A Brief History of Concussion as a Public Health Issue

The stigmatizing language of concussions

In the early 1900s, “punch drunk” emerged as a boxing term describing the dazed condition of boxers who had sustained many blows to the head. The term soon gained significant scientific usage; pathologist Harrison Martland’s 1928 paper, borrowing the vernacular boxing term, labeled the chronic neurodegenerative condition observed in boxers “punch drunk.” However, the term also carried stigmatizing connotations. It was used as a derogatory term outside of the context of head injury: an insult that implied chronic behavioral problems or a dysfunctional view of reality. Moreover, because of the stigma associated with “punch drunk,” it was even potentially libelous. In 1956, gym owner Lou Stillman sued for defamation when a character in the movie The Country Girl stated that one could “get a punch drunk fighter” at Stillman’s gym. The fact that “punch drunk” gained significant scientific and clinical use allowed this stigmatizing language to permeate concussion research.

Accusations of goldbricking and malingering

Another source of stigma for concussion patients was accusations of goldbricking and malingering. In a 1964 interview with Ebony magazine, star NFL running back Jim Brown recalled sustaining a concussion during a pileup in a game. But when he stayed on the bench after the injury, the coach accused Brown of goldbricking—purposefully avoiding work, with the added implication that Brown was swindling his employer. But because of the invisible nature of concussions, Brown was unable to prove his injury to the coach. 

The accusation that a patient was feigning injury to avoid work was certainly not unique to the mid-twentieth century. In his 1912 presentation on malingering, Dr. Byrom Bramwell discussed how doctors could identify feigned injury or illness, arguing that “it is the functional conditions which are easily simulated.” As an injury that left few external signs, concussion fell under the category of “functional conditions” that were considered easy to feign. Consequently, concussion patients were held under heightened suspicion of malingering. Moreover, the charge of malingering often implied a motive of cowardice or desire for undeserved compensation, which only increased the stigma faced by concussion patients.

Intimate partner violence and concussions in women

While the previous examples of stigma are from traditionally male-dominant contexts, it is also necessary to acknowledge the presence of women concussion patients. Moreover, their experience often differed significantly from that of their male counterparts. In the 1970s, the feminist movement brought the issue of intimate partner violence to the forefront of public consciousness. The movement was directed against a culture that sought to protect the privacy of the home by blaming, silencing, and stigmatizing victims of intimate partner violence—especially women. 

Concussions are common in intimate partner violence cases. However, despite the increased public awareness of intimate partner violence, the brain injuries of “battered women” were “largely perceived as emotional and psychological rather than physical and neurological.” In other words, while the symptoms of “battered women” were recognized, they were often attributed to emotional and psychological causes rather than to traumatic brain injury. Even until the late twentieth century, the stereotypical association between women’s injuries and their psychology remained influential. 

NFL

All of the major domestic contact sports have played a colossal role in the advancement of concussion, research, treatment, and advocacy, but none have been as significant as American Football. In the 1970s,….The year 1994 signaled the NFL’s entrance into the arena of concussion research with the establishment of the Mild Traumatic Brain Injury Committee, with the goal of monitoring the effect of concussions on NFL players. After completing its principal study in 1999, the committee announced that head injuries had remained “remarkably the same” in reference to the incidence of TBI among NFL players during the four-year period of the study. These findings would come to define the NFL’s position on TBI and their transcending interest in protecting their assets.

In the year 2006, football families around the world were put on high notice following findings by British pathologist Bennet Omalu. Upon completing an autopsy, along with a self-funded tissue analysis on former NFL football player Mike Webster, Dr. Omalu was able to detect an atypical form of denaturation within the brain tissue of the patient. Using staining techniques, Omalu discovered a substantial accumulation of tau protein in Webster’s brain. He proceeded to publish a paper on his discovery, in which he denoted the condition as Chronic traumatic encephalopathy (CTE). The findings by Dr. Omalu put the NFL front and center of a burgeoning concussion crisis, that only worsened its image as it stayed put with the discoveries of its committee years before. The NFL would forego acknowledging the link between concussions and cognitive decline until 2009 when they finally established the presence of cognitive decline arising from repeated concussions.

The NFL currently attempts to incorporate concussion research in the development of safer protective equipment for athletes, such as helmets, which have been updated multiple times since 2010. In 2013, the league finally mandated a four-step concussion protocol for athletes, which, though late, provided a sense that the NFL was beginning to prioritize the opinions of leading scientists in the field.

Association football (soccer)

Soccer has had a labored history with concussions. The sport ranks among the top five in concussion incidence for both genders and is first among female sports. According to CPSC statistics, the most frequent cause of concussions are head-to-player contact (40%) with head-to-ground being the next leading cause (10.3%).

A pivotal event occurred in a 2006 premier league match in Great Britain, during which goalkeeper Petr Cech suffered a major blow to his skull from the opponent’s knee, leaving him with a complicated concussion. Similar events with goalkeepers have repeatedly brought up discussions about incorporating additional safety equipment for soccer players, which at the moment are nonexistent. Unlike the NFL, the sport has not faced much universal controversy on the danger of head injuries, likely in part of the fact that many athletes do not encounter a decreased life expectancy, nor do they frequently generate the same life-changing symptoms seen in those of NFL players.

…….Researchers found that only 23.4% included all mandatory state law tenets. While many included return-to-play protocols (74.5%), return-to-classroom or return-to-learn protocols were notably absent (32.4%), especially considering the impact school-based athletics can have on students’ academic performance. However, schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers.

This finding led researchers to conclude that employing full-time athletic trainers may help establish high school SRC protocols that include state law requirements more closely and provide additional advice for best SRC practices. This article was published in the Journal of Athletic Training.

While concussion-specific legislation would not be enacted in the US until the late twentieth century, in the early 1900s, many states began to enact worker’s compensation laws—starting with Wisconsin’s Workmen’s Compensation Act in 1911. These laws allowed injured workers to receive compensation, provided that they were not at fault for their own injury.  On the federal level, the Occupational Safety and Health Act was passed in 1970.  However, these early laws primarily focused on injury prevention and compensation, rather than patient treatment. This changed in 1996, when President Bill Clinton signed the Traumatic Brain Injury Act into law. It was the first federal law to specifically address concussion risk reduction, research, and treatment—and when it was amended in 2000, it also authorized the implementation of a national traumatic brain injury education and awareness campaign.

Perhaps the most significant concussion law in recent history was the Lystedt Law. In 2006, high school football player Zack Lystedt sustained a head injury during a game. Though he shook off his injury and was allowed to return to play, Lystedt collapsed on the field immediately after the game. After multiple strokes, a three month coma, and major surgery, Lystedt was permanently disabled. Consequently, in 2009, the state of Washington passed the Lystedt Law, which strictly regulated return-to-play concussion protocol for young athletes. In addition, it mandated concussion education for athletes, parents, and coaches. Similar laws were soon enacted in many other states.

Early history

In the first portion of the 20th century, clinical self-education was fairly nonexistent outside of academic circles. Early pathologists, such as Cyril Courville, “would ascertain whether or not concussion was a genuine clinical entity,” through the analysis of the oral history of Native Americans. He also took a closer look at historical cases of concussion to develop an understanding of the underlying physiological changes at play. It was not until his findings in the 1950s, along with others during the same period, that there was a fairly clear consensus that concussions were somatic in nature, rather than psychogenic. As a result, the reliability of information outside research circles was inconsistent at best. In fact, a frequently referenced study on the gap between clinicians and researchers stated that it takes 17 years for 14% of the original research to translate to clinical practice, which may further explain the delay seen in this period. As far as individualized medical information, personal medical history was not ordinarily documented until the 1960s with the inception of paper filing methods, making it difficult for patients to track their medical history/progress over time. The sparse documentation of this data itself as it relates to concussion was largely subjective until the characterization of the tau protein in the 1970s, which resulted in the widespread establishment of concussion pathology shortly after.

Contemporary barriers

With the dawn of the social media age in the 21st century, an increasing proportion of the population has begun to rely on major media platforms, such as YouTube, as the primary outlet for self-education. Keeping this in mind, it is essential that the latest trends in concussion research are communicated properly through these mediums. Unfortunately, as a result of the ease to share information on these platforms, these sources have been hubs for rampant misinformation as it relates to concussion pathology and research. A recent study that addressed this issue was able to find, “that the majority of the videos (70.4%) addressed concussion causes, with 48% stating sports,” as the cause. In fact, few videos discussed symptoms of concussion and failed to properly demonstrate preventative methods. As concussion patients look for resources to both educate themselves on the condition and create personalized treatment plans with the help of physicians, it is essential that they have access to reputable, peer-reviewed sources to fill in the void currently held by unchecked content creators.

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