Part 1: The NFL
By Andrew M. Blecher MD
Collision sports are full-contact sports with a greater than average risk of injury. They include sports such as football, rugby, ice-hockey, mixed-martial arts and boxing. But there is something different about the last two. In the professional sports of MMA and boxing the intent is to hurt your opponent. In fact the best outcome would be to knock-out your opponent. Since a knockout is a concussion, the intent of the sport is therefore to cause brain injury to your opponent. How can this be right? In fact, for decades the American Medical Association has called for banning professional boxing for this very reason. From the Summaries and Recommendations of Council on Scientific Affairs Reports 1999 AMA Annual Meeting:
“Until such time as boxing is banned in this country, the following preventive strategies should be pursued to reduce brain and eye injuries in boxers: (a) Ideally, head blows should be prohibited…The World Boxing Council, World Boxing Association, and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting including APOE e4 screening, neuroimaging, clinical neurological assessment, neurophysiological assessment, and indices of cumulative brain injury… [They] should develop and enforce standard criteria for referees, ringside officials, and ringside physicians to halt sparring or boxing bouts when a boxer has experienced concussive or subconcussive blows that place him or her at imminent risk of more serious injury…The AMA will: Promote the concept that the professional responsibility of the physician who serves in a medical capacity at a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not be controlling. The physician’s judgment should be governed only by medical considerations.”
Now wait a second. This sounds very familiar. This was over a decade ago, but if you re-read this and replace “boxing” with “football” and replace “World Boxing Council” with “NFL”…. suddenly it perfectly describes today’s current events. Football is an inherently dangerous sport. We know this. It has an injury rate of over 100 percent. With an injury rate that high, there must be something within the sport that includes intent to cause harm. Do 100 percent of NFL players get injured and they are all just “work-related accidents”? Or does the “Bounty” scandal illustrate that there may be something else going on? NFL players have a higher rate of injury than any other profession according to the National Worker’s Compensation Board. But just being a dangerous sport isn’t the problem. It is specifically the specter of traumatic brain injury and its long term affects that defines football’s current crisis.
The problem with boxing is that the cumulative concussive and subconcussive blows (especially those that are not medically managed correctly) are risks for developing long term brain injury. That brain injury has a name. It’s called Dementia Pugilistica, also known as chronic boxer’s encephalopathy, traumatic boxer’s encephalopathy, boxer’s dementia, chronic traumatic brain injury associated with boxing (CTBI-B), and punch-drunk syndrome. This is not something new. It was first described in the 1920’s. But the injury that is new is CTE or Chronic Traumatic Encephalopathy. What’s the difference? Well nothing really, other than the fact that it’s what we use to describe the exact same condition but in non-boxers… namely, Football Players.
The evidence might not yet be as clear-cut in football as it is in boxing and some will say that we shouldn’t jump to conclusions, but we are starting to connect the dots and medical research is catching up. As the brain bank full of ex-football players with CTE continues to grow we must acknowledge that although the object of football might not be to cause brain injury, as it is in boxing, there does seem to be a growing preponderance of evidence that the game of football is not good for brains. But what about the helmets, you ask? There are no helmets in boxing but we have the best helmets that money can buy in the NFL. Surely that must make a difference. Unfortunately it doesn’t. There has never been a single medical study to show that helmets reduce the incidence of concussion or long term brain injury. Do they reduce the incidence of skull fracture and death due to acute brain trauma? Absolutely. But that’s not what we are discussing here. We are concerned with long-term cumulative brain injury.
Let’s take a quick look at how helmets are tested. The majority of helmets that are used for recreational activities such as biking and skiing and skateboarding are designed to withstand a single impact. This means that the helmet absorbs impact by deforming and is therefore intended to be replaced after a single impact. However, in contact sports, helmets are certified by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) to withstand multiple impacts. How does NOCSAE test these helmets? Approximately 27 different impacts are created at different locations on the helmet with different velocities and under different temperature conditions. “A passing helmet model is able to withstand all impacts.” This means that the helmet survived the impacts. It says nothing about the forces that occurred inside of the helmet and whether the accelerating/decelerating brain inside of the skull that is inside of the helmet can survive those impacts. Furthermore, 27 impacts occur in a single day’s worth of a football game or practice. So these tests do not measure whether the helmet can survive an entire season of impacts.
So the majority of helmets are indicated for single use only. But some, such as football are indicated for repetitive use. Does this mean that they prevent the effects of repetitive or cumulative brain injury? No. It just means that with repetitive use the helmet (or your skull for that matter) won’t break down. But even still, the helmet needs to be refurbished or replaced after a certain amount of use. But what about your brain? Does it get to be refurbished or replaced after a certain amount of use? Isn’t it time that the helmet companies and NOCSAE start calling the football helmet what it really is? It’s a device that will protect your skull up to a certain amount of wear and tear but has no claims whatsoever for protecting your brain against long term brain damage. In fact, it’s really a device that is only certified to withstand 27 impacts. So therefore it should only be used for one day of playing football. So either NOCSAE has to develop more rigorous testing, or the certification should only be good for one day of use and football players should only be allowed to wear a helmet for one day until it needs to be replaced. Otherwise it violates NOCSAE standards. Since the NFL, NCAA and National Federation of State High School Associations all require the use of NOCSAE approved helmets, one could therefore say that in order to be in compliance, each of these organizations would need to supply its players with new football helmets for every single day of use. While the NFL might be able to afford this, surely most colleges and high schools could not. So if someone were so inclined to “legislate the banning of football” all they would have to do would be to deny government funding (high school and collegiate) to schools that weren’t following these standards. I am not going so far as to say that this is what needs to be done, however, it is important that we all understand what is currently occurring with football helmet use and certification. I can guarantee that these are facts that the majority of past and present football players are unaware of. Once we have all completely digested and understood these facts, can we then make well-educated decisions about whether or not we want to play football. And if we as a society (or the AMA as a medical society) decide that playing this dangerous game of football should not be allowed to continue in its current form until a helmet can be designed to prevent the long term brain damage… Well, then we may in fact be seeing the beginning of the end of football as we know it.
Ultimately isn’t that what today’s crisis is all about? We already know what the potential effects of football related concussions and head injuries are. The cat is out of the bag. The question is whether or not the NFL has understood this and made sure that its players were fully informed about the risks. How the NFL chooses to handle its past is up to them. But going forward let’s make no mistake… EVERY NFL PLAYER SHOULD BE FULLY INFORMED THAT PLAYING PROFESSIONAL FOOTBALL CARRIES AN INCREASED RISK OF HEAD INJURY WHICH MAY HAVE LONG-TERM EFFECTS AND HELMETS DO NOT PREVENT THIS. Does this mean that professional football needs to be banned or changed? No, I don’t believe that it does. But we do need to be aware of what it is. Let’s call a spade a spade. Let’s not gloss over the issue by having a safety first campaign, or throwing millions of dollars towards helmet research or touting an independent neurologist on the sidelines and that concussions are finally going to be managed correctly. These things are great and long overdue, but they ultimately don’t negate the fact that unless repetitive head contact is taken out of the game of football, (let’s say it again): EVERY NFL PLAYER SHOULD BE FULLY INFORMED THAT PLAYING PROFESSIONAL FOOTBALL CARRIES AN INCREASED RISK OF HEAD INJURY WHICH MAY HAVE LONG-TERM EFFECTS AND HELMETS DO NOT PREVENT THIS. I don’t know whether or not that means that every player needs to sign something that clearly illustrates this understanding before they play in the NFL. I will leave these issues up to the lawyers. Whether or not the NFL recognizes itself for what it truly is will be something that may ultimately end up being determined in a court of law. But what I do know is that sooner or later the public will realize what the NFL truly is. It’s bloodsport. It’s still a great sport. It’s entertaining and love it or leave it, it’s part of our culture. But let’s not call it safe anymore. It’s a very unsafe sport and it’s a very unsafe profession. If players fully understand their risks and agree to play, and spectators understand the risks and agree to watch, then the NFL will continue to exist, just as it has… just as boxing has. And I will continue to watch.
Stay tuned for the more complicated part of the story with Part II of “The Reclassification of Football: The Collegiate, High School and Youth Game of Football”.
Dr Andrew Blecher is a Board Certified Sports Medicine physician at the Southern California Orthopedic Institute. He provides concussion management for both amateur and professional athletes including youth sports, high school and college, and he also has experience as a physician in the NFL as well as for the Los Angeles X-Games. He is a Certified ImPACT Consultant and has lectured extensively on concussions from hospital grand rounds to national conferences. By providing continuing education to other physicians, athletic trainers, coaches, parents and athletes, he strives to improve concussion awareness and prevention. Dr Blecher is also the Director of the SCORE Concussion program which, in partnership with the Wells Fargo Play it Safe Program, provides comprehensive concussion insurance coverage for 10 Los Angeles area High Schools.
