Brain Expert Omalu Wants Longer Rest for Concussed Football Players
Sideline concussed juveniles for three months, says the breakthrough neuropath
Neuropsychological testing lacks validation and might be harmful, critics caution
NFL players rebuke theory of ‘safer’ football through their ‘behavior modification’
By Matt Chaney
Posted Friday, January 28, 2011
So-called concussion awareness is said to be sweeping American football, and Scott Fujita, veteran NFL linebacker, agrees to a point.
Yes, Fujita confirms, even hard dudes like him have sobered in their perspective. Head injuries are no longer considered trivial in football but as serious business, and NFL players get it, especially Fujita, nearing 32 years old at arguably the game’s most violent position for Cleveland.
In his mind the most menacing guys don’t appear so tough anymore, just more human, fragile—even as he targets one to smash on the field.
“I gotta be honest, I think about that every time I go in now to tackle somebody,” Fujita, 6-foot-5 and 250 pounds, said this week in a phone interview. “I’m concerned for my own safety as well as theirs. I’m a married guy, I’ve got two young kids, and I see a lot more the big picture than I ever did before.”
But has anything changed about danger in tackle football, the game that kills and maims? Is so-called safer play really taking over?
Fujita, member of the players union executive committee, doesn’t equivocate in answering, typical of his trademark frankness. “Do I feel safer with the emphasis on the rules and all that kind of stuff? No, that doesn’t make me feel safer,” Fujita said. “Do I think the emphasis makes the game safer? No. Overall, I don’t, no.”
“I just think that I’m going to be smarter about things, and I think a lot of players feel the same way, when an issue (of head injury) comes up for each of us.”
Fujita doesn’t yet detect benefit of concussion management, including neuropsychological (NP) testing like ImPACT software, designed to help assess and control head injury in players.
In fact, Fujita says he’s only been NP-tested a few times during nine years in the NFL. Despite all the talk by management and associate experts, swearing newfound vigilance and concern over brain health in players, Fujita hasn’t seen tangible effect.
His neurological baseline wasn’t re-assessed this season, as concussions exploded into the biggest controversy for American football in more than a century. Fujita even played on the infamous October Sunday at Pittsburgh, Browns versus Steelers, when three shocking headshots leveled guys within minutes.
Had Fujita suffered a concussion this season—or been diagnosed—the NFL would’ve been without proper neural data to gauge his condition. “I took one (a baseline) probably, maybe three years ago?” he said, considering. “Maybe two years ago was the last time, down in New Orleans.”
“Yeah, I think it’s been at least two years,” the linebacker determined. “And there have been a whole lot of train wrecks in two years.”
* * * * * * *
Dr. Bennet I. Omalu, the pioneering sport-forensic pathologist who first linked brain damage to tackle football nine years ago, warns that players are dangerously mishandled still—despite official claims this season of “safer” play through rule changes and “concussion management” for the injured.
“That is the name of the game,” Omalu said of the rhetoric, calling it a “corruption at various levels” in information and science designed to deflect damning evidence amid crisis for football.
The official goal, Omalu charges, is not to protect life but to sustain football as pervasive in culture, sanctioned by American government, education, medicine, media and even religion, with elements of each profiting from the violent activity.
Omalu maintains that every concussed football player needs isolation from physical and mental stimulation followed by lengthy rest, further shielding—as he testified one year ago for the House Judiciary Committee. “Two weeks is insufficient time for the recovery of (cerebral) membrane and micro-skeletal injuries caused by concussions. The absence of symptoms does not mean that the brain has healed,” Omalu, chief medical examiner of San Joaquin County, Calif., told congressional members on Feb. 1, 2010.
“I recommend that if a child sustains a concussion in football, that child should be kept out of play for at least three months, or for the entire season to lower the risk of developing any degree of irreversible brain damage.”
Omalu’s public call went unheeded, but a rest mandate would’ve prevented at least one death of a teen player this season. In a recent phone interview, Omalu alleged that rampant, serious brain trauma continues to be disregarded at all levels of football, with injured players fast-tracked back to contact.
“What you do is remove the person from all types of stimulation,” Omalu stressed for diagnosed concussion, especially casualties of football. “You remove him (the athlete) from play. You remove him from school. You remove him from all types of intellectual stimulation.” Omalu is particularly alarmed about concussed juveniles, for the predominant attitude to quickly return kids to football, despite evidence suggesting young brains to be most vulnerable.
Rather, every concussion of a child football player—regardless of diagnosed severity, regardless what anyone says, regardless what post-concussion tests compute—should automatically sideline the patient for three months, Omalu argues in rhythmic Nigerian accent. “There’s no question about it, O-K?” he said, in crescendo and pause as emphasis. “For juveniles… any con-cussion.”
The NFL’s insistence for returning many concussed players within 1 to 2 weeks is a scary problem, according to Omalu and more experts, but college football follows that clinical assumption as do many schools and youth leagues.
The national mentality of “necessary roughness” endures for tackle football, or the belief that benefits outweigh risks for players. The game teaches toughness, discipline and teamwork, supporters say, and is irreplaceable for boosting social interaction and economy in America.
Critics counter or suggest the game is a public health problem that resists impact reform such as downsizing, annually exposing millions of kids to brain trauma that confounds medicine, of repetitive blows, recurring or “second-impact” concussions, and hemorrhaging.
Omalu says too many sport parents trust intuitive-based “return to play” (RTP) guidelines and instruments at real peril of their concussed children. The trauma is lasting, he argues, and often undetectable in popular neuropsychological tests like the computerized ImPACT software.
Conversely, medical voices within the football-business umbrella disagree with Omalu’s side, led by researchers who receive funding from the NFL or Players Association or otherwise gain remuneration from the sport—such as sales of their NP tools to schools and more clients in the surging market of concussion management.
Football-supportive experts acknowledge, however, that a false-negative assessment triggered at least one death in 2010, Nathan Stiles, 17, of Spring Hill High School in Kansas. Stiles suffered a first concussion during an Oct. 1 game and missed two games before allowed to resume football contact. He then suffered both a second concussion and a lethal subdural hematoma during an Oct. 28 game, according to new pathology results.
Some experts and trainers tactfully direct blame onto the teen for faulty assessment of his condition, not NP protocols. They say Stiles failed to properly report lingering symptoms of the original concussion, leading to doctor clearance and parental permission for his premature return to play.
Objective, educated self-reporting by the brain-injured Stiles—an intelligent youth of undisputedly high character—would have been “the most important thing” for preventing his tragedy, Dr. Robert C. Cantu said in a recent phone interview.
An esteemed neurosurgeon and injury researcher, Cantu’s myriad of football associations include his consulting for NFL teams and NCAA member universities while also serving as vice president of the National Operating Committee on Standards for Athletic Equipment, a non-profit group funded by manufacturers like Riddell, producer of skull-preserving helmets currently under scrutiny for claims to reduce brain injury.
Cantu, of the Boston University Medical School, the Center for Study of Traumatic Encephalopathy, and the non-profit Sports Legacy Institute—last year awarded a $1 million research grant by NFL commissioner Roger Goodell—heads one team analyzing cerebral tissue of Stiles.
Cantu says their findings, contrary to previous reports, show the youth suffered both the concussion re-bleed and cerebral hemorrhaging during his last game. “I’ve talked with Mrs. Stiles, Connie Stiles, and she tells me that (son Nathan) was not telling her he had symptoms (of lasting injury),” Cantu said. “I have a very hard time really thinking he was asymptomatic. It takes honesty on the part of the individual, as they’re symptomatic with headache, nausea, on and on and on, to come forward with it. It’s not safe to play with it.”
Cantu concedes, though, “research out there suggests all (healthy) brain functions may not have returned to normal even though somebody has become asymptomatic.” He added: “But those research tools that are being used (magnetic resonance imaging) are not standard tools. They’re research tools. They make us want to study it further, but they don’t give us the answers.”
But concussion management endorsed by Cantu is scant on scientific answers itself. Prominent counter-voices warn of invalidity and unreliability in the clinical practice that’s flown through football nationwide, along with dubious new policy to govern field collisions, driven by states’ rush to enact anti-concussion laws.
Critics Doubt Efficacy of NP testing for concussion diagnosis, ‘return to play’
Today’s general view that concussion management works or can work in tackle football is rendered highly suspect, if not effectively discredited, by independent review and mounting adverse opinion of experts and witnesses like players.
Linebacker Fujita notes he hasn’t been measured on neural baseline for two NFL seasons. Might not matter, anyway, for NP testing has taken a systematic beating by reviewers of late. Observations and findings of medical literature from 2005 to 2010, listed without full author groups or first names, include:
*Randolph et al, 2005, for Journal of Athletic Training: “Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion, no NP tests have met the necessary criteria to support a clinical application at this time. Additional research is necessary to establish the utility of these tests before they can be considered part of a routine standard of care… until NP testing or other methods are proven effective for this purpose.”
*Patel et al, 2005, for Sports Medicine: “Numerous guidelines have been published for grading and return-to-play criteria following concussion; however, none of these have been prospectively validated by research and none are specifically applicable to children and adolescents.”
*Mayers, 2008, for Archives of Neurology: “Current guidelines result from thoughtful consensus recommendations by expert committees but are chiefly based on the resolution of symptoms and the results of neuropsychological testing, if available. Adherence to this paradigm results in most injured athletes resuming competition in 1 to 2 weeks.”
*Duff, 2009, for ASHA Leader: “Indeed, the identification and management of concussion has become a growing public health issue. Considered to be the fastest-growing sub-discipline in neuropsychology, concussion management poses unique challenges and opportunities for those working with school-aged children. … There is no consensus on the best course of action for concussion management. In fact, there are as many as 22 different published guidelines for grading concussion severity and determining return to play. … Developers are working to collect data regarding reliability, validity, and clinical utility of these (NP) tools; independent replication is still forthcoming.”
*Echemendia et al, 2009, for British Journal of Sports Medicine: “Post-injury assessment requires advanced neuropsychological expertise that is best provided by a clinical neuropsychologist. Significant international differences exist with respect to the training and availability of clinical neuropsychologists, which require modification of these views on a country by country basis.”
*Covassin et al, 2009, for Journal of Athletic Training: “…little is known about the use of baseline neurocognitive testing in concussion assessment and management. … We found that the majority of ATs (athetic trainers) are interpreting ImPACT results without attending a neuropsychological testing workshop. … The use of baseline-testing, baseline testing re-administration, and post-concussion protocols among ATs is increasing. However, the ATs in this study reported that they relied more on symptoms than on neurocognitive test scores when making return-to-play decisions.”
*Maerlender et al, 2010, for The Clinical Neuropsychologist: “Although computerized neuropsychological screening is becoming a standard for sports concussion identification and management, convergent validity studies are limited.”
*Piland et al, 2010, for Journal of Athletic Training: “Obtaining (self-reported symptom) statements before a concussion occurs assists in determining when the injury is resolved. However, athletes may present with concussion-related symptoms at baseline. … In other words, some post-concussive symptoms occur in persons who have not sustained concussions, rendering the specificity of alleged post-concussive symptoms suspect.”
*Schatz, 2010, for American Journal of Sports Medicine: “Computer-based assessment programs are commonly used to document baseline cognitive performance for comparison with post-concussion testing. There are currently no guidelines for how often baseline assessments should be updated, and no data documenting the test-retest stability of baseline measures over relevant time periods.”
*Comper et al, 2010, for Brain Injury: “Despite the proliferation of neuropsychological research on sports-related concussion over the past decade, the methodological quality of studies appears to be highly variable, with many lacking proper scientific rigour. Future research in the area needs to be carefully controlled, repeatable and generalizable, which will contribute to developing practical, evidence-based guidelines for concussion management.”
*Eckner et al, 2010, for Current Sports Medicine Reports: “The sports medicine practitioner must not rely on any one tool in managing concussion and must be aware of the strengths and limitations of whichever method is chosen…”
Unfortunately, software packages like ImPACT, long criticized for its direct connections to the NFL, are widely employed as cornerstone for concussion evaluation and typically by untrained clients, as literature and news reports confirm.
A trusting public opinion reigns foremost because of America’s loyalty and lust for football that has killed thousands of players, mostly children, while physically and cognitively disabling millions over some 130 years of the purely tackle game, according to collective documentation in science, history and communication study.
Mainstream media, meanwhile, construct feel-good gridiron mythology. Sport media literally underwrite the happy concussion outlook by privileging and parroting the game’s official claim that brain trauma can be minimized and controlled. Contemporary mainstream media show scant interest for seeking credible counterclaim or opposing information.
Root of it all, grounding the message, is clinical philosophy of a few media-favorite sources—experts sanctioned by the NFL too, not coincidentally—led by neurologists such as Dr. Cantu. They espouse tools like ImPACT but only, they say, for helping diagnose a concussion and, most importantly for legalize, aiding a multi-faceted approach for returning the player to action.
Respected researcher and athletic trainer Kevin Guskiewicz stands firm in the Cantu camp, whose members today align with the NFL and football at-large, preaching that “concussion awareness” and “behavior modification” can save the game in largely present form, tens of thousand programs youth to adult.
“I think we’re headed in the right direction,” said Guskiewicz, PhD and chair of the Department of Exercise and Sport Science at the University of North Carolina. Last year he was appointed to concussion committees for the NFL, NFLPA and NCAA.
In recent past, colleagues Guskiewicz and Cantu criticized the NFL and union for foolishly challenging evidence linking the game to long-term cognitive impairment in retired players. But now Guskiewicz and Cantu are on-board with the NFL, avowing faith in new research, concussion management and rules enforcement while also receiving funding from “The League.”
The Cantu camp believes that lofty change and awareness for head injury can reform pro football and “trickle down” through the sport’s vast outback, thousands of cash-strapped colleges, schools and youth leagues.
But they affirm a daunting problem cited by critics: The education and adherence on part of millions of people, beginning with child athletes, for building the theoretical wall of concussion prevention and treatment within prevailing economic and political forces of inherently brutal football.
Guskiewicz is confident though. “We’ve come a long way in the last five years,” he said during a recent phone interview, speaking of protocols for diagnostic and return-to-play decisions. “We have validated neurocognitive testing, we have validated balance or postural stability testing,” he countered for doubters.
“I think the hardest part has been trying to convince the users (of tools), the clients, meaning all the high schools out there, colleges, even the pro teams,” Guskiewicz continued. “I mean, at NFL level, they’ve only over the last two years mandated (ImPACT or like NP) testing for all their football players. And they’ve put into place and standardized, to some extent, return-to-play protocols and having independent neurologists be part of the evaluation process.”
“I think the science has actually been there. I think it’s just been the ability to convince the end user that we need to remove the guesswork from concussion management and begin to put more objective data on decision-making to return to play.”
Guskiewicz qualified charges of invalidity for protocols as “bullshit” during a tough give-and-take with this skeptical analyst. “I’ve published two or three papers,” he replied, “that show the one week (layoff)—if you have the right tools, and you have the right recovery curves information, and you’re using the right instruments—that on average (athletes) recover within a week to 10 days, and that 75 percent of the repeat concussions within the same season occur within about a 10-day window. So there’s data out there for that.’
Such data fuel ongoing debate that includes polar-opposite interpretations. Even some football researchers who use NP protocols are cautious, associates of Cantu and Guskiewicz such as Dr. Jeffrey Kutcher, neurologist for NCAA teams, director of Michigan Neurosport, and their fellow member on the NFL concussion committee reshaped in past year by Goodell.
“First, concussion is a complicated injury,” Kutcher testified before the House Judiciary Committee on Jan. 4, 2010. “We know from other brain disorders that there is a tremendous amount of variability between individuals. When a mechanical force is applied, we do not expect one brain to react the same as another.”
“Computerized neurocognitive testing is used as an extension of our physical examination, rather than a decision tool unto itself. With little published clinical data to help make (RTP) decisions, there is very little that we can point to and say this is when it’s safe to go back.”
“Relying on (clinical) protocols is, in my opinion, potentially dangerous,” Kutcher said, “as they assume that conclusions are similar enough to each other to fit a predetermined paradigm.”
Other concussion experts rip NP testing, further removed themselves from American football or entirely independent.
Dr. Omalu is certainly labeled an outsider by NFL powerbrokers, whom he’s battled since finding evidence of toxic brain proteins, chronic traumatic encephalopathy or “CTE,” during his landmark 2002 autopsy of Hall of Fame lineman Mike Webster. Omalu bluntly calls computerized NP assessment a “scientific fraud” for promoted or implied reliability.
Omalu, of his legal expertise, extensive courtroom experience, along with having examined thousands of brains, many damaged, says one researcher-marketer claimed his software had determined a concussed teen could safely return to play. Omalu objected: “I challenged him, ‘How can you say a patient is cured because he passed (your test)? Based on what?’ ”
“He became very defensive and started attacking me. I just told him, ‘Just to avoid medical-legal issues, somebody suing you, don’t make such statements.’ ”
Controversy dogs research and experts funded within the football umbrella
Allegations of shoddy research and unethical experts have followed football since the 1990s, when the NFL began in-house studies of brain injury and possible treatments, particularly for returning concussed players to action.
Debate thrives still, hotter than ever, angry and insulting, inflaming the entwined circles of football experts, the fully independent experts, and those straddling middle with a foot in each side. Most everyone but the bona fide independents receives or is connected to football funding, like a fresh $1 million the NFL spread among researchers and institutions a month ago.
Today’s science or scientific attempts surrounding brain trauma in megalith American football cover the scale of strong, flimsy and invalid. But the muddling mess is more about everyone’s necessity than someone’s conspiracy, about the reality of a modern society talking lofty ideals, ethics, while functioning primarily on economics, politics.
So-called validating research of anything anymore is subject to bias, spin, lying—for gaining precious opinion leverage geared for the money. Many individuals feel caught around Big Football, good people and bad, closed in by one door or another. In fact, only about half the experts of all types queried for this analysis would respond; fewer commented on record.
Scientific controversy reaches beyond tackle football in sport entertainment, including to the WWE, and author-blogger Irvin Muchnick observes: “The concussion story is more than the sum of the blocking and tackling by dueling experts. It is also the story of a process: the ecosystem of clinical research, an interdependent web of leading doctors, research journals, and commercial interests.”
As concussion storm overtook football and particularly the NFL in the 2000s, for convincing pathological evidence led by Omalu findings, journalists began to examine validity of research that encompasses concussion management. One writer was Peter Keating, of ESPN The Magazine and network show Outside The Lines, who produced reports such as investigative content based on insider accusations of misconduct by NFL officials and associates.
Keating encountered several provocative figures, and quite intriguing were a pair of neuropsychologists in Pittsburgh, co-entrepreneurs who worked in sports: Mark R. Lovell and Michael W. “Micky” Collins. Lovell was then the NFL’s director of neuropsychological testing, having worked with the Steelers for a decade on diagnosing head injuries and returning players to game action.
Lovell and Collins, researchers with PhDs, were lightning rods for allegations even from prudent professionals in science, medicine and athletic training. Their business venture along with third partner Dr. Joseph Maroon, Steelers neurosurgeon and NFL concussion committeeman, was ImPACT computerized NP testing—their prize product and magnet for criticism.
Today ImPACT is used by a reported 1,000 high schools, 300 colleges and 250 sports-med facilities, which typically promote the online tool for handling young athletes amid concussion crisis. A client pays $500 to $700 annually and training of novice personnel costs extra, for small workshops held in Pittsburgh.
In August 2007, Keating and The Magazine published a report taking ImPACT business to task, particularly Lovell in his capacity: “The National Football League’s director of neuropsychological testing is also the chairman of a company that sells testing software to NFL teams, a dual role which raises conflicts of interest.”
Keating continued: “Lovell’s overlapping roles (in multiple sports) and financial interest in ImPACT have drawn criticism from several doctors and athletic trainers working in the field of sport concussion. Their ire has intensified as Lovell sometimes has not identified himself as one of ImPACT’s developers in his scientific research. … ‘It is a major conflict of interest, scientifically irresponsible,’ says Christopher Randolph, professor of neurology at Loyola University Medical Center in Chicago and former team neuropsychologist for the Chicago Bears. ‘We are trying to get to what the real risks are of sports-related concussion, and you have to wonder why they are promoting testing. Do they have an agenda to sell more ImPACTs? And if you’re writing a paper and you have anything to do with a company involved, it’s imperative that you disclose it.’ ”
Keating noted “almost all of the research supporting ImPACT has been written or co-written by its inventors. For example, Lovell and Collins are co-authors of all 19 of the publications listed in the ‘Reliablity and Validity’ section on the ImPACT Web site.”
Nothing has changed on the ImPACT site, apparently still displaying the page Keating examined in 2007, the same articles by Lovell, Collins et al vouching for the application’s worth in sport. The latest articles still date at 2006.
Lovell, Collins and Susan Manko, PR director for University of Pittsburgh Medical Center, employer of the research duo, did not respond to questions recently forwarded each by email.
Guskiewicz vouches for Lovell and Collins although he doesn’t use their software, as a staunch proponent himself of concussion management in football. “Yeah, ImPACT (marketers do) publish—they are the authors on some of the papers, so it looks like industry-funded research,” Guskiewicz said. “They’ve been criticized about that, but I think over the past five or six years, there’s been bit of a change there, in terms of other people publishing, you know, using that instrumentation.”
“I just had a conversation with my own doctoral students, saying that we gotta start looking, unfortunately, to industry,” Guskiewicz said of UNC research funded by the NFL. “They’re the ones who have the money right now. But if you sign a good contract with them and have your attorney looking at that contract closely, you make sure you don’t get yourself into a situation where you’re allowing them to have too much control over the data collection and where ultimately it’s published.”
Questions of competing values in concussion management is focus of researcher L. Syd M. Johnson, postdoctoral fellow in neuroethics at Dalhousie University, Nova Scotia, where she examines the practice in youth sport. “The research has shown pretty conclusively that repetitive head trauma is a risk factor for serious cognitive impairment in athletes and ex-athletes,” Johnson stated in email. “Now we are entering the next phase of the problem, which is figuring out what to do about it, and where the conflicts of interest might arise.”
“I’m not saying that doctors or researchers are acting unethically. But this is an area where such conflicts could potentially arise, and so vigilance is required, as well as attention to issues of research and medical ethics.”
Epidemiologist Charles E. Yesalis works outside concussion management in football, but the independent scientist sees analogy in his expertise of drug use by athletes, specifically the in-house setup of research for ineffective anti-doping—or “prevention” testing in that issue. “That’s something that’s really kept me in the drug research, because the politics are so interesting, to see how (the issue) plays out in the cultural aspects and so forth,” Yesalis said in a phone interview.
And head injury is bigger than doping, Yesalis says, with higher stakes for tackle football because smoking-gun evidence links long-term problems of former players. In response, the NFL and all of football must claim remedy is possible—or concede nothing can be done.
“The intricate part of the culture of the game, violence, isn’t going away anytime soon,” Yesalis said. “It’s very obvious why the NFL is concerned about this. I think that’s why they’re dumping money on this, and this academic show. … This is going to eclipse the drug problem, and it probably already has.”
Like anti-doping in sport, invalid and woefully funded, Yesalis believes some experts are in too-deep with American football, ethically and legally, for their promising to police head injury with tools lacking proper vetting. Funding is paltry, regardless of a few million thrown around by billion-dollar profiteers.
Neuropsychological tests both written and computerized are good in theory but far from proven for sound specificity and sensitivity, only possible through peer review and replication in the realm of long-term, random clinical trial.
“In medicine, that’s your gold standard, random clinical trial,” Yesalis said. “The proof in the pudding would be, at one year later, two years later, or three years down the road, ten years down the road: What is the neurological health status of the patient?”
“I’m not dismissing clinical intuition (for NP testing), some of these neurologists. But any of those men or women who are scientists will admit that is a huge distance from a random clinical trial.”
“Let’s put it this way: Some of the best physicians in the United States and worldwide at one time believed in bleeding people, and making people vomit for treatments. They really believed in these methods, that was their clinical intuition at the time… And, um, that’s why we have clinical trials.”
Evidence, expert opinion prescribe longer rest for every concussed athlete, any age
Dr. Omalu also has brain slides of Nathan Stiles, for microscopic cellular analysis by his team of the Brain Injury Research Institute at West Virginia University, which does not receive funding from the NFL or union.
Omalu declined comment on the Stiles case, but he suggests the recent football tragedy was preventable had anyone listened to him and others before. His conservative proposal of lengthy rest for every concussed juvenile athlete is truly representative of the cry currently distorted by football supporters, “When in doubt, sit ’em out,” as if mere days or few weeks were something above minimally ethical precaution.
Omalu explains, repeating, why longer minimum recovery for any head injury must be readily accepted and practiced universally by American football. And politicians currently riding popular bandwagon should look to Omalu’s stance, for mandating real law over toothless state drafts they file presently—thanks especially to Big Football’s opinion-shaping tentacles infesting thought and influence of every major institution in this society.
Omalu stresses there exists no exceptionally tough brain for the human species by any specimen, from giant football player down to tiny infant.
Omalu challenges anyone to argue otherwise. An avowed Christian and passionate scientist, boasting numerous medical certifications and academic degrees crossing disciplines, Omalu stands his ground convincingly. The human brain became his lifelong study, fascinating him, the most delicate and mysterious life organ, while his path has been earnest, leading him to forge milestone history of sport medicine—and incur wrath of Big Football and Associates.
“I know how I discovered (CTE) in Mike Webster. I wasn’t in search of any fame, or any recognition. I was just a young man who was intrigued by brain trauma,” he recalled. “I realized we didn’t know so much about a brain. So I was just doing my bit to understand. I thought the brain was a very sexy organ, honestly. I thought the brain was beautiful. I thought the brain was more beautiful than the best-looking woman on earth.”
“So because of that enthusiasm, and the excitement, I stumbled across something which I recognized… and God gave me the courage to present it to the world. It was something good.”
Omalu, a soccer player in his Nigerian youth, does not cop tickets from anybody in American football. He does not attend Super Bowls, wouldn’t even on comp, and won’t be in the grandstand at local schools. Doesn’t want to. He cannot watch the nationalistic sport for the evident, genetic carnage among smallest children and largest men.
He is astounded the culture comprehends bone injury for a colliding football player while typically disregarding cerebral trauma as though unseen, benign.
“Because of short-term adrenaline rush, OK?” Omalu declared in zeal that American writers often label as bitterness; typically they misunderstand, non-comprehend, for their ethnocentrism peculiar to football denial. “Almost a masochistic attitude,” Omalu hissed.
“You want to excite people! Almost reminds of the old, ancient Roman gladiatorial sport. You want people to yell and scream! Just for the season. Just for the moment! Meanwhile, you are sacrificing the life of an individual.”
Narrowing to medical analysis, making a base comparison easy for Football America, Omalu discusses and teaches the volatility of head trauma capable of combusting into lasting damage.
“The brain is a post-mitotic organ. It means the brain cells do not have the ability to divide and create new cells. … A very good example I always give people: When you suffer a stroke, your stroke cannot be cured (at cellular level). Once you’ve suffered a stroke, it is permanent. Even if you die 50 years later and we examine your brain, we see the stroke. It creates a space in your brain.”
“Same applies to concussions. A concussion is simply fracture. You know how you break your bone? That is what a concussion is, but now it is on the cellular level. A concussion is a fracture of the skeleton of the brain cells. If you fracture your bone, the NFL will keep you out of play for the entire season. They say it is a season-ending injury. But the bone has the ability to divide, and create new bone, and heal. A fracture can become healed, OK?”
“But—a fracture of the brain, which is a concussion, does not have the ability to heal as well as the bone. The bone is more resilient, but somebody fractures his bone you keep him out of play for three months. But if somebody fractures his brain? You keep him out of play for only two weeks? Does that make sense even if you’re not a doctor?”
Does for Dr. Cantu in many cases. He says he’s secure in knowing most concussed players return to football rapidly, and he does not endorse mandated lengthy rest in every case regardless of severity. “We don’t have the evidence to say that should be the case for all players, no. Those who clear very, very quickly—symptoms are over in less than an hour, or less than a day—I think can safely go back a week after they’re asymptomatic.”
“But it’s true: There are a lot of questions still to answer,” Cantu added. “There are real issues with regard to taking on this trauma quite young in life. But I don’t think we quite know enough about what the risks are.”
Guskiewicz dismisses Omalu regarding longer rest. “I heard him say that. I was in a meeting when he proposed that, and to be honest with you, there’s no science behind that three-month thing. It could be six months, it could be one month (for some cases),” Guskiewicz said.
Others disagree, seeing scientific grounding for the general proposal of longer rest, based on evidence and opinion of works including by Guskiewicz, a 2003 study on NCAA football players he co-authored with at least one colleague who has expressed differing interpretation of outcomes.
Some supporters of longer rest note decades of autopsy results on boxers, like amateurs who died of brain bleeds and with scarring apparent. But all found argument on a 1994 study published by The Lancet that found trauma lasting up to 99 days following head injury in patients who were asymptomatic at their deaths of other causes.
In addition, proponents are excited and rather convinced about diffusion tensor imaging, research developments at Purdue and Wayne State universities involving this functional MRI for detecting lasting trauma in victims observably symptom-free. Concussion is only one focus of these experts, who likewise examine the progressive injury of recurring blows that worsen without symptoms.
Even a Cantu team member once entertained the idea of longer rest for concussed athletes, before recently partnering-up with the NFL. Boston neuropath Dr. Ann McKee is Cantu’s research partner in charge of autopsy at the Sports Legacy Institute and the Center for Study of Traumatic Encephalopathy. Like Omalu of the competing BIRI, she’s the one producing findings of destruction in brain tissue of deceased football players.
McKee suggested in late November 2009 she might support longer sidelining of all brain-injured football players. “My thinking is that you really need to rest that nerve cell, and those nerve cells are very jarred by the experience,” she told Ray Suarez of PBS NewsHour. “They have all sorts of microscopic and metabolic changes that actually go on for weeks after that injury. So, you have a concussion one day, and, six weeks out, your nerve cell is still slightly unsettled. It’s not really back to its resting state. And if you are injured a second time while you are already in this sort of limbo state, the consequences are much greater.”
But barely one year later, last month, McKee was quoted about Packers quarterback Aaron Rodgers. The emerging NFL star had just suffered his second concussion in as many months, and some experts wondered whether he should sit longer than when declared asymptomatic through NP testing.
“We don’t know the answer to that,” McKee told Wisconsin Outdoor Fun magazine. “Generally, if he’s cleared from his concussion he should be able to play.” Rodgers returned to football after a 10-day layoff and has since led Green Bay to the Super Bowl, absorbing headshots along the way. (On Feb. 6 when the Packers face the Steelers, Rodgers will encounter All-Pro linebacker James Harrison, branded villain of vicious hits by league officials and many media.)
McKee declined a recent question forwarded by this analyst, seeking clarification of her stance regarding longer rest. “I am overwhelmed with requests,” McKee emailed in reply on Dec. 20, ignoring the offer to answer at her convenience by email or phone.
Based on her published quotes about Rodgers’ fast comeback from concussion No.2, McKee steps now with Cantu philosophy that every concussion case is different for individual variables and thus no single guideline fits all.
The same Wisconsin story contained rebuttal by neurologist and imaging expert Dr. Randall R. Benson, who argued the uncertainties of individuality in head injury constitute exactly the reason for longer recovery in every football case, a genuine medical precaution.
“There is a vulnerable period, and that vulnerable period does not go away within a couple of days,” said Benson, of Wayne State University School of Medicine, who was frightened at prospect of what became rapid return for the twice-concussed Rodgers. “That vulnerable period is there for weeks and sometimes months, at least a couple months, depending on the severity of the original incident.” Benson argued that diffusion tensor imaging of Rodgers’ condition might have shown the quarterback needed layoff for months.
A further question of safe recovery for head injury concerns whether a standard of complete isolation first—several days to weeks devoid of external stimulation, spent largely in sleep—should apply to a diagnosed concussed athlete.
Athletes of any age typically begin NP testing within about 48 hours post-concussion, pushed by urgency of returning to play if possible. Some experts question the practice as potentially harmful while Omalu outright condemns it, convinced lasting cellular harm occurs in some cases at least. Written and computerized assessments are neurologically stressful, any expert agrees.
For example, the patented software Immediate Post-Concussion Assessment and Cognitive Testing, headlined as “Valid. Reliable. Safe.” on its Web-site homepage, challenges the brain as designed. The online test is eight parts, requiring 20-30 minutes, and “the athlete is asked to remember words, shapes, letters and colors and must do so against a backdrop of intentional distraction,” wrote columnist John Doherty, certified athletic trainer and licensed physical therapist.
Acute head injury has no need of that, Omalu argues, especially for mere sport. “The brain is an electrical organ, just like the heart,” he said. “And the basic fundamental currency of brain function is what we call AP, for action potential. And AP is simply an electrical current generated across the membrane of the brain cell. OK?”
“What generates that electrical current is the movement of ions, sodium and potassium, and sometimes chloride. Sodium, potassium, chloride ions cross the membrane, and in order to do that, they move through channels in the cell membrane. Am I making sense? All brain function goes through this basic mechanism. All brain function, everything that defines you as a human being, goes through this basic mechanism I have explained.”
“Now, when you suffer the concussion—concussion disrupts the membranes of the brain cells, as the skeleton of the brain cells. It disrupts these channels! So what happens is trauma. What you do is remove the person from all types of stimulation.”
Omalu expresses incredulity for sport officials’ insistence on neuropsychological assessments during acute phase of injury. “Doctors who are out there, who are not associated with the NFL, will tell you that if somebody suffers a concussion and you subject him to the testing, it makes symptoms worse,” he said.
Many general practitioners agree at least in principle, based on media reports of concussed juvenile athletes sidelined months and longer by doctors, including a Texas boy being withheld from football for two years. Expert references also support Omalu’s concern about NP testing in sport, with the practice dating to NFL of the early 1990s at Pittsburgh, the work of Lovell and Maroon with the Steelers.
In December 2004, neuropsychologist William B. Barr of New York, then a consultant for the Jets and a co-author of Guskiewicz and Cantu, spoke during a conference at Madison Square Garden, discussing their recent study involving 3,000 college players. “Barr talked about some of the findings from that NCAA study,” Keating later reported. “He said the research indicated that the best time to do neuropsychological tests on players with concussions was after their symptoms had completely cleared, usually five to 10 days after the trauma.”
Barr did not respond to a recent request for comment.
In 2008, Dr. Lester Mayers addressed isolation and lengthy rest in his review of return-to-play criteria for Archives of Neurology, subtitled “A Need for Revision.” Mayers, director of sports medicine at Pace University, wrote, “During recovery in the first few days after concussion, it is important to emphasize to the athlete that physical and cognitive rest are required. Activities that require concentration and attention may exacerbate symptoms and delay recovery.”
Mayers found credible research indicated “that safe RTP might require at least 4 to 6 weeks to facilitate more complete recovery and to protect from reinjury, reported by Guskiewicz et al (including Barr and Cantu) to occur much more frequently in the immediate period after a concussion. Consequently, for athletes competing in many sports, concussion would be a season-ending injury.”
“This idea is a significant departure from current practice and will probably provoke concern and resistance at all levels of sport,” Mayers concluded. “Nevertheless, given the prevalence of sports head injury and the numbers of young brains at risk, a post-concussion RTP interval of at least 4 weeks is imperative. Future studies that use longer follow-up periods may conclude that even this time requires extension to permit complete healing."
Real football experts sound off: NFL players debunk 'behavior modification'
Browns linebacker Scott Fujita is a doctor of football collision, expert of highest degree, and he concludes theory of behavior modification to eliminate helmet contact is scientific mumbo-jumbo, or the null hypothesis.
"I don't think anybody wants to appear irresponsible, but when it comes down to it, you know, that's just the reality of this business," Fujita said this week. "The helmet-to-helmet stuff, that's gonna happen. The facemask stuff, that's gonna happen. That's just part of the game, and all of us (players), we do understand the inherent risks of playing football. That's a given."
"As far as the physics are concerned and the technique changes they want to see in players, to me what they're asking is impossible."
Researchers for the NFL say risk of brain trauma in football can be reduced and controlled if players, coaches and others cooperate.
"I firmly believe that we can prevent these injuries," said Guskiewicz at UNC, "as well as the long-term consequences of head impact with behavior modification, and changing the way in which these players attempt to tackle. We'll get to concussion prevention sooner by focusing on behavior modification, which will involve everybody: coaches, parents, players, athletic trainers, trained coaches at every level."
"I think that we need better coaching clinics," Guskiewicz continued. "We need coaches to be held more accountable. Again, it's a trickle-down effect. At the NFL level, you shouldn't have to teach technique. The fines have been levied this year and we've seen a difference already. So I'm convinced it's a trickle-down effect. If we can show it can be done at (NFL) level, then we sure as heck can begin to get college and high-school coaches to begin focusing on it."
Focusing on what, however, remains unclear for players and coaches of any level, according to Fujita and many others. Following the Oct. 17 game of his Browns versus the Steelers, which resulted in $75,000 in fines for Pittsburgh linebacker James Harrison, no one was sure about anything. Fujita said a clarification attempt by the league office was no help.
"They sent around a DVD for all the clubs to watch," Fujita recalled. "And we sat in the team meeting room to watch this video. It was supposed to be kind of what was a fair hit and what was an illegal hit. And we watched that video, players and coaches alike, and we walked out of that room more confused then when we were going in."
"To me, that kind of tells the story, about where this thing's at and how there's so much gray area. The messages are so mixed right now."
Dr. Cantu tries to simplify, calling for enforcement of existing football mandate against "butting" with the head or facemask, a rule since 1976. "I think the rules ought to be changed both with regard to practices and the amount of hitting, and with regard to (referees') calling the rules correctly," Cantu said. "The helmet is not to be the initial point of contact in blocking or tackling, and the rule is on the high-school and college rulebooks. It's almost never called."
Because the rule is faulty, unenforceable for the dictating physics of tackle football that channel helmet clashes, say critics like retired NFL tight end Nate Jackson, backed by referees for schools and colleges who requested anonymity for this story.
"When you are in an athletic position, and you're trying to move somebody, you're leaning forward, your knees are bent, and your head is the tip of the spear," said Jackson, a budding writer, during a phone interview this week. "There's no way to be running forward, moving forward, and to be powerful without using your head. That's how you're taught to hit, and if you don't do it that way, then you get trampled by everyone who does it that way. So you learn."
"I had to block guys who were 50 pounds heavier than me, and the only possible way was to shoot off out of a cannon, head-first, and hit 'em in the face with my face. I mean, that was my goal on every play. There was no way to avoid that. I knew that was the only way I was going to get the job done."
"I saw stars all the time," continued Jackson, who retired in 2008 after seven years in the NFL. "I saw stars when I would knock myself silly, but it was either that or getting made to look like a fool on film. And then get called out in meetings. And then, just cut from the team. I knew that was worse for me than seeing stars, and so I led with my head."
Fujita said, "You talk about the physics, and that's one of the things we (players) talk about all the time, is trajectory angles and going full-speed, and (now) how you're supposed to change your point of contact trying to hit a moving target who's comin' up, comin' down, sticking his foot in the ground and moving."
Football contact finalizes instantly, physically and cognitively, among parties powerful and athletic seeking leverage.
"There are so many moving parts in this game, that what they're asking... is impossible," Fujita repeated, wondering if "safer" contact is just another smearing of lipstick on football brutality, or the time-honored PR tact of officials who seek to absolve the system of blame and affix it solely on individuals.
"What do they want us (players) to do about it?" Fujita posed of irremovable violence. "I don't know. If you take that part of it away, there's no longer contact football, which America loves. And that's just the reality of it."
"Whether that means football is going to be doomed in the future? Perhaps. That could be the reality we all face, not in the too far future."
Matt Chaney is a journalist, editor, publisher and teacher living in Missouri, USA. Email him at email@example.com. For more information, including about his 2009 book, Spiral of Denial: Muscle Doping in American Football, visit the homepage at www.fourwallspublishing.com.
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