Mar 26 2015

Fox News, the NFL, and Concussion Denial

I have been a fan of professional football since my college days (go Pats) but I also recognize that it is a brutal sport prone to injuries. In recent years awareness of the true neurological risk of concussions, especially repeated concussions, has been increasingly coming to light. This may cause some cognitive dissonance among fans, players, and anyone involved with the NFL, including broadcasters.

Recently Fox News published and article in which Dylan Gwinn writes:

Don’t look now, but concussions have become the new global warming: a debate where “consensus” trumps evidence, and heroes and villains are determined by their stances on an issue where the science is bogus at worst and murky at best.

This is classic FUD – fear, uncertainty, and doubt, the primary tactic of those who find reality not to their liking in some particular aspect.

Gwinn creates the classic false dichotomy between consensus and evidence. What if the consensus is based upon scientific evidence, and in fact the consensus of experts is the best way for non-experts to understand what the evidence actually says.

Further, all science is murky, at least to some degree. The clarity of a scientific conclusion exists along a spectrum from genuinely controversial to rock solid, but scientific evidence is always complex, subject to multiple interpretations, and incomplete. It doesn’t take much creativity to portray any scientific conclusion (even those at the rock solid end of the spectrum) as murky. Creationists are evidence of that.

Gwinn also does not address another issue at the core of this debate – the precautionary principle. This is the notion that it is best to err on the side of caution regarding a potential harm when the science is still preliminary. Application of the precautionary principle is admittedly complex and is easily abused. I write often about abuse of the precautionary principle when it comes to vaccines, GMO, and unnamed “toxins.” I also write about ignoring the precautionary principle when it comes to things like global warming, and now concussions from playing contact sports. These represent opposite extremes, when the reasonable position is somewhere in the middle, with Aristotle’s golden mean.

Abuse of the precautionary principle generally takes the form of overhyping possible risks, cherry picking evidence suggesting risk, ignoring, dismissing, or downplaying evidence of safety, and demanding unreasonable assurances of “zero risk.”

Ignoring the precautionary principle usually takes the form of FUD – we don’t know everything, so let’s act as if we know nothing and ignore potential risks. Until you can prove beyond doubt that the risk is real, we should not take any steps to mitigate it, even if by the time the risk is certain it will be too late.

There is no simple algorithm to calibrate where an issue lies along this spectrum. It takes a working knowledge of the science along with a fair and nuanced evaluation of all the relevant issues. Personally I have absolutely no idea if the planet is warming due to human activity. By this I mean that I am not competent to look at the raw data and meaningfully evaluate it while putting it into the context of a thorough understanding of climatology. That is because I am not a climatologist, and the kinds of data they deal with are not really accessible to a non-expert. I am dependent on the consensus of expert opinion. I can decide if their arguments make general scientific sense, and which side seems to have the last word when specific points are thoroughly debated.

With concussions I have a much better personal handle on the science. I am a neurologist. I treat patients with concussions, some from sports injuries. I can read the primary literature and understand it. With regard to concussions and sports the consensus has shifted over recent years to be far more cautious in returning players to the field. This is based upon studies showing that the risk of a second concussion is greater in those who have suffered a first concussion, and the damage is also more severe and longer lasting. The current recommendations are for a player to be symptom free before returning to play following a concussion.

We are also gathering more evidence about the long term neurological effects of repeated concussions over a career. A recent examination of retired NFL players found:

The retired players’ ages averaged 45.6 ± 8.9 years (range, 30-60 years), and they had 6.8 ± 3.2 years (maximum, 14 years) of NFL play. They reported 6.9 ± 6.2 concussions (maximum, 25) in the NFL. The majority of retired players had normal clinical mental status and central nervous system (CNS) neurological examinations. Four players (9%) had microbleeds in brain parenchyma identified in SWI, and 3 (7%) had a large cavum septum pellucidum with brain atrophy. The number of concussions/dings was associated with abnormal results in SWI and DTI. Neuropsychological testing revealed isolated impairments in 11 players (24%), but none had dementia. Nine players (20%) endorsed symptoms of moderate or severe depression on the BDI and/or met criteria for depression on PHQ; however, none had dementia, dysarthria, parkinsonism, or cerebellar dysfunction. The number of football-related concussions was associated with isolated abnormalities on the clinical neurological examination, suggesting CNS dysfunction. The APOE4 allele was present in 38% of the players, a larger number than would be expected in the general male population (23%-26%).

The concern is that repeated brain trauma causes chronic neurodegenerative disease over time. The above study finds evidence of chronic damage in a substantial minority of retired players. A 2015 review of the literature on chronic traumatic encephalopathy found:

We found that a history of mTBI was the only risk factor consistently associated with CTE.

But also:

Our review reveals significant limitations of the current CTE case reporting and questions the widespread existence of CTE in contact sports.

What both these recent reviews find, essentially, is that there is evidence of chronic neurological damage in professional athletes correlating with concussions, but that chronic injury is not widespread and exists in a minority of players. You can focus on either the positive or negative aspects of this data – on the fact that there is evidence of neurological injury in some players, or on the fact that injury is only present in a minority of players. Everyone agrees we need further research.

How do we apply the precautionary principle to this incomplete scientific data? As with global warming, those who wish to deny that there is any problem are likely to argue against the strawman of the most extreme solution, such as banning all contact sports. Often reasonable measures that are proportional to the evidence and the potential risk are ignored.

With global warming, for example deniers warn of a government take over of entire industries, and degrading civilization to a hippie paradise without electricity and automobiles. How about just investing in greater energy efficiency and renewable sources. Those are win-wins, whatever you think about global climate change.

With regard to contact sports and concussions there are also reasonable measures that can be and are being taken short of a total ban on high-risk sports. Recommendations are already moving in this direction – players should not return to play the day of a concussion, and they need a longer period of recovery before returning to play. Certain styles of play are more dangerous than others, and so rules can be tweaked to minimize risk (as they always have been). Incremental improvements in equipment can also reduce player injury.

Making contact sports safer for players is a no-brainer. We now have more information about concussions to inform efforts to make contact sport safer.

Gwinn is right about one thing – concussions in sports is the new global warming, just not in the way he intended. There is emerging science indicating a risk. The science has not all been worked out yet, but the signal of a risk of neurological injury is there, and is also quite plausible. At the very least we should be taking reasonable measures to minimize injury. This situation is fairly analogous to global warming in the context of risk management.

In both cases the evidence supports taking reasonable measures to mitigate risk. In both cases deniers are engaging in FUD to argue that we should do nothing.

27 responses so far

27 thoughts on “Fox News, the NFL, and Concussion Denial”

  1. What is the incident rate for concussions in NFL football ? Are helmets a factor in NFL injury by weaponizing the players heads ? For Australian rules football, a very different game, played without helmets,

    “Concussion is a relatively common injury in Australian football. The overall
    incidence rate is 5-6 concussions per 1000 player hours, which equates to an
    average of 6-7 injuries per team per season.” (AFL Research Board, AFL Medical
    Officer’s Association)

    I love footy (Go Pies!) and am wondering how the two games compare. Helmet use is not recommended by the AFL, fearing it would change game play and increase head impacts.

  2. Heptron says:

    Great article! A couple of things…

    1. One thing I’ve never understood is why equipment isn’t made to absorb impact. The same case exist with elbow pads in hockey. They are made from rigid plastic so if someone gets an elbow to the chin, there is nothing to soften the impact. Now I’m not saying that all sports should go back to the leather caps worn in football back in the day, but I wonder if they can’t find a middle ground where the hits are softened more by helmets or elbow pads.
    It’s like how cars used to be built with solid frames but now have crumple zones built in to absorb impact.

    2. Regarding your comment on investing in renewable resources, I completely agree. Regardless of your feelings on climate change, oil is a finite resource, so we’ll need to have something else ready to satisfy our energy needs.

    @DevoutCatalyst I also listen to the Freakonomics Radio podcast for better or for worse and the first episode they did talked about how the more protected people feel, the more reckless they become. I’m sure if the NFL got rid of helmets, there would be far fewer players leading with their helmets.

  3. Heptron says:

    …Not that I’m suggesting the NFL get rid of helmets, it just speaks to the increase in protection leading to an increase in risk-taking.

  4. joshguth says:

    “Making contact sports safer for players is a no-brainer.” It’s at least a bruised brainer.

  5. pdeboer says:

    Catalyst, that sounds a little too similar to the argument that bicycle helmets cause more head injuries than they save (which is false) by increasing the confidence of the rider.

    I’m not a big american football guy, but I don’t think that they use their heads as a weapon in any way that would cause concussions.

    Football people maybe weigh in?

  6. Helmet-first hits have been illegal in the NFL since 2010. Players can get an on-field penalty, and may also be fined.

  7. Bruce says:

    As a rugby player, when I American Football tackles I always wince. The “spearing” and complete recklessness of the way they make contact is really quite brutal. You are also allowed to hit the guy without the ball, which to me really amplifies the opportunities for injury.

    Nothing compared to those crazy Aussies though… proper hard men play that.

  8. Wolfbeckett says:

    A clear, rational argument. Just one of the reasons why Mr. Novella is one of the most respectable bloggers on the…

    “go Pats”

    Ugh, NEVERMIND.

  9. KeithJM says:

    Heptron — Football helmets are not hard plastic against flesh. There is significant padding in the helmet and there have been some experimental designs to further improve the padding. They are far better than leather helmets by any measure.

    Be careful when comparing NFL pads to cars with crumple zones. Motorcycle helmets are similar. Both of these will be significantly safer on the first hit than something that just pads your head — as you point out, they absorb some of the blow themselves. The problem is that really only works for the first collision. Your car can crumple on the first hit, but that makes it LESS safe on the second hit than something that was just rigid and padded. If your motorcycle helmet splits in two in your first accident that’s fine — you’ll have to buy another helmet before you start riding again. Football helmets clearly need to survive multiple impacts, so crumple zones or the helmet absorbing damage to reduce the force on the wearer wouldn’t work.

  10. tmac57 says:

    pdeboer- Concerning the bicycle rider and increased risk with helmet use, my understanding is that the hypothesis was that the car drivers, not the cyclists, would see the cyclists with helmets as less vulnerable (subconsciously I suppose) and thus not give them the margin of safety that they would a more vulnerable cyclist, which leads to more accidents.
    Not sure if any of those studies were all that rigorous though. Maybe BillyJoe7 could weigh in.

  11. Lukas Xavier says:

    Football helmets clearly need to survive multiple impacts, so crumple zones or the helmet absorbing damage to reduce the force on the wearer wouldn’t work.

    Maybe I’m asking a stupid question, but why wouldn’t it work? Football tends to go in short bursts with pauses in between. Surely changes could be made so that players can switch helmets between downs if they get hit hard.

    Am I missing something?

  12. pdeboer says:

    tmac57 – I was actually researching this, as I do after I say something that I’m not 100% on.

    Seems like the opposition to bicycle helmet laws have quite an array or minor gripes that may add up to a reasonable argument.

    They say that:

    bicyclist confidence goes up.

    Helmets can cause torsion brain damage(by being a big knob on your head)

    Driver caution is reduced (as you said)

    You are just as likely to get injured as a pedestrian.

    The most compelling is the argument that the health benefits for the higher ridership without the helmet law, outweighs the decreased injury with the helmet law.

    My take away was that helmets still reduce your chance of serious brain injury, that you are still more likely to get injured as a bicyclist than pedestrian(many anti-helmet law people do not use proper statistics to get to that conclusion) but, helmet laws may still be a bad idea.

    In other words, biking without a helmet is good, biking with a helmet is better.

  13. RedMcWilliams says:

    There was an idea floated out a few years back, though I don’t remember from who or how much science there was to back it up, about simply removing the face mask. You’d still get virtually all the protection afforded by the helmet, but you’d lose some of the recklessness because you’d feel much more exposed.

  14. locutusbrg says:

    Red it was now retired Wide Receiver Hines Ward that made the argument that removing the facemasks would lower the concussion rate, and that it would remove some of the fearless hits that take place. Maybe he is right. I am not advocating that the players would be better off losing teeth and/or an eye. Just that more intricate facemasks in use today could make players hit more fearlessly. Again that is based on player anecdote.

    A fair overall view Steve, I have not completely covered the newest available research. I did look closely at the literature on this 1-2years ago when jr Seau took his own life. I had a great deal of trouble with the families narrative that this was causally related to his concussion Hx. This could be outdated info but I think that NFL players in general suffer from high rates of depression when compared to other multiple trauma sports like boxing. Despite the high rates of permanent post concussive brain damage in boxing, suicide was statistically rare.
    From a clinician standpoint what do you think about the causal relationship being drawn by the players union with major depression and suicide? obviously any major disability in an athlete can lead to depression but the players union is going beyond that. Directly linking brain damage with suicide. What is your impression.. Plausible unlikely not enough data?

  15. locutusbrg says:

    @pdeboer
    As an avid road cyclist I find little downside to wearing a helmet. I did not grow up wearing one and it took me a while to get used to it. You are exposed on a bike, I have been hit by a car if you cycle long enough accidents, no matter how careful, will happen. I will accept that the benefit is minimal. I think the arguments against them are puerile. Now I don’t even really notice I wear it even if I ride a century ride (100 US miles). They are quite expensive far more so than the benefit. They do give sun relief if you have hair and some models claim they cool you better than riding without(maybe). Falling hurts helmet or no. Anyone who has fallen at a good speed can have major injuries even if your head is fine. Everyone riding knows that. No one thinks I’ll be perfectly safe if I fall because I have my helmet on, never mind hit by a car. So I hold little stock in the helmet make cyclist inappropriately fearless hypothesis. It just doesn’t hold water that slapping on your helmet makes you feel invincible to injury.
    Anecdotally I wouldn’t say it makes me fearless, just if I don’t have it on I feel anxious, like trying to drive my car without a seatbelt.
    In my opinon it has been helpful for me and I don’t see a great benefit to going without one.

  16. mnestis says:

    Great topic today, enjoyed the read, and particularly the PLOS One article, which I thought was balanced. I agree with most everything you wrote – as equating this line of research with global warming (and all its baggage) is wrong. However, and one of the articles you linked to gets at some of this, this line of research (CTE specifically) is not without its critics (not that it the syndrome doesn’t exist – but that we need more than case studies; and that the data we have does not warrant a press conference every time we find a new case to report). There have been many in my field (neuropsychology) calling for much more rigorous research before we call something settled science – and while I think most would agree (as you wrote above) that this is not considered settled, it sometimes seems that of the researchers involved (and there are two main groups) would have you believe it is. As you’ve said countless times, we want results to be replicated, ideally by a varied and diverse set of researchers/labs – and so far, we have basically two main groups. Longitudinal data (which will obviously take years) collected at multiple sites and with multiple research groups would be ideal. I think that most agree that there is something “real” here, but incidence and the predisposing factors are almost entirely unknown due to sampling bias and other problems. The biggest problem I have is that some have proposed a CTE clinical syndrome in the living (obviously without pathological confirmation), but developing a syndrome based on retrospective case review (where amount and accuracy of actual premorbid clinical data is, in many cases, suspect) can be a dangerous thing. I’ve rambled a bit – and completely agree that what data we do have is enough to warrant that we take measures to reduce repeated head injuries and problem-solve rule-changes and other ways to improve safety. Just wanted to chime in a bit more on the specifics of CTE research – and you rightly said that we are in the beginning stages – something i haven’t seen enough in everyday press accounts. As always, love your (and the SBM crew) work!

  17. pdeboer says:

    locutusbrg – Agreed

    The risk benefit argument I was interested in earlier appears weaker and weaker as I explore more research. I’m now heavily leaning towards helmet laws for adults as well, especially in a country like mine that makes the taxpayers pay for your lack of safety.

  18. glblank says:

    Regarding the equipment issue. There simply is no way to engineer a helmet to absorb the force generated by the collision of junior level athletes much less that of a pro level. Please also consider that not all concussions are helmet to helmet or helmet to ground. The picture depicted would rate a 10 on the concussion probabilty scale and that is a shoulder to chin hit. The hitter is making a near perfect form tackle that unfortunately is too high. Removing the face mask would increase exposure. The ball carrier may be more cautious but the defender would not. The speed of the game would only increase the risk of facial injuries as well as concussion.

  19. tmac57 says:

    I live in Dallas, and they recently did away with mandatory bike helmet laws for adults. What I have noticed though, is that all of the really serious riders (on high tech road bikes and Lance Armstrong like physical appearances) are almost universally still wearing their helmets. Maybe they know something that others don’t? In any case, I kept mine on too after I heard an interview with an ER doc who recounted the horrific fatal or brain injuring results of non-helmet wearing bike crashes.

  20. BillyJoe7 says:

    Australia was the first country to introduce compulsory car seat belt legislation. In fact it was first introduced in 1970 in my home state of Victoria, followed by the rest of the states soon after. The rationale was that public money was being spent to treat drivers who chose not to wear seat belts and suffered injuries in accidents that they would not have suffered if they had been wearing seat belts. So personal freedom had to give way. It has been fairly convincingly demonstrated that they save lives.

    Australia was also the first country to introduce compulsory wearing of bicycle helmets and, again, my home state of Victoria led the way in 1990. Unlike car seat belts, the advantage of wearing bicycle helmets has never been proven. It seems drivers tend to take less care if they see a cyclist who is wearing a helmet, especially if they are also in lycra. In fact cyclists in helmets and lycra are sometimes actual targets for motorists, as I can personally attest.

    (I ride for about five months every year leading up to the 200km “Around The Bay” event in October. After that, it’s back to running in the hills in preparation for “The Great Train Race” in early May)

  21. tmac57 says:

    BJ7- that’s why I always wear cotton 😉 … much safer!

  22. BillyJoe7 says:

    t57 – I use the “Tour de France” as inspiration. They wouldn’t be seen dead in cotton. (:

  23. cloudskimmer says:

    So far the discussion has included American football, everyone else’s football (American soccer) rugby and cycling, but what about the so-called sport where the objective is to beat another person into unconsciousness? I refer of course to boxing and am disgusted that it is still included among the Olympic sports. Isn’t there ample evidence of brain damaged boxers? When the objective is moving a ball down a field, and exercise has health benefits as well as being a lot of fun, I can see continuing it, despite occasional and incidental damage, but fail to see how any civilized society can accept boxing as a sport. Shouldn’t it be included in any discussion of sports, concussion, brain damage, and protecting athletes from long term damage?

  24. BillyJoe7 says:

    …and then there’s hunting, where a damaged brain is a pre-requirement.
    (Can anyone watch “The Deer Hunter” and still go hunting?)

  25. Bill Openthalt says:

    BillyJoe7 —

    Movies aren’t reality. In my neck of the woods, hunters are most useful since there are no other top-tier predators. The Greens would like to replace the hunters with civil servants who don’t “enjoy the hunting”, and as they are part of the ruling coalition, this inanity might even hit the statute books. Hunting is one of humankind’s oldest occupations, and even if it’s decidedly less dangerous (and more effective) with a rifle than with a flint spear, most of the animals still get away, and many a hunter is much worse for the wear.

    Hunting’s an integral part of country life, and it would be a damn shame if it would disappear.

  26. Bruce says:

    Bill,

    I agree.

    I have a good friend who is a professional hunter in Zimbabwe and he does more to protect the environment and the animals he hunts than anyone I know. There are strict controls on quotas and the money made from the hunts go directly towards anti-poaching and developing of the wildlife in the area.

  27. tmac57 says:

    BillyJoe7- ” I use the “Tour de France” as inspiration. They wouldn’t be seen dead in cotton.”

    Yeah, well that’s kinda my point. I don’t want to be “seen dead” on my bike!
    Cotton it is, for me 😉

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