Monday, July 30, 2012
As the NFL training camps open, it appears that there is no shortage of players who want to play the game of football at its highest level, its most intensity and its greatest violence. The thousands who have taken the field this week must be aware of the risks involved, including the likely risk of head injury. The lawsuit brought by more than 2,000 former players against the NFL continues to make headlines. The retired players claim that they were misled about concussion symptoms and the connection between concussion and long term brain injury. It will be up to the legal system to decide what the NFL knew and when they knew it, but it isn’t a secret that getting hit in the head is a bad thing.
There is a language problem when trying to understand concussions. The medical community often uses the phrase minor head trauma and that gives the impression that it’s just a “minor” problem. In reality, a minor head injury is one where there is no bleeding or swelling that needs an operation. There is nothing minor about the symptoms. In fact, the symptoms can be very frightening. The most recent international consensus statement about concussion in sports (Zurich 2008) noted that being knocked unconscious or having a seizure after getting hit in the head does not make a concussion more severe, even though the sight of a convulsing player is more than a little frightening. They concluded that there is no simple or complex concussion, there is only concussion.
The next problem with understanding concussion and how often they occur is the wide spectrum of symptoms that can occur immediately or that can be delayed for hours. The player may not self-recognize the concussion and it may be teammates who are aware. The symptoms may be subtle and hard to connect to a blow to the head. A mild headache or feeling foggy, being irritable or having a hard time concentrating are not very specific symptoms. Parents of teenagers recognize some of those as normal behavior in their home and other might relate them to a hangover or two.
The diagnosis is based on history since physical examination is almost always normal. There can be subtle changes in neuropsychologic testing, but that is more helpful in giving guidance as to when the player can return to practice and play. And while pro players routinely get CT scans and MRIs of the brain, the repeated brain imaging is likely a waste of time, money and radiation. There are guidelines for when a CT is likely to show bleeding but they usually begin with a patient who is not fully awake, is vomiting and has signs of a skull fracture on physical exam.
Perhaps the most difficult part of making the diagnosis is the lack of cooperation by the player. They routinely hide their injury because the need to play is so strong. Troy Polamalu of the Pittsburgh Steelers admitted to hiding the concussion instead of taking himself out of the game and he was not alone. In an AP/USA Today survey taken last season, 23 of 44 players would hide a head injury so that they could continue to play.
There is still a steep learning curve when it comes to understanding the science of head injury. The return-to-play guidelines of the mid 1980s were based less in research than on intuition. The severity of injury was graded on how long a player was knocked unconscious, how much amnesia and how long it took to recover on the sideline. There were competing guidelines developed by the American Academy of Neurology, the Colorado Medical Society and Dr. Robert Cantu that decided if a player could return immediately or whether their season was over. Interestingly, Dr. Cantu has been a pioneer in concussion research and is an advisor to the NFL head, neck and spine committee. These guidelines remained the gold standard until the first international panel on concussion in sport held in Vienna in 2001.
Education has been slow to invade the culture of sport because it requires buy in not only from the player, and that has been a challenge, but also from teammates, coaches, referees and parents. Each group needs to be schooled in the recognition of symptoms and be given the authority to remove the player from competition without consequence. Trainers and doctors need to follow through with their evaluation and treatment plans to protect the player and their brain from further harm. It’s a reasonable analogy to compare the rest and rehab of a sprain or strain to the return to play for the brain. Initial treatment is rest followed by gradually easing back into activity. If increased work causes symptoms, then the rehab process starts over again and for most players, return to practice and play takes about a week.
Interestingly, the Zurich concussion panel made an exception for NFL football players and observed that because of the many resources available on the sideline, including physicians skilled in concussion management, return to play in the same game was a possibility. But in the same recommendation, they also recognized that studies showed that high school and college players who have concussions often have their symptoms delayed and should be removed from play. Presumably, brain development in the few month transition from college senior to NFL rookie was sufficient to alter return to play recommendations.
But the NFL player lawsuit had more to do with long term effects of head injury and how the league hid information. Perhaps it’s best to look at a sport whose goal is to inflict a concussion upon the opponent. Professional boxing has been well studied and 10-20% of fighters will end up with long term brain function issues ranging from Parkinsonism and dementia to depression and addiction. German studies published in 2010 found that the most serious consequences occurred in boxers with longer careers.
Chronic traumatic encephalopathy (CTE), the same condition found at autopsy of numerous NFL veterans, including Dave Duerson, Mike Webster and Ray Easterling, is also known as dementia pugilistica. In a boxer, the risk of long term brain injury increases if they are older than 28, had a career that lasted more than 10 years, had been knocked out more often, had long sparring sessions and …carriedthe apolipoprotein A4 gene. This gene also seems to predispose to Alzheimer disease and when brains are dissected, CTE looks a lot like Alzheimers under the microscope.
The lawsuit has brought to light much uncertainty, but this is what we know, or don’t. Football is an addictive sport. Players will hide a concussion so that they can continue to play. The risk has become more clear, but it is even more clear is that the medical and research community do not know how many or how few blows to the head it will take to cause long term brain damage. It is also uncertain how long it takes for the brain to recover from a concussion and the guidelines are, at best, guesswork. Finally, there seems to be a potential genetic predisposition to complications from concussion.
The players who are lining up in training camps, competing for a spot on an NFL roster are now well aware of the potential dangers of the sport. Regardless of rule changes, the head is still vulnerable in a full contact sport and concussions will occur. The long term consequences are real. Minimizing those consequences will require culture change. Players will need to accept personal responsibility and report their concussion. Teammates and referees will need to take responsibility and remove a player from the field. The NFL has already arranged for a neurologist on the sideline but the injured player must already be recognized and it seems that their role is to determine who can return immediately to the field of play. And in a league where players and owners cannot agree on testing for performance enhancing drugs, it will be unlikely that screening for the “Alzheimers” gene would ever happen.
Race car drivers race, mountain climbers climb, hang-gliders fly and football players play football. While the lawsuit makes its way through the court system, today’s football players need to decide whether the adrenalin of the game and the adulation of the fans is enough to offset the risk of concussion and the long term complications of brain damage.