NFL and Concussions

It is no secret that football is a contact sport. If youve ever been to a football game, at any level, you are sure to see hard hits and sometimes injuries. After these injuries, most of the time the player gets up and brushes it off like nothing happened, and continues to play the game. Scientists are starting to believe that these injuries, especially involving the head, are nothing to brush off. An increasing amount of retired NFL players have been experiencing symptoms of chronic traumatic encephalopathy (CTE), which is caused by repeated blows to the head. This paper is going to go through what illnesses have exactly occurred after the player has retired and what their symptoms are, what caused it, and what is being done to help these retired NFL stars in their time of need. Jeremy Goves 2012 article titled Three and Out: The NFLs Concussion Liability and How Players Can Tackle the Problem provides a history lesson of sorts about the concussion issue in the NFL. The NFL implemented a new rule in 1979, which prohibited a player from using their helmets to butt, spear, or ram an opponent with the crown or top of the helmet. Prior to this rule the NFL would turn their heads when there was helmet-to-helmet contact, and the coaches would actually teach and encourage their players to perform hits in that manor (Gove, 2012). In 1994 the Mild Traumatic Brain Injury (MTBI) committee was formed and Dr. Elliot Pellman was appointed their chairmen. Pellman was the New York Jets team physician with a specialty in rheumatology, which raised questions when he was appointed as chairmen because concussions and cognitive injuries were not his area of expertise. According to Gove (2012) Pellmans lack of knowledge was exploited in 2003 when Jets wide-receiver Wayne Chrebet was knocked unconscious during a game, Pellman examined the player and cleared him to return to the game although he was showing obvious signs of a head injury.

NFL and Concussions On September 24, 2002 hall of fame center for the Pittsburgh Steelers Iron Mike Webster passed away. Websters autopsy done by Dr. Bennet Omalu revealed the presence of tau proteins in his brain, which is an indication that he had been suffering from CTE at the time of his death. Webster was the first documented case of long-term cognitive decline in a former NFL player similar to the CTE reports in other former athletes, specifically boxing. Although not medically diagnosed, Websters family confirmed he showed strong symptoms of both Alzheimers and Parkinsons diseases. Gove (2012) explained that the MTBI demanded a retraction of Dr. Omalus article, stating his understanding of CTE in boxers was false, and that

they used the fact that Webster never missed a game due to head injuries to diminish the thought that head trauma is the primary reason for his brain illnesses. Dr. Omalu compared Websters brain to the brains of multiple boxers, and they all exhibited the presence of tau-proteins just as Websters did. Boxing is a sport based off serious repeated blows to the head, so concussions are quite prevalent among professional and amateur boxers. Many doctors and outside specialists complained that Dr. Pellman and the committee were driven more by a desire to protect the NFL than by a commitment to protect the health and welfare of the players (Grove, 2012). On August 14, 2007 the NFL distributed new concussion guidelines following the Chicago summit in June. According to Gove (2012), the organization distributed information pamphlets to its players urging them to become more knowledgeable on concussions. Clearly uneducated and nave on the situation, the leagues outside legal counsel later withdrew the pamphlet, as well as the NFLs August press release that denied permanent problems result from experiencing more than two concussions. Finally, the NFL admitted that its 2007 concussion guidelines were inadequate, and enacted stricter regulations for the 2009 season (Gove, 2012).

NFL and Concussions Rodney Smiths article in 2013 Solving the Concussion Problem and Saving Professional Football spoke a lot about what the NFL was doing to help the retired players suffering from head illness. According to the article, in 2007 the NFL granted former players with brain ailments $88,000 a year if they require institutionalization. In 2011 the NFL Players Association agreed to fund a ten-year, $100 million project with the Harvard Medical School to

support further, independent research. Following this commitment, the NFL granted $30 million to the National Institute of Health to study brain injuries (Smith, 2013). In 2010 the MTBIC was replaced with the Head, Neck, and Spine committee. Roger Goodell was put under fire when he failed to include neuroscientists on the committee. According to Smith (2013), Goodell responded to the media and governmental pressure, which was based on other studies regarding CTE by emphasizing that our game today is played with the understanding that medical decisions must always take priority over competitive interests. This commitment to player safety was manifested in a series of efforts to change the rules of the game to protect against head injuries. The efforts include providing and supporting research to develop safer equipment, meeting to discuss what can be done to protect against head injuries, and taking other steps designed to improve player safety. Nakatsuka and Yamamoto (2013) looked into the new and safer equipment Commissioner Goodell spoke of. Players assume the hard exterior of the helmet will protect them while they use it to drive into another player, it wont. The equipment company Riddell produced a new helmet design with pieces of 1.3 cm polyolefin foam on the exterior surface (Nakatsuka and Yamamoto, 2013), it was tested using a pendulum mechanism and a human dummy. According to Nakatsuka and Yamamoto (2013)s study, the results supported the

NFL and Concussions hypothesis and concluded that increasing the number of exterior foam layers to a helmet may decrease the impact magnitude and further reduce injury potential for concussion. Ryan Smith (2014) covered the NFL concussion settlement earlier this year. Smith (2014) reported the settlement proposed by the NFL to compensate for the former players who suffered from head injuries was $765 million. Judge Anita Brody did not find this amount suitable and denied their settlement. Judge Brody is questioning whether this amount is enough to cover the estimated 20,000 retired players and their families over a 65-year period (Smith, 2014). Judge Brody fears the money will run out. However, the NFL and players attorneys are viewing this as a preliminary approval and are confident the deal will get done. Casson et. al. (2011) examined a study done by the NFL where they received data from their team physicians collected from 1996-2007 on the clinical signs and symptoms, medical action, and management of concussions. The physicians collected this data to get a better hold on how to improve player safety. Their study was split in half, addressing the recent six years

while comparing it to the earlier six years. Casson et. al. define Mild Traumatic Brain Injury as; traumatically induced alteration in brain function that is manifested by a) alteration of awareness or concussiousness, including but not limiting to loss of consciousness, sensation of wooziness or fogginess, seizure, or amnesic period; and b) signs and symptoms commonly associated with post concussion syndrome including persistent headaches, and many other symptoms. According to Casson et. al. (2011) from 1996-2001, 160 players had repeat concussions and 52 players had 3+ head injuries, while from 2002-2007, 152 players had repeat concussions and 44 players had 3+ head injuries. The study concluded that over the 12 years; 1,200 players were concussed and 353 of them experienced repeat concussions, 12 players experienced 5+ concussions, 126 players experienced 3+ concussions. When repeat concussions

NFL and Concussions occurred, 227 out of 353 had only two concussions, and the total concussions over the 12 years was 1,741, 48.7% being single injuries (Casson, et. al., 2011). Dicesare et. al. (2014) studied the concussion rates in all active NFL players from the 2012 and 2013 seasons. Their main focus was finding out whether or not altitude has and affect on concussion incidences. According to Dicesare, et. al. (2014), approximately 30% of games played were done so at, or above a predefined threshold for higher altitude, which is 644 feet.

The stadiums were divided into two categories, lower-elevation and higher-elevation. During the 2012 and 2013 seasons, 300 concussion events were reported involving 284 players. Dicesare, et. al. (2014) assessed the data and concluded that there was a significant lower rate of concussion at higher-elevation stadiums compared to games played at lower-elevation stadiums. The reason for reduced concussions in higher altitude is speculated to be due to physiological adaptations in increased altitudes. However, although it is unlikely, the reason may not be physiological, it may be because athletes who are not used to the altitude do not perform at their highest level of intensity. Football is not the only sport where concussions are prevalent, Drezner, et. al. (2013) examine concussions in all sports. There are estimated as many as 3.8 million concussions per year in the USA during competitive sports, however 50% go unreported (Drezner, et. al., (2013). The highest concussion incidences obviously occur in football, but concussions are also a huge issue in hockey, rugby, soccer, boxing, and basketball. According to Drezner, et. al. (2013), recent data suggests a trend of increased annual concussion rates over the past decade, the reason for this is speculated to be the result of an emphasis on concussion education and awareness, leading to increased identification and reporting. The most common mechanism of a concussion is due to player-to player contact, in soccer it is from purposefully heading, and from hockey it is

NFL and Concussions from checking. Athletes, parents, and coaches alike need to be better educated to make more

informed decisions about concussions, it may help enhance the identification of concussions and improve treatment and prevention. Shurley and Todds 2012 article titled Boxing Lesson: An Historical Review of Chronic Head Trauma in Boxing and Football goes in depth on the similarities of symptoms shown by retired football players and boxers. Boxing has been under medical scrutiny for its high incidence of head injury and long-term degenerative consequences for at least 80 years (Shurley and Todd, 2012). In 1928 Dr. Harrison Martland named the notion that the brains ability to properly function gradually declines because of knockouts and sub-concussive blows they suffer; punch drunk. In the same year, Dr. Martland examined five men who were exhibiting signs of punch drunk. All of the men exemplified the same symptoms and were diagnosed with Punch Drunk Syndrome. Martland then focused on one particular boxer who had fought for seven years and had been retired for 15. This mans symptoms included a staggering walk, shakiness of the hands, and stammering. Martland contributed these symptoms to brain injury due to single or repeated blows to the head or jaw, which caused multiple concussions (Shurley and Todd, 2012). In 1949, British neurologist Macdonald Critchley published a very important study on head trauma in boxers. He examined 21 men and came to the conclusion that behavioral and neurological changes took a minimum of six years for symptoms to manifest, and the average was 16 years after retirement (Shurley and Todd, 2012). When Critchley and Martland did these experiments the technology we have to look into a brain was not developed yet, however experts believe that the boxers they examined would have showed similar readings, as did the deceased football players who have been reported on.

NFL and Concussions Jason Schwartzs 2013 article Hail-Mary Medicine explains the popular notion that a cure for CTE has been found. Overstating what a cure for CTE would mean for football is

nearly impossible, however Bernie Kosar, a former Cleveland Browns star quarterback, believes he has met the person who has it. After a rant of incoherent tweets during a radio interview, Kosar was examined and diagnosed with CTE. Then on January 10, 2013 Kosar called for a press conference, declaring himself to be cured of CTE and crediting his medical remedy to Dr. Rick Sponagule. Up until now, the only way to look inside a brain was during an autopsy, Dr. Sponagule claims that he has a machine called the positron emission tomography scan which allows him to look inside a brain to see what is wrong with it (Schwartz, 2013). Dr. Sponagule is the most prominent member of an increasingly sought out group of doctors who claim to have the remedy for CTE. Jeffery Leiberman, the head of the American Psychiatric Association, labeled this cure for CTE as being false hope for players. Leiberman seems to be correct, Kosar has returned to his erratic ways of a CTE patient. Also Kevin Turner, a retired full back with ALS, who spent most of his money on Dr. Sponagules treatment abruptly ended his association with the doctor claiming that his techniques were only slowing down the affects of the disease, not curing it (Schwartz, 2013). Josh Hunsucker took a different approach when writing about concussions in the NFL; he instead focused on the precautions that are being taken to protect the youth of our nation, specifically in California. In 2011 California mandated a return-to-play law which states when in doubt, sit them out adding that coaches now must take CPR and first aid courses, although only some of those courses include training on concussions (Hunsucker, 2013). Assembly member Mary Hayashi introduced Chapter 173 which requires coaches to receive critical training that will help them better respond to head injuries. Although chapter 173 does

NFL and Concussions not grant the coaches medical training, it gives them a better understanding of the signs and symptoms of a concussed player, which gives them a better judgment on whether they should return to the field or seek medical attention (Hunsucker, 2013). Chronic traumatic encephalopathy is caused by repeated blows to the head resulting in major brain illness. After multiple retired NFL players have showed symptoms of CTE ranging from shaky hands to suicide, there is finally something being done about it. Commissioner

Goodell and the NFL are implementing new rules and changing old rules to ensure the safety and well being of the current players, unfortunately there is nothing they can do for retired players except offer them settlements and try to ease their lives as much as possible. Medical remedies for the disease have been proposed but do not seem to be perfected, and wont be for a long while. Research is being done on all aspects of the situation including new protective headgear by Nakatsuka and Yamamoto (2013), whether altitude has an effect by Dicesare et. al. (2014), and the raising of awareness to help better understand the causes and effects of CTE in not only football but all sports.

NFL and Concussions References Casson, I., Viano, D., Powell, J., & Pellman, E. (2011). Repeat concussions in the national football league. Sports Health: A Multidisciplinary Approach, 3(1), 11-14. Dicesare, C., Smith, D., Barber Foss, K., Kiefer, A., Kushner, A., Thomas, S., Sucharew, H., & Khoury, J. (2014). Rates of concussion are lower in national football league games played at higher altitudes. The Journal Of Orthopaedic And Sports Physical Therapy. Drezner, J., Harmon, K., Gammons, M., Guskiewicz, K., Halstead, M., Herring, S., Kutcher, J.,

& Pana, A. (2013). American medical society for sports medicine position statement: concussion in sport. British Journal of Sports Medicine, 47(1), 12-15. Gove, J. (2012). Three and out: the nfl's concussion liability and how players can tackle the problem.(national football league). Vanderbilt Journal of Entertainment and Technology Law, 14(3), 43. Hunsucker, J. (2013). "when in doubt, sit them out": Chapter 173 effectively supplements california concussion law and raises awareness among coaches. McGeorge Law Review, 44(3), 600-607. Nakatsuka, A., & Yamamoto, L. (2013). Redesigning football helmets to reduce concussion risk: Return to the leatherheads?. Hawaii Journal of Medicine and Public Health, 72(9), 66. Schwartz, J. (2013). Hail-mary medicine.(treatments to cure chronic traumatic encephalopathy). The New Republic, 244(19), 10. Shurley, J., & Todd, J. (2012). Boxing lessons: An historical review of chronic head trauma in boxing and football. Kinesiology Review, 1(3), 170. Smith, R. (2013). Solving the concussion problem and saving professional football. Thomas Jefferson Law Review, 35(2), 127-191.

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Nakatsuka, A., & Yamamoto, L. (2013). Redesigning football helmets to reduce concussion risk: Return to the leatherheads?. Hawaii Journal of Medicine and Public Health, 72(9), 66. Smith, R. (2014). NFL concussion settlement denied. Good Morning America, 1.

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Michael DeVries Doctor Magolis March 1, 2014 NFL and Concussions