No Apology Necessary

A physician should not have to apologize for protecting the health of an athlete. Football at the university level, like professional football, is a multi-million dollar business. With all of the emphasis on television, bowl bids, gate receipts and coaching contracts, the athlete is often left as a pawn with the medical staff serving at what seems like his only advocate. Ed Wesley, TCU running back, suffered a concussion against SMU on September 24. After Wesley was diagnosed with a concussion with a brief loss of consciousness, TCU Head Football Coach Gary Patterson confronts and proceeds to berate Dr. Haraldson for not allowing Ed Wesley to return. The day after the game, Coach Patterson told a journalist for ESPN Dallas that Ed Wesley was ”fine 10 minutes after he got hurt”. On October 21, ESPN revisited the story by reporting that Dr. Haraldson apologized to Coach Patterson. Possibly the greatest mistake that a coach can make is to compromise an athlete’s health. A public disagreement between a coach and physician such as this may place athletes in a position where they may not truthfully report injuries. That is a true disservice to the athlete.

In football, a mistake may be catastrophic

Lest we forget, football is a dangerous game. Most injuries in football like all other sports are a result of a mistake. If injuries are to be prevented, the mistakes must be identified and then eliminated. Eric LeGrand from Rutgers University, unfortunately made the mistake of lowering his head during a kick-off during the 4th quarter of a game against Army. This mistake resulted in the axial loading of the cervical spine and in his case resulting in catastrophic damage to the 3rd and 4th cervical vertebrae. When the cervical spine is straightened by lowering the head, it turns into a segmented column. Axial loading through this segmented column may then result in displacement of one or more vertebra, which in turn damages the spine. New York Times published a thorough article illustrating Eric LeGrand’s injury and then follow up with an article referring to Adam Taliaferro’s cervical spine injury while playing football at Penn State in 2000.

Can we save football from ourselves?

Football is a sport where the excitement of the game is based on simple physics. Much effort is put into increasing the size of the athlete (to increase mass), increasing the athlete’s strength (to increase acceleration) and increasing the speed of the athlete (the velocity of the moving mass). During the course of the game/practice, it is not uncommon that these three properties come into play in the form of a projectile. As has been widely published lately, many of these projectile collisions are violent enough to create a cerebral concussion. The effect of multiple concussive forces has been demonstrated by the development of CTE (Chronic Traumatic Encephalopathy) in athletes. More recently, sub-concussive forces to the head are being studied. The New Your Times published a story regarding the thousands of sub-concussive forces during the course of a season in college football. The Chicago Tribune has also recently published an article referring to the thousands of sub-concussive forces during the course of a high school season. Then on October 7, 2010, USA Today published an article on the seemingly trend of football helmets inadvertently coming off during the course of the game. If we can step back (and think about the concept that injuries are caused by a mistake) and take a look at all of the contributing factors (mass, acceleration, speed, excessive hitting in practice, properly fitting helmet, etc), it is possible to save the game before we destroy it.

Time To Rethink How Practice is Conducted?

Practice gives greater exposure to concussive and sub-concussive forces than the games themselves. As reported in the New York Times, recent studies conducted on three NCAA Division I teams, a football team will encounter more than 2500 significant blows to the head that are in excess of 50g’s of force and approximately 200 head blows that are above 200g’s. These are just the blows that are of significance and are considered great enough for the athlete to sustain a concussion. The sub concussive forces that occur every time there is contact with another athlete or the ground are too great in number to count. The deaths of Chris Henry (Cleveland Bengals) and Owen Thomas (University of Pennsylvania) have shown the importance of limiting the exposure to sub concussive forces to the brain, not just those significant enough to create injury.

There have been some important research findings in the past few months that, if taken seriously, will lead to safer sport. Until recently, purposeful heading of the ball in soccer was considered a non-issue in regards to brain trauma. According to the American Academy of Pediatrics (AAP), the rate of concussions among soccer athletes in both recreation and elite leagues is similar to football and hockey. With the recent evidence of Tau protein formation resulting from multiple sub concussive hits to the head, the AAP has recently (released September 2010) altered their position that the “contribution of purposeful "heading" of the soccer ball to both acute and potential long-term concussive effects, such as cognitive dysfunction, seems less controversial today than previously.” (Clinical Report Injuries in Youth Soccer) The AAP is waiting for more definitive evidence to actually site the relationship between purposeful heading and long term brain damage. But the sport of soccer (or any of the contact and contact/collision sports) should not wait for long term studies to come to fruition before action is taken. Currently Chronic Traumatic Encephalopathy (CTE) can not be definitively diagnosed except through an autopsy of the brain.

Heat Illness is Preventable

Heat illness is preventable [period]. This also means that the associated complications that arise from a heat illness situation are also preventable. There is more to take into consideration than just temperature and hydration. With the proliferation of medications, dietary supplements and energy drinks, it is important to understand the effects and side effects of what the athlete is ingesting. Common side effects with many supplements and energy drinks include diuretic effects and increased core body temperature. This means that more emphasis needs to be placed on hydration and physically cooling the body. Heat illness and dehydration can also play a significant role in a condition known as exertional rhabdomylosis, a rare but serious condition resulting in increased levels of CK (creatine kinase) that may cause muscle and kidney damage. (Exertional rhabdomylosis is a major concern with athletes who carry the sickle cell trait.)

Knowledge of heat illness prevention and recognition is important knowledge for all levels of sport coaching. A football coach the state of Kentucky was arrested (also acquitted) for negligent homicide in the heat illness death of one of his athletes. Two Middletown, CT football coaches were charged with reckless endangerment (charges were also dropped) after an athlete collapsed from dehydration. While these cases resulted in the respective charges being dropped, this emphasizes the need to prevent preventable conditions such as heat illness.

Lou Gehrig's Disease May Be Connected to Concussions

There is no more important time than now to stress the importance of using a neurocognitive concussion test, like the ImPACT test, on all contact and contact/collision athletes. This means starting at the youth/club level and continuing through the elite and professional levels. There has been an effort to educate the sport culture about the danger of increased intracranial pressure caused by of Second Impact Syndrome (SIS). Now as this education effort is taking place, we find that SIS is not the only danger if an athlete is allowed to return-to-play before a head injury has been resolved. Chronic traumatic encephalopathy (CTE) has been identified by the Tau protein in the brains of former professional football athletes. This is a condition where repetitive concussive and sub-concussive forces to the head have resulted in depression and dementia-like symptoms. Dr. Ann McKee (Boston University Center for the Study of Traumatic Encephalopathy) was instrumental in discovering the Tau protein which is evident in CTE. She and the Boston University Center for the Study of Traumatic Encephalopathy are also instrumental in the very recent discovery (to be published next week in the Journal of Neuropathology & Experimental Neurology) which possibly has a significant connection between head injury and ALS (Lou Gehrig’s disease. In this study, another protein has been identified (TDP-43) creating a connection between ALS and head injuries. With evidence mounting concerning the effects of repetitive traumatic forces to the brain, if sport is to survive the athlete must be protected. Developing a concussion protocol and requiring neurocognitive testing must not be a thought for a sport league or athletic program. It must be a reality. What a coincidence that a concussion may have had a role in Lou Gehrig’s roll in securing a spot on the NY Yankees as well as in the disease that ultimately took his life.

See New York Times article:
Study Says Brain Trauma Can Mimic A.L.S.