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doi: 10.1097/01.NT.0000437149.24964.c2
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THE CONCUSSION CRISIS — A ‘FRONTLINE’ DOCUMENTARY: What Did the NFL Know and When and What Could Neurology Have Done?

Shaw, Gina

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ARTICLE IN BRIEF

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Concussion experts weigh in on a new PBS “Frontline” documentary that alleges that the National Football League (NFL) — as well as physicians who served on NFL committees — did not do enough to prevent concussion in the sport.

Could neurologists and neurosurgeons have done more to challenge the National Football League (NFL) on its handling of concussion in team players? That's one of the questions raised in a provocative two-hour documentary that aired on PBS' “Frontline” on Oct. 8. The show, “League of Denial,” takes a detailed, back-to-the-beginning look at the evolving saga of chronic traumatic encephalopathy (CTE), the NFL, and how the developing body of evidence regarding serious brain damage to players was handled — or mishandled — by the leadership of the most powerful entity in US professional sports.

The question of long-term damage to football players' brains induced not just by direct head trauma from diagnosable concussions, but also from repeated bone-jarring tackles, first began to make major national headlines in 2005, when Pittsburgh Steelers' center “Iron Mike” Webster, who died of a heart attack in 2002, was posthumously diagnosed in 2005 with the first case of CTE by Bennet Omalu, MD, then a neuropathologist with the University of Pittsburgh. [Dr. Omalu is now with the University of California, Davis.]

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JOURNAL RESPONSE TO CTE REPORTS

The first hour of the “Frontline” documentary focuses on Webster's story, and the immediate (and fierce) response from the NFL. Three members of what was then called the NFL Concussion Committee (none of whom were neuropathologists) wrote to the journal Neurosurgery, which had published Dr. Omalu's findings, and demanded a retraction.

There was no retraction — but, according to Mark Fainaru-Wada, one of the two brothers who made the film and wrote an accompanying book, League of Denial: The NFL, Concussions, and the Battle for Truth (Crown Archetype) published this month — the NFL spent the next several years engaged in an active campaign to discredit the science behind CTE, and used the venerable journal Neurosurgery to do it.

“The NFL published all 16 of its papers [aimed at refuting the evidence of CTE] in Neurosurgery,” Fainaru-Wada told Neurology Today. “People told us that this was entirely unheard of, that you would have this one journal acting as a ‘house organ’ for the NFL. As it turned out, the journal's editor at the time, Michael Apuzzo, MD, was also a consultant to the New York Giants.”

While the NFL itself waged a formidable battle to deny CTE for the next five years, Fainaru-Wada alleges, leading neurologists and neurosurgeons — even those who helped to develop the science of CTE — could have done more to challenge the league on the issue.

“Dr. Robert Cantu, one of the foremost authorities on the issue, was the section editor at Neurosurgery at the time,” said Fainaru-Wada. “He was the first stop on those NFL papers, and he's told us that he went to Apuzzo to suggest that those papers were not legitimate and the authors were being self-serving to the NFL, but Apuzzo overruled him. But Cantu didn't resign his position: he stayed on as sports editor.”

Robert Cantu, MD, co-director of the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine, told Neurology Today he stayed on in hopes of making his voice heard. “Regardless, it was pretty clear that all of those papers were going to see publication in that journal. Even though I was overruled, at least they allowed me — although I ultimately tired of it — to write sidebars with my opinion.”

In the small (although growing) field of CTE and football-related brain injuries, it's almost impossible to find a neurologist without some current or former affiliation with the NFL, Dr. Cantu said. “Even on the League's current Head, Neck, and Spine Committee, you have individuals that are in positions of subcommittee chairmanship that have received funds from the NFL to do research,” he noted. “Is that not a conflict? It's in the eyes of the beholder. I would never criticize someone for pointing that out as a potential conflict, but I would point to the reputations of the people involved, and I would hope that they would rise above it.”

Julian Bailes, MD, co-director of the NorthShore University HealthSystem Neurological Institute, based in Evanston, IL, worked with Dr. Omalu to identify CTE in Mike Webster's brain and was a coauthor on other papers with him on CTE. He himself was a former team physician for the Steelers and knew Mike Webster both professionally and personally.

He said that the denial of CTE at first wasn't limited to leaders of the NFL. “I had the same emotion and reaction myself. There was disagreement about what was causing what we were seeing, and there was even denial that it was real. I think to some degree it was understandable. But I also think things have changed.”

[Earlier this year, the National Institute of Neurological Disorders and Stroke convened an independent panel of neuropathologists to examine brain tissue from three unidentified sources, including the former NFL player Junior Seau, who killed himself in May 2012. In the blinded review, the panel confirmed a diagnosis of CTE in Seau. See the Neurology Today article, “NIH: NFL'S Junior Seau Had Chronic Traumatic Encephalopathy”: http://bit.ly/14ORoiX.]

“Things are run much better now,” said Howard S. Derman, MD, co-director of the Houston Methodist Concussion Center. “The doctors in charge of the Head, Neck, and Spine Committee are now neurosurgeons — [H. Hunt Batjer, MD, chair of neurological surgery at University of Texas Southwestern in Dallas, and Richard Ellenbogen, MD, chair of neurological surgery at University of Washington] — where the previous chair was a rheumatologist.”

(The previous chair of the committee was the controversial Elliot Pellman, MD, former Jets team doctor and a lead author of that string of Neurosurgery papers, who famously wrote in a 2006 article that “concussions in professional football are not serious injuries.”)

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CHANGES IN PLAYER RULES

Dr. Cantu said that the NFL, which in August reached a proposed $765 million settlement with some 4,500 former players diagnosed with football-related brain damage, has righted the ship over the past several years with major rule changes. (Still to be approved by a federal judge at press time, some say the settlement may prove seriously inadequate to the total scope of injuries; it reportedly would exclude families of players who died before 2006.)

“They started with reducing the four-man wedge to a two-man wedge,” Dr. Cantu said. “It used to be somebody's job to throw his head into the four-man wedge and break it up so the people behind them could bring down the ball carrier. It took a broken neck and a lot of concussions to bring about that change, but it did happen.”

New penalties have also been added, such as those aimed at targeting players particularly at risk for trauma because they don't see the hit coming. “If your neck is strong and tensed at the moment of impact, there's less trauma to the brain,” Dr. Cantu said. “So anyone in the act of throwing a ball, receiving a ball, punting a ball or receiving a punt — you can't hit them on the head. It's a 15-yard penalty, and if it's egregious, you're out of the game. And starting this year, it's no longer legal to hit with the crown of your head when running.”

So are these rule changes really effective in reducing the head trauma that appears to be almost inseparable from football? In some cases, there's evidence that they are.

“The most dangerous moment in a football game is the kickoff, with players rushing at each other with a full head of steam from 30–40 yards,” Dr. Cantu said. A few years ago, the NFL moved the kickoff line to the 35-yard line and reduced the run-up from 10 yards to five yards. “There's been almost a 50 percent reduction in concussions on kickoff as a result.” (Forty-three percent, to be exact, according to Edgeworth Economics, which is studying injury data provided by the NFL Players' Association.)

But despite the kickoff's peril, the fact is that this moment is responsible for only a fraction of the concussive injuries in football, and the rate of concussions in the NFL overall is not down. Some of that could be attributable to a better diagnostic process. “Ten years ago, maybe as many as 70–80 percent of all concussions were not recognized, and we believe that figure to be much less today,” Dr. Cantu said.

Could all this have happened much sooner? Absolutely, said Dr. Bailes. “You could say that football, and particularly the NFL, had their own vested interest in this not being true. But, at first, many aspects of this condition were not intuitive. It was hard to believe that if you didn't have a history full of known concussions, you could still end up with chronic brain damage. There are a lot of reasons that it took longer than one would like for change to happen.”

It's hard to blame the NFL for being reluctant to accept the concept of CTE when it has taken a long time for the medical community to do so, notes Jeffrey Kutcher, MD, associate professor of neurology and director of Michigan NeuroSport at the University of Michigan. “Do I wish they had done all this earlier? Yes, I do. But I also wish that we in the medical community had been involved in this sooner as well. Neurologists have just started taking this seriously within the last five years or so.”

Dr. Kutcher also pointed out that the science behind CTE and the effect of contact sports on the brain is still very much an evolving body of work. “To this date, there is a tremendous amount that is unknown, and not a true consensus as to what the risk actually is.”

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WHAT MORE CAN BE DONE?

Even as the research into CTE continues to evolve, Dr. Bailes thinks that there are additional protective measures that could be taken in football at all levels. “I think we ought to move to reduce contact as much as possible. From the NFL down to Pop Warner, that is already occurring, but we need to go further.” He suggests the concept of “smart helmets” with instrumented devices that can measure the forces a helmet has sustained and how many.

“We also need to continue to evolve the rules of play to do everything possible to eliminate head-to-head contact,” he said. “For example, linemen ought to be taken out of the three-point stance and placed in a squatting, two-point stance, so that there is not mandatory gratuitous head-to-head contact on every play.”

There should be more uniformity in teams' medical expertise, said Dr. Derman. The roster of physicians who provide consultation for the concussed athlete for most NFL teams is shared by multiple specialties, ranging from orthopedists to sports medicine specialists and internists. “Because neurology and neurosurgery don't have specific sports medicine programs, most NFL team doctors who initially see concussions have traditionally come from family practice or orthopedics, so that's who typically saw the concussions first,” he noted. “This year, the NFL mandated that a neurosurgeon be available on the field to benefit both teams.” While each team still sends players to an independent neurologist for an evaluation, Dr. Derman believes more neurologists and neurosurgeons may be added to the regular rosters of team physicians soon.

No sport, football included, can ever be made “injury-free.” But the specter of permanent brain damage is much more haunting than, say, the prospect of a blown knee or Tommy John surgery. “The very nature of the game exposes you to head trauma,” said Fainaru-Wada. “No one would argue that the NFL hasn't made appropriate changes, but the question that is still being raised is: What is the actual impact of just playing the game? I think that's the real question the League is facing right now, and the research is still very much in development.” (Last year, the NFL agreed to donate $30 million to the National Institutes of Health for brain injury research.)

One of the biggest challenges in CTE research is that there is no way to diagnose the condition in living people. That may change with the use of the radionuclide F18 DDNP glucose-PET, the only tracer to date that is a marker for in vivo tau protein deposits. “We began a study at the University of California, Los Angeles, building on the work of Dr. Gary Small there, and will continue it at NorthShore Neurological Institute as well. If borne out in large studies, this would give us, for the first time, the ability to sample populations and follow people while they are still alive,” said Dr. Bailes.

One group that Fainaru-Wada expects to be watching such findings especially closely: parents. “If you reach a point in which parents decide this is not a place they want their kids to be going for fear of long-term implications, that's going to have a dramatic impact on the sport,” he said.

And that worries Dr. Kutcher. “The media attention to this problem has moved the discussion very far and very fast without a full underpinning of basic scientific understanding,” he said. “We're making statements and policies that are designed, with the best intentions, to promote health and minimize the risk of significant neurological disease, but we have to be careful to understand the damage we may be doing by assuming too much about the degree of risk from contact sports.

In other words, scaring young people (or,more probably, their parents) away from football and other contacts sports may be more detrimental to their health than a few years or decades of playing football — and Dr. Kutcher isn't just referring to the physical exercise benefits of sports.

“For some young men, football is about having a structured, guided way in which to release physical aggression,” he said. He suggested that, in fact, some former contact sport athletes who experience mood and behavioral changes after retirement may not be suffering from CTE — but that, instead, playing the sport had served as a treatment for problems that had already existed, symptoms that returned once they were no longer playing.

“I see it in my clinic numerous times: a former contact sports athlete who, three or four years after retirement, starts having problems with mood, frustration, anger, and cognitive concerns,” he said. “They're told that the sport caused this problem. But when you talk to them, you uncover that these issues were always present in their lives. They would get in very significant, repetitive situations of getting kicked out of the school and having difficulty with the law, until they were introduced to a structure in which they could exist and thrive. When that was removed from their lives, the problems came out again — the contact sport was actually the thing treating these issues all along.”

Clearly, he said, there is much that remains unknown about CTE. “Even if it is a rare occurrence that a former NFL player, or someone who plays a lifetime of contact sports, will go on to have a degenerative disease, we now understand that it is a risk. But this is an extremely complicated pathophysiological construct that we are trying to put together, even today, and I worry that the way the media has focused on this issue may be driving people away from participation altogether, and that would be a travesty.”

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LINK UP FOR MORE INFORMATION:

•. NFL Head, Neck & Spine Committee and related safety committees: http://on.nfl.com/13C91i8.

•. NFL safety rules: http://bit.ly/1bhh7Wr.

•. Turner RC, Lucke-Wold BP, Robson MJ, et al. Repetitive traumatic brain injury and development of chronic traumatic encephalopathy: a potential role for biomarkers in diagnosis, prognosis, and treatment. Front Neurol. 2012; 3:186.

•. Omalu B, Bailes J, Hamilton RL, et al. Emerging histomorphologic phenotypes of chronic traumatic encephalopathy in American athletes. Neurosurgery. 2011; 69:(1):173–83

•. Omalu BI, DeKosky ST, Minster RL, et al. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery. 2005; 57:(1):128–134.

•. Neurosurgeryarchive on chronic traumatic encephalopathy: http://bit.ly/1avtzgV.

•. Neurology Todayarchive on dementia-concussion link: http://bit.ly/15jqW3X.

•. AAN sports concussion toolkit/resources: www.aan.com/Concussion.

Wolters Kluwer Health | Lippincott Williams & Wilkins

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