Timed with the Super Bowl, the consumer press has been doing extension coverage of the issue of concussions, brain injury, football and the NFL. For someone who has been doing almost nothing but represent those with brain injury for over 15 years that is welcome news, even if it does come with the risk that all of the focus is on what are usually the least severe of brain injuries.
The recent stories prompted Dr. Johnny Benjamin an orthopedic spine surgeon, to write a blog about it on the Huffington Post. http://www.huffingtonpost.com/johnny-benjamin/player-safety-in-the-nfl_b_454703.html
In his piece, “Whose Responsibility Was Player Safety in the NFL?,” Benjamin notes that Time magazine did a cover story on the topic, and that even The New Yorker has tackled it. Even Business Week recently chimed in on concussion awareness.
http://www.businessweek.com/lifestyle/content/healthday/635745.html
“Knowledgeable observers should be concerned that the medical director of the player’s union, the NFLPA, did not do enough to adequately protect his client/patients, the players,” Benjamin writes. “Virtually all meaningful advancement, dialogue and pressure that were exerted were provided by interested individuals, physician, researchers and journalists outside of the NFLPA’s medical director’s office.”
The Associated Press has been avidly writing about the concussion/sports issue. It did a story on the Zackery Lystedt Brain Project’s quest to have all 50 states pass law s setting safety guidelines for athletes who suffer head injuries.
http://www.latimes.com/sports/football/nfl/wire/sns-ap-fbh-high-school-concussions,0,7027744.story
The brain project is named in honor of a teenager who sustained brain injury when he went back to in a football after having a concussion in 2006. The advocacy group is lobbying for state laws similar to legislation on Washington state that mandates that athletes under 18 who are suspected of having a concussion must get written permission from a doctor before returning to play.
The AP also wrote a pre-Super Bowl story where it asked players on the Indianapolis Colts and the New Orleans Saints teams how many concussions they have sustained. http://www.latimes.com/sports/football/nfl/wire/sns-ap-fbn-super-bowl-concussions,0,156838.story
Saints defensive lineman Anthony Hargrove reportedly is the Saints player who has had the most concussions on his team, but he can’t remember exactly how many he has had, according to AP.
The kicker, a quote from retired NFL player Rod Woodson, is great on that AP story.
“Players are starting to realize how important it is to take care of your brain,” he said. “You only get one of them.”
A Dozen NFL Players Agree To Donate Their Brains For Concussion Research
More than a dozen present and former NFL players have pledged to donate their brains for research on concussion, the Associated Press reported Monday. http://www.latimes.com/sports/football/nfl/wire/sns-ap-fbn-nfl-concussions-players-brains,0,1348935.story
The players, who include Hall of Fame member Mike Haynes and Chicago linebacker Hunter Hillenmeyer, will donate their brains and spinal cord tissue after their deaths to the Center for the Study of Traumatic Encephalopathy at the Boston University School of Medicine.
Boston University researchers claim they have found ties between repeated head trauma and brain damage among football players, a former NHL player and boxers, according to AP. The researchers have criticized the NFL about its allegedly lenient approach to concussions.
Among those who have committed to donate their brains to the research project are: Sean Morey of the Arizona Cardinals; Matt Birk of the Baltimore Ravens; and Lofa Tatupa of the Seattle Seahawks. In addition, the wife of Hall of Fame member John Mackey, who has dementia, has agreed to donate his brain to the research project, AP reported.
In response to the issues raised by the Boston University researchers, and following a congressional hearing on pro football and concussions, the NFL has instituted tougher rules in terms of letting players take the field after getting hit in the head.
This is such an important thing, even though it will take generations to make an impact. The only real way to determine the full extent of brain damage is through autopsy, because the neurons and other brain cells which get damaged, are too small to see except under a microscope.
The players, who include Hall of Fame member Mike Haynes and Chicago linebacker Hunter Hillenmeyer, will donate their brains and spinal cord tissue after their deaths to the Center for the Study of Traumatic Encephalopathy at the Boston University School of Medicine.
Boston University researchers claim they have found ties between repeated head trauma and brain damage among football players, a former NHL player and boxers, according to AP. The researchers have criticized the NFL about its allegedly lenient approach to concussions.
Among those who have committed to donate their brains to the research project are: Sean Morey of the Arizona Cardinals; Matt Birk of the Baltimore Ravens; and Lofa Tatupa of the Seattle Seahawks. In addition, the wife of Hall of Fame member John Mackey, who has dementia, has agreed to donate his brain to the research project, AP reported.
In response to the issues raised by the Boston University researchers, and following a congressional hearing on pro football and concussions, the NFL has instituted tougher rules in terms of letting players take the field after getting hit in the head.
This is such an important thing, even though it will take generations to make an impact. The only real way to determine the full extent of brain damage is through autopsy, because the neurons and other brain cells which get damaged, are too small to see except under a microscope.
NFL Players Brain Injury Committee Holds First Meeting
The committee formed by the NFL Player’s Association to tackle, so to speak, the issue of brain injuries and professional football has its first meeting this week in Palm Beach, Fla. http://www.google.com/hostednews/canadianpress/article/ALeqM5hN5mqFoFXXSvkaDO9Nec2JaZ1GKQ
The Mackey-White Traumatic Brain Injury Committee was named after two Hall of Fame players: John Mackey, who has Alzheimer’s disease, and Reggie White, who passed away at the young age of 43 after retiring from the NFL. See http://news.bostonherald.com/sports/football/other_nfl/view/20100127nfl_establishes_brain_trust/srvc=home&position;=recent
The special committee is made up of past and current NFL players, researchers and physicians. They want to start a discussion on brain trauma and professional football, evaluate the latest research and begin work on recommendations for player safety.
The issue of the dangers of players, NFL and high school, going back on the field after sustaining concussions a hot topic in the past few months, receiving a lot of press. Congress recently conducted hearings on head injuries, taking testimony from players, doctors and NFL commissioner Roger Goodell.
The Mackey-White committee is being chaired by Arizona Cardinals wide receiver Sean Morey and Dr. Thom Mayer, medical director for the NFL union.
Chris Nowinski, an ex-college football player and pro wrestler, is a member of the committee. Nowinski, who has had at least a half dozen concussions, has taken on less dangerous work now. He is president of the Sports Legacy Institute and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University.
The Mackey-White Traumatic Brain Injury Committee was named after two Hall of Fame players: John Mackey, who has Alzheimer’s disease, and Reggie White, who passed away at the young age of 43 after retiring from the NFL. See http://news.bostonherald.com/sports/football/other_nfl/view/20100127nfl_establishes_brain_trust/srvc=home&position;=recent
The special committee is made up of past and current NFL players, researchers and physicians. They want to start a discussion on brain trauma and professional football, evaluate the latest research and begin work on recommendations for player safety.
The issue of the dangers of players, NFL and high school, going back on the field after sustaining concussions a hot topic in the past few months, receiving a lot of press. Congress recently conducted hearings on head injuries, taking testimony from players, doctors and NFL commissioner Roger Goodell.
The Mackey-White committee is being chaired by Arizona Cardinals wide receiver Sean Morey and Dr. Thom Mayer, medical director for the NFL union.
Chris Nowinski, an ex-college football player and pro wrestler, is a member of the committee. Nowinski, who has had at least a half dozen concussions, has taken on less dangerous work now. He is president of the Sports Legacy Institute and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University.
NFL Football Concussions Versus Real World Brain Injuries
I am always pleased when the news cycle shifts to concussion and brain injury because that raises public awareness that concussion means brain injury and that brain injuries can cause permanent brain damage. Thus, the NFL being grilled by Congress as to the safety of its players is a very good thing. Likewise, the greatly increased awareness of brain injury coming out of all the publicity that the Iraq and Afghanistan wars brain injuries is also increasing public awareness. But I always worry that people will think that because athletes recover from concussions so quickly, that accidental concussion does not have the potential to permanently injure someone.
The bigger problem in the legal arena is that there is some very bad research being published now that would directly correlate a young athlete’s recovery from a concussion to real world brain injuries. (I apologize to those who see the obvious that sports is also part of the real world, but I find the phrase works to distinguish better than the use of other terms, such as civilian, because of course athletes are civilians, too.)
So, before we spend the next several blogs commenting on the NFL Congressional hearings, I think it is important to discuss what makes accidental (real world) concussions potentially more serious than sports injuries. Here is a partial list.
Sport Concussion a Young Person Injury. First, sport concussions typically happen to those with the greatest chance of a good recovery from concussion, young and athletic people. If we were going to list the three or four most common risk factors for a bad result from concussion, age would be at the top of that list. The reason for this is multiple but includes the fact that younger brains have a gene that stimulates neuronal regrowth that just does not exist when a person is over 40. The closer someone is to 40 at the time of the concussion, the more likely they will have persisting deficits from the brain injury.
Men Are at Less Risk. Most sport concussions happen to men and men are at less risk of poor outcomes from brain injury. This may be seem politically incorrect to say, but women are just simply more vulnerable, not just because they are not as strong, but also because concussive type forces are more likely to damage the white matter of the brain and women are more white matter dependant in there thinking. Complicated topic for another blog.
The Blow is Expected. Sport concussions happen to people who most times are prepared to get hit. The sport concussions that are the most serious are usually to someone who is surprised or motionless at the time of the blow. In contrast, almost all accidental concussions are a surprise. When the body knows it is going to get hit, it protects itself, considerably reducing the extent of and the arc of the acceleration/deceleration.
Athletes are Stronger. Sport concussions happen to people whose bodies have stronger muscles, which also significantly reduces the speed and the length of the acceleration/deceleration arc. When I speak about arc, I am speaking about how far forward, backwards or sideways the head will move on the neck, after being hit. It is this motion that accounts for most of the force on the brain’s axons.
There are about another half of dozen things I could add to this list, but the point of this blog is to remember when you hear about permanent brain damage to professional athletes, there is a far higher risk of that occurring to a 40 year old person who is in a motor vehicle wreck.
The bigger problem in the legal arena is that there is some very bad research being published now that would directly correlate a young athlete’s recovery from a concussion to real world brain injuries. (I apologize to those who see the obvious that sports is also part of the real world, but I find the phrase works to distinguish better than the use of other terms, such as civilian, because of course athletes are civilians, too.)
So, before we spend the next several blogs commenting on the NFL Congressional hearings, I think it is important to discuss what makes accidental (real world) concussions potentially more serious than sports injuries. Here is a partial list.
Sport Concussion a Young Person Injury. First, sport concussions typically happen to those with the greatest chance of a good recovery from concussion, young and athletic people. If we were going to list the three or four most common risk factors for a bad result from concussion, age would be at the top of that list. The reason for this is multiple but includes the fact that younger brains have a gene that stimulates neuronal regrowth that just does not exist when a person is over 40. The closer someone is to 40 at the time of the concussion, the more likely they will have persisting deficits from the brain injury.
Men Are at Less Risk. Most sport concussions happen to men and men are at less risk of poor outcomes from brain injury. This may be seem politically incorrect to say, but women are just simply more vulnerable, not just because they are not as strong, but also because concussive type forces are more likely to damage the white matter of the brain and women are more white matter dependant in there thinking. Complicated topic for another blog.
The Blow is Expected. Sport concussions happen to people who most times are prepared to get hit. The sport concussions that are the most serious are usually to someone who is surprised or motionless at the time of the blow. In contrast, almost all accidental concussions are a surprise. When the body knows it is going to get hit, it protects itself, considerably reducing the extent of and the arc of the acceleration/deceleration.
Athletes are Stronger. Sport concussions happen to people whose bodies have stronger muscles, which also significantly reduces the speed and the length of the acceleration/deceleration arc. When I speak about arc, I am speaking about how far forward, backwards or sideways the head will move on the neck, after being hit. It is this motion that accounts for most of the force on the brain’s axons.
There are about another half of dozen things I could add to this list, but the point of this blog is to remember when you hear about permanent brain damage to professional athletes, there is a far higher risk of that occurring to a 40 year old person who is in a motor vehicle wreck.
Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances
I began my treatment of the Congressional hearings on the long term brain damage of concussion in the NFL yesterday at my Brain Injury Lawyer Blog – http://www.waiting.com/blog/2010/01/nfl-concussion-hearings-in-congress.html I will continue that discussion on this blog for the next several blogs, as I tackled an even more important topic at http://waiting.com/blog that of why an experienced brain injury attorney is even more important in a severe brain injury case than it is in a non-coma brain injury case.
Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:
1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.
2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.
3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.
4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.
5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.
6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.
In our next blog more about advances in MRI and neuroimaging.
Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:
I would like to share with you some observations from eight years of evaluating traumatic brain injury cases, the vast majority of which I obtain neuropsychological testing and advanced MRimaging:That was a hell of an introductory statement from Dr. Benson. He seemed to capture the challenge in representing the survivors of brain injury in those seven bullet points. He goes on to detail the excitement of using state of the art MRI techniques to diagnosing mild traumatic brain injury, which I will discuss in future blogs. But today, I want to focus on the first six bullet points.
- 1) People with TBI are frequently misdiagnosed, often by multiple physicians;
- 2) The most frequent diagnostic category given is psychiatric—anxiety, depression, conversiondisorder;
- 3) Two neuropsychologists studying the same patient may differ considerably regarding existence of TBI;
- 4) TBI symptoms overlap considerably with those of “primary” psychiatric disorders;
- 5) Without the ability to “see” the brain injury with imaging, there is no completely objective way to determine what is TBI and what is something else, e.g., posttraumatic stress, conversion, malingering;
- 6) People with brain injury seem to vary considerably in severity of symptoms and recovery in the face of similar falls, crashes, etc. This may speak to population differences in resistance to injury or effectiveness of neural recovery mechanisms and is in agreement with Collins, et al. who found large differences in recovery from single concussion (North American Brain Injury Society Annual Meeting, 2009);
- 7) Advanced MR imaging techniques, including susceptibility-weighted (SWI), diffusion tensor (DTI) and MR spectroscopy (MRSI) are able to reveal brain injuries where CT scans and conventional MRI appear normal.
1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.
2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.
3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.
4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.
5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.
6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.
In our next blog more about advances in MRI and neuroimaging.