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Invited Commentary

Honoring Scientific Leadership in an Era of Change

Kutcher, Jeffrey S. MD

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Current Sports Medicine Reports: May/June 2012 - Volume 11 - Issue 3 - p 111-112
doi: 10.1249/JSR.0b013e31825641cf
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In the early part of the 20th century, concern over the neurological health of athletes in the United States was growing, fed mainly by the catastrophic brain injuries being seen in football players around the country. As the number of deaths mounted, the call for protecting athletes was loud and significant, leading to rule changes, the introduction and improvement of protective equipment, and the establishment of an organization charged with looking after the health and safety of collegiate athletes: the National Collegiate Athletic Association (NCAA). These changes were ushered in as the result of a groundswell of public concern and political intervention, without a clearly established base of science to help provide a well-measured response. These interventions were, however, largely successful, as football saw a dramatic decrease in the number of deaths from traumatic intracranial injury.

Back then, the public and its institutions responded to what they could see. These injuries were obvious and dramatic. They took or altered lives in an instant, leaving behind a powerful and disturbing image of the destructive power of the forces humans could generate in the course of playing sports.

In 1928, nearly 20 years after the founding of the NCAA, a forensic pathologist in New Jersey, Harrison Martland, MD, brought to light another type of brain injury that was occurring as the result of participation in sports: dementia pugilistica (DP). Unlike the catastrophic acute injuries seen in football, this diagnosis was not obvious until many years after the exposure to offending forces. Dr. Martland described a neurodegenerative course that was subtle at first but unrelenting and eventually catastrophic in its own way, as an unknown pathology slowly obliterated the brain function of ex-boxers.

Although significant to the boxing population, DP was a minor concern to the public because of the perception that it did not touch the life of the average athlete. This belief was held widely for more than 50 years. In the later part of the 20th century, DP, being known increasingly as “chronic traumatic encephalopathy” (CTE), began to be discussed not only as a possible clinical outcome from participation in pugilistic competitions but also as one possible result of playing some of our more popular contact sports, such as football, rugby, soccer, and ice hockey. At the same time, rare but catastrophic injuries, given the label “second-impact syndrome” (SIS), began to show up in media reports and take hold in the collective societal consciousness. With these two entities, CTE and SIS, being discussed with increasing urgency, the public, media, and government institutions again responded to something they could see, something that potentially could be as catastrophic as the skull fractures and brain hemorrhages that marred the early days of organized football. Now, like then, there was a call for change.

In just a few short years, consider the degree to which the issue of concussion has come to permeate the consciousness of organized sports. While it is unclear how the clinical syndrome of concussion specifically relates to CTE or SIS, the term “concussion” has come to represent the entire spectrum of brain injury that may occur as the result of playing contact sports. Concussion has evolved from a nuisance injury to a significant public health concern. Once thought to be an issue primarily limited to professional combat sports, we now see concussion laws and policies that govern sports, contact and otherwise, at all levels of play. We have witnessed a steady redefinition of what concussion means, both medically and socially.

Unlike the catastrophic injuries seen in football in the early 20th century, the diagnoses under intense scrutiny today are steeped in the unknown. Compared with the rather obvious pathologic mechanisms of skull fracture and hemorrhage, the diagnoses of concussion, CTE, and SIS are not well understood and are very difficult to study. The incredible complexity of brain physiology, the lack of objective testing for concussion, and the wide range of normal brain function within a population all combine to make this issue one of the most vexing in clinical medicine today. As such, the need for well-performed clinical science has never been more critical.

Over the past decade, we have witnessed an explosion in sports concussion research, efforts that continue to move the science forward and improve our understanding of both the short-term and long-term consequences of playing contact sports. Despite this, we still have relatively few data to help us accurately estimate the true risks. Although our media and legislative bodies look to construct a simple narrative, one does not exist in the scientific literature. While our patients and their families look for concrete answers and data-driven advice, both continue to be well out of reach.

As a field, sports medicine strives to understand the mechanisms of injury. Its foundation is the application of basic science toward a better understanding of human performance, while it is driven by the quest for data that accurately describe varying clinical outcomes. What happens when the basic science required to understand fully a particular aspect of human performance and injury simply does not exist to any significant degree? In the end, we must acknowledge that our most important role is to advocate for the well-being of our patients. Oftentimes, we are forced to make decisions based more on our collective clinical experience than on solid basic science. Given this, the need for critical thinkers experienced in the clinical practice of sports concussion is paramount.

Unfortunately, there is no easy answer or protocol-driven paradigm for diagnosis or management. To understand reasonably these injuries to the brain, the most complex and dynamic biological system imaginable, requires careful and meaningful discourse, rigorous dogged research, and, most importantly, a sense of humility and awe. In the nearly 20 years that Kevin M. Guskiewicz, PhD, FACSM, has been contributing to the field, he has displayed all of these attributes and more. He has provided not only critical thinking but also novel approaches to complex problems. He has been a leader in his field of athletic training and an inspiration to researchers and clinicians from every walk of life. As the science of sports concussion continues to unfold, only then may we truly begin to appreciate the contributions he has made to the well-being of the millions of athletes who have participated or will participate in contact sports.

Like a century ago, we find ourselves in a time of evolution in our understanding of the risks of participating in contact sports. What remains to be seen is just how much contact is too much and for whom. While we wait for the continued progression of science to help bring clarity, the call for action continues. It is not always prudent to delay changes in policy that seem to be based on common sense. At the same time, it is folly to conclude that we understand a problem of such complexity without the science to support us. To that end, I am grateful to Dr. Guskiewicz for his efforts, creativity, and leadership.

The author declares no conflict of interest and does not have any financial disclosures.

© 2012 American College of Sports Medicine