Coming to a bookstore and TV near you today is “League of Denial” a book and documentary about one of the dirty little secrets the NFL has been avoiding for some time. Fortunately, I have been provided with advance copies of both; the Frontline film was easy to digest, as for reading a book, well we can just say I am trying to read as fast as possible.
I was reminded quickly, yesterday via Twitter, that I may lack valuable perspective when it comes to concussion information (and that I am not normal – this is not breaking news). Will Carroll of Bleacher Report let me know that this information will be new to a lot of people out there. He is exactly right, not only that, this documentary will be easily digestible for the fan of football. For any person just wading into this, when you tune into PBS tonight to view “League of Denial” you will be absolutely hooked from the start.
The sounds of the crowd, visuals of big hits grab your football part of the brain IMMEDIATELY, over those sounds you will quickly discover the problem NFL players have faced with brain injuries playing their sport. Harry Carson saying “and then they are gone” when talking about former players. A bold statement that the level of denial was “just profound.” An NFL lawyer saying “we strongly deny those allegations that we withheld information or misled the players.” And more video and sound of punishing hits that used to fill the highlight reel bring the opening curtain of this very important documentary.
This problem is real – it’s not just real for the professionals – and from the get go Frontline makes you understand, vividly and personally, why this is. After listening to old radio calls of the Steel Curtain it all begins with the story of Mike Webster and the forensic pathologist who studied his brain, Bennet Omalu.
The discovery of a possible reason one of the most respected and lauded players in Pittsburgh sports pantheon fell from grace and eventually found and early demise. If the football portion of your brain does not connect to what is being presented then I would haphazardly guess that you are not ingrained within the fabric of football.
As Harry Carson explains how the game was played and to some extent how it’s still played you can begin to understand the issue at hand. This is hammered home when Robert Stern, PhD tells the audience blows to the brain are at forces 20 times greater than the force of gravity (20 G’s); or as he so eloquently put it “driving into a brick wall at 35mph”, 1,000 times or more in a season.
In the first 11 minutes of this 2 hour presentation you are at full attention and want to understand the “whats”, “whys” and “whos”. If you are not engaged and ready for further explanation I can only say that you don’t care or want to bury your head in the sand.
Contributions in the film include many prominent doctors (Robert Cantu, Bennet Omalu and Julian Bailes among the many) as well as poignant commentary from some of football’s greats (Harry Carson and Steve Young to highlight). Even those that make it their job to get players the money they deserve, the agents (in this documentary, one Leigh Steinberg) recounts the Troy Aikman concussion that shook both of their worlds. As you hear Steinberg tell the story, how can you not find it disturbing that this mountain of a man and Hall of Famer could not remember the game or a conversation that was had 10 minutes prior. The theme among all of the above is that this cannot be good, yet no one was openly discussing this in the manner it deserved; specifically from the place people thought it should have been, the league.
As in the companion book by Steve Fainaru and Mark Fainaru-Wada the documentary takes a look at how the NFL had a grasp on information or research and it was controlled; even looking at how the so-called “peer-reviewed” science was distributed in medical journals. The documentary goes as far as to describe how Omalu was basically ostracized by some in the medical community for his finding about the cumulative effects of brain trauma in professional football players – orchestrated by the NFL and its scientific arm.
As evidence mounts of chronic traumatic encephalopathy, found by Omalu and further researched by Ann McKee and the Sports Legacy Institute headed by Chris Nowinski, questions come to bear about how much is too much, and can we find a way to subvert these issues we are starting to see in full Technicolor. Still with all the information there are plenty of people who want to cast a shadow of doubt on all the work done, which is OK, but to hide or not disclose information in the pursuit of saving a game is not the right path.
As the film comes to the end the timeline is evident, those that may have had a hand in covering up this issue well documented and the points within hammered home by recent events; Junior Seau and the concussion litigation settlement.
As I stated above, it is perfectly acceptable to challenge information but in a civil and open manner. Certainly, we should not make rash and ill-conceived conclusions nor policies based on little information. What we need to have is transparency and discover what we all can do to help with this problem. As the film showed this is not a professional one, there are outliers, so we all are stakeholders.
Regardless of what your preconceived notion is about this issue, this documentary presents issues we will ALL face at some point when dealing with sports and life. Yes, this film is about the NFL and its professional employees; to which few of us will come in contact with, personally. However, we all watch and connect with the largest sport in America – many of our kids, grand kids, nephews/nieces, friends and acquaintances play the sport. What is presented in a very neat and understandable manner needs to be watched and understood to its fullest.
The reason is simple, if we would like to continue to enjoy our love affair with this sport and others grasping the information and making sound and corrective – proactive – policies will allow for this torrid relationship to continue.
The Concussion Blog 
I have never listened to a podcast, and only occasionally look at blogs for cooking ideas. A peer asked me if I ever saw your blog or listened to the ATPodcast you did pertaining to concussion, and I am ELATED that you are doing this!!! Please tell me that you’ll be at the IATA state meeting in November. I would love the opportunity to chat!
Very good work, I appreciate your passion!
Don’t know if I will be at IATA…
Wow! Here it is 9:00 AM on the east coast on the morning after and I am the first one to comment directly on the League of Denial documentary? That is hard to believe!
In the interest of full disclosure, I was a co-author of the 1st NATA Position Statement on Sports-related Concussions in 2004. I have been a certified athletic trainer for 28 years and I love football. I am also the Founder of the Chattanooga Concussion Prevention Initiative, so obviously I am interested in concussions and all of the peripherals.
With all of that said, I thought the job done by Frontline was excellent for the most part. Was it a tainted or slanted view against the NFL? Yes, I believe any objective viewer would believe it was, but the NFL refused to appear on the documentary. Were the points against the NFL wrong or unfair? Based on the evidence presented, I would argue not at all. Were a lot of questions answered? Well, maybe, but it depends on your perspective and previous knowledge. I am sure for the “average fan” there were a lot of questions answered. For me, it raised a lot of questions too.
I applaud the work of Dr. Ann McKee. She came off as a straight forward, honest, scientist, who is passionate about her love of football and of her science. I agree with her when she said they had evaluated 45 brains of former NFL football players and 44 of them had CTE. Her comment about it being “an alarming hit rate for any disease” is correct. However, I think Dr. Joseph Maroon’s comments raising questions about CTE being caused by concussions and only concussions was also an excellent point. He pointed out that perhaps alcohol or drug abuse or steroid use could be contributing factors to CTE too. Perhaps, it is a combination of the use of these drugs and the head trauma causing the CTE? I don’t know?
I would also ask Dr. McKee if she is blinded to the brains when she examines them? From what I could tell in the presentation, she is not. Also, her study of brains with CTE appear to be all former NFL players, 1 from high school and 1 from college, but what about soccer players? Or what about athletes from other sports? What about females vs. males? What about those players who play college football, but never go on to play in the NFL? Of the number of high school players who never play college football? Are any of their brains examined for CTE? If so, what were the findings?
One point that was touched on ever so slightly is the genetic relationship. There is some research out there that does appear to indicate a potential genetic link between APOE promoter genotypes and concussions. This certainly cannot be ignored or not investigated by Dr. McKee and others like her.
Obviously, this documentary is lightening rod for those who want to ban football and for those who wish to legislate safety into all aspects of society. But sometimes, despite the best of intentions, you are going to get hurt for no other reason than just because!
I will make two final soap box statements. Nowhere in the documentary did it state the fact that these players, in many cases, bring the concussions and/or the CTE on themselves. How many of them are wearing a properly fitted helmet? I know, helmets are not made to prevent concussions! I get that and understand it, but I believe an ill-fitted helmet pre-disposes one to a concussion. How many players do you see put their helmets on or take them off with one hand? Secondly, how many of the highlights they showed last night, did the player lead with their head? How many of those hits were penalized? I am a Steeler fan, but I will acknowledge that former Steeler James Harrison has led with his head way too many times, causing injuries to himself or to his opponent. Until we get the officials to make the calls on the field, the problem will continue to exist.
Thank you for having this forum Dustin. It is a wonderful thing you do!
Scott L. Bruce, MS, ATC
What is the solution for the young 10-11 year olds? I feel additonal padding on crown of the helmet would help only if it were slippery enough to deflect the blow. Helmet manufactures will not have that. In addtion the warning sticker on a youth helmet releases them of any liability. What have you found is the solution? Shawn O
A 10 or 11 year old playing tackle football? My solution would be to not have them engaged in “tackle” football at that early age. I would argue that 14 is an arbitrary number. There are some who can handle blows to the head due to neck strength and overall body/core strength and coordination, while there are other 14 year olds who can not.
The other solution is NOT a quick fix, and I sound like a broken record, but it is proper coaching AND proper officiating. Until the coaches get back to teaching proper heads up tackling and officials start to enforce the rules regarding leading with the head this epidemic will continue at an alarming rate.
Thanks, Scott
Mr. Bruce: Your comments were irrelevant to the point of being childish. You need to establish that drugs and alcohol can cause CTE before introducing them as significant variables. If you ever studied statistics you would know that 44 out 45 is almost irrefutable.
Robert Gallo BSCE, MBA
Mr. Gallo:
I appreciate your comments related to my post on this blog. I don’t appreciate being insulted or the public name-calling you have resorted to. Also, I clarified the paradigm from which I was making my comments when I stated:
“In the interest of full disclosure, I was a co-author of the 1st NATA Position Statement on Sports-related Concussions in 2004. I have been a certified athletic trainer for 28 years and I love football. I am also the Founder of the Chattanooga Concussion Prevention Initiative, so obviously I am interested in concussions and all of the peripherals.”
What I didn’t say is that I am in the final weeks of my doctoral studies and dissertation, so when you accuse me of not understanding statistics, in all due respect sir, you know not of which you speak!
I see by your credentials you are a civil engineer and you have an MBA. Congratulations on those two degrees. Do you currently do any work related to concussion? Have you ever researched concussions? Have you ever done any medical research? If so, you did not preface your comments with that disclaimer.
I ask these questions because although “44 out of 45 is almost irrefutable” (97.78%) it is not perfect. As I stated, I respect and accept Dr. McKee’s findings, but I believe that all possibilities have to be considered. For example, was she blinded to the brains she was examining? Blinding is an excellent way in research to assure the amount of biasing is limited. Has she compared the brains of former NFL players who have had dementia and other related symptoms, to those of NFL players who have not had these signs and symptoms? According to what was reported in the Frontlines documentary, she has not. Have the researchers, examined any of the other potential factors or variables and correlated them to those cases of CTE? Again, from what I could tell in the documentary, they had not.
I am not slamming or saying that what Dr. McKee and other researchers at Boston University have done in the area of brain and CTE research is not valuable or should be considered irrelevant. What I am saying is that the more we learn about concussions, the more we find out that we don’t know. Are concussions the only cause of CTE? I don’t know. But to say that because of 44 out of 45 brains were assessed this way that concussions cause all CTE, is incorrect and not very scientific. Does the possibility exist that there are other contributors to CTE than just blows to the head and only blows to the head? I don’t know, but is it worth examining? I believe so.
Finally, if the researchers had examined brains of like players who had not had the signs and symptoms associated with CTE and found they too had the same tau plaque and markers of CTE or did not have the same markers then we could run a logistic regression model, to assess univariable models and multivariable models. We could calculate the sensitivity, the specificity, the likelihood ratios (both positive and negative), and the odds ratio and relative risk to determine what the odds and the risk are associated with playing professional football and developing CTE. We could then examine the degree of collinearity that may exist between multiple variables, and examine for interaction effects to determine if one variable is acting independently or interact to one degree or another with a 2nd or 3 variable. But because the sample size is so small, (n = 45) from a population of thousands, we cannot determine these statistics. Or do you not understand Bayesian analysis?
Thank you for the opportunity to comment on this important point and I again that Mr. Gallo for his comments. He certainly has stimulated further thought and discussion on this topic.
Scott L. Bruce, MS, ATC
Founder, Chattanooga Concussion Prevention Initiative
I’d like to praise, and thank Dr. Omalu. He is a hero, and after 30 years in health care, I know one when I see what he has done for the good of others – at a huge cost to himself. Please create an award for this man, and physician.
Mr Bruce,
I am a pharmacist, physician, clinical epidemiologist and clinical researcher. I do understand Bayesian analysis. I also understand clinical appraisal of the medical literature. Throwing out terms as logistic regression, relative risk, odds ratio…What about number needed to treat as in a RCT (one of the basic elements involved in considering such things in developing a randomized clinical trial) to figure out exactly what outcome you are looking for and what are you going to do to cause this outcome? Ultimately, cohort data WILL have to lead to intervention to help prevent the catastrauphic effects of TBI in athletes, not only elite NFL football players, but our children who play contact sports. This is not going away. Please address the future options as the SAMPLE SIZE when looking at OUR CHILDREN in high school and college sports who suffer from multiple concussions are all at risk and to gloss over this is to not look out for their future quality of life.
Thank you.
Rebecca Greenberg, MD