No, I am not talking about the Iowa Caucus this week or the continued herding behavior of our political candidates who more and more resemble a menagerie of clowns. Donald Trump and Ted Cruz particularly fit the definition of a clown in being rude and vulgar fools. I am still waiting on one of their political opponents to have the cojones or ovarios to stand up and call them out.
What I am referring to is the impending Super Bowl, which could well be described as the greatest clash of brain tissue ever viewed. History indicates the ancient Roman Circus Maximus at times attracted an eye-witness audience of 250,000 people for chariot races and other forms of destructive entertainment. Our modern day equivalent is not the Indianapolis 500 or Daytona – it is the Super Bowl. It is probably a conservative guess that 250 million people will view the 50th Super Bowl on television. It is called a game of football; an expression of our competitive valor; a demonstration of our loyalty to urban solidarity. In reality it is the highlight of a 9 billion-dollar business presented as a test of athletic strength and skill, that just happens to appeal to our most sanguineous (that is blood thirsty) traits.
Unfortunately the popularity of the event will not be altered at all by the growing evidence that the game is clearly dangerous to the human brain. It is fair to estimate at least half the players will suffer from chronic traumatic encephalopathy in future years. However, public health concerns are no competition for the juggernaut of the NFL.
Concussion, the Film and Bennet Omalu
Recently I saw the film “Concussion” starring Will Smith as the neuropathologist Dr. Bennet Omalu. I viewed the movie with a critical eye to be sure the story was portrayed without excessive dramatic license, sensationalism or excessive tendentious gore. My wife and I were free to express our thoughts during the showing of the film because we were widely separated from the other four people in the large theater. The phenomena of poor attendance, particularly with the very popular Will Smith in the lead role, I attribute to the fact football in the South is a religion – “Go Dawgs”- that brings meaning to the lives of many people. Thus, anything that might be a negative about football or the NFL, will overwhelm any concern about the neurologic potential of children. There was very little advertising of the movie, at least in the Augusta area.
Dr. Omalu has admitted in several interviews that there was some dramatic license in regard to his personal life, but it is my professional opinion that the depiction of the actual damage to the brain was certainly down played; perhaps real images of damaged brains would have earned an R rating.
Evidence in Support of Dr. Omalu
Since the original paper by Dr. Omalu and his co-authors was published in 2002, there has been a wealth of supporting information on the damage of repeated blows to the head, with and without signs of concussion and the high incidence of Chronic Traumatic Encephalopathy (CTE) has been well documented. You may recall a quote from a previous post to this blog: September 29, 2015 “Carted Off the Field of Play.”
According to PBS Frontline, a new report that was published from the brain bank of Boston University revealed some startling news: 96% of deceased NFL players tested by researchers had evidence of the brain disease chronic traumatic encephalopathy (CTE).” (Visit Concussion Watch on Frontline.) Another figure quoted by Frontline indicated 87 of 91 brains examined of previous professional football showed evidence of CTE.
For me, the prevalence of CTE in retired professional football players is alarming. It prompts the question: what is the prevalence in former high school and college football players? Again, Frontline noted that “Additional data from the study indicates of ALL brains examined, not just the NFL, but anyone with a history of playing football at any level, including high school and college, 79% had evidence of chronic traumatic encephalopathy.”
There is no mention in the movie of the voluminous information published in both the medical and lay press about traumatic brain injuries. There is an excellent series (collection) of 15 articles in the New York Times; the lead journalist is Alan Schwarz. Entitled “Sports Concussions and the Brain,” the articles ran from Jan 2007 to May 2011; you can download it here. (There is also a wonderful collection of articles titled “Understanding the Brain.”)
Dr. Omalu, Dr. Maroon and Me
I watched the movie very carefully for any mention of the long history of brain injury from repeated trauma, initially noted in boxers in 1928, but there was only a very brief glimpse of an article on Dr. Omalu’s desk with the word boxing. There is no question that Dr. Omalu was aware of this previous work but I suspect the movie would have been too tedious if the entire history of traumatic brain injury was documented. The last scene in the movie was very powerful. Dr. Omalu watched a youth football game with two boys running head on into each other. It prompts me to say every parent should watch this movie well before their child thinks about athletic endeavors of any kind.
In the September 29, 2015 post I mentioned the name of Dr. Joseph Maroon, a neurosurgeon at the University of Pittsburg to whom I sent a young patient for a second opinion, 30 years ago. Unfortunately Dr. Maroon was depicted in the movie as a physician consultant for the NFL in regard to neuro trauma. Somewhat surprisingly to me the actor who played him in the movie looked very much like him, at least as I recall from meeting him many years ago. I was disappointed in the portrayal of Dr. Maroon and therefore I searched for more information. I found a Frontline interview with Dr. Maroon under the title “League of Denial: The NFL’s Concussion Crisis” by Jim Gilmore on April 17, 2013. [View the interview online.] The interview is very worth reading by anyone interested in this topic.
The questions were thoughtful and probing. Dr. Maroon was serious and I feel sincere in his answers, but profoundly disappointing. He repeatedly stated the science was not yet conclusive to say there was a significant problem. In regard to Dr. Omalu’s original paper Dr. Maroon admitted that “not only I but other independent, non-NFL affiliated individuals commented on the papers and thought that there was overreaching, overstatements, extending the observations too far.” (Please note: he is not an independent observer as he is on the payroll of the NFL.)
As of 2013 he stated “there is still no consensus on the clinical diagnosis of this prior to autopsy.” He never does state there is a serious problem with brain injury in football. Dr. Maroon parses his answers carefully, stating “A certain percentage of the individuals diagnosed with this have had steroid use, alcohol abuse, other substance abuses. We don’t know the concussion history in many of these, and there may be confounding factors in terms of the genetics that we simply don’t understand.” He is ignoring the elephant in the room which is repeated traumatic brain injuries. He dismisses “subconcussive” blows to the head as inconsequential.
In regard to an athlete who had a concussion returning to play after being cleared to play, he believes the risk “is extremely small…the incidence of CTE has to be extremely small.”
Dr. Maroon feels that professional football players are different; their brains are different. He supports his belief with this statement in regard to their ability to return to play sooner:
One of them may have been the fact that some bodies, that those more concussion-prone individuals have been weeded out, if you would, before they got to the NFL. They’re more tolerable to traumatic injuries — and that could be any number of factors from genetic or otherwise, that they’re responding better. We know that the older brain is more tolerant, older in terms of the age of the NFL players versus youth; they’re more tolerable to concussive blows. And they do return quicker and are less injured with the same types of blows. So all of these factors were speculated as to why they had lesser long-term problems.
Lesser long-term problems because they have brains more tolerant of trauma? For me this is an embarrassing statement from a noted neurosurgeon of my generation. The process of CTE begins in youth sports, begins to kindle in high school with more blows to the head, accelerates with more violent blows in college, and reaches a critical threshold for neurological degeneration when they are playing for a spot in the Super Bowl. To say that professional players have “lesser long term problems” flies in the face of the scientific evidence, not to mention common sense.
Please, see the movie and believe Dr. Omalu and not Dr. Maroon.
Then, count the number of times a brain is bounced around on Super Bowl Sunday: call it Circus Maximus Cerebrus.
Rise in the Diagnosis – and Awareness – of Concussion
One final note in the news is that on January 29, 2016, Ben Shpigel wrote under the headline “Diagnoses of Concussions Increase by Nearly a Third Over Last Season” in 2015 in the NFL. [read the entire article online.] 271 concussions were reported across the preseason and regular season games. There were 182 reported concussions in 2014. It was reported that various experts felt this increase was due to increased surveillance (the surveillance system was also in place in 2014) and not due an increase in actual violence on the playing field. “Jeff Miller, the NFL’s senior vice president for health and safety policy, said that twice as many players were screened for concussions this season as in 2014, and that players self-reported head injuries to an ‘unprecedented’ degree.”
In contrast is the following statement by Dr. Matthew Matava, team physician for the Los Angeles Rams (at present it is the St. Louis Rams) and past president of the NFL Physicians Society: “I have often asked players, would they rather injure their knee or would they rather injure their head?” To a man, historically, they would rather sustain a concussion and take my chances. Now that is changing. Now they have to hesitate.”
However the explanation is analyzed, there is no indication the game has become less violent; that blows to the head are decreased by common sense rule changes. It seems the NFL is still giving the public what the NFL thinks the public wants in entertainment: violent impacts.
There is no mention in the report of the thousands of blows every week in football games at all levels that are considered minor or “sub-concussive” but we know are part of the constellation of repeated brain insults that add up over the months and years.