-risk-athletes-who-stop-playing-football-after-high-school