Football. A game that has been woven into the social constructs of American society for decades. Football is a violent, punishing, unforgiving game, but does it really lead to detrimental health conditions years after players hang up their cleats and shoulder pads? Was there something the NFL conveniently ‘forgot’ to tell the thousands of players that rotate through the ranks or was the commissioner and other top officials in the dark about the risks of playing professional football?
As a society, we are currently trying to shift the popular opinion about concussions. For so many years, concussions were not seen as a serious injury. It was a rite of passage on the football field to ‘get your bell rung’ as the old timers would say. Athletes in a variety of sports were suffering a mild to moderate degree of brain injuries, and they were sent right back onto the field as if nothing had happened. Thankfully, with time and research, that opinion is slowly changing. There are still non-believers out there, like the members of the NFL’s first Mild Traumatic Brain Injury Committee (mTBI).
A concussion happens when a blow to the head causes enough force for the brain to move and strike the inside of the skull. The brain is suspended in a fluid-type substance inside the skull cavity. While one of the functions of the fluid-like substance is shock absorption, a force strong enough to cause a collision of the brain into the bone will cause brain injury. Symptoms from a concussion can have an immediate onset and can last for a few days to months and can range from memory disruptions and mood changes to fatigue and sensitivity to light. A common misconception is that a person must lose consciousness to be diagnosed with a concussion, but that is quite false. In 90% of concussions, there is no loss of consciousness.
Stepping forward and reporting a concussion does not happen in professional football, players do not want to be perceived as weak. The stigma around concussions is still alive and well. Traditional coaches and even some players see concussions as a ‘fake’ injury or not serious enough to be treated, when they are one of the most important injuries to treat. You can break a collar bone and tear an ACL and go through a recovery process that is visible and predictable. You cannot even see a concussion, except for an MRI or CT scan. Treatment approaches vary from clinician to clinician, but the consensus for the treatment of concussions is plenty of rest, light activity (non-sports related with no risk of further brain injuries), restriction of ‘screen time’ (cell phones, computer, tv, etc.), plenty of fluids and over the counter analgesics for headache symptoms. Even effective treatment can elicit healing times of weeks to months, the brain is a fickle and delicate organ.
Concussions are unpredictable, and like other injuries they vary from person to person. There is no research showing definitive answers about who is susceptible for concussions or CTE (chronic traumatic encephalopathy). There is a clear consensus on diagnosis of concussions, but for that to be followed, there must be contingencies in place for these diagnosis processes to be successful. In the past decade the NFL has changed and re-changed the concussion protocol, working towards a safer playing field for the athletes. Have these changes made a difference is the question that interested spectators, players and their families would like to know the answer to.
In 2002, Dr. Bennet Omalu, a forensic neuropathologist, did an autopsy on a retired NFL player by the name of Mike Webster. Mike played in the NFL for 17 years (15 years with the Pittsburg Steelers, 2 years with the Kansas City Chiefs) playing the position of center or guard. Mike literally used his helmeted head as a battering ram. He was a relentless player nicknamed ‘Iron Mike,’ but after his long NFL career, his life began to spiral out of control.
Dementia pugilistica, a clinical disease with combination of symptoms resembling Alzheimer’s and Parkinson’s disease. This form of dementia was originally only recognized in boxers and was also called ‘punch-drunk syndrome.’ After Dr. Omalu’s autopsy of Mike Webster and closer examination of his brain, Dr. Omalu concluded that instead of punch-drunk syndrome, Mike Webster had gridiron dementia, ‘drunk’ from the repeated blows to the head. This disease does not occur in all contact sport athletes, but in the population that it does effect, it is progressive, and deteriorative.
When he passed away, Mike Webster was homeless, broke and starving. He had been arrested for forging prescriptions for Ritalin, a drug that helped keep his thoughts together. His NFL earnings were gone, his marriage fell apart, and his relationships with his kids crumbled. He was not the Mike Webster he once was, and he knew that. Tragically, Mike isn’t the only former NFL player to suffer like this, and in other cases even more tragically ended in horrific suicides.
Former Commissioner Paul Tagliabue formed the NFL’s mTBI committee in the mid 90’s assigning Dr. Elliot Pellman (a rheumatologist), team physician for the New York Jets, as chair-person of the committee. This committee was tasked with researching the long-term effects of concussions and head injuries on football players. Dr. Pellman was an avid believer that concussions were not serious injuries and that they had no long-term effects. Dr. Pellman and the other members of the mTBI committee published papers and journal articles, notorious for saying there was no connection between hitting your head in football and cognitive problems later in life.
After completing Mike Webster’s autopsy and brain analysis, Dr. Omalu published a paper with some of the most recognizable names in the neuroscience field about CTE (chronic traumatic encephalopathy). They submitted their paper to the journal Neurosurgery, the paper was accepted and published in the journal. Not long after that the NFL’s mTBI Committee released a statement requesting Dr. Omalu retracted his findings because they were not based on scientific fact, they even eluded that he wasn’t practicing medicine, but instead he was practicing voodoo. According to Dr. Omalu, “You can’t go against the NFL, they’ll squash you.”
But Dr. Omalu wasn’t squashed, and his research findings were presented in 2007 during an NFL summit on brain injuries (This summit came after a change in NFL commissioner from Tagliabue to Roger Goodell). While the NFL did not invite Dr. Omalu, (he was basically shunned by the NFL) his research partner Dr. Julian Bales was invited and decided to present their work. Commissioner Roger Goodell sat in the crowd, listening, baffled by the information Dr. Bales was presenting. This summit brought about some change, stricter concussion protocols and recognition criteria. Changes for the future of the NFL are great, but what about the former NFL players and their families that are suffering every day?
Chronic traumatic encephalopathy is a degenerative neurological condition that attacks the brain cells. Years of chronic concussions and sub-concussive (blows to the head that do not rise to the clinical definition of concussion) hits create the deposition and transformation of a protein in the brain. Tau protein deposition in certain areas of the brain characterize and differentiate CTE from other forms of dementia. This condition causes fine motor function decline, cognitive and memory impairments, inability to control mood and emotions, decline in basic decision making skills, ultimately leading to a major depressive state and in many cases, suicide.
A study done by Kerr et al looks at a cohort of former NFL players and the rate of nondisclosure in relation to concussions. In the sample of 829 former players, 417 players reported that they had suffered at least one concussion that they did not report to the medical staff. Fifty percent of this study DID NOT REPORT a concussion, a serious brain injury, to the medical staff. As a future athletic trainer, I see that statistic and say, “What the actual **** is going on here…?” Part of the problem in the NFL (until very recently) is the ‘self-reported’ piece that was classically connected to concussions. Players shouldn’t have the opportunity to self-report a head injury, unless it is missed by the medical staff.
Athletic trainers, team physicians and neurologists are now all present at NFL games. Third party neurologists sit in the booths, analyzing every play and collision for signs of possible concussions. Is this making the game safer? Does this put the minds of parents whose children’s’ dream is to play professional football at ease? The presence of medical staff should add a layer of protection to player safety, but when the hands of the medical staff are tied by rules of the NFL, who is going to protect the safety of these players? Concussion research, even though plentiful at this point, is still in its infancy relating to the NFL and CTE. Will developing research in this field destroy football? Nothing, not even looming degenerative brain disease in its players will stop the NFL from expanding and making more money.
The effects surrounding concussions are not just medical; there are financial and social ramifications of even mild and well managed concussions. Navarro et al studied the non-medical short-term outcomes related to concussions in the NFL. This study was focused on player longevity, performance and financial losses following concussions, the sample was taking from 5,894 eligible NFL players over an 11-year span. Of the eligible players only 307 sustained concussions requiring them to enter the concussion protocol and were listed as DNP (did not participate). Right off the bat this number is staggeringly low, going to back to the other study that was discussed, reported nondisclosure of concussions.
Some interesting findings of this study include: players who sustain reported concussions have significantly shorter overall careers in the NFL than their counterparts, a mean overall salary reduction of $300,000 – $1,300,000 per year, and performance reductions in offensive scoring positions (possibly due to less playing time). The study sites that more research is warranted, but there is a connection between publicly reported concussions and reductions in career length and compensation.
More than 70 former NFL players had a lawsuit drawn up alleging that the NFL lied to them about the dangers of playing football. The players and even the public was starting to catch on that there had to have been a major cover up going on in the NFL, with the amount of vehement denial coming from their officials. The NFL eventually settled the lawsuit for $765 million in damages paid to the plaintiffs for medical bills and extended care. The settlement did not come with an admission of a connection between football and long-term brain injury, but the NFL didn’t need to confirm that for everyone to understand there is indeed a link. Former linebacker Harry Carson of the New York Giants said, “The NFL just gave everybody 765 million reasons not to want to play football…”