ARTICLE IN BRIEF
The issue of concussion in football is back in the news as 75 retired football players filed a lawsuit against the league in Superior Court of Los Angeles County, claiming that it failed to warn them about potential long-term neurological consequences of repeated concussions and mild traumatic head injuries despite ample evidence of such risk, and Ivy League football teams limit contact and practice time.
As the National Football League (NFL) went into overtime trying to resolve a contract impasse for the 2011-2012 season, 75 retired football players filed a lawsuit against the league in Superior Court of Los Angeles County, claiming that it failed to warn them about potential long-term neurological consequences of repeated concussions and mild traumatic head injuries despite ample evidence of such risk.
According to the lawsuit, the NFL knew of these risks for years, yet failed to warn players. The players also alleged that they were not provided adequate medical evaluations after injuries that might have averted or reduced the long-term neurocognitive consequences.
The lawsuit, Maxwell v NFL, which also names Riddell, the company that supplies the League's official helmets, was brought by Vernon Maxwell, a linebacker who played for several professional teams from 1983 to 1989. He was joined by 74 other players who have suffered problems.
The former players claim that the NFL had been aware of potential problems with head injuries since the 1920s, but did not begin warning players until 2010.
“For decades defendants have known that multiple blows to the head can lead to long-term brain injuries, including memory loss, dementia, depression and CTE (chronic traumatic encephalopathy) and its related symptoms,” the players charged in the lawsuit.
“By failing to exercise its duty to enact reasonable and prudent rules to protect players against the risks associated with repeated brain trauma, the NFL's failure to exercise its independent duty led to the deaths of some, and brain injuries of many former players, including [the] plaintiffs'.”
In support of their claims, the complaint cited 36 studies and reports showing long-term sequelae of repeated head trauma and concussions.
The NFL's Mild Traumatic Brain Injury Committee, formed in 1994, has published a number of studies that reportedly found no long-term risks among players, and sent letters to journals that published studies showing an elevated risk.
“I think this remains a major challenge, but I fear the NFL lawsuit is just the tip of the iceberg,” Tony Strickland, PhD, chairman and CEO of the Sports Concussion Institute in Los Angeles, told Neurology Today in a telephone interview.
Although he could not comment specifically on the NFL lawsuit, Dr. Strickland, a clinical neuropsychologist, said many changes have already taken place at the state level to improve sideline evaluations, with more expected soon.
In 2006, 13-year-old Zackery Lystedt struck his head on the ground during a football game. He was sidelined for 15 minutes then returned to play. Soon afterwards, though, he tackled an opponent, stood and collapsed. Rushed to the nearest hospital, it was discovered that he had suffered a brain hemorrhage that proved fatal. In 2009, Washington State signed into law strict requirements for returning players after a head impact.
“The increase in awareness and education has been phenomenal since then,” Dr. Strickland said.
A number of states have passed laws either identical to, or similar to Washington's Lystedt law, while most others are considering similar legislation. Nine states enacted concussion laws between 2009 and 2010 that are consistent with the model Zachary Lystedt Law, and seventeen states passed Lystedt-type laws in 2011. Delaware and New York legislatures also passed concussion laws in 2011 that are awaiting their respective governors' signatures.
NEW LIMITS: IVY LEAGUE TEAMS
At the college level, Ivy League university presidents approved a set of recommendations in July aimed at reducing concussion risks, including mandatory limits on field play and practice exercises that can involve head impacts.
The ad hoc committee, co-chaired by Dartmouth University President Jim Yong Kim, MD, and David J. Skorton, MD, president of Cornell University, developed the recommendations with input from a range of medical and sports injury experts, coaches, administrators and others.
The guidance places strict limits on the number of full-contact practices before and during the football season, requires educating players on avoiding higher-risk tackling, and requires instruction in the signs and symptoms of concussion and sub-concussive injury as well as the short- and long-term risks of repetitive head trauma. Moreover, the rules will require routine review of helmet-to-helmet and targeted head hits among players after each game, with further review going back two seasons where possible.
Under the new rules, players cannot be involved in more than two full-contact days per week, 60 percent fewer than the current National Collegiate Athletic Association maximum. They also limit the number of contact days allowed during practice sessions, including spring training.
Jeffrey Kutcher, MD, assistant professor of neurology and director of Michigan NeuroSport at the University of Michigan in Ann Arbor, told Neurology Today in a telephone interview that he believes that the Ivy League policy has the best of intentions and may improve injury rates, but that the issue is more complicated.
“It is an excellent initial step in the right direction, but one that would be more difficult for other conferences to adapt, unless changes were made across the NCAA. I applaud the effort, but we must realize that it's unclear what effects this new policy may have.
“To a degree, football players need to learn proper hitting technique, and how to better absorb or deflect forces when they are getting hit. Could decreasing this aspect of practice put athletes at greater risk for injury?”
The NFL lawsuit is a “natural” development of findings that have emerged only recently about the serious long-term sequelae of repeated mild head trauma and concussions among contact sport players, he said, something that has been recognized in boxing for around 80 years. Although there are not a lot of data on such injuries in contact sports, new information is emerging about the risks.
NEW RISK DATA
Dr. Strickland cited data presented by Christopher Randolph, PhD, clinical professor of neurology at Loyola University Medical Center, Chicago, at the Alzheimer's Association International Conference (AAIC) July 18 as a case in point.
Dr. Randolph reported findings of a study that tracked symptoms of mild TBI in 3,729 former NLF players, first sending questionnaires to all retired players in 2001 and following up with a standardized Alzheimer disease (AD) screening questionnaire in 2008, from which they received 513 responses.
They then conducted telephone surveys of the respondents, asking about any cognitive impairment, with clinical examination and evaluation of those who reported symptoms. Afterwards, they compared the results with a matched group of individuals who had never played contact sports.
Their rate of cognitive impairment among the retired players, including AD, was 35 percent versus 13 percent in the control group.
“These findings support the hypothesis that repetitive head trauma from many years of playing football may result in diminished brain reserve, and lead to the earlier expression of age-related neurodegenerative diseases such as [mild cognitive impairment] and Alzheimer's,” Dr. Randolph said at the AAIC. However, he cautioned that the data should be considered preliminary and that additional research is needed to confirm the findings.
In May 2010, the Government Accountability Office (GAO) published the results of an investigation that found many academic athlete concussions go unrecognized and are underreported, and that athletes often return to the field before being sufficiently evaluated for concussion. During the 2005-2008 school years, the report estimated that as many as 400,000 concussions occurred in high school athletes, many of them unrecognized by players, parents, or athletic coaches.