Concussions and repercussions

The recent discovery of a degenerative brain disease in former football players throws into question the safety of players and whether enough is being done to protect them.
November 05, 2009

It was homecoming 1981 — Minnesota’s last in Memorial Stadium. Bob Stroup, a fullback for the Gophers, sustained a hit to the back of the helmet.
Everything went dark.
“It was like someone poured ink over my face,” Stroup said. “I stayed in the game. The first time I saw the next two plays was on film on Sunday.”
Nearly 1,000 miles away, Mike Webster was playing center for the Pittsburgh Steelers. “Iron Mike” was a future Hall of Famer, renowned for playing through all sorts of injuries, including concussions. He played 150 straight games from 1976 to 1986.
In September of 2002, Webster died at age 50. His life post-retirement was tormented by depression, debt and addiction. An autopsy uncovered that Webster suffered from chronic traumatic encephalopathy (CTE) , a degenerative brain disease similar to Alzheimer’s found in those with histories of repetitive head trauma.
Webster’s was the first known case of the disease afflicting an ex-football player. In the seven years since, various neuropathologists have begun examining the brains of deceased NFL players. They keep finding CTE — a trend with frightening implications.
The most startling diagnosis came on Oct. 22, 2009, from the Center for the Study of Traumatic Encephalopathy (CSTE), a group formed in 2008 that joined the Boston University School of Medicine and the Sports Legacy Institute. Dr. Ann McKee, who runs the CSTE’s “brain bank” at the Bedford VA Medical Center in Bedford, Mass., found CTE in Mike Borich, who died from a drug overdose in February, at age 42.
Borich wasn’t the youngest to be diagnosed with CTE, nor was his case the most extreme. But the former wide receiver had never played professional football; his career ended after he graduated from Western Illinois University. McKee has also observed early but inconclusive signs of the disease in an 18-year-old high school football player who suffered multiple concussions. She said it’s evidence that the increased risk of developing CTE pervades all levels of football — not just the NFL.
‘That was it’
After his first concussion, Stroup sustained three more in the next 10 months. Nobody mentioned CTE because nobody knew about it. The hit he sustained in the fourth game of the 1982 season, against the University of Illinois, was by far the worst.
Nausea. Headaches. Any light or sound caused “overpowering pain.”
Still, Stroup wanted to get back on the field; the doctors said he couldn’t yet. They told him he had seepage in the capillaries of his brain. “Whatever that meant,” he said.
At the time, playing through head injuries was accepted, even encouraged. George Adzick, who played safety for the Gophers from 1974 to 1976 and spent two years with the Seattle Seahawks in the NFL, said only after being knocked unconscious was he ever evaluated for a concussion. That happened twice; beyond that, it was, “How many fingers am I holding up?” and he went back in.
“I had my share of ‘seeing the birdies,’ ” Adzick said. But he played right through them.
Eventually, Stroup’s headaches abated. He began to practice again and was cleared to play in the final game of the season. On a screen pass in that game, he was hit in the head, and the ink returned.
The trainers came onto the field and told Stroup to get up, so he tried to push himself off the ground.
“It took me maybe 30 seconds before I figured out the reason I’m not able to push myself up is I’m laying on my back,” he said. “That was it. I had another year of eligibility left, but I got admitted into law school, and the football program was 3-8 and going south.”
So he walked away. In law school, bright lights and certain high-pitched sounds still bothered him from time to time. He’d have to go into a pitch black room and put a pillow over his head to make the headache subside.
That doesn’t happen anymore, although he sometimes forgets a name or struggles to find the right word. He’s almost 50, so he figures age is most of the issue. But Stroup still thinks about the hits and the headaches and the ink over his face.
“In the back of my mind, I wonder if it’s me getting old or if it’s some kind of lingering effect.”
An elusive disease
CTE is similar to Alzheimer’s, but it takes hold at a much younger age. Also unlike Alzheimer’s, CTE’s origin is not mysterious; it is the result of repetitive head trauma.
Its onset may occur months or years — even decades — after a player’s last concussion. Its symptoms, like Alzheimer’s, begin with memory loss and eventually progress to full dementia.
Diagnosis of CTE has yet to occur anywhere but on an autopsy table, and even in autopsies, finding CTE requires a specific type of screen . In other words, if you’re not looking for it, you won’t find it. Oftentimes, CTE is mistaken for Alzheimer’s, even though its clinical profile is distinct, McKee said.
NFL retirees over 50 are nearly five times more likely than the general U.S. male population to suffer from dementia, Alzheimer’s disease or other memory-related diseases, according to a 2009 University of Michigan study. It’s even worse for NFL retirees age 30-49, who are 19 times more likely than the average male.
Though alarming, the rates presented in the study provide no definitive number on those suffering from CTE. McKee said the rate of players suffering from the disease is probably around 20 percent, but that’s based only on what’s known about the rate of CTE in boxers.
“We’re seeing the consequences in these players who’ve agreed to autopsy — we know it exists,” she said. “We’re not sure what the percentage is of affected players.”
Helmets and HIT
The ex-players now being diagnosed with CTE played primarily in the 1970s and ’80s. Knowledge about and focus on head injuries has come a long way since then. But even with the advances, is football safe enough?
Not yet, according to McKee and Dr. Kevin Guskiewicz, who leads the sport concussion research program at the University of North Carolina and has researched head injuries for 17 years.
In 2002, helmet manufacturer Riddell released its Revolution helmet, which was specifically designed to reduce the risk of concussions. A three-year study conducted by the University of Pittsburgh Medical Center revealed that it did, by 31 percent . Other companies, such as Schutt and Xenith, have since also developed helmets with concussion reduction in mind.
At Minnesota, players wear all three brands, head trainer Ed Lochrie said. It comes down to the equipment manager’s evaluation of the right fit for an individual player.
As helmets have evolved, not only have they reduced concussions, but now they’re better at preventing skull fractures, broken noses and various cuts and bruises. But McKee said helmets can only do so much.
The brain does not fit snugly inside the skull; it floats in cerebrospinal fluid. When a head comes to an abrupt stop, McKee explained, the brain accelerates and decelerates rapidly, crashing against the wall of the skull. McKee said hits to the head usually cause some amount of rotation of the brainstem, too.
“It’s the invisible injury. You’re not weak, you’re relatively pain free, but you’re still damaging yourself,” McKee said.
She also said there is evidence to suggest the cumulative effect of subconcussive hits — that is, head trauma that doesn’t quite cause a concussion — can have lasting effects.
This would put linemen and linebackers, who receive some kind of blow to the head on nearly every play, at the highest risk for CTE. Based on those diagnosed with CTE thus far, and on what Guskiewicz has observed working with the football team at North Carolina, the theory is legitimate.
Just before it was patented and sold to Riddell in 2004 as the Sideline Response System, Guskiewicz began using a monitoring system developed by Simbex called the HIT System (Head Impact Telemetry), which places sensors in helmets and transmits the force and location of blows to the head in real time to a laptop computer on the sideline. The system has captured nearly 250,000 impacts. To his initial surprise, it’s not always the hardest blows that cause the most damage in terms of clinical measures of concussion.
Guskiewicz said researchers have tried to determine a threshold for injury, but he has yet to observe a specific level where hits become dangerous.
“My point all along has been we just don’t know, because the threshold changes with each player,” he said. Size, neck strength and previous concussions can all play a role.
In the last five years, the NCAA has implemented rule changes in an attempt to eliminate dangerous helmet-to-helmet hits. This season, the regulations became more stringent. They mandate that illegal hits be reviewed by the offending player’s conference — even the hits not called for penalties in the game. Also, players who lead with the top of their head can now be suspended.
But Guskiewicz continues to see players drive into tackles with the crown of their helmet.
“When [the hits] do land, they tend to have higher magnitudes [on the HIT System],” he said. “That’s concerning, because for years we’ve been emphasizing not to lead with the head because of the risk of not only concussion but also cervical spine injuries.”
So Guskiewicz uses the HIT System to teach. He can bring in players who have sustained a concussion, show them where and how hard they were hit, then show them a video of the impact.
“We’ve been able to take players, especially those that may be at risk for a second or third injury, and we’ve been able to teach them some changes,” he said.
In Minnesota's program, incoming freshman players are administered a computer test called ImPACT , Lochrie said. It measures their baseline levels of memory, processing speed and reaction time. When a player receives a concussion, he takes the test again before he returns to the field to assure he’s returned to baseline levels or within normal limits.
‘Health should be No. 1’
If he could do it over, Stroup wouldn’t change a thing. He’s not upset with the training staff for allowing him to play through a concussion, and though he finds it curious there was no follow-up care after he left the team, he said he figures they were working with the best information they had about head injuries at the time — which wasn’t much.
“Some days I regret not taking my fifth year,” he said.
Stroup said he doubts he would be allowed to continue playing if he had suffered those hits in 2009 instead of 1981.
But McKee wants something more proactive than concussion management. She wants prevention. She loves football, but she loves her father and brothers — all of whom played — more.
Guskiewicz agrees. He has three sons who have played youth football and said he would still allow them to play, but he is trying to do more as a parent and researcher to make football safer.
In the NFL and college football, McKee’s biggest disappointment is that a player’s health doesn’t always come first.
“The players seem more like a part of a business machine than human beings,” she said. “I don’t think health is always the primary concern.”
She’s trying to make it the primary concern, and people are beginning to listen. McKee spoke in Washington, D.C. last week at the the House Judiciary Committee’s hearing on issues related to football head injuries .
She advocates sweeping rule changes to tackling and blocking. Take the helmet completely out of tackles and blocks, she said. The number and length of full-contact practices has been dropping consistently for years; McKee wants even less contact — maybe even none — in practices, especially at the high school and college levels.
Guskiewicz isn’t after, and doesn’t expect, significant alterations in the way football is played. The speed of impacts on special teams plays and the constant helmet-to-helmet blows being absorbed by linemen concern him most.
Many, including Lochrie, say “that’s football.” Players understand the physical risks of the game, and it’s their choice to undertake those risks.
Stroup said he understood the risks and made the choice to play and continue playing after multiple concussions. What he didn’t understand — what he didn’t ever consider — was the potential long-term damage from the trauma he suffered.
“When you’re 20 years old, you don’t think anything’s going to hurt you,” he said. “Sometimes other people need to look out for you.”

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