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A Conversation About Concussion

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This Super Bowl weekend, don’t expect to hear a lot about the risk of head injuries. But the conversation continues in the public forum.

By Taylor Sisk

This Sunday’s Super Bowl between the Denver Broncos and Seattle Seahawks will be the most viewed television program of the year.

Many of those tuning in will do so to join friends at a party or – in a once-a-year 180 – strictly to watch the commercials.

But most will actually be into the game: A recent Associated Press-GfK poll found that about 50 percent of Americans consider themselves professional football fans.

Football is now America’s undisputed pastime.

Meanwhile, though, the sport is taking some knocks, most visibly in a documentary released in October called League of Denial, about the National Football League’s handling of head injuries.

While focused on the NFL, the film, adapted from a book by ESPN investigative reporters Mark Fainaru-Wada and Steve Fainaru, also addresses head injuries in high school and collegiate sports.

Brain MRI images courtesy UCLA

Brain MRI images courtesy UCLA

It tells of the 2010 death of Owen Thomas, a 21-year-old All-Ivy League football player at the University of Pennsylvania who hanged himself. An examination of his brain after his death revealed chronic traumatic encephalopathy, a disease that’s been linked to behavioral disorders in former NFL players.

Thomas had never been diagnosed with a concussion, but, having played football since youth league, had sustained hundreds, perhaps thousands, of blows to his head.

Interviewed in League of Denial, Ann McKie, co-director of the Center for the Study of Traumatic Encephalopathy, who examined Thomas’ brain, said she had expected to find nothing.

“It just floored me,” she said. “I just couldn’t believe what I was seeing.”

“He’s 21; he’s so young,” McKie said. “That [changed] the game for me…. Those subconcussive hits, those hits that don’t even rise to the level of what we call a concussion or symptoms … Just playing the game can be dangerous.”

Culture change

There certainly will be discussions in many households tuned into the Super Bowl on Sunday about the potential for head injuries.

At a recent screening of League of Denial at Duke University’s Bryan Center, sponsored by the Sanford School of Public Policy’s DeWitt Wallace Center for Media & Democracy, Steve Fainaru said he believes that such conversations are among the most encouraging outcomes of the heightened media attention on sports-related brain injuries.

League of Denial screenshot

Click here to go to the Frontline: League of Denial webpage

Research suggests that those conversations are critical. A report released in October by the Institute of Medicine and National Research Council found that a “culture of resistance” prevails among young athletes to reporting symptoms of head injuries.

“We need to change that culture,” said Robert Graham, a professor at George Washington University’s School of Public Health & Health Services and chair of the committee that wrote the report.

The committee called on the NCAA and the National Federation of State High School Associations, in conjunction with the Centers for Disease Control and Prevention and others, to “develop, implement, and evaluate the effectiveness of large-scale efforts to increase knowledge about concussions and change the culture … surrounding concussions among elementary school through college-aged youth and their parents, coaches, sports officials, educators, trainers, and health care professionals.”

Meanwhile, the committee members urged, pay attention to your child after an injury.

‘Ringing in my ear’

Carl Fowler is a 14-year-old sophomore at Northern High School in Durham. He’d played a year of football in middle school and felt he was ready to play varsity at Northern.

Carl Fowler

Carl Fowler suffered a concussion while playing for Northern High School in Durham. Photo courtesy Carl Fowler

He discussed it with his parents. They were aware of the risks; his stepmom, Kara McGee Fowler, a physician’s assistant, had seen parts of League of Denial. It was something Carl wanted to do; it was his decision. And they appreciated that players were given a battery of preseason neurological tests for baseline measurements in case of an injury.

In an early-season game, Carl, a defensive end, sustained a concussion when he was hit from the side. He blacked out for a few seconds. When he came to, “I had a ringing in my ear and I felt kind of like I was floating,” he said.

His stepmom said that the coaches and trainers did a great job of recognizing that the hit was cause for concern. They immediately took him out of the game and did assessments on the sideline, after the game and the next day. He was then seen at Duke Sports Medicine Center’s concussion clinic.

Carl had realized right away that something was wrong. The morning after he was hit, he said, was the worst, and he continued to feel poorly for several days, with headaches and trouble concentrating. Cognitive rest was advised.

Over the course of two weeks, he gradually returned to exercise, then some light practice. He visited his trainer’s office each day for evaluation. In three weeks, after a full assessment, he returned to play.

“It was very reassuring to me that they had done that preseason battery of tests so that we could see where his deficits were during the concussion, then see him make a complete recovery and get back to his baseline,” McGee Fowler said.

When Carl returned to play, she said, “He was ready, and we felt comfortable he was ready.

“I was nervous, but I’m nervous every time he plays.”

Teaspoons

Philip Bennett is director of Duke’s DeWitt Wallace Center and served as managing editor of League of Denial. He believes that two things are most responsible for raising public awareness of sports-related head injuries: the fact that the issue has involved high-profile players – such as Junior Seau, who committed suicide, and was subsequently found to have suffered from chronic traumatic encephalopathy (CTE) – and a widespread concern for the safety of youth athletes.

The first confirmed case of CTE to garner much press attention was Hall of Fame Pittsburg Steeler center Mike Webster. Webster tumbled after his retirement into homelessness and extreme depression. When he died in 2002 of heart failure, at age 50, his death certificate indicated that he had suffered from “chronic concussive brain injury.”

An autopsy of his brain found tau protein deposits that create neurofibrillary tangles similar to those found in Alzheimer’s patients. These tangles can cause depression, emotional outbursts and issues with executive functioning that can be linked to dementia.

Similar traces were found in Owen Thomas’ brain.

MatthewGfeller

Matthew Gfeller died of a head injury after playing in his first varsity high school football game. Photo courtesy the Matthew Gfeller Foundation

“I can only say for myself that Owen was a very unlikely person to, in his normal state of mind, to commit suicide,” Thomas’ mother, Katherine Brearley, told the Associated Press soon after her son’s death. “He didn’t have a history of depression. There are no significant factors that we could see that trigger that kind of action.”

The many subconcussive hits her son had taken had been “like teaspoons,” she said. “A thousand teaspoons of water could be the same as a big jug. It’s possible.”

Robert Cantu, co-director with McKie of the Center for the Study of Traumatic Encephalopathy, is quoted in League of Denial as saying that a young person’s brain is lighter than that of an adult, and is thus more easily jarred. He believes that no one under the age of 14 should be allowed to play tackle football.

Kevin Guskiewicz, co-director of UNC’s Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, disagrees with that proposal. He said that kids begin at 8 or so to develop proprioceptive and kinesthetic skills that help them protect themselves.

Those skills are best learned in Pop Warner football or youth hockey leagues, he said, where there’s less disparity in size among kids than there is at the high school level.

One brain

Of course, head injuries occur in sports other than football.

According to the Institute of Medicine’s October report, football, ice hockey, lacrosse, wrestling and soccer are associated with the highest rates of reported concussions for boys at the high school and college levels.

Soccer, lacrosse, basketball and ice hockey are highest for girls at the high school and college levels.

Rusty Lee, athletic director at Page High School in Greensboro, said the worst most-recent sports-related injuries at his school were in volleyball, tennis and cheerleading.

League of Denial raises the question of how much we really want to change our sports in attempt to make them safer. Equipment continues to improve, but the Institute of Medicine’s report found that there’s little evidence that current sports helmet designs reduce the risk of concussions.

So do we want to forbid our kids from playing?

“Matthew was all football,” Bob Gfeller told the audience at the Matthew Gfeller Neurotrauma Symposium, held last March at UNC.

UNC’s Matthew Gfeller Center is named in honor of Gfeller’s son, who died in 2008 after a helmet-to-helmet collision during his first varsity football game at R.J. Reynolds High School in Winston-Salem.

Gfeller isn’t on an anti-football crusade. He just wants to help make it, and all contact sports, as safe as possible.

Others who are intimately involved in the issue are less sanguine.

“I don’t feel I am in a position to make a proclamation for everyone else,” McKie, a self-proclaimed lifetime football fan, said in League of Denial. But if she had young kids, she said, they wouldn’t be allowed to play football.

“You only get one brain,” McKie said. “The thing you want for your kids to do most of all is succeed in life and be everything they can be. And if there’s anything that may infringe on that, that may limit that, I don’t want my kids doing it.”

Ensuing discussion

Carl Fowler would like to play football at the University of Florida. “I would love to play college football,” he said. “Florida would be incredible.”

The first hard hit he took after returning from his injury left him just a little bit jittery. But he’s past that now, and doesn’t think a lot about it.

Not that he and his teammates don’t sometimes talk about how it feels to get rung – and when you need to take it seriously.

“There’s definitely a threshold,” Carl said, describing the perceived portal between mere pain and injury. It’s important to know, he said, when you’ve crossed it.

But who can know where that lies?

“The findings of our report justify the concerns about sports concussions in young people,” Robert Graham wrote. “However, there are numerous areas in which we need more and better data. Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know, as with any decision regarding risk, so they can make more informed decisions about young athletes playing sports.”

North Carolina has taken measures. In 2011, the General Assembly passed the Gfeller-Waller Concussion Awareness Act mandating the development of athletic-concussion safety training programs in schools and defining guidelines under which athletes can return to action after injury.

“I think you’ve got a discussion taking place at a number of levels,” Bennett said. “I expect it to be a conversation that evolves.”

He points out though that the conversation about high school athletics is in many ways a different one from that about professionals.

“Do kids really know what they’re getting into? Do they have informed consent? What is the potential risk/benefit analysis for them?” Bennett asked, rhetorically.

“For all those arguments,” he said, “the lower you go in age, the less they apply.”

Bennett remains a fan – albeit one with qualms. He sings the praises of those Friday night lights: “It’s a big thing, and it’s a good thing. Think about what effect it’s had on community spirit, on race relations, on a million things that have brought a lot of value.”

He’ll be watching the Super Bowl. But he doesn’t expect to hear a lot about chronic traumatic encephalopathy.

“Way more people,” Bennett said, “are going to be interested in what Doritos says at the Super Bowl than what Ann McKie says.”

The awareness, he said, comes “little by little.”

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