On the front lines

On the opening kickoff of the Toledo-Central Michigan game, less than 48 hours after images of NFL quarterback Tua Tagovailoa’s violent concussion thrust head injuries back into the spotlight, UT safety Maxen Hook was leveled by a Central Michigan player.

Hook fell to the ground and awkwardly, got back on his feet, and stumbled backward. When he reached the sideline, Hook was immediately taken to the medical tent, where he underwent a battery of tests that took several changes of possession. He did not return to the game and didn’t play last week at Northern Illinois.

UT, citing HIPPA laws, cannot disclose Hook’s injury, but anyone who watched the play knows what occurred: The sophomore suffered a concussion.

“Player safety is at the forefront of everything that goes on, whether it’s ACLs [or] labrum tears,” Toledo coach Jason Candle said. “Head injuries are part of the sport we play. That’s not a major thing in baseball or basketball. You have to do a good job of coaching to keep your head out of there and prevent the things you can prevent. Some of it is not preventable. You hate to say that, but you have to keep educating them on what’s a good hit and what’s not a good hit.

“And we have to keep listening to the people who have the degrees who make the decisions on what’s smart and what’s not smart. Twenty years ago, the football coach told the doctor what to do. That’s not the case anymore, and it never should have been the case.”

Tagovailoa’s injury came four days after it appeared he suffered a previous concussion. It was obvious enough that there was an outcry prior to Miami’s Thursday night game at Cincinnati from doctors and media that Tagovailoa should not play.

In the aftermath, the unaffiliated neurotrauma consultant who allowed Tagovailoa to return in the first game was fired, and the NFL and players association agreed to make changes to the league’s concussion protocol, adding language addressing abnormality of balance/​stability to the league’s protocol list of symptoms that would prevent a player from returning to a game.

The University of Toledo already checked balance when assessing potential concussions.

“A lot of guys will say they’re fine. In the heat of the moment, they want to keep playing,” said Adam Barta, the head athletic trainer for UT football. “But if it’s a borderline thing, we’re going to hold them [out].”

UT was part of a pilot study on concussions in college football during the 1999, 2000, and 2001 seasons, putting the university on the front lines of concussion protocols.

If a concussion is suspected, a series of events unfold on the Rockets’ sideline. Physicians and trainers evaluate how a player got back on his feet — did they stumble, how violent was the hit? A cognitive assessment is completed, checking the affected player’s memory, concentration, balance, and eyes. A dazed appearance or glazed-over eyes is the biggest tell, because players can’t fake it. An exertion test is last to see if physical activity exacerbates symptoms.

Protocol tests are sometimes administered a second time at halftime or even after a game because symptoms can be delayed.

“I meet with every team, not just football, at the beginning of the year, and we talk about concussions all the time,” said Brian Jones, UT’s senior associate athletic director for health and wellness. “The only people that know what’s going on in that kid’s head is that kid. They have got to be honest about what they’re dealing with. That educational aspect is what’s changed the most. The scariness of CTE in the news has helped. It’s not just, suck it up and play through it.”

Chronic traumatic encephalopathy, or CTE, is the degenerative brain disease caused by repeated head impacts, including concussions.

Since 2017, the Mid-American Conference has had an independent medical observer in the press box at every MAC team’s home games. They have direct communication with the medical staffs and officials. The independent medical observer has the ability to stop the game if they see a potential head injury.

“We use our head almost every play. It’s something we don’t really think about. We just don’t want it to happen,” Toledo center Devan Rogers said about concussions. “The game has changed a lot. It comes with coaches teaching better tackling form, guys keeping their heads up, and the advancement of helmets.”

Research by the NCAA found that 72 percent of football concussions and 67 percent of total head impact exposures come in practice. In 2017, the NCAA outlawed two-a-day practices to help limit injuries. Toledo only has one fully-padded practice per week.

In 2014, the Michigan High School Athletic Association began allowing just 90 minutes of contact in practice per week. (It was reduced to 30 minutes in 2019.) According to a study in the Journal of Athletic Training, the rule change resulted in one Michigan high school team suffering 53 percent fewer head impacts in practice.

Kickoffs are the most dangerous plays in football, as the kicking team and receiving team run full speed at one another. Hook and cornerback Ronald Delancy III have each suffered concussions on opening kickoffs this season.

The Ivy League in 2016 started requiring teams to kick off from the 40-yard line, instead of the 35, and touchbacks started from the 20-yard line, rather than the 25. According to the Journal of the American Medical Association, the rate of concussions per 1,000 kickoffs fell to two from 11.

This week the NCAA is entering its most difficult trial related to negligent concussion protocol. Alana Gee, the widow of former USC linebacker Matthew Gee, who played for the Trojans from 1988-92 and was posthumously diagnosed with CTE, is alleging wrongful death and negligence, saying the NCAA failed to educate Matthew Gee about the dangers of head injuries and failed to protect him.

It used to be that seven days after a concussion players weren’t even tested anymore. They simply returned to practice and played in the next game.

Those days are long gone, and players and coaches are (mostly) on board with the advancements.

“I’ve seen over the years that guys do understand it and take it seriously,” Barta said. “You will have players say they can’t go back in. Coaches just understand the severity of concussions and the return-to-play protocols, and we have objective data. We have strict numbers. We do a cognitive assessment, and it can tell you how the person is functioning mentally.”

The severity of each concussion is different, but if you suffer one at Toledo, it’s nearly impossible to play the following week. Sometimes, it takes players months to fully recover. Delancy was injured on the opening kickoff of the Ohio State game and didn’t return until last week at Northern Illinois.

Symptoms must decrease before returning to physical activity. First, players will ride a bike. If symptoms don’t re-emerge, they can run. Lifting weights is next, then non-contact practice, then full-contact practice. If a player gets through each stage without any symptoms being present, they can play in that week’s game.

“We know these guys and how they normally act and what their personalities are like,” Barta said. “A lot of times, we can tell if something is off or wrong.”

Two decades ago, Candle was a wide receiver at Division III powerhouse Mount Union, leading the Purple Raiders to national championships as a junior and senior. He only recalls suffering one concussion after getting blasted coming over the middle. But he did what most players did in that era: stayed in the game for the next play.

Toledo’s medical staff hasn’t had a Tua moment, and they don’t plan on starting anytime soon.

“I think we’re in a good spot,” Candle said. “During the offseason, we continue to wrap our heads around what’s real and what’s perception and do the best we can to keep our game as safe as we possibly can. It’s a game we all love, and we want to preserve it as long as we can. The only way to preserve the game is to preserve the people who are playing in it and protect the players.”

Contact Kyle Rowland at:

krowland@theblade.com, or

on Twitter @KyleRowland.