By: Madisen Giordano
Interdisciplinary Studies: Sports Medicine
Senior Seminar Research Article
Football. A game that has been woven into the social constructs of American society for decades. Football is a violent, punishing, u
nforgiving game, but does it 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 were 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’ or ‘see stars’ as the old timers would say. Athletes in a variety of sports were suffering a mild to moderate degree of brain injury, and 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-like 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. Follow this link to see a short video about concussions: https://www.youtube.com/watch?v=55u5Ivx31og Symptoms of 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.
Steve Young, a former quarterback in the NFL (1984-1999) suffered seven concussions during his active playing time. His seventh concussions knocked him out cold and he’d never play another game of competitive football again. Steve describes concussions and CTE as “Such a nefarious injury, one that you never feel until it’s too late,” (League of Denial). 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. While there is an inherent risk of injury when signing up to play sports, the football players of the past had no idea what could be waiting in their futures, degenerative disease waiting to take over their brains.
Follow this link to see some hard hits that would concern neurologists and athletic trainers: https://www.youtube.com/watch?v=mYgY_gYn5ew
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 a 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 (also referred to as CTE), ‘drunk’ from the repeated blows to the head. This disease does not occur in all contact sport athletes or football players. Those effected by the disease see progressive symptoms and deteriorating conditions.
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 tragic, ended in horrific suicides.
Read the tragic story of Terry Long’s demise after his battle with CTE here: http://www.espn.com/nfl/news/story?id=2307003
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. Not long after Dr. Omalu’s paper was published, 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” (League of Denial).
Listen to a TEDTalk about concussion prevention here: https://www.ted.com/talks/kim_gorgens_protecting_the_brain_against_concussion
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 in 2006). While the NFL did not invite Dr. Omalu, (he was basically shunned by the NFL) his research partner Dr. Julian Bailes was invited and decided to present their work. Commissioner Roger Goodell sat in the crowd, listening, baffled by the information Dr. Bailes 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 and self-care/personal hygiene 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…?” Second impact syndrome is a fatal condition that can occur when an athlete who suffered a concussion returns to play before the initial concussion is healed and suffers from another concussion. Second impact syndrome is serious, athletes die, but the NFL knowingly sends its players back onto the playing field after hits that warrant entering the concussion protocol. Where does the negligence end?! (Although the NFL has made strides to correct these issues, there is no doubt that nondisclosure is still a part of the game). 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. Click here for the full journal article: http://journals.sagepub.com/doi/pdf/10.1177/0363546517728264
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, coaches or owners, 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, 307 concussions in 11 years…. doesn’t seem possible.
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.
All the media coverage of the NFL is high-profile, every decision made is news-worthy. The NFL is one of the most lucrative businesses in the world, grossing $14 billion in 2017. With all this money comes power, high profile lawyers and promoters. The NFL will stop at nothing to protect itself and its revenue, but will it go the distance to protect its most important assets… the athletes.
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 were 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…” (League of Denial).
When this large lawsuit went public, the US Congress started considering the NFL’s concussion crisis. Roger Goodell was put on the spot in 2009 in a judiciary hearing where Representative Linda Sanchez lit up the NFL, comparing it to Big Tobacco. Sanchez said, “The NFL reminds me of the tobacco companies pre-90’s where they were saying, no there’s no link between smoking and damage to your health or ill health effects” (League of Denial). This comment was a turning point for Commissioner Goodell and NFL executives, they couldn’t be compared to Big Tobacco, bad for business.
Before the next season Commissioner Goodell released new rules on concussion protocols and return to play regulations. The changes are made in the name of player safety, and money was donated to fund more research on the effects of football on the brain. Commissioner Goodell donated $1 million to Boston University’s CTE Research Center and promised leading researchers in the CTE field something even better than $1 million, access to brains. Goodell promised to encourage families of deceased NFL players to donate their brains to BU. Funding research for the future is the answer to the current crisis. Education on concussions should be provided to athletes and parents of all ages as well as coaches before every season. Athletic trainers are educated on recognizing concussions, this is a reason why AT’s should be mandated on every sideline at every athletic event.
As the concussion issue grows, the uncertainty of the safety of contact sports in youth athletes grows right along with it. Developing brains should not be introduced to extreme stressors, as it can affect growth a
nd functioning in many ways. Commissioner Goodell started the HEADS-UP initiative to bring about change in the way the nations’ youth learns the game. Speaking directly to the youth population, football concussions aren’t the only
concussions to be worried about. Most childhood concussions come from bicycle accidents, even when helmets are being used. Along with bicycling, other contact sports such as lacrosse and hockey add to the concussion concern for youth athletes. Prevention is the first line of defense in concussions, prophylactic equipment such as helmets and mouth guards are essential for young, developing athletes to keep their brains functioning correctly.
The high publicity of the NFL concussion crisis is making strides in the right direction. Its brought about talks of change, projects initiated to raise awareness in young athletes about concussions, and education on how to play the game correctly. As a lifetime fan of football, realizing its dangers wasn’t an easy pill to swallow. Although players should know the inherent risk, it is not possible to foresee every situation and every outcome. Developments in technology will continue to add to the understanding of the brain and the conditions that affect it.
What does all this mean for the future? How will concussions effect sports? We do not know the answers to these questions as of now, but we do know the research is out there. Very smart people in white coats are in labs looking at microscope slides of brain tissue mulling over how to create concise tests that diagnose a concussion or design of the perfect helmet to prevent concussions. Professional athletes across the sports are pledging their brains to CTE research; hockey players, Olympic bobsledders, and rugby players alike. In a previous paragraph I stated that prevention was the first line of defense in concussions, but that wasn’t true. Education is the first line of defense and should be wide spread, this topic is something that should be covered in every year of school. You only have one brain and it should be of the utmost importance to protect it.
Fainaru-Wada, M., & Public Broadcasting Service (U.S.) (Directors). (2014). Frontline – League of Denial : The NFL’s concussion crisis[Motion picture on Online video]. Kanopy Streaming.
Fainaru-Wada, M., & Fainaru, S. (2014). League of denial: The NFL, concussions, and the battle for truth. New York: Three Rivers Press.
HEADS UP to Health Care Providers. (2015, February 16). Retrieved May 7, 2018, from https://www.cdc.gov/headsup/providers/index.html
Kerr, Z. Y., Register-Mihalik, J. K., Kay, M. C., Defreese, J., Marshall, S. W., & Guskiewicz, K. M. (2017). Concussion Nondisclosure During Professional Career Among a Cohort of Former National Football League Athletes. The American Journal of Sports Medicine,46(1), 22-29. doi:10.1177/0363546517728264
Navarro, S. M., Sokunbi, O. F., Haeberle, H. S., Schickendantz, M. S., Mont, M. A., Figler, R. A., & Ramkumar, P. N. (2017). Short-term Outcomes Following Concussion in the NFL: A Study of Player Longevity, Performance, and Financial Loss. Orthopaedic Journal of Sports Medicine,5(11), 232596711774084. doi:10.1177/2325967117740847
Omalu, B. (2008). Play hard die young: Football dementia, depression and death. Lodi, CA: Neo-Forenxis Books.
What Is a Concussion? (n.d.). Retrieved May 8, 2018, from https://concussion.weillcornell.org/about-concussions/what-concussion