We are high above the plush seats in the Tottenham Hotspur Stadium, the NFL’s chief medical officer and I, watching the Atlanta Falcons’ Cordarrelle Patterson getting dumped on his back. “As he throws the ball, keep an eye on his head,” Dr Allen Sills says. The tackle looks innocuous, at least at first. But then Sills asks a technician in the video review booth to slow down the footage before viewing it from another angle. Now it is clear that, as Patterson falls, his head spanks the turf and ricochets up. The incident, from the NFL game in London on Sunday 10 October, led to a call being made downstairs from an independent neurologist to the game officials – and to Patterson being checked immediately for concussion.
In recent years we have learnt that, when it comes to brain injuries, what the NFL has faced first – from class-action lawsuits from former players to having to make rule changes to prevent concussions – other sports will eventually experience. It has been forced to confront and adapt. That is one reason the Premier League held a medical conference with the NFL last week: to share best practice when it comes to player health and safety, including concussion.
So what could other sports learn from the NFL? First, size matters. When there are 22 players strung across an entire field, it is impossible for a single official or doctor to follow all the action and detect a concussion. Incredibly the NFL now has 30 medical professionals at every game – including an independent neurologist on each sideline and another in a video replay booth as part of a team of spotters who scrutinise every play. “And one of the really unique things about an NFL game is that the spotters, as medical professionals, are empowered to actually stop the game because of concern over a medical injury,” says Sills.
If that happens, players are taken to a blue tent where their team doctor and an independent neurologist perform a standard series of tests – including checking memory, speech, eye movements and gait – before making a decision together. The point of involving a team doctor is that sometimes the only sign of a concussion is a slight change in personality – with a player who is really chatty suddenly going quiet – something an independent doctor might miss.
When Sills arrived at the NFL in 2017 it had just experienced an unwelcome record of 190 concussions in the regular season. Last year that figure had dropped to 142. Sills says that other rule changes – it is now a foul to lower your head to make contact – and far better helmet technology are key factors, too.
But he stresses it is not only about protocol but a shift in culture. Sills says that around half the NFL’s concussion protocols now start when a player on the field reports a concussion – which would have been unthinkable a decade ago.
Yards away from the Miami Dolphins locker room on Sunday, for instance, there was a massive safety poster, which ranked every helmet the players wear from green to yellow to red – with the ones in green doing the best job at dispersing force and the ones in red now banned. The poster, which also hangs at every NFL team’s training facilities, reminds them of the importance of the safety equipment and the choices that they make.
“We’re certainly not saying we’ve cured the problem,” Sills says. “We have more work to do not only to prevent concussion but to reduce avoidable head contact. But there were types of collisions that fans used to cheer for and enjoy seeing that are now outlawed from the game.”
The next big challenge for all sports is understanding the impact of smaller, sub-concussive hits to the brain such as from light punches or even heading a football. In 2017, for instance, I wrote about groundbreaking research from scientists at Purdue University, who found that when teenage girls regularly head balls it could take four or five months before the brain looked normal on MRI scans, because of the G-forces involved.
“We’re actually studying that really aggressively,” says Sills. ”We’ve developed sensors in players’ mouth guards to measure the forces that are transmitted – because sometimes there will be quite a bit of force transmitted to the head, even when a player is struck in the shoulder. By merging the sensor information with video footage we can really understand what types of impacts are creating what types of forces for the brain.”
The billion dollar question here, of course, is how different the sporting landscape might look in 10 or 20 years. Sills refuses to be drawn on whether combat sports, such as boxing and MMA, can survive without significant changes given what we now know about concussion. However he believes that collision sports can be made even safer without losing the thrills and spills that we all enjoy.
“Every sport has different challenges,” he says. “I always say as a neurosurgeon, we don’t need to study whether head trauma is good for the brain. We’ve pretty well established that it’s not. So it’s really about how do we reduce trauma, provide additional protection, and make sure that we diagnose and recognise concussion as quickly as we can. And when it comes to the NFL, I believe that our sport can be safe and exciting at the same time.”