Less Football Practice Contact Time May Mean Less Concussions

In the evolving discussion regarding the impact of limited high school contact football practice time on concussion risk, findings from the University of Wisconsin suggest that less contact practices may indeed result in less football-related concussions.

Photo courtesy: http://www.ocregister.com/articles/orange-681360-park-last.html

The state of Wisconsin was one year ahead of California in mandating contact practice time restrictions. Starting with the 2014 high school fall season, the Wisconsin Interscholastic Athletic Association (WIAA) prohibited contact in practice for the first week and limited full contact to 75 minutes per week for week 2, with 60 maximum minutes per week for week three and beyond. These limits are more restrictive than in California where two 90 minute contact practice sessions are allowed per week during the high school football season, thought the definitions of full contact are similar (game speed drills/situations where full tackles are made at competitive pace and players are taken to the ground).

• Click here for related posts on California High School Football Contact Practice limitations.

Licensed Athletic Trainers at several Wisconsin high schools recorded incidence and severity for each sport-related concussion, and compared the two years previous to the rule change (2081 players) with data from the first year of the new limitations (945 players). 

Significant findings included

·        The rate of sport-related concussion sustained in practice was more than twice as high in the two seasons prior to the rule change

·        There was no change in the rate of concussion suffered in games pre and post-rule change

·        There was no difference in the severity of concussion (defined as average days lost from football activity) pre (13 days lost) and post-rule change (14 days lost)

·        Tackling was the primary mechanism of injury in 46% of sport-related concussions

·        Years of football playing experience did not affect the incidence of sport-related concussion in the first year of the new limitations

The authors concluded that limitations on contact during high school football practice may be one effective measure to reduce the incidence of sport-related concussion

How might this relate to California?

This is a well-constructed and much needed initial evaluation on the outcomes of contact practice reductions in high school football, with subsequent years of analysis now being anticipated to see if the above findings hold true over multiple seasons.

The maximum allowed football contact times in Wisconsin are about 42% of the maximal time currently allowed in California, so one may wonder if that increased contact time may make direct extrapolations between the states more difficult. This is where a similar study after the 2015 California high school season is vital to measure the outcomes here in this state.

I was greatly impressed with the finding that there was no change in game-based concussion rate and that the years of previous playing experience not affecting the incidence of new concussion as two potentially landmark outcomes for the future of football safety.  Coherent arguments have been voiced that lack of appropriate contact practice time might increase risk for inexperienced or under-prepared players, especially in game time situations. This was particularly voiced for freshman players with no previous tackle football experience. I eagerly await future studies to see if these outcomes are consistent and robust.

The lack of change in severity (again, measured in days lost) brings up a couple of thoughts. The initial reaction might be a bit of disappointment, in that reduction of cumulative head impacts in practice should perhaps lead to a lower burden of injury with a concussive blow and hopefully a quicker recovery. One may not want to try and read much into using number of days lost as a strong measure of severity, for standard return-to-play protocols often mandate a minimum of 8-10 days off from full activity which could influence the return time possibly more than symptoms and other measures of severity.

One important subject not analyzed in this study was the incidence of non-concussion injury rates before and after the practice contact limits were enacted. Concerns have been issued over under-prepared players not confident in tackling techniques or changes in technique (hitting opponent lower in body, for example) both possibly contributing to less concussions, but more shoulder, elbow, knee, leg and other musculoskeletal injuries. 

Curious if any groups in California are interested or have proposed a similar analysis of our first year with the high school football practice limitations?

New California Football Contact Limits Provide Unique Opportunity to Study Effect on Concussions

According to the findings of a study published in the May 4th online edition of JAMA Pediatrics, practice periods are a major source of concussion for the high school football player. 

While the actual rate of concussion is higher in game play, just over half of the reported concussions took place during practice times.

The authors suggest that strategies should be implemented to evaluate technique, limit player-to-player contact and overall head impact exposures, and reduce other higher risk practice situations.

While the jury is still out on what constitutes proper technique, the mandates of California Assembly Bill 2127 will afford a vital opportunity to further study the influence of practice time limitations on concussion rates in high school football players.

The bill prohibits high schools from conducting more than 2 full-contact practices per week during the preseason and regular season, and prohibits this full-contact portion of the practice from exceeding 90 minutes in a single day.

To clarify, "full-contact practice" means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game.

Based on the findings of the above JAMA Pediatrics study, the hypothesis is that these new restrictions should reduce concussion rates in practice simply by limiting exposure time and cumulative risk.

Now, one might ask, why would there possibly not be a reduction in concussion rates?

• Is there a chance that limited practice times could lead to less comfort with tackling that could result in an actual higher game rate of concussion?
• Could football programs feel pressure to get in as much contact as possible during the 2 allocated 90 minutes practice periods, possibly leading to more cumulative exposure during that time?

A multi-location review of concussion rates (game and practice) is essential to confirm the effects of California AB 2127. 

In such a study, I would also suggest that concussion rates be broken down by academic grade of player, and even take into account years of experience of tackle football.

I wonder if neophytes (namely incoming freshman) who have never previously played tackle football could be at higher risk from contact practice time limits.  Would the contact time restrictions have less influence on upperclassman who have played tackle football for a longer period of time?

All stakeholders will be eager to see if indeed there is a documented reduction in overall concussion rates, and if such a reduction is seen across all levels of high school football.

Thoughts on California Interscholastic Federation Concussion Return Protocol

Right before California Assembly Bill 2127 became law on January 1, 2015, I wrote on this blog many questions remained unanswered about certain provisions, namely clarifying what is meant by "no less than a seven day" return progression, when does this seven day period begin, and a better definition of appropriate supervision during this period.

Today, after reviewing the recently released California Interscholastic Federation (CIF) Concussion Return to Play Protocol, it is now readily apparent that the intent of the law was to ensure that if an athlete was concussed let's say on a Friday night, that they will not be able to return to play the following Friday night.

This comes as no great surprise to many of us in the sports medicine community and serves to bring uniformity to something that we had suspected since the bill was signed into law.

There are several other provisions of the Return to Play progression that should be of unique interest, and I will list them below along with my professional comments:

• Return to play cannot be sooner than 7 days AFTER the diagnosis of a concussion by an physician MD/DO
  • Now we know when the "clock can start" and what concerns me is not so much the sports with one game a week, but those with multiple games a week.
  • If a football player is concussed on Friday night, having the physician evaluation the following Monday or even Thursday doesn't have a real time sensitivity since that athlete is out for that next week's game and still has the seven day period potentially available to play in the following weeks game.
  • However, let's take the case of a basketball player with a tournament that involves key games possibly 8-9 days after a concussion. There might be pressure placed on the physician to see that athlete ASAP to get the clock started for a potential return in that 8-9 day period
• No physical activity for at least 2 full symptom-free days AFTER you have seen a physician 
  • Given the emphasis on the no return within a full week after a concussion, can certainly see why this element was put into place.
  • Does limit the judgement of medical teams to allow light, low-risk activities that might be well-tolerated in the initial post-concussion period and may also actually assist in that recovery.
• A certified athletic trainer (ATC), physician, or identified concussion monitor (e.g., coach, athletic director), must initial each stage successfully passed
  • Leads to an increase in the paper trail but also makes each school responsible for monitoring a step-wise return to play and not just allowing a full immediate return to sport. 
  • Hopefully this provision will further underscore the important role of a certified athlete trainer on a school campus. For those schools that don't have one, this might serve as a strong motivator to find necessary resources to support the hire of an ATC to help maintain compliance with this new law.
•  Minimum of 6 days to pass (non-contact) Stages I and II. Prior to beginning (contact) State III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor. 
  • That 6 day minimum again written with a direct eye on football and not having an athlete return for that next game after a concussion
  • Here's another spot where having an ATC can make the process easier- as a physician, if I have a strong working relationship with an ATC, I might not need to see the athlete back in my office before allowing return to contact if the ATC is comfortable with the return protocol and progress of the individual athlete.
  • Now, if there is no ATC on campus, stronger chance that I will require an office visit between non-contact and contact return.
• MANDATORY: You must complete at least ONE contact practice before return to competition. (Highly recommend that Stage III be divided into 2 contact practice days as outlined above.) 
  • Remember that AB 2127 also limits full contact  practices to only 2 ninety minute sessions per week. 
  • Curious to see how a return to play that recommends 2 contact sessions works out with these new contact practice limitations

I will close out this post with a  passionate request to CIF and the sports and school communities: despite any concerns or disagreements, this protocol is now in place and thus must be publicized, discussed and shared through multiple mediums to get the word out to all coaches, athletes, parents, administrators, and medical providers. . I can honestly say that with past state or CIF concussion policy updates, I was shocked at how often reasonable, involved, and usually well-informed colleagues were unaware or ignorant of these changes. If all schools are following the same protocol, there will be more universal acceptance of this new policy, so CIF cannot passively oversee dissemination, it must take a very active and vocal role to increase the appropriate use and eventual greater acceptance of this new protocol.

Are California Schools and Medical Providers Prepared for New Concussion Law?

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) will take formal effect on January 1, 2015 and will provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

For my initial reaction to this law, click here

In discussions with coaches, administrators, and fellow sports medicine providers, I'll throw out a few questions that have arose regarding several nuances of the law:

• When is the earliest that the 7-day return protocol begins?
  • Is it potentially at the time of formal diagnosis of a concussion by a licensed provider?
  • Is it when the athlete is fully cleared of post-concussion symptoms?
  • Can the period begin before a formal diagnosis is made?
• What is the formal definition of supervision?
  • Can an athletic trainer assume the role of supervision under the guidance of a physician?
• Given that the bill also limits contact football practices to two 90 minute periods per week, if the timing of those two practices is perhaps a day before a player's progression is ready for contact, can he have alternate contact to possibly play in a game if otherwise having an appropriate recovery?
• Are school and medical providers aware and sufficiently prepared for these new edicts?
  • Is there agreement or clarification on the above terms and concerns?
  • Have concussion management plans, if already in place, been modified or reviewed to address the new mandates?

Certain that there are other questions and thoughts out there- please use this as a forum to share with others.

Initial Thoughts:CA Limits Contact Practice, Mandates 7 Day Minimum Return after Concussion

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) has been passed by both legislative houses and now awaits the likely signature of Governor Jerry Brown. The date of implementation is uncertain at this time, but the following changes are certain to come to high school football in the Golden State:

• All high school football teams (public, private and charter) would be limited to no more than 2 full-contact practices per week during the pre-season and regular season.
• The full contact portion of each practice cannot exceed 90 minutes per day
• Full-contact practices are prohibited during the off-season
• “Full-contact practice” means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game

In addition to the contact practice limitations, the bill would further provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

Click here for more information on football safety

Click here for more information on concussions

Upon initial review of this legislation, l commend efforts to reduce concussive injuries and rushed returns to play after concussion, and also realize that many teams at all levels of football have already made live contact limitations. I also realize that there are several unanswered questions and controversies to share:

• The current scientific literature does not have a sufficient body of evidence to declare with certainty the precise risks and benefits of live contact limitations in football. The thought that reducing cumulative sub-concussive head impacts is indeed commendable, but the counter-result of potentially having athletes participate in game situations without adequate exposure of didactic hitting instruction has not been fully studied. Ideally, live contact football limitations would have the same injury reduction outcomes as seen with ice hockey checking limitations. Raising the age of initiating checking actually reduced injuries at all levels, thus countering the argument that early and more frequent exposure to checking was important to reduce injuries in older athletes. However, these proposed checking limitations were debated (and probably still questioned in some circles) for years until good studies were done that provided a sufficient supporting evidence base. It is sensible to think that less live contact overall reduces cumulative risk, but would be more appealing to eventually have good science to further support this contention.
• Is this global reduction on contact practice equally beneficial for all levels of high school football? Does maybe the freshman team with several members playing tackle football for the first time need more live contact versus the varsity program with more experienced athletes? Again, I have no numbers or science to support this statement, but do have to wonder.
• Could teams try to maximize the 90 minute sessions of live contact with more drills or hitting repetitions? Is that increased exposure better or worse than spreading it out over more days?
• I do wonder if the tackling limits will encourage the expansion of football camps and other training programs outside the formal high school environment that will allow greater exposure to live contact tackling drills and instruction? If players, parents, and coaches are concerned about receiving sufficient instruction, will they look elsewhere and if so, will those venues have appropriate coaching along with proper medical support (especially Certified Athletic Trainers) and referral mechanisms? 
• How do other medical professionals who routinely manage concussed patients feel about the mandatory 7 day minimum return progression? Don't think that anyone out there is ever excited to speed a player's return to play (in fact, we might actually appreciate having "the law" force us to slow down eager players), but one unintended consequence might be the challenge of even more players and families reluctant to present for medical evaluation with the knowledge that they will be required miss the next game. On the other hand, will it possibly increase demand for immediate post-concussive evaluation to "start the clock" as quickly as possible for the small subset of concussed athletes who truly become symptom free within 24-48 hours of injury? 
• The bill urges the California Interscholastic Federation to work in consultation with the  American Academy of Pediatrics and American Medical Society for Sports Medicine to adopt rules and protocols for developing the return to play progression. I am a member of both organizations, and can state that they are populated by caring and scientifically rigorous members who strive for the best safety interests of children and adolescent athletes. I implore my colleagues in these groups to rigorously evaluation these new mandates in hopes of developing more evidence-based answers to the queries and uncertainties raised above.

What do you think about the live contact tackling limitations? Do you also have any thoughts about the minimum 7 day return progression after a concussion? Very curious to hear from football players, parents, coaches, school administrators and fellow medical professionals.