Jan 29, 2015
NFL Holds Concussion Discussion

By R.J. Anderson

On Tuesday, June 19, many of the country’s foremost experts on concussions gathered in Rosemont, Ill., for a breakthrough symposium on an injury that is of growing concern in the athletics community. Prompted largely by the attention surrounding published studies, along with the deaths of four former players in recent years, the NFL Concussion Summit brought league officials and former players together with team physicians, team athletic trainers, and noted neurologists and concussion researchers to discuss prevention techniques and better understand the long-term effects of mild traumatic brain injuries.
The meeting was momentous, as was the league’s decision to invite longtime opponents of its concussion positions to attend and provide input on the issue. This list included Robert Cantu, MD, Chief of Neurosurgery at Emerson Hospital in Concord, Mass., and Kevin Guskiewicz, PhD, ATC, a Professor and Director of the Sports Medicine Research Laboratory in the Department of Exercise Sport Science at the University of North Carolina-Chapel Hill–two longtime thorns in side of the NFL’s Concussion Committee.

Though not everyone at the meeting was in perfect agreement on how to approach the treatment of concussions, the gathering served to open an important stream of dialogue that has long been missing from the solution-seeking process. Long a critic of the NFL’s concussion analyses, which have consistently indicated there are few if any long-term effects of concussions, Guskiewicz told the Washington Post he was “very encouraged” by the meeting and Cantu described the symposium a “great scientific exchange.”

One person who was not invited to the symposium was Bennet Omalu, MD, Clinical Instructor of Neuropathology at the University of Pittsburgh School of Medicine. Omalu has drawn the ire of the NFL in recent years after he linked the deaths of four retired NFL players–safety Andre Waters and offensive linemen Mike Webster, Terry Long, and Justin Strzelczyk–to brain damage resulting from repeated football collisions.

Though each player died of different immediate causes–Webster of a heart attack, Waters and Long from suicide, and Strzelczyk after crashing his pickup truck during a high-speed police chase–Omalu says he found common denominators that contributed to each man’s death.

Each player reported experiencing what were likely a number of concussions during their playing careers, which later lead to chronic traumatic encephalopathy–a condition common in boxers–and then extreme bouts of depression. Omalu told USA Today he examined brain tissue from each former player under a microscope. “On the cellular level, it looks absolutely abnormal,” he said.

Ira Casson, MD, a neurologist at the Long Island Jewish Medical Center and the Albert Einstein School of Medicine, challenges Omalu’s conclusions. Casson, Co-Chair of the NFL’s Concussion Committee, responded to Omalu’s claims in a recent USA Today article.

• Webster, 50, died in a Pittsburgh hospital; he had been homeless at times. In his report in the journal Neurosurgery, Omalu said based on interviews with family members, Webster had exhibited depression, memory loss, and Parkinsonian symptoms.

He “was smoking heavily, was eating injudiciously. Why? Because of his dementia. Yes, his dementia contributed to his death,” Omalu says.

Casson says: “There is nothing mentioned from any neurologists or psychologist or psychiatrist who ever evaluated him … The punch-drunk state in boxers … is completely different than what Dr. Omalu reported.”

• Long died in 2005 at 45. The Allegheny County (Pa.) coroner’s office ruled he committed suicide by drinking antifreeze. “Terry attempted suicide multiple times, suffered from major depression … due to his traumatic encephalopathy … due to his previous concussions,” Omalu says.

Casson says: “Terry Long has a completely different (brain) pathology than Mike Webster … but yet (Omalu) tries to say they’re both the same thing … (Long) had severe psychiatric problems dating back to his playing days … So this case also is filled and fraught with inconsistency.”

• Waters died in November at 44 of what Tampa authorities said was suicide by gunshot. “Andre had major depression, attempted suicide multiple times, was broke,” Omalu says.

Casson: Suicide is “unfortunately one of the major causes of death … Just because it happened to a few football players doesn’t mean it’s linked to football.”

• Strzelczyk died in 2004 at 36 when his pickup crashed during a police chase in New York. Omalu says there is no documentation he had concussions but that “macho” players can play through them without knowing. He says “sub-concussive blows,” from play-to-play pounding, could cause the brain damage.

Based on an interview with Strzelczyk’s mother, Omalu says her son had “bizarre” behavior” before his death and brain damage “may have contributed to his abnormal behavior and … accidental death.”

Casson says: “What medical journal or scientific journal is that published in? … If Dr. Omalu and his colleagues want to be taken seriously, they should publish this information.”

Omalu has reported his findings on Webster and Long in Neurosurgery. He says he is preparing reports on Waters and Strzelczyk and also investigating other possible cases.

Guskiewicz is the lead author of another study of NFL players that recently grabbed national attention. The University of North Carolina study concluded that players who sustained multiple concussions during their careers were more susceptible to mental impairment.

More than 2,500 retired NFL players were surveyed for the North Carolina study. Sixty-nine percent of those who were contacted responded. Among those, 595 players reported having sustained three or more concussions during their career. Guskiewicz and his researchers concluded that these players were 20 percent more likely to develop clinical depression than players who hadn’t suffered a concussion. The NFL responded by criticizing the size of Guskiewicz’s research sample and the fact that the survey required retirees to rely solely on their memories when chronicling their concussive episodes.

One NFL-commissioned study recently drew a lot of negative attention after a couple of its authors publicly questioned the paper’s conclusions. Published in the January 2005 issue of Neurosurgery, the study has been shrouded in criticism after it concluded that “it might be safe” for high school football players who sustain concussions to return to the same game in which they were injured.

These flames of criticism were fanned in June when two of the study’s five authors publicly questioned its final analysis. Henry Feuer, MD, of the Indiana University Medical Center, and Cynthia Arfken, MD, of Wayne State University told The New York Times that the paper’s conclusion was inappropriate, and that the research should not be applied to high school and college players. Arfken told the Times a passage had been added at the end of the process without their knowledge.

The Times wrote:

Arfken and Feuer disavowed the paper’s recommendation that high school and college medical personnel “keep an open mind” about the paper’s analysis of concussions, which deemed safe the league’s record of allowing half of the players with concussions to return to the same game. Arfken and Feuer thereby joined critics who had long claimed that such a suggestion was dangerous for younger players. Their less-developed brain tissue is believed to be more susceptible to short- and long-term damage than adults’. They also receive considerably less medical attention than players in the N.F.L.

Feuer feels that the section about that “it might be safe to return to play” should be eliminated from the paper. “It’s been shown that they don’t seem to recover as fast. Period.”

Many critics have called the study’s conclusion dangerous. This showed true at last month’s annual meeting of the American College of Sports Medicine in New Orleans, where The New York Times reported that about a dozen high school and college medical professionals said the assertions in Neurosurgery had influenced the care that players at lower levels received, whether through the doctors who read it, Internet sites that linked to it, or word of mouth.

“That was a major disservice, and it continues to be an ongoing one in conversations I have with parents and coaches and players,” Dr. Gerard Malanga, director of the New Jersey Sports Medicine Institute in Verona, and team physician for several high schools and colleges, told The New York Times.

“They will reference back to that article,” Malanga said. “It creates confusion when there’s increasing clarity on the subject. They say what I tell them about it not being safe to go back in the same game is totally wrong, and they’re backed by the N.F.L. So they go to a doctor who tells them what they want to hear. It’s happened. Sure it’s happened. And we remain the guys holding our breath that the kid doesn’t get hurt again.”

Though there remains much controversy surrounding concussion protocols, there seems to be a movement to change the culture at the highest level of athletics. When he gave his opening remarks at last month’s concussion symposium, NFL Commissioner Roger Goodell told observers, “medical decisions must always take priority over competitive concerns.” Goodell’s statement flew in the face of criticisms by some doctors and players who claim the NFL has preferred to ignore the seriousness of concussion because it isn’t in the league’s best interest to have players missing games.

However, recent steps seem to indicate that Goodell and the league are now taking the problem more seriously. The NFL will require every team to perform neuro-psychological baseline testing this season in an effort to help the league establish uniform guidelines to determine when players should return to play. Baseline testing helps document each player’s normal brain function, and the results can later be compared against a similar test if the player is suspected to have sustained a concussion.

Goodell has also initiated a whistle-blower program in an attempt to quell concerns that coaches and team officials pressure players to return to action too soon following concussions. The new program is designed to give players a forum to complain anonymously if they feel they are being pressured to play while still experiencing post-concussive symptoms.

In addition to the implementation of baseline testing and the whistle-blower program, rules requiring players to properly buckle their chinstrap will be enforced. Also, the league will distribute a brochure to players to help educate them and their families about concussions.

Though the June 19 meeting yielded no definitive league-wide policies on when a player should and should not return to play following a concussion, it definitely left both the NFL’s supporters and skeptics a little more optimistic. The lines of communications seem to be more open than before, and that’s a good start.

T&C Links:
• For information on the science behind concussions, read “Making Headway.”

• For information on updating your program’s concussion protocols, read “From Hands to Head.”

R.J. Anderson is an Assistant Editor at Athletic Management.

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