In February, Josh Begley, a San Francisco native and Cal graduate, finished producing one of the most haunting short films of 2018.
For more than five minutes, viewers are presented with stitched-together footage that includes stretchers, motionless bodies, thousand-yard stares and high-impact collisions that result in flying spittle and, on one occasion, a pair of trembling, locked arms that suggest a seizure.
Begley’s film, “Concussion Protocol,” is a compilation of every reported concussion from the 2017 NFL season. An avid football fan who increasingly struggles with the game’s violence, Begley wanted to create a historical record of the carnage to which many fans have become desensitized.
“We all kind of hear about a concussion crisis in the NFL, and maybe we can all remember seeing a few concussions in the course of watching a game,” Begley said. “But it felt very difficult to see the totality of that, if you were to have aggregated it all, the sum total of that kind of violence.”
The 34-year-old Brooklyn-based app developer wound up documenting a historically violent season that might well be viewed as a tipping point in the way football is played.
Last season, despite years of increased attention and resources from the NFL to address its burgeoning health crisis, there was a notable spike in concussions. There were 291 reported concussions across preseason, regular season and postseason practices and games. That’s a 16.4 percent increase from 2016, and the highest number of concussions since the league implemented its current injury-tracking system in 2012.
For those charged with making an inherently unsafe sport safer, the spike in concussions was a blow.
“That number,” said Dr. Allen Sills, the NFL’s chief medical officer, “obviously alarmed us.”
Said Jeff Miller, the league’s top executive for health and safety policy: “I think all of us felt like it was a call to action.”
49ers co-chairman John York, the chairman of the NFL owners’ health and safety advisory committee, said his peers took it as a challenge: “It was a case of ‘we have got to look at this and figure out how to get those numbers to go down.’”
With evidence mounting that the sport is dangerous and debilitating, many believe the NFL, which generated about $14 billion in revenue in 2017, must transform itself to protect its long-term health. And the alterations to the sport this season, which are partly inspired by last year’s rash of concussions, could offer the first look into a less violent future for football.
Before this season, the league introduced a series of safety-related rule changes. Two directly focused on lessening head trauma: the helmet-lowering rule and modifications to kickoffs. The NFL also made its roughing-the-passer rule more stringent, making it illegal for a defender to land on a quarterback with his full body weight.
In addition, for the first time, the NFL banned the use of 10 helmet models that tested poorly for safety, a nod to recent advances in an equipment industry that had long been stagnant due to a lack of competition.
So far, the changes appear to be having the desired effect. According to the NFL, concussions in preseason practices and games were down from 91 to 79. Based on The Chronicle’s review of NFL injury reports, there were 42 concussions in the first six weeks of the season, which projects to 121 concussions over the course of all regular-season and postseason games. According to its injury tracking system, the NFL had a yearly average of 168 concussions in the regular season and postseason from 2012 to 2017.
Former 49ers linebacker Chris Borland views such data as deeply flawed. In 2015, Borland retired at 24 after one standout NFL season due to concerns about the long-term effects of repetitive head trauma. Borland had just two diagnosed concussions, both before college, but he says he sustained 13 suspected concussions he didn’t report throughout his football career.
“Any specific number with concussions presented as data is, at best, horribly inaccurate,” Borland said. “It’s an ill-defined injury, it’s hard to articulate, players are incentivized to withhold sharing that information. ... So the 291 figure isn’t worth anybody’s focus.”
Borland works with Gridiron Greats, a nonprofit organization that assists former NFL players who are in need due to brain injury or chronic pain. He also does advocacy work for the Concussion Legacy Foundation, focusing on the issue of children waiting until at least junior high before playing tackle football.
Borland views the NFL’s concussion-inspired rules changes as a public-relations response to forces threatening the sport’s future. In February, a national NBC News/Wall Street Journal poll found 48 percent of Americans would encourage a child who wanted to play football to participate in another sport due to concerns about concussions, an increase of eight points since 2014.
Borland says the focus on concussion-producing hits ignores sub-concussive collisions. These are smaller impacts, often absorbed by offensive and defensive linemen, that have been linked to brain trauma. Borland says he took an untold number of such lesser hits that resulted in him “seeing stars” or getting “dinged.”
“In terms of these measures, frankly, I think it’s P.R.” Borland said. “A third of NFL players don’t have brain injury because a linebacker lands on a quarterback when he sacks him. It has more to do with the repetitive nature of sub-concussive hits baked into the game. And I think that’s an important distinction in talking about concussions and repetitive brain injury.
“Because if you present it as concussions, you can present a figure that’s basically pulled out of thin air like the 291 figure and then claim that improvements are being made to address that. When, in reality, the reason so many former players have cognitive impairment is because they hit their head many, many, many times.”
Since 2002, the NFL has made 50 rule changes designed to make the sport safer, many of them geared toward reducing concussions. But there were indications in the offseason that the latest changes could be transformative.
It began with the initial reaction to the helmet-lowering rule, which the NFL’s 32 team owners unanimously approved in March.
The rule states that a player, regardless of position, will be penalized for lowering his head to initiate contact with the helmet against an opponent. That is, actions that are synonymous with football — think of Chicago Bears Hall of Famer Mike Singletary dropping his head to stop a running back — can result in a 15-yard penalty and possible ejection.
In the preseason, 71 helmet-lowering penalties were called in 65 games, and it appeared the rule could be a game-changer.
Before the preseason, Dr. Julian Bailes, a former Steelers physician who is one of the leading experts on the long-term effects of brain trauma in NFL players, said the rule could signal a significant and progressive shift.
“It’s a rule that involves more stringent behavior modification, or playing style modification, than we’ve ever seen,” said Bailes, the director of neurosurgery and the co-director of NorthShore University HealthSystem Neurological Institute outside Chicago. “It’s probably part of the sign of the times. Here football, in this case the NFL, is trying to, quote, ‘figure it out.’”
In the preseason, many prominent players worried about the helmet rule changing the sport’s fabric. Among them was 49ers left tackle Joe Staley, a 12-year veteran who has been diagnosed with two concussions since 2011.
“I think this is one of those things where you’re going to be really changing the sport,” Staley said. “You’ll be making it safer, but as football players we know there’s some inherent risk in playing a sport that has contact and some violence built into it.”
But in the regular season, enforcement of the rule has been nearly nonexistent: In the first six weeks, only three helmet-lowering penalties were called in 93 games.
Some believe the preseason emphasis, when 83 percent of helmet-lowering penalties were called on defenders, helps explain this season’s avalanche of scoring.
For years, mounting evidence has linked football violence with brain trauma and life-threatening conditions. Now that we know the sport can produce deadly results, where do we go from here?
Today: How is the NFL trying to make its game safer? B1
We know what needs to be done. But will we finally do it? A1
Monday: Falling youth participation is a sign of things to come.
Tuesday: What will the future of football look like?
Online: Read the full series now at www.sfchronicle.com/future-of-football
After the first six weeks, the NFL was on pace to have the most points in league history, as scoring was on track to increase 11 percent from 2017.
Niners cornerback Richard Sherman pointed to the new rules as the reason defenses are less effective and offenses are more potent. After six weeks, the NFL was on pace to have 146 roughing-the-passer penalties called in the regular season and playoffs, up from 107 in 2017. Sherman, tongue in cheek, advocated that the NFL put flags on quarterbacks to ensure they don’t get touched.
“It’s making it really difficult on (defenses) to combat (offenses) because every rule in the book is designed to make sure you don’t get them stopped,” Sherman said. “They’re just trying to make it impossible for guys to play defense. ... It’s an interesting league we play in.”
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A less controversial rule change involves kickoffs, a signature play that the NFL has said is about four times more likely to result in concussions than other plays. The hallmark play, which often involves high-speed collisions, has been significantly tweaked this season to reduce them. Most notably, players on the kickoff team can line up only 1 yard behind the line of scrimmage, eliminating the 5-yard running start.
The changes come after a 2017 season in which three of the NFL’s fiercest defensive players, Steelers linebacker Ryan Shazier, Panthers inside linebacker Luke Kuechly and Seahawks safety Kam Chancellor, sustained troubling injuries.
Shazier, 25, who suffered a spinal cord concussion and spent months in a wheelchair, is unlikely to play football again. Kuechly, 27, who some have labeled the poster boy for the NFL’s concussion issue, sustained his third concussion in three seasons. And Chancellor, 30, was forced to retire in July because of a neck injury, but he expressed concerns about brain trauma on his farewell message on social media: “Pray for your boy,” he wrote. “I have no clue how these head injuries will go after the game.”
Still, plenty of current coaches and players resent the changes.
In September, Raiders defensive coordinator Paul Guenther said the “rules have gotten a little bit out of control” and called it a shame. Packers linebacker Clay Matthews offered that the NFL is “getting soft” after he was called for a controversial roughing penalty on Washington quarterback Alex Smith, who also disagreed with the flag.
“You come to play football, you come to watch a football game, you understand as a player and as a fan that there are certain risks involved in it,” said the 49ers’ Sherman. “And I think the league is trying to supersede those risks.”
Sherman has said the NFL’s helmet-lowering rule is an ineffective change, tantamount to “throwing darts at a wall.”
The league would counter that its changes were informed by intensive research.
In 2016, the NFL committed $100 million to make the game safer. Of that, $60 million was devoted to its five-year Engineering Roadmap, which was designed to improve the understanding of concussion biomechanics and encourage equipment manufacturers and others to develop safer products, with a strong emphasis on the helmet industry. The other $40 million was funneled to medical research.
Engineers examined, via video, more than 500 concussion-causing hits in the NFL over the past three years. They tracked them against more than 100 variables, including factors as disparate as a player’s posture at the point of impact and the time of the game.
The research to better understand what happens when players are concussed has also included on-field simulations with crash-test dummies, which are monitored by impact-measuring sensors and 3-D cameras. The study has produced data that led directly to this season’s helmet-lowering rule and kickoff modifications.
The review of last year’s 235 concussions sustained in games, for example, found that 46 percent occurred on helmet-to-helmet hits. From 2015-16, only 36 percent of the 458 concussions sustained in games came on helmet-to-helmet hits. The league’s competition committee chairman, Rich McKay, has said 71 of the NFL’s 693 concussions that occurred during games from 2015-17 occurred on kickoffs.
Asked whether he feels research is being done with football’s long-term survival at stake, Miller, the league’s top health and safety official, pointed to the elimination of dangerous plays such as the leg whip, head slap and chop block over the years.
“I think it’s an ongoing evolution,” Miller said. The “NFL continues to be open to evolution and change. And here we have a level of information, detail and expertise, from the medical and engineering side, that’s helping inform those changes.”
Dr. Jeff Crandall, the chair of the NFL Head, Neck and Spine panel’s engineering subcommittee, has done extensive research into auto safety, which uses crash-test dummies to inform many design improvements. And he points to progress made in that arena when asked about the potential limits of improving safety in a violent sport.
“Look, we’ve got some outlines to follow here,” said Crandall, the director of the center for applied biomechanics at the University of Virginia. “If you go back to the ’50s and ’60s, they talked about (car) accidents and ‘unavoidables.’ And if you look at what’s been done through injury prevention, and better engineering, and structured public policy programs, you’ve had a 90 percent reduction in serious injury the past three decades. …
“I see opportunities to make the game safer. … This is not stuff we are putting together here, and it’s the first time it’s ever been implemented. We are actually borrowing from tried and true practices that have had great success in other areas.”
The NFL’s study has produced information it has shared with the helmet industry, which now better understands the motion of the head under the most common, concussion-inducing hits. The NFL hopes to have position-specific helmets in 2020. Those for quarterbacks, for example, could be designed to account for the back of the helmet striking the ground when they are hit by defenders and driven backward.
In the meantime, guided by advances in NFL-funded helmet testing, the league has banned 10 models this season, including the Riddell that has been worn by Patriots quarterback Tom Brady.
The demise of the NFL due to its violence has been forecast for decades. Sports Illustrated did just that with a cover story headlined “Brutality: The Crisis in Football.” That story ran 40 years ago, on Aug.14, 1978.
However, there are reasons to believe the NFL’s long-term health has never been in such peril.
In July 2017, a study published by the American Medical Association examined the brains of deceased former football players and found that 110 of the 111 brains of those who played in the NFL had CTE, the degenerative brain disease that’s also been found in deceased high school and college players.
In June, the family of Washington State quarterback Tyler Hilinski, 21, who committed suicide in January, said an autopsy revealed their son had extensive CTE and the brain of a 65-year-old at the time of his death.
Such news could further discourage parents from allowing their children to play football, shrinking the talent pool at all levels. And news in November foreshadowed a time in which medical advances could drive current players out of the game: Researchers said CTE, which previously could be diagnosed only after death, was confirmed for the first time in a living patient. As part of a study published in the journal Neurosurgery, CTE was detected in the brain of former Vikings linebacker Fred McNeil in 2012, and the diagnosis was confirmed when he died in 2015.
However, Bailes, the brain trauma expert who was involved in that research, isn’t among those forecasting football’s doom. An independent member of the NFL’s Head, Neck and Spine committee, the neurosurgeon’s enthusiasm for the game remains intact partly because of recent safety advances that he expects to continue.
“It’s still my favorite sport,” said Bailes, who is a volunteer leader of a Pop Warner medical advisory committee that has significantly reduced youth practice contact. “I had two sons who played, and I think it’s America’s greatest sport. ... I’m very much for football. And I believe there’s been a lot of changes made at every level to make it safer. And I think it is safer. I know it’s safer.”
It’s notable that the league and the players’ union, the NFL Players Association, which have disagreed on countless issues, have worked collaboratively on the majority of safety-related initiatives in recent years.
In the past, the NFL was often viewed as tone-deaf when it comes to the health risks its players assume. CTE was first identified in 2002, in the brain of the late Steelers center Mike Webster, who died at age 50 from a heart attack but had struggled for years with mental illness and erratic behavior, attributed by his doctors to multiple concussions over the course of his 17-year NFL career. But the NFL didn’t publicly acknowledge a link between football and CTE until Miller did so in 2016. The league only recently backed off of the idea of extending the regular season by two games. The NFL continues to draw criticism for weekly Thursday night games that usually allow just three days for players to recover from their previous game.
Last year, the league reached a concussion class-action settlement worth an estimated $1 billion with more than 20,000 retired players.
Sean Sansiveri, who has managed the NFLPA’s health and safety and medical research projects for eight years, says he’s noticed an increased interest from the league in improving player safety.
“We have been dragging them in that direction for as long as we’ve been associated with the NFLPA,” Sansiveri said. “It’s still a fight every single day, but on certain issues ... the NFL has certainly been more willing to advance the ball.”
Added Sansiveri: “I certainly wouldn’t want to guess at their motivations on any of these issues, whether it’s limiting themselves from liability based on past experiences with class-action suits, or just overall viewership and interest in the game. Regardless, our motivation continues to be protecting the safety, health and wellness of our members.”
Sills, a neurosurgeon who was hired last year to occupy the new full-time position as the league’s chief medical officer, is confident that the league’s commitment to safety isn’t fleeting.
“I can’t speak to what happened in the NFL before I arrived,” Sills said. “I can only tell you that since I’ve been in the job, I believe that we are walking the talk of making health and safety our No. 1 priority.”
But as last year’s 291 concussions illustrate, plenty of work remains.
And former President Barack Obama’s words from 2013 remain prescient.
“I think that those of us who love the sport are going to have to wrestle with the fact that it will probably change gradually to try to reduce some of the violence,” Obama said. “In some cases, that may make it a little bit less exciting, but it will be a whole lot better for the players. And those of us who are fans maybe won’t have to examine our consciences quite as much.”