Repeated Concussions In Football & The NFL’s Handling Of Them: Does the Ruling on the Field that the League is Fairly Handling Them --- And Retired Players with Chronic Traumatic Encephalopathy Possibly Because of Them --- Need to Be Reviewed?

I am one of the tens of millions of fans of college and professional football. I played football when I was in junior high. (I was a right guard: Not the deodorant, the position!). I watch football religiously on Thursday nights, all-day & evening on Saturdays, Sunday afternoons and evenings,  and Monday nights to boot. I follow the New England Patriots  (my hometown professional franchise), the Holy Cross Crusaders (my undergraduate alma mater) and the University of  Arkansas Razorbacks (the team of my current employer).

 

But I am also a Biomedical librarian with over 35 years of experience, with the duty and competence to identify and supply well-vetted scientific and clinical studies to library patrons, who will go on to use the information in their own professional practice or as part of their ongoing program of study.

 

So it is entirely fair to say that I have conflicted feelings, when comparing the claims of the NFL that repeated concussions  (also known as Mild Brain Traumatic Injuries) have not been shown necessarily to lead prematurely to Chronic Traumatic Encephalopathy ----- persistent cognitive declines,  other neuropsychological effects,  and severe emotional turmoil ----- that emerges later on in the lives of its players, usually after their retirement, sometimes as early as their mid-thirties.

 

I certainly want this denial to be the case, but wanting it to be the case, is not the same as having a preponderance of evidence on one side or the other.

 

Dr. Ira Casson and the NFL team of experts

 

To its great credit, the NFL has started its own “in-house” studies, and these have been generally headed up by Dr. Ira Casson, a board-certified neurologist who has made a career of  studying athletes and brain injuries, particularly concussions. He has frequently worked with other physicians, most commonly  Drs. D.C. Viano, and E.J. Pellman, as part of  a group called ProHEALTH Care Associates, LLP.

 

Dr. Casson  is, in fact, arguably the most published physician in this area. I have identified at least 17 studies, often also involving Viano and Pellman, involving concussion and NFL football players (as well as a few studies of boxers whose record of permanent brain trauma is almost universal). These studies  all appeared in highly reputable journals such as the American Medical Association’s Archives of Neurology, Elsevier’s Physical Medicine and Rehabilitation Clinics of North America and its Neurological Clinics, and perhaps most importantly in the journal, Neurosurgery, a Lippincott, Williams & Wilkins title that is the official voice of the Congress of Neurological Surgeons.

 

Many of his studies are uncontroversial and some results and measures taken by the NFL in response to them, such as the establishment of its official  Mild Traumatic Brain Injury Committee, are undisputed as positive measures in terms of advancing knowledge of concussions and other brain trauma in modern professional football:

 

·     There is now extremely little chance for very severe one-shot head injuries among NFL players. This has already been substantially minimized by intense cooperation between equipment suppliers (particularly of helmets), NFL-retained physicians and trainers, and significant support from science and engineering studies contracted for this purpose.

 

·     There   continues to be a surprising number of ongoing studies that attempt to identify the various dynamic forces in terms of unnatural head and neck deflection and extension with regard to angle of   collision and degree of force behind the collisions. What the auto industry did with respect to auto crashes, seat belts, and air bags, and crash test dummies, is effectively being duplicated in earnest by groups within and without the NFL’s auspices.

 

·     There is a continuous  training program for team physicians and  allied sports professionals to examine and quickly screen for on-field concussions. If the players report them, or show overt symptomatology, they will be closely examined and possibly sent off field for treatment. The NFL has even developed some screening tools to help them overcome the natural reluctance of players who fear losing their starting position, contract renegotiation, or being traded, because they have had one or more concussions and do not want to be considered “whiners who won’t play through the pain.”

 

·     Deliberate helmet-to-helmet collisions in the course of a game now involve, not only a serious 15-yard penalty during the game, but also a stiff fine for the offending player afterwards from the NFL commissioner.

 

·     The NFL has now mandated baseline neurocognitive testing of all incoming NFL players, so as to be able to check not only if there are existing deficits in these players, but more importantly, perhaps, to provide for comparison points between the beginning of a career vs. its immediate end and even the situation several years past retirement. An inventory of facts regarding prior psychiatric issues, chemical dependency, learning disabilities, and some factors of emotional stability is also involved.

 

·     A program of outreach to retired NFL players who are having neurocognitive declines, that includes screening, and follow up for those willing and able to complete any paperwork and to make their own arrangements to come to their facilities.

 

The Criticisms & the Sad, Adverse Case Histories

Dr. Casson and associates are not without critics. Those complaints center around:

·     A lack of independence of the studies from those who paid for the studies. In other words: Is it any surprise that the NFL pays for studies that essentially suggest that the NFL’s current arrangements for handling concussions (i.e. Mild Brain Traumatic Injuries)  are safe and effective in preventing Chronic Traumatic Encephalopathy?

·     Too few subjects within the studies that have been conducted to render scientifically valid results. This is a criticism that the NFL suggests is technical rather than indicative of a lack of good faith on their part. Critics suggest that larger numbers are much more likely to reveal the truth, whatever the intention or motivation of the sponsoring organization.

·     The claims by Casson and others that professional football players who have had a concussion in the course of a game, can often be returned to play very quickly,  often within the same game. It is exactly this accumulation of Mild Brain Traumatic Injuries  that critics suggests leads to Chronic Traumatic Encephalopathy. They say that lack of immediate serious cognitive defects does not preclude long term cumulative damage down the road.

The scientific and clinical ammunition of the opponents is partly statistical and anecdotal of itself. It basically consists of :

·     Bringing to the attention of the media, the U.S. congress, and the public, a growing number of retired NFL players who had experienced multiple concussions and have since undergone drastic declines in their mental faculties and ability to cope with life, far beyond what would be expected for their ages. Their clinical pictures makes them look like they are Alzheimer’s patients in the 70’s as opposed to men in their 40s or 50s.

·     An accumulating body of postmortem brain studies from former NFL players that show that even small concussions, if too many and too often over a career, do result in visible brain damage that cannot be otherwise explained away.

·     Federal support in terms of competitive NIH grants for the Center for the Study of Traumatic Encephalopathy, a collaboration of the not-for-profit (but clearly biased towards the cumulative-effects-leading –to-the-Chronic-Traumatic-Encephalopathy viewpoint)  Sports Legacy Institute and the Boston University School of Medicine. While paper of Dr. Anne McKee and her own team of experts, cited below, is clearly outnumbered by the studies of Casson, Viano and Pellman, it is no less prestigious in terms of its venue, the Journal of Neuropathology and Experimental Neurology.

Congress Throws the Red Flag

In professional football, the coach of a team who wishes a reexamination of a call adverse to that team that has been made by the referees on the field, has the limited right to throw a red flag on the field. This causes the play to be reviewed using additional replays based on multiple camera angles, which supply different perspectives, and which have the potential for overturning that ruling. On Thursday, October 26, 2009, members of congress, during special hearings, clearly threw their flag, and were especially not pleased with the absence of the head referee, Dr. Ira Casson,  who was presumably going to be asked to review the call on the field. While other physicians and league officials were there, and gave testimony and answers as best they could,  it seemed that no conclusive result could be reached in his absence.

In the interest of football and football players, both current and retired from the NFL players, plus the players in college, high school, and even journal high schools who learn how to play, by watching the pros, it might well be that it really is time for someone else other than the NFL’s own experts “to review the tapes” either to confirm or overturn the current ruling on the field concerning whether or not current leagues practices relating to concussions really do avoid or minimize the chances of chronic traumatic encephalopathy, and whether or not the league owes even more to its brain-damaged veterans.

Tony Stankus, FSLA tstankus@uark.edu Life Sciences Librarian, Science Coordinator  & Professor

University of Arkansas Libraries MULN 223E

365 North McIlroy Avenue

Fayetteville AR  72701-4002

Voice: 479-575-4031

Fax: 479-575-4592

 

Cao, C., Tutwiler, R. L., & Slobounov, S. (2008). Automatic classification of athletes with residual functional deficits following concussion by means of EEG signal using support vector machine. IEEE Transactions on Neural Systems and Rehabilitation Engineering: A Publication of the IEEE Engineering in Medicine and Biology Society, 16(4), 327-335.

Casson, I. R., Sham, R., Campbell, E. A., Tarlau, M., & Didomenico, A. (1982). Neurological and CT evaluation of knocked-out boxers. Journal of Neurology, Neurosurgery, and Psychiatry, 45(2), 170-174.

Casson, I. R., Siegel, O., Sham, R., Campbell, E. A., Tarlau, M., & DiDomenico, A. (1984). Brain damage in modern boxers. JAMA: The Journal of the American Medical Association, 251(20), 2663-2667.

Casson, I. R., Pellman, E. J., & Viano, D. C. (2006). Chronic traumatic encephalopathy in a National Football League player. Neurosurgery, 59(5), E1152-E1152.

Casson, I. R., Pellman, E. J., & Viano, D. C. (2006). Chronic traumatic encephalopathy in a national football league player. Neurosurgery, 58(5), discussion e1003.

Casson, I. R., Pellman, E. J., & Viano, D. C. (2008). Concussion in the national football league: An overview for neurologists. Neurologic Clinics, 26(1), 217-41.

Casson, I. R., Pellman, E. J., & Viano, D. C. (2009). Concussion in the National Football League: An overview for neurologists. Physical Medicine and Rehabilitation Clinics of North America, 20(1), 195.

Casson, I. R., Pellman, E. J., & Viano, D. C. (2009). National Football League experiences with return to play after concussion. Archives of Neurology, 66(3), 419-420.

Casson, I. R., Viano, D. C., & Pellman, E. J. (2008). Synopsis of the National Football League player health and safety meeting: Chicago, Illinois, june 19, 2007. Neurosurgery, 62(1), 204.

Fréchède, B., & McIntosh, A. S. (2009). Numerical reconstruction of real-life concussive football impacts. Medicine and Science in Sports and Exercise, 41(2), 390-398.

Goldberg, D. S. (2008). Concussions, professional sports, and conflicts of interest: Why the National Football League's current policies are bad for its (players') health. HEC Forum: An Interdisciplinary Journal on Hospitals' Ethical and Legal Issues, 20(4), 337-355.

Greenwald, R. M., Gwin, J. T., Chu, J. J., & Crisco, J. J. (2008). Head impact severity measures for evaluating mild traumatic brain injury risk exposure. Neurosurgery, 62(4), 789.

Lau, B., Lovell, M. R., Collins, M. W., & Pardini, J. (2009). Neurocognitive and symptom predictors of recovery in high school athletes. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine, 19(3), 216-221.

McKee, A. C., Cantu, R. C., Nowinski, C. J., Hedley-Whyte, E., Gavett, B. E., Budson, A. E., et al. (2009). Chronic traumatic encephalopathy in athletes: Progressive tauopathy after repetitive head injury. Journal of Neuropathology and Experimental Neurology, 68(7), 709-735.

Mello, M. J., Myers, R., Christian, J. B., Palmisciano, L., & Linakis, J. G. (2009). Injuries in youth football: National emergency department visits during 2001-2005 for young and adolescent players. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 16(3), 243-248.

Miller, G. (2009). Neuropathology. A late hit for pro football players. Science (New York, N.Y.), 325(5941), 670-672.

Pellman, E. J., Lovell, M. R., Viano, D. C., & Casson, I. R. (2006). Concussion in professional football: Recovery of NFL and high school athletes assessed by computerized neuropsychological testing--part 12. Neurosurgery, 58(2), 263.

Pellman, E. J., Lovell, M. R., Viano, D. C., Casson, I. R., & Tucker, A. M. (2004). Concussion in professional football: Neuropsychological testing--part 6. Neurosurgery, 55(6), 1290.

Pellman, E. J., Powell, J. W., Viano, D. C., Casson, I. R., Tucker, A. M., Feuer, H., et al. (2004). Concussion in professional football: Epidemiological features of game injuries and review of the literature--part 3. Neurosurgery, 54(1), 81.

Pellman, E. J., Viano, D. C., Casson, I. R., Arfken, C., & Feuer, H. (2005). Concussion in professional football: Players returning to the same game--part 7. Neurosurgery, 56(1), 79.

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Pellman, E. J., Viano, D. C., Casson, I. R., Tucker, A. M., Waeckerle, J. F., Powell, J. W., et al. (2004). Concussion in professional football: Repeat injuries--part 4. Neurosurgery, 55(4), 860.

Pellman, E. J., Viano, D. C., Tucker, A. M., Casson, I. R., & Waeckerle, J. F. (2003). Concussion in professional football: Reconstruction of game impacts and injuries. Neurosurgery, 53(4), 799.

Randolph, C., & Kirkwood, M. W. (2009). What are the real risks of sport-related concussion, and are they modifiable? Journal of the International Neuropsychological Society: JINS, 15(4), 512-520.

Ross, R. J., Casson, I. R., Siegel, O., & Cole, M. (1987). Boxing injuries: Neurologic, radiologic, and neuropsychologic evaluation. Clinics in Sports Medicine, 6(1), 41-51.

Rowson, S., Brolinson, G., Goforth, M., Dietter, D., & Duma, S. (2009). Linear and angular head acceleration measurements in collegiate football. Journal of Biomechanical Engineering, 131(6), 061016.

Schwarz, A. (October 29, 2009). NFL scolded over injuries to its players. New York Times, CLIX, (54843), A1, continued on A18.

Solomon, G. S., & Haase, R. F. (2008). Biopsychosocial characteristics and neurocognitive test performance in national football league players: An initial assessment. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of Neuropsychologists, 23(5), 563-577.

Takhounts, E. G., Ridella, S. A., Hasija, V., Tannous, R. E., Campbell, J. Q., Malone, D., et al. (2008). Investigation of traumatic brain injuries using the next generation of simulated injury monitor (SIMon) finite element head model. Stapp Car Crash Journal, 52, 1-31.

Tsushima, W. T., Oshiro, R., & Zimbra, D. (2008). Neuropsychological test performance of Hawai'i high school athletes: Hawai'i ImPACT normative data. Hawaii Medical Journal, 67(4), 93-95.

Viano, D. C., Casson, I. R., & Pellman, E. J. (2007). Concussion in professional football: Biomechanics of the struck player--part 14. Neurosurgery, 61(2), 313.

Viano, D. C., Casson, I. R., Pellman, E. J., Bir, C. A., Zhang, L., Sherman, D. C., et al. (2005). Concussion in professional football: Comparison with boxing head impacts--part 10. Neurosurgery, 57(6), 1154.

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“Unnecessary risks are being taken by patients seeking the liberation treatment.” says Dr. Avneesh Gupte of the CCSVI Clinic. “It has been our contention since we started doing minimally invasive venous angioplasties nearly 6 years ago that discharging patients who have had neck vein surgery on an outpatient basis is contra-indicated. We have been keeping patients hospitalized for a week to 10 days as a matter of safety and monitoring them for symptoms. Nobody who has the liberation therapy gets discharged earlier than that. During that time we do daily Doppler Ultrasounds, blood work and blood pressure monitoring among other testing. This has been the safe practice standard that we have adopted and this post-procedure monitoring over 10 days is the subject of our recent study as it relates to CCSVI for MS patients.”

Although the venous angioplasty therapy on neck veins has been done for MS patients at CCSVI Clinic only for the last 18 months it has been performed on narrow or occluded neck veins for other reasons for many years. “Where we encounter blocked neck veins resulting in a reflux of blood to the brain, we treat it as a disease,” says Gupte. “It’s not normal pathology and we have seen improved health outcomes for patients where we have relieved the condition with minimal occurrences of re-stenosis long-term. We believe that our record of safety and success is due to our post-procedure protocol because we have had to take patients back to the OR to re-treat them in that 10-day period. Otherwise some people could have run into trouble, no question.”

Calgary MS patient Maralyn Clarke died recently after being treated for CCSVI at Synergy Health Concepts of Newport Beach, California on an outpatient basis. Synergy Health Concepts discharges patients as a rule without in-clinic provisions for follow up and aftercare. Post-procedure, Mrs. Clarke was discharged, checked into a hotel, and suffered a massive bleed in the brain only hours after the procedure. Dr. Joseph Hewett of Synergy Health recently made a cross-Canada tour promoting his clinic for safe, effective treatment of CCSVI for MS patients at public forums in major Canadian cities including Calgary.

“That just couldn’t happen here, but the sooner we develop written standards and best practices for the liberation procedure and observe them in practice, the safer the MS community will be”, says Dr. Gupte. “The way it is now is just madness. Everyone seems to be taking shortcuts. We know that it is expensive to keep patients in a clinical setting over a single night much less 10 days, but it’s quite absurd to release them the same day they have the procedure. We have always believed it to be unsafe and now it has proven to be unsafe. The thing is, are Synergy Health Concepts and other clinics doing the Liberation Treatment going to be changing their aftercare methods even though they know it is unsafe to release a patient on the same day? The answer is no, even after Mrs. Clarke’s unfortunate and unnecessary death. Therefore, they are not focused on patient safety…it’s become about money only and lives are being put at risk as a result.”

Joanne Warkentin of Morden Manitoba, an MS patient who recently had both the liberation therapy and stem cell therapy at CCSVI Clinic agrees with Dr. Gupte. “Discharging patients on the same day as the procedure is ridiculous. I was in the hospital being monitored for 12 days before we flew back. People looking for a place to have the therapy must do their homework to find better options. We found CCSVI Clinic and there’s no place on earth that’s better to go for Liberation Therapy at the moment. I have given my complete medical file from CCSVI Clinic over to my Canadian physician for review.” For more information Log on to http://ccsviclinic.ca/?p=866 OR Call on: +1 (404) 461-9560.

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After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”
Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.
Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.
Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.
Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy.

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All told, the NFL should never stop seeking for studies with regards to football-related head and brain injuries. In the same manner that a knocked tooth should immediately be brought to a dentist, the more severe cases should be studied in order to present with solutions to lessen these injuries.

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