By Matt Chaney

Posted Wednesday, June 29, 2011

This is Part 5 of an analysis series titled Brain Trauma Dictates Epic Football Reform, which will culminate with independent recommendations for steps imperative to the blood sport’s survival at public schools, colleges, and likely the professional level.

Believe what you’re seeing, parents, in tackle football. Use common sense and drop your sentiment for the game mythologized as pure, essential Americana.

Tackle football is simply blood sport, not the glorious rite of manhood and education you’re always led to believe.

No, collision football is not beneficial for kids overall, and it turns brutal at competitive levels that begin far below professional football, incidentally, on any field where aggressive competitors roam, predators of all ages—who become prey too at some point to the game’s perpetual maw, battering themselves down if not falling to peer attackers.

An American football player can only hope to leave the sport on his own volition, because forcible exit by injury is neither kind nor prideful, ranging from orthopedic maiming to rattled brain cells, to, yes, spinal paralysis or death for the most unfortunate.

“This crazy game will hurt you; this ain’t no party, this ain’t no disco,” said David Meggyesy, book author, former head-hunting NFL linebacker, and retired players union official, referencing the Talking Heads classic “Life During Wartime.”

Nothing, no one will ever change the extreme danger of tackle football—no rules, no education or “awareness,” no experts with their theories and snake-oil “testing” for preventing concussions, steroids or whatever risk.

Understand, parents, never can football be but fundamentally violent and terribly unsafe, whether staged in your town or on television, and whether it’s your own flesh and blood on that field or someone else’s.

If that doesn’t grab you, know this: Football costs the public foremost for its fun of destructing bodies by the thousands, human damages amounting to billions of dollars annually. The game and its profiteers don’t carry the carnage, just us, society at-large, paying already and forever for today’s mass of living football wounded, children to elderly.

Most importantly, reject football officials who always claim control of the latest health concern, like muscle doping in recent decades and brain injuries in the present. Every so-called prevention of football danger ends up a sham if not scam, and players suffer real consequences.

Last year, for example, football organs and their medical experts, from NFL commissioner Roger Goodell to his associate Dr. Robert Cantu, claimed a “culture change” and “awareness” toward "safer" football—reviving the sport’s antiquated response during injury crisis—but fatalities remained virtually unchanged.

At least 17 young Americans died of football during 2010, according to news reports and injury research, compared to the official 18 recorded for 2009.

Six of those players died of collisions in 2010, ranging in age from 11 to 21, three more than the previous year, proving no fundamental shift in football brutality.

Nothing could’ve saved Zach Shaver, an 18-year-old defensive tackle rendered comatose by a turf hit during a team scrimmage at Tarleton State University in Stephenville, Texas, March 27, 2010. The 6-foot-2, 280-pound freshman battled an opponent while the two fell over other players, slamming Shaver’s head to ground with the offensive lineman atop him.

“It looked like an ordinary football play,” said witness Brad Keith, local sports editor. “An assistant coach said that the offensive lineman said Shaver fell limp in his arms.”

Shaver was air-lifted to a hospital but didn't regain consciousness; he died of the head injury two days later, survived by his parents and a sister.

Six weeks later, during spring scrimmage at Eastern Oregon University in LaGrande, safety Dylan Steigers came off the field after making a tackle and told a coach he’d taken a headshot. Then he began vomiting and seizing.

Steigers was suffering a subdural hematoma, massive hemorrhaging of blood vessels in the brain. The 21-year-old was placed on life support and died the next day, leaving a 2-year-old daughter in his wake.

Steigers’ former high-school coach in Montana, Pete Joseph, said, “He played the game the way it should be played. He had excellent physical tools, he played the game hard, he played the game fast, and he loved football.”

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American football likely isn’t long for present form, pervasive and carried by the public in expenses from operations to healthcare. Not in this litigious, cash-poor country.

Too many health risks impact players and families, including drug abuse, cardiac disease, heatstroke, orthopedic disabilities and, of course, brain trauma and damage, says epidemiologist Charles E. Yesalis, professor emeritus at Penn State University.

“To me, it’s either a tsunami or perfect storm on the horizon with football,” said Yesalis, a foremost expert on muscle drugs in sport, during a telephone interview in December, when he surmised that head injuries had surpassed doping as an issue.

Yesalis noted boxing’s immense popularity of the past, when thousands of schools and colleges hosted pugilism and it commanded prime-time telecasts, until medical findings indelibly stamped the hazards in public conscience and turned-off too many people, especially parents.

“How many white middle-class parents today let their kids box?” emphasized Yesalis, whose father was a top amateur boxer. “How many boxing teams still remain at colleges? How many in high schools?”

“You have to view it in that milieu: What happened in boxing and our risk-adverse culture today. For me it’s a no-brainer: Parents today are dramatically more risk-adverse than were the parents of my generation or my dad’s generation.”

“Then there’s our litigious society today,” Yesalis continued, “and all the costs within the maelstrom regarding healthcare, how that plays into this [sport head injuries]. And the overall economy. When’s the last time your heard of a school district that was flush with money?”

“So the notion that the thousand-dollar helmets, for example, are going to save the day? Even those are not scientifically validated.”

Kids comprise the biggest annual body count for football, as the overwhelming majority of participants, with more than 1 million playing at 15,000 schools and 3 million in youth leagues. Children and adolescents far lead in casualties minor to severe, with medical facilities having treated about 920,000 for football injuries in 2007, according to a government report.

Research methods on injuries nationwide vary in construct, always subject to error for collection limitations, but the data clearly establish a long-standing public health menace in tackle football, especially for juveniles.

Researchers at Nationwide Children’s Hospital in Columbus, Ohio, recently concluded football-related injuries among youths increased 27 percent over an 18-year period from 1990.

In the study’s final year, 2007, hospital emergency rooms treated 346,772 injuries of players ages 6 to 17, including about 97,000 serious orthopedic cases such as bone fractures, joint dislocations and tendon tears. The ERs handled 8,631 diagnosed concussions, per the report.

“Adolescents aged 12 to 17 years old suffered a greater proportion of the injuries (78 percent),” a release states, “and were more likely to sustain a concussion or be injured at school when compared to younger players.”

Hospital ERs treated a daily average of almost 2,000 juvenile injuries during football season 2007, and investigators condemned the average of 57 concussions. “The potential long-term consequences of this type of injury make this an unacceptable rate,” said study co-author Lara McKenzie, professor of pediatrics at Ohio State University College of Medicine.

Annual concussions are incalculable in close terms, but an estimated 43,000 to 67,000 occur in high-school football, according to the National Athletic Trainers’ Association.

Catastrophic injuries involve the central nervous system, trauma to spinal cord, brain or both. Last year at least 7 American football players were paralyzed of spinal injuries without complete recovery, 5 at high schools and 2 at colleges, while at least 4 were brain-injured without full recovery, all at high schools, according tor the annual report by the National Center for Catastrophic Sport Injury Research at University of North Carolina.

The center is the American football’s official clearinghouse of worst-case reports, based at UNC since 1965, with famed neurosurgeon Dr. Cantu serving as medical director since 1987. The researchers’ inexact method is to gather news accounts of catastrophic football injuries, assisted by a national network of spotters such as coaches, trainers, doctors and organizers, with everyone utilizing electronic search and transmission for collection and reporting.

The center records 1,021 collision deaths in football over the last 80 years, along with 722 deaths of “indirect” game conditions such as heatstroke. More than 1,400 of those fatalities since 1931 were players for schools and community programs like youth leagues.

The data are profound but incomplete, for the Catastrophic Injury Center cannot account for every case across the vast realm of tackle football. Prior to Internet explosion of the 1990s, a portion of reports was assuredly overlooked in the old, limited process of locating and “clipping” from newspapers, magazines and journals.

Even with e-search, the Injury Center missed at least one collision fatality in football during 2010—Quadaar White, age 15—for its new annual report posted on the UNC site, listing only 5 such deaths for the year as of posting for this analysis.

White died on Aug. 31 in a Philadelphia hospital after suffering a neck injury in practice for a youth team comprised of boys 13 to 15, one of five squads in a community program of Upper Darby, Pa.

The smallish White shot low into a collision at practice, helmet out front for proper football leverage, and his head struck the knee of another boy. He lay motionless, not breathing by the time paramedics arrived, and he died seven days later, survived by parents and nine brothers and sisters.

Tony Jackson, a coach in the Wildcats program, said of White: “He was fast. He was aggressive. He knew how to tackle.”

A blog promoting lawsuit services addressed the White tragedy, stating “a Philadelphia personal injury attorney might argue that there was negligence in the incident, which can be grounds for a personal lawsuit.”

“Both amateur and professional athletes can be held civilly liable for the injuries they inflict on other athletes, even with contact sports like hockey and football,” the legal ad continued. “With recreational football teams, the sporting institutions or coaches can also be held liable for injuries or fatalities of athletes.”

Last season 2 football deaths involved rare “second-impact” brain trauma to the juvenile victims, cases demonstrating the hopelessness of alleged safety net known as concussion management.

An 11-year-old boy in Muskego, Wis., Evan Coubal, was apparently concussed during a youth-league scrimmage on Aug. 25. The injury wasn’t detected initially, and a week later Coubal struck his head on a contact sled for football during recess at his school. The second impact “exacerbated the earlier undiagnosed injury,” Jane Ford-Stewart reported for Community Newspapers, Inc., and the boy was rushed to a hospital, where he died on Sept. 5.

Nathan Stiles, 17, of Spring Hill, Kan., died of a subdural hematoma on Oct. 29 after returning to football from a diagnosed concussion he’d sustained four weeks previous. Although the brain hemorrhage killed the teen, Dr. Cantu confirms a re-bleed of the initial concussion also occurred, according to pathology results of his colleagues at Boston University.

Stiles had returned to football after his family doctor’s interpretation of concussion guidelines cleared the youth as asymptomatic, ready again for collisions, reports The Kansas City Star. The youth’s parents, Ron and Connie Stiles, did not respond to an interview request from this writer.

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Episodic concussion is only one concern of brain trauma for tackle football, attests a chorus of contemporary medical experts, along with decades of case studies of "dementia pujilistica" in pro boxers.

“We know, from the literature in boxing, the problem is not necessarily these major concussive events,” Yesalis said. “What can be of greater damage is the constant hitting short of concussion.”

“Every blow to the head is dangerous,” neuropathologist Dr. Bennet Omalu told Congress a year ago. “Repeated concussions and sub-concussions both have the capacity to cause permanent brain damage.”

A long-held assumption of medicine—holding that sub-concussive or mild repetitive head impacts of contact sport can cause neural degeneration—is jelling into expert indictment against tackle football, particularly upon milestone findings of imaging studies with prep players at Purdue University.

Purdue researchers employ advanced MRI to detect sub-concussive brain trauma in active football players, in real time, as the teens absorb collisions to become cognitively impaired while appearing asymptomatic.

Diffusion tensor imaging sees “functional” changes of brain regions caused by impacts milder than concussion, the disruptions and redirections of liquid through white-matter axon fibers that are stretched and sheared, thus altering chemical flow among neuron cells comprising the grey matter at cerebral surface.

The Purdue fMRI research and modern pathology of football brain damage are helping finally place repetitive head blows above concussion for medical priority in the sport. “What’s come to the fore is the risk of repetitive minor hit injuries,” said neurosurgeon H. Hunt Batjer, who co-chairs the NFL Head, Neck and Spine Committee.

Although many football fans are slow to grasp issue complexities—like most mainstream media and parents—many doctors aren’t waiting to propose epic remake of the game, beginning with dramatically reducing contact exposures.

“I don’t see that there’s any way of lowering the incidence of this without changing the way the game is played,” said neuropathologist Dr. Ann McKee. “I’m sure it’s going to be incredibly unpopular, but it’s going to have to be a game that maybe isn’t such a violent sport, that doesn’t have the thousands of sub-concussive hits that occur in every season.”

L. Syd M. Johnson, postdoctoral fellow in neuro-ethics at Dalhousie University, Nova Scotia, has researched brain trauma and policy in hockey and tackle football. "Preventing the kinds of chronic head impacts that are just part of the game would be impossible without radically altering the game of football,” Johnson stated in email

So do juvenile players accumulate enough hits for risk?

Does the football impacts of school and youth leagues cause brain damage?

Both McKee and Omalu have found early stages of chronic traumatic encephalopathy, or CTE, in the brain cells of deceased 18-year-olds, former prep football players dead of other causes, and the alert spreads to other youth sports like boxing. Experts agree the brain is most vulnerable in development, until the ages of 14 to 16.

“The real question we are going to have to ask is when is it that the body is too young in order to engage in contact activity,” said Dr. Byran Wasson, a physician for the U.S. Amateur Boxing Association.

Eric Nauman, engineering professor and co-head of the imaging and collision studies at Purdue, notes exposures of football contact for teens far exceed numbers for higher levels of the game. “In the NFL, players take, on average, 50 blows to the head per week,” Nauman said. “High-school players may, however, take upwards of 160 blows per week.”

Chris Nowinski, concussion author and co-founder of the Sports Legacy Institute [SLI], advocates reducing football contact. “I don’t think the jury’s out at all on whether high-school exposure’s enough for CTE,” he told Boston Magazine. "We’ve seen it in a kid who’s just 18. We just haven’t looked at a lot of 40- and 50-year-olds who just played high-school football. If it starts in your teen years and it just progresses, some percentage of kids are walking out of high-school football with CTE already in their brain. And probably the earlier they started, the higher their risk. If you played from 6 to 16, that’s probably just as bad as someone who plays in the NFL [and competes from ages] 14 to 24. Maybe worse, because the young brain is, again, more sensitive.”

College football is prime suspect for brain injury and long-term disease en masse, and the NFL certainly wants to research a possible distinction, proposing to study 100 to 150 of its retirees for comparison with “an age-matched and position-matched study of football player who played NCAA but not the pros,” Batjer said.

Harry Carson, Hall of Fame linebacker and retirees' advocate, has his gripes with the NFL and union about head injuries, but he believes lower levels of football are problematic too. Carson reports being “inundated” with contacts from former college and prep players experiencing permanent cognitive problems.

“Their emails bring me to a point of understanding that there are some major problems with concussions sustained in contact sports (but especially football) that have not been adequately addressed by anyone,” Carson wrote on his blog.

Nowinski, a former Harvard defensive tackle and WWE performer, criticizes the NCAA for inaction on brain injuries. “They’ve been completely absent from this conversation,” he said at a March symposium on legal questions for sports.

A total of 16,277 concussions were reported in NCAA football of 2009, according to The Daily Kansan, among programs in division classifications I, II and III. The NCAA is one of three collegiate federations for tackle football in the United States, with an estimated total of 75,000 players competing annually.

Chronic traumatic encephalopathy is confirmed in two cases involving NCAA football: Mike Borich, a former receiver and coach dead of a drug overdose, and 21-year-old defensive end Owen Thomas, who committed suicide last year at the University of Pennsylvania.

“Mike Borich played football in college, but did not play football professionally,” reported the research team of McKee at Boston University and the SLI. “He died at age 42 after exhibiting a pattern of erratic behavior throughout much of his adult life. His college playing career included stints with Snow College and Western Illinois University in the 1980s. He was known to have approximately 10 concussions during his college football career with no subsequent concussions or head injuries after college.”

“Mr. Borich’s brain revealed less pathology overall than many previous cases of confirmed CTE [from the NFL], but was consistent with CTE nonetheless.”

McKee group findings in the Thomas case were released to The New York Times, which broke the major story last September as brutal NFL hits and concussions were raising public scrutiny on head injuries in football. “A brain autopsy of a University of Pennsylvania football player who killed himself in April [2010] has revealed the same trauma-induced disease found in more than 20 deceased National Football League players, raising questions of how young football players may be at risk for the disease,” Alan Schwarz reported for The Times.

Neuropathologist Dr. Daniel Perl reviewed the BU results, remarking, “This is a call for a broader range of research into this problem that extends beyond the heavy duty NFL level of athletics.”

Thomas hanged himself in an off-campus apartment as spring football concluded and he was elected team captain at Penn. Six-foot-two and 240 pounds, Thomas was a highly aggressive football player, relishing head contact but without sustaining a diagnosed concussion in the sport he played since age 9.

“It really shows us that you don’t need to have had known or reported concussions to develop this brain disease,” BU neurologist Robert Stern told CNN. “It really shows us that those multiple, repetitive sub-concussive blows to the head that are experienced by so many athletes in many different sports can bring on the beginnings of this disease.”

Thomas “loved to hit people,’ his mother, the Rev. Kathy Brearley, told The Times. “He loved to intimidate,” she said. “It’s kind of sad. We all love football. We all love watching. We all love these great hits.”

What would be regarded a “proper” hit by promoters of “safer” football, without direct helmet-on-helmet contact, resulted in concussion and paralyzing injury on Nov. 20 for Jesse Reising, a Yale senior linebacker and honors student. Reising was set to become a Marine officer when he collided with Harvard running back Gino Gordon in the season finale for both teams.

“His helmet ended up hitting my shoulder pad, and my helmet hit his shoulder pad,” Reising told Jim Fuller of The New Haven Register. “That created a motion when my shoulder went downward; my head went to the side and stretched a lot of nerves in my neck, and that is what caused a lot of the damage.”

A few months later, Reising still had not regained feeling and motor function in his deltoid muscle, capping the right shoulder, with bicep and rotator-cuff muscles also affected. Thus the Marine Corps determined he was no longer needed.

“My low point when the reality of the situation really sunk in, how much of a turn my life is going to take, was probably the conversation I had with my recruiter [dropping] me from officer’s candidate school,” Reising said.

Reising graduated from Yale on May 23, majoring in economics and political science with a 3.75 grade-point-average. He recently underwent surgeries on the nerve damage and will work as a contractor in Afghanistan, still hopeful of recovering enough to someday serve in the Marines.

Elsewhere, Minnesota, doctors are perplexed in the case of a former college football player struck by degenerative syndrome. Scott Wierschem, 51, is a former offensive lineman at St. Cloud State, a NCAA Division II school, whose progressive condition has forced retirement from his 25-year career in corrections.

Doctors have yet to diagnose the ailment, described as a neuro-physical disorder, but Wierschem’s speech is slurred and he avoids hard food for fear of choking. His body core is particularly weakened, so he doesn’t stand upright long and walks with a cane.

No one knows if brain or spinal injuries are at root of the problem, and in the past Wierschem had no diagnosed trauma involving football. “I’d block low, at the knees,” Wierschem said of college football, speaking recently with The West Central Tribune. “I suppose my helmet took a lot of hits.”

In Canada, a 2009 brain study of former college football players who were concussed detected long-term problems, although all 19 subjects led productive, active lives. The former concussed players had a mean age of 60.

College football’s heavyweight conferences have taken heat from Congress for concussion mismanagement, as brain trauma became jock issue du jour in the news. Politicians have summoned officials, athletes and experts for well-publicized hearings of head injuries in multiple sports, and lawmakers ripped the NCAA.

Naturally, the NCAA responded with revised policy on so-called mild traumatic brain injury, new concussion guidelines for member institutions that include requiring removal of a symptomatic athlete from competition until evaluation and clearance by a specialist. In addition, all athletes must sign a pledge to self-report “their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussion,” states an NCAA release.

The measures lack punitive teeth, since no association bylaw was enacted, and offer minimal protection to athletes—reflecting all policy and state law yet enacted for head injuries in sport.

And enforcing consistency of standards among universities, such as confirming a staffs of qualified medical personnel for brain injury and management, is virtually impossible on part of the NCAA.

Unsurprisingly, concussion controversy marked the collegiate year in men’s and women’s sports. At the University of Missouri, medical staff came under question for quickly returning head-injured basketball stars to action, male and female.

“Concussion management and assessment is not a perfect science by any means,” Dr. Chris Farmer, MU athletics physician, told The Columbia Daily Tribune. “It is a mix of subjective data, objective data and professional judgment.”

Authorities of brain trauma like Dr. Omalu and Dr. Lester Mayers, director of sports medicine at Pace University, recommend concussed athletes be minimally sidelined from one to three months, depending on age and diagnostic tools. They contend recovery of brain trauma should begin with strict isolation, meaning no physical or mental stimulation—including no “concussion testing”—for several days if not weeks.

About 85 percent of concussed football players of all ages currently return to contact within two weeks. Computerized testing like ImPACT, panned by independent reviewers as invalid for years, usually begins for the athlete within 48 hours of injury.

The NCAA recommends “the return-to-play progression should occur in a step-wise fashion,” but the association provides no time frame and points to expert disagreement over recovery, stating: “How quickly [an athlete] moves through this progression remains controversial.”

Matt Chaney is a writer, editor, teacher and restaurant worker living in Missouri, USA. Email him at mattchaney@fourwallspublishing.com. For more information, including about his 2009 book, Spiral of Denial: Muscle Doping in American Football, visit the homepage at www.fourwallspublishing.com.

References

Alessi, A. (2010, December 17). Telephone interview with author.

Bachman, R. (2011, February 12). Concussions, an injury rising among teen athletes, more profound and enduring than previously known. Portland Oregonian.

Bauer, L. (2011, May 15). To family, Nathan Stiles’ death was part of God’s plan. Kansas City Star.

Benson, R.R. (2010, January 4). Testimony of Randall R. Benson, M.D., assistant professor of neurology, Wayne State University. In Committee on The Judiciary, U.S. House of Representatives, (2009, October 28, & 2010, January 4). Legal issues relating to football head injuries, Part I & II, (Serial No. 111-82). Washington, DC: Committee on The Judiciary.

Benson, R.R., Meda, S.A., Vasudevan, Z.K, Govindarajan, K.A., Hanks, R.A., Millis, S.R., Makki, M., Latif, Z., Copin, W., Meythaler, J., & Haacke, E.M. (2007, November 3). Global white matter analysis of diffusion tensor images is predictive of injury severity in traumatic brain injury. Journal of Neurotrauma, 24(3).

Benson, R.R., Gattu, R., Zhifeng, K., Haacke, E.M. (2010, May 1). The use of advanced MR Imaging methods in traumatic brain injury: Development of imaging biomarkers for improving diagnosis, outcome prediction and treatment. Integrated Neuroscience Session, American Academy of Neurology.

Blount, R. (2011, April 13). Concussion symptoms hard to recognize, treat. Minneapolis Star Tribune.

Blumbergs, P.C., Scott, G., Manavis, J., Wainwright, H., Simpson, D.A., McLean, A.J. (1994, October). Staining af amyloid precursor protein to study axonal damage in mild head injury. The Lancet, 344(8929).

Boxing Brain. (1973, November 24). Boxing and the brain. British Medical Journal.

Brewin, B. (2011, March 16). Battlefield brain-injury assessment tool has high failure rate. www.nextgov.com.

Breen, P. (2010, October 4). High school pupil suffers spinal injury on football pitch. www.seriousinjurylaw.com.

Briggs, D. (2011, February 27). No messing with the head at MU. Columbia Daily Tribune.

Brix, S. (2011, January 21). Local schools implement concussion testing programs to ensure safety of student athletes. North Shore Sun.

Branch, A. (2010, April 1). Tarleton football player died of brain injury, ME rules. Ft. Worth Star-Telegram.

Broglio, S.P., Macciocchi, S.N., Ferrara, M.S. (2007, June). Sensitivity of the concussion assessment battery. Neurosurgery 60(6).

Broglio, S.P., Puetz, T.W. (2008, November 1). The effect of sport concussion on neurocognitive function, self-report symptoms and postural control: A meta-analysis. Sports Medicine, 38(1).

Bryant, H. (2010, October 27). The risky business of football’s future. ESPN.com.

Byers, B., & Self, J. (2010, August 14). S.C. teen dies after football scrimmage. Rock Hill Herald.

Buckner, C. (2010, October 7). McLouth receiver loses part of his leg. Kansas City Star, p. B7.

Cantu, R. (2010, December 21). Telephone interview with author.

Carpenter, B. (2011, March 18). Study finds youth boxing injuries on the rise. www.the33tv.com.

Carpenter, L. (2007, April 25). ‘Brain chaser’ tackles effects of NFL hits. Washington Post.

Carson, H. (2010, February 23). It’s becoming clearer to me…. . www.harrycarson.com.

Chaney, M. (2001). Sports writers, American football, and anti-sociological bias toward anabolic drug use in the sport. Warrensburg, MO: Graduate School of Communication, Central Missouri State University.

Chaney, M. (2009). Spiral of Denial: Muscle Doping in American Football. Warrensburg, MO: Four Walls Publishing.

Cheers, I.M. (2010, October 26). Head injuries raise questions about safety of football. PBS NewsHour Extra.

Cleary, L. (2011, January 26). Concussions remain a gray area. www.nbcwashington.com.

Clover, J., & Wall, J. (2010, January). Return-to-play criteria following sports injury. Clinics in Sports Medicine, 29(1).

College Coaches. (2010, October 29). College coaches: Don’t blame us for helmet hits. Sports Illustrated.

Collins, M.W., Lovell, M.R., McKeag, D.B. (1999). Current issues in managing sports-related concussion. Journal of The American Medical Association, 282(24).

Colombo, M. (2010, September 16). JSPS insurers to pay Max Gilpin’s parents $1.75 million settlement. WHAS.com.

Committee on The Judiciary, U.S. House of Representatives, (2009, October 28, & 2010, January 4). Legal issues relating to football head injuries, Part I & II, (Serial No. 111-82). Washington, DC: Committee on The Judiciary.

Comper, P., Hutchison, M., Magrys, S., Mainwaring, L., & Richards, D. (2010, October). Evaluating the methodological quality of sports neuropsychology concussion research: A systemic review. Brain Injury, 24(11).

Concussion Tests. (2011, March 6). Panel suggests concussion tests for Butte players. www.ktvq.com.

Conferences Criticized. (2010, February 2). Conferences criticized over concussion policies. The Associated Press.

Cronin, T. (2011, May 16). Doctor: Football must change rules to protect players. Chicago Sun-Times.

Death Lawsuit. (2010, February). Family of late Chapel Hill football player files wrongful death lawsuit. Chapel Hill Herald-Sun.

Deford, F. (2010, October 13). Schools forfeit games, putting safety above football. NPR.org.

DeKosky, S.T., Ikonomovic, M.D., & Gandy, S. (2010, September 30). Traumatic brain injury—Football, warfare, and long-term effects.

Doherty, J. (2010, October 18). Concussion test tests patient’s patience. www.nwitimes.com.

Duff, M. (2009, July 14). Management of sports-related concussion in children and adolescents. ASHA Leader.

Echemendia, R.J., Herring, S., & Bailes, J. (2009). British Journal of Sports Medicine, 43.

Eckner, J.T., Kutcher, J.S. (2010, Jan-Feb). Concussion symptom scales and sideline assessment tools: A critical literature update. Current Sports Medicine Reports, 9(1).

Ehrlich, C. (2010, November 12). A relentless opponent stalks the locker room. New York Times.

Eliminate Football. (2009, November 25). Superintendent’s decision to eliminate football stands. www.indychannel.com.

Ely, D. (2010, November 23). Schools seek ways to protect athletes. ESPN.com.

Emmons, M. (2010, August 21). Concussions among high school football players a major concern. San Jose Mercury News.

Epstein, D. (2011, November 1). The damage done: While concussive hits dominate the debate, a groundbreaking new study suggests that minor blows—and there can be hundreds each game—are just as traumatic. Sports Illustrated.

Epstein, D. (2011, April 13). Unique study explores cumulative effect of hits in high school football. Sports Illustrated.

Evan, F. (2010, November 1). Early warning: Even at PeeWee level, coaches struggle to balance safety concerns with teaching toughness. Sports Illustrated.

Fargen, J. (2010, September 26). Schools face high price of keeping athletes safe. Boston Herald.

Finder, C. (2011, January 2). Former football player’s concussion has altered his life. Pittsburgh Post-Gazette.

Fishman, L. (2010, September 7). Teen dies after football injury. philadelphiapersonalinjuryblog.com.

Fitz, G. (2011, April 3). ImPACT tests coming to a high school near you. Nashua Telegraph.

Ford-Stewart, J. (2010, October 11). Community helps family deal with boy’s death. www.mymuskegonow.com.

Fujita, S. (2011, January 26). Telephone interview with author.

Fuller, J. (2011, February 12). One hit changed everything for Jesse Reising. New Haven Register.

Fuller, J. (2011, May 22). Yale’s Jesse Reising still making big plans. New Haven Register.

Galvan, K. (2010, November 18). Mom says school handled son’s injury the wrong way. www.myfoxhouston.com.

Gavett, B.E., Stern, R.A., & McKee, A.C. (2011, January). Chronic traumatic Encephalopathy: A potential late effect of sport-related concussive and subconcussive head trauma. Clinics in Sports Medicine, 30(1).

Gholson, N. (2010, March 29). Former Rider player dies as result of practice accident. Times Record News.

Goodell Announces. (2009, November). Goodell announces latest developments relating to concussion prevention and treatment. NFL.com.

Goodell Talks. (2010, October 23). Goodell talks about big hits. Scout.com.

Gray, A. (2010, November 1). A football player goes down, unconscious: Where’s the ambulance? Virgin Islands Daily News.

Green, R. (2010, February 2). High-school athletes need legal protection from concussions. Hartford Courant.

Gregory, S. (2010, February 8). Problem with football: Our favorite sport is too dangerous: How to make it safer. Time.

Grindel, S.H., Lovell, M.R., & Collins, M.W. (2001, July). The assessment of sport-related concussion: The evidence behind neuropsychological testing and management. Clinical Journal of Sports Medicine, 11(3).

Guskiewicz, K. (2011, January 8). Telephone interview with author.

Guskiewicz, K.M., McCrea, M., Marshall, S.W., Cantu, R.C., Randolph, C., Barr, W., Onate, J.A., & Kelly, J.P. (2003). The NCAA concussion study: Cumulative effects associated with recurrent concussion in collegiate football players. Journal of The American Medical Association, 290(19).

Habib, H. (2010, October 23). Concussion Q&A for parents: Should I let my child play football? Palm Beach Post.

Hack, D. (2006, December 14). Former Steeler’s family wins disability ruling. New York Times.

Halchin, L.E. (2008, April 8). Former NFL players: Disabilities, benefits, and related issues. Washington, D.C.: Government and Finance Division.

Hamilton, J. (2011, February 2). Doctors throw flags on high school concussions. www.npr.org.

Hoag, C. (2010, November 1). Will they play again next year? Do the penalties of playing football as a kid outweigh the rewards? Mokena Patch.

Hobson, K. (2010, September 24). How worried should parents be about concussions in young athletes? blogs.wsj.com.

Hobson, M. (2010, October 27). NFL looking to avoid possible lawsuits stemming from severe player concussions. Vancouver Sun.

Hopper, M. (2009, October 29). Is the NFL too dangerous? Birmingham Weekly.

Hruby, P. (2010, October 22). Future shock: The death of football. ESPN.com.

Huff, D. (1987, January 5). High school deaths, injuries raise questions about safety: Athletes’ medical care may be inadequate. Washington Post, p. C3.

Jackson, N. (2011, January 7). A former player responds to Goodell’s open letter. Deadspin.com.

Jackson, N. (2011, January 24). Telephone interview with author.

Jenkins, C. (2011, March 5). For former players, brain injuries finally getting attention. San Diego Union-Tribune.

Jenkins, J. (2006, January 1). Who pays the bills? Former players frequently face financial pain. Sacramento Bee.

Jolly, T. (2010, February 8). Goodell stresses a culture of safety. www.nytimes.com.

Jhally, S. (1989). Cultural studies and the sport/media complex. In Wenner, L. (Ed.), Media, sport & society. Newbury Park, CA: Sage Publications.

Johnson, L.S.M. (2010, October 5). Kids, concussion and ConTACT: The shortcomings of return-to-play guidelines. Neuroethics & Law Blog.

Johnson, L.S.M. (2011, January 13). Email correspondence to author.

Johnson, O. (2010, November 17). DA: Football player’s death ‘tragic accident.’ Boston Herald.

Keating, P. (2010, December 2). Is concussion testing good enough? ESPN.com.

Kirkland, L. (2010, December 14). As budgets decline, injury concerns rise in high school football. NeonTommy.com.

Kivela, P. (2010, November 1). Head injuries come to mind. Napa Valley Register.

Klaft, H. (2011, March 20). Effects of concussions go beyond playing field for Western High School student. Jackson Citizen Patriot.

Knapp, G. (1997, September 16). Football is a guilty pleasure. San Francisco Examiner.

Knee Injuries. (2008, May 23). High school knee injuries by sport and gender. Science Daily.

Knight, D. (2010, December 21). Can’t rush recovery. WashingPost.com.

Koebler, H. (2011, May 25). Media all over NFL lockout, completely ignoring head injuries. www. opposingviews.com.

Koeske, Z. (2010, November 8). Laws aim to protect student athletes with concussions, but money is lagging. PoliticsDaily.com.

Kutcher, J. (2010, January 4). Testimony of Jeffrey Kutcher, M.D., director, Michigan NeuroSport. In Committee on The Judiciary, U.S. House of Representatives, (2009, October 28, & 2010, January 4). Legal issues relating to football head injuries, Part I & II, (Serial No. 111-82). Washington, DC: Committee on The Judiciary.

Lockridge, N. (2010, May 11). Proud father, friend: Former Sentinel standout Dylan Steigers’ life taken from him on eve of new start. Missoulian.

Loh, S. (2010, December 26). 2010: The year of the concussion. Patriot-News.

Maerlender, A., Flashman, L., Kessler, A., Kumbhani, S., Greenwald, R., Tosteson, T., & McAllister, T. (2010, November-December). Examination the construct validity of ImPACT computerized test, traditional, and experimental neuropsychological measures. The Clinical Neuropsychologist, 24(8).

Magliocca, G. (2009, December). Assumption of risk and football. ConcurringOpinions.com.

Martin, M. (2009, October 1). NFL players at risk for dementia. www.npr.org.

Masko, D. (2011, March 8). Football players have some sort of brain damage, states top neurologist. www.huliq.com.

Mayers, L. (2008, September). Return-to-play criteria after athletic concussion: A need for revision. Archives of Neurology, 65(9).

Mayers, L. (2011, January 31). Telephone interview with author.

McChesney, R. (1989). Media made sport. In Wenner, L.A. (Ed.). Media, sports & society. Newbury Park, CA: Sage Publications.

McCollum, D. (2011, April 14). Nac docs tell athletic directors to evaluate concussions. www.ktre.com.

McCrea, M., Guskiewicz, K., Randolph, C., Barr, W.B., Hammeke, T.A., Marshall, S.W., & Kelly, J.P. (2009, November). Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery, 65(5).

McDonald, J. (2010, September 23). Concussion cases hard to figure. ESPNBoston.com.

McKee, A.C., Gavett, B.E., Stern, R.A., Nowinski, C.J., Cantu, R.C., Kowall, N.W., Perl, D.P., Hedley-Whyte, E.T., Price, B., Sullivan, C., Morin, P., Lee, H., Kubulis, C.A., Daneshvar, D.H., Wulff, M., & Budson, A.E. (2010, September). TDP-43 proteinopathy and motor neuron disease in chronic traumatic encephalopathy. Journal of Neuropathology and Experimental Neurology, 69(9).

McKenna, D. (2010, October 29). The NFL’s concussion politics. www.washingtoncitypaper.com.

Meggyesy, D. (2011, May). Email to author.

Middleton, R. (2011, April 23). Ex-football star Wierschem dealing with disability. West Central Tribune.

Miller, J.J. (2011, April 21). How Teddy Roosevelt saved football. Wall Street Journal.

Moore, A. (2011, March 5). From one hit in basketball practice, months of concussive injury. Lehigh Valley Express-Times.

Moore, B.E. (2009, November 3). Football is linked to dementia, and why it should be banned from high schools. KevinMD.com.

Muchnick, I. (2011, January 11). Joseph Maroon, doctor for NFL and WWE, has it every which way on concussions. BeyondChron.

Muchnick, I. (2011, January 23). Sports concussion scandal ground zero: NFL and WWE Doc Joseph Maroon’s hype article in ‘Neurosurgery’ on Riddell Football Helmets. wrestlingbabylon.com.

Mueller, F.O., & Cantu, R.C. (2011). Annual Survey of catastrophic football injuries, 1977-2010. Indianapolis, IN, and Waco, TX: National Collegiate Athletic Association, National Federation of State High School Associations, and American Football Coaches Association.

Mueller, F.O., & Colgate, B. (2011, February). Annual survey of football injury research, 1931-2009. Indianapolis, IN, and Waco, TX: National Collegiate Athletic Association, National Federation of State High School Associations, and American Football Coaches Association.

Murphy, K. (2009, October 23). Evansville girl’s football lawsuit settled. Wisconsin State Journal.

Nation, A.D., Nelson, N.G., Yard, E.E., Comstock, R.D., & McKenzie, L.B. (2011, March). Football-related injuries among 6- to 17-year-olds treated in U.S. emergency departments, 1990-2007. Clinical Pediatrics, 50(3).

NCAA Guideline. (2010, July). NCAA guideline 2i: Concusion or mild traumatic brain injury (mTBI) in the athlete. www.ncaa.org.

Nelson, G. (1989, June 11). Courts are needed to ease players’ pain. Seattle Times.

NFL Safer. (2011, March 13). Hershey Medical Center neurosurgeon is working with NFL to make football safer. blog.pennlive.com.

NFL Study. (2010, December 12). NFL study could study effects of college, pro football. The Associated Press.

Novack, A. (2010, September 1). Youth football player dies from injury. philadelphia.cbslocal.com.

O’Connell, P.M. (2009, September 23). High blood pressure killed teen football player. St. Louis Post-Dispatch.

Omalu, B. (2010, January 4). Testimony of Bennet I. Omalu, M.D., co-director, Brain Injury Research Institute, West Virginia University. In Committee on The Judiciary, U.S. House of Representatives, (2009, October 28, & 2010, January 4). Legal issues relating to football head injuries, Part I & II, (Serial No. 111-82). Washington, DC: Committee on The Judiciary.

Omalu, B. (2010, February 8). Dr. Bennett Omalu’s remarks to the House Judiciary Committee in Houston. BrainInjuryResearchInstitute.org.

Omalu, B. (2011, January 15). Telephone interview with author.

Omalu, B.I., DeKosky, S.T., Minster, R.L., Kamboh, M.I., Hamilton, R.L., & Wecht, C.H. (2005, July). Chronic traumatic encephalopathy in a National Football League Player. Neurosurgery, 57(1).

Omalu, B.I., DeKosky, S.T., Hamilton, R.L., Minster, R.L., Kamboh, M.I., Shakir, A.M., & Wecht, C.H. (2006). Chronic traumatic encephalopathy in a National Football League player: Part II. Neurosurgery, 59(5).

Omalu, B.I., Bailes, J., Hammers, J.L., & Fitzsimmons, R.P. (2010, March). Chronic Traumatic Encephalopathy, Suicides and parasuicides in professional American athletes. American Journal of Forensic Medicine and Pathology, 31(1).

Oriard, M. (1993). Reading football: How the popular press created an American spectacle. Chapel Hill, NC: University of North Carolina Press.

Owen Thomas. (2010, September 14). Penn’s Owen Thomas had CTE. ESPN.com.

Park, M. (2010, September 14). College football player who committed suicide had brain injury. www.Scnn.com.

Padwe, S. (1986, September 27). Drugs in sport: Symptoms of a deeper malaise. The Nation.

Pardo, S. (2008, October 21). Injury waivers challenged. Detroit News.

Patel, D.R., Shivdasani, V., & Baker, R.J. (2005). Management of sport-related concussion in young athletes. Sports Medicine, 35(8).

Patnaik, R. (2011, April 25). Study on football concussions looks at how early damage can be done to players.

Pepper, M. (1997, December 14). Too much sports or too little? Kansas City Star, p. B2.

Piland, S.G., Ferrara, M.S., Macciocchi, S.N., Broglio, S.P., & Gould, T.E. (2010). Investigation of baseline self-report concussion symptom scores. Journal of Athletic Training, 45(3).

Player Dies. (2008, October 2). High school football player dies of MRSA. CFNews.com.

Player Dies. (2010, October 12). Football player dies from heat-related injuries.www.4029tv.com.

Posnanski, J. (1997, August 10). Can’t we just watch the games? Kansas City Star.

Potkey, R. (2010, October 23). Tackle football is popular, but data about head injuries has parents considering safety issues. Ventura County Star.

Powers, S. (2010, December 27). Illinois athletes partake in concussion survey. ESPN.com.

Randolph, C., McCrea, M., & Barr, W.B. (2005, September). Is neuropsychological testing useful in the management of sport-related concussion? Journal of Athletic Training, 40(3).

Randolph, C., Barr, W.B., & McCrea, M. (2006, June). Letters to the editor. Journal of Athletic Training, 41(2).

Reilly, L. (2010, September 1). Family, teammates mourn tragic death of young football player. Delaware County Daily Times.

Reynolds, R. (2009, December 4). Sports lawsuit to trigger further debate. Risk & Insurance Online.

Robertson, D. (2010, October 25). Concussions and the NFL: Gregg Bingham. Houston Chronicle.

Rodgers’ Concussion. (2010, December 17). Ignoring Green Bay Packers quarterback Aaron Rodgers’ multiple concussions is tempting fate. Wisconsin Outdoor Fun.

Rousmaniere, P. (2009, December 1). A game changer. Risk & Insurance Online.

Rule Change. (2010, November 10). Rule change on youth football hits. The Associated Press.

Schatz, P. (2010, January). Long-term test-retest reliability of baseline cognitive assessments using ImPACT. American Journal of Sports Medicine, 38(1).

Schwarz, A. (2010, September 13).  Suicide reveals signs of a disease seen in the N.F.L. New York Times.

Schwarz, A. (2010, September 15). Eagles’ handling of head injury draws spotlight. New York Times.

Schwarz, A. (2010, September 22). Despite law, town finds concussion dangers lurk. New York Times.

Schwarz, A. (2011, January 23). Oversight group vows to pursue updates to football helmet standards. New York Times.

Screening Limits. (2010, December 3). Football player’s death points to screening limits. The Associated Press.

Shedden, M. (2010, December 28). Concussion concerns are changing football, but it’s still hit and miss. Tampa Tribune.

Shyr, L. (2011, February). New research suggests that even small hits to the head may lead to brain deterioration over time. So what can be done? National Geographic.

Siegel, A. (2010, December 8). Varied symptoms can result from concussions. Washington Post.

Slager, P.A. (2009, March 13). Tackling head trauma: The concussion problem in sports. Sports Litigation Alert.

Stamm, D. (2010, September 1). Upper Darby teen dies playing football. www.nbcphiladelphia.com.

Stern, R., Gavett, B.E., Baugh, C., Nowinski, C.J., Cantu, R.C., & McKee, A.C. (2011: In Press). Recurrent sports-related traumatic brain injury and tauopathy. Washington, DC: The National Academies Press.

Suarez, R. (2009, November 27). Hard knocks: Does playing in the NFL cause brain trauma? PBS NewsHour.

Szostak, M. (2011, April 16). Proposals debated to allow sports fees, require baseline concussion testing. Providence Journal.

Talan, J. (2008, October 2). New report links sports concussions to chronic traumatic encephalopathy. Neurology Today, 8(19).

Talan, J. (2010, September 16). Does concussion cause motor neuron disease? The question stirs debate. Neurology Today, 10(18).

Talavage, T.M., Nauman, E.A., Breedlove, E.L., Yoruk, U., Dye, A.E., Morigaki, K.M., Feuer, H., Leverenz, L.J. (2010, electronic pre-publication). Functionally-detected cognitive impairment in high school football players without clinically diagnosed concussion. Journal of Neurotrauma.

Vargas, A. (2010, December 13). Carver High School mourns football player who died after collapsing at practice. New Orleans Times-Picayune.

Vevea, B. (2010, September 7). Muskego school mourns 11-year-old. Milwaukee Journal Sentinel.

Wenner, L.A. (Ed.). (1989). Media, sports & society. Newbury Park, CA: Sage Publications.

Wharton, D. (2005, April 16). Safe but not safer. Los Angeles Times.

Whiplash Injuries. (2011, January 16). Whiplash may include brain and spinal-cord injuries. NutritionDietNews.com.

Whiteside, K. (2010, December 28). Concussions no fun, take toll on school for injured athletes. USA Today.

Wightman, K. (2010, August 13). 2 high school players in comas; 3^rd in critical condition. www.fox15.com.

Williams, J. (2010, October 27). Wekiva football player Olivier Louis died from sickle-cell trait. Orlando Sentinel.

Williams, P. (2010, October 7). The Brentsville community strives to overcome the heartache of Austin Trenum’s death. Washington Post.

Wilner, B. (2010, October 20). NFL players wonder what’s happening to sport after league crackdown on hits. The Associated Press.

Wilner, B. (2010, October 28). Some NFL players not sold on how safe game will be if low hits are emphasized. The Associated Press.

Wise, M. (2010, October 23). Amid football’s sound and fury, tragedy can strike at any time. Washington Post.

Wodraska, L. (2007, Aug. 12). So many reasons to love football. Salt Lake Tribune.

Wood, C. (2010, September 7). Congress and concussions, prepping for further litigation. PointOfLaw.com.

Wulf, S. (2010, November 15). Play it safer. ESPN The Magazine, p. 25.

Yard, E.E., & Comstock, R.D. (2009, October). Compliance with return to play guidelines following concussion in U.S. high school athletes 2005-2008. Brain Injury, 23(11).

Yesalis, C. (2010, December 22). Telephone interview with author.

Youngmisuk, O. (2007, July 11). Former players say enduring pain, concussions not worth it. New York Daily News.

Zimmerman, P. (1986, November 10). The agony must end. Sports Illustrated, p. 17.