Professional sports have always been big business, but when players' heads are being sacrificed for that all important win, it is time to draw the line.
Former athletes have been known to have a particularly difficult time settling back into everyday life after retiring from their successful careers. However, the reported eccentric behaviours of Super Bowl legend Mike Webster took this phenomenon to a whole other level. From his rotten teeth falling out, accompanied by his tendency to glue them back into place, to self-administered electric shocks [1], Webster’s behaviour represented a problem far more sinister than an identity crisis.
Under Pressure
In 2002, when Webster passed away from a heart attack, a young forensic pathologist Bennet Omalu was assigned to perform a routine autopsy. Fuelled by his own curiosity, he was eager to have a closer look at Webster's brain. At first glance, there were no anatomical signs of deterioration, but upon closer inspection, he identified that Webster’s brain had amyloid plaques and neurofibrillary tangles in the neocortical regions, an area linked to hearing and sight [2].
Omalu deduced that the brain was affected by Chronic Traumatic Encephalopathy (CTE). CTE, colloquially known as ‘punch drunk syndrome’, is the result of a series of neurological injuries that typically lead to the pronounced atrophy (shrinkage) of the frontal and medial temporal lobes, enlargement of the lateral and third ventricles, and in some cases, degeneration of the amygdala and the mammillary bodies [3]. Ultimately, CTE results in lower executive functioning and cognitive decline, across domains of memory, problem solving skills and self-control, all deficits which Webster had displayed [3].
Figure 1. A coronal view of a brain affected by advanced CTE showing generalised atrophy and severe degeneration (marked temporal lobe degeneration [the bottom half]) [4].
Omalu’s findings provided fresh evidence surrounding the controversial issue of head trauma in the NFL. Omalu published his findings, “Chronic Traumatic Encephalopathy in a National Football League Player”, in the journal ‘Neurosurgery’ and much to his surprise, the NFL was unimpressed. Feeling more pressure than that imposed on a defensive lineman’s skull, the NFL demanded a retraction of the article [5]. In response, the NFL, under the Mild Traumatic Brain Injury Committee, published a series of controversial papers. Notably, in a paper led by the head of the MTBI committee, it was said that due to a ‘selection’ process, in which those who are more susceptible to MTBI do not progress to a professional level, NFL players are ‘probably less susceptible to MTBI and prolonged post-concussion syndrome than the general population’ [6].
Figure 2. The MBTI attempted to undermine neurologist Bennet Omalu’s academic reputation [7].
A Far and Wide Crisis
Failure to realise the severity of head trauma is not isolated to the NFL. A 2021 study found that nearly 20% of NRL players who had sustained a suspected concussion did not report it to their trainer, coach or doctor [8]. When questioned, players disclosed that not wanting to miss training or let the team down motivated their decision. This suggests that a deeper social problem is responsible for what many perceive to be as careless behaviour.
At an organisational level, there are many improvements to be made. The AFL’s return-to-play policy states that a player returning from concussion is prohibited from entering the graded loading program (a modified and incremental increase in training) for 24 hours after all symptoms have been alleviated [9]. While this policy may seem sufficient, it fails to acknowledge recent scientific findings in which Australian AFL players were the subjects. The data suggests that the brain has increased susceptibility to further injury for up to two weeks following the initial trauma, due to increased neurofilament levels, even when an athlete is asymptomatic [10].
Figure 3. A strong feeling of ‘owing it to the team’ means that many athletes fail to report concussions [11].
Future Directions
Further research is needed to validate the effectiveness of these policies through analysis of the successes and failures of previous strategies. Sporting organisations must work with medical specialists to develop evidence based policies that can be effectively implemented and practiced at every level of management in both professional and amateur sports. Furthermore, these policies need to both evolve as new scientific findings emerge and address the responsibilities of all involved, including community clubs, medical officers, coaches, parents and athletes. It is essential that these policies take into account the unique neurological considerations of children and adolescents, who are in particular danger of disturbing their neuron maturation, while simultaneously being less likely to disclose or recognise concussion symptoms [12].
A successful example of such a policy is Netball Australia’s ‘Concussion Policy’, which was released in 2018 [13]. The policy, which is based on resources and information supplied by the Australian Institute of Sport, the Australian Medical Association and the British Journal of Sports Medicine, mandates that before returning to play, all athletes must be cleared by a physician. This practice has been proven to be more effective in recognising concussion than the strict application of baseline measurements [14]. Through similar collaborative efforts, the social and organisational weaknesses that allow for the inappropriate management of head injuries in sport can be better tackled (wearing an appropriately padded helmet, of course).
References:
[1] Lau E. A head on collision with the National Football League. The Lancet Neurology. 2016; 15(7).
[2] Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery. 2005; 57(1), 128–134.
[3] Stern R, Riley D, Daneshvar D, Nowinski C, Cantu R, McKee A. Long-term Consequences of Repetitive Brain Trauma: Chronic Traumatic Encephalopathy. PM&R. 2011;3:S460-S467.
[4] Boston University Center for the Study of Traumatic Encephalopathy. Chronic Traumatic Encephalopathy. Wikimedia. 2014. Available from: http://www-tc.pbs.org/wgbh/pages/frontline/art/progs/concussions-cte/h.png
[5] Casson IR, Pellman EJ, Viano DC. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery. 2006;58(5):E1003.
[6] Pellman EJ, Viano DC, Casson IR, Arfken C, Powell J. Concussion in Professional football: Injuries involving 7 or more days out - Part 5. Neurosurgery. 2004;5(5)
[7] Wilkinrim1. Bennet Omalu. Wikimedia [Internet]. Available from: https://commons.wikimedia.org/wiki/File:Omalu_Picture_(7).jpg
[8] Longworth T, McDonald A, Cunningham C, Khan H, Fitzpatrick J. Do rugby league players under-report concussion symptoms? A cross-sectional study of elite teams based in Australia. BMJ Open Sport and Exercise Medicine. 2021;7
[9] AFL. The management of sport-related concussion in Australian Football [Internet]. 2021 [cited 3 June 2021]. Available from: https://resources.afl.com.au/afl/document/2021/04/26/9a186f44-ad48-4fab-b6ab-e4be45a578d7/Management-of-Sport-Related-Concussion-in-Australian-Football-25-April-2021-FINAL.pdf
[10] McDonald SJ, O’Brien WT, Symons GF, Chen Z. Prolonged elevation of serum neurofilament light after concussion in male Australian football players. Biomark Research. 2021:9(4)
[11] Beausjour J. blacks australia. Wikimedia [Internet]. Available from: https://commons.wikimedia.org/wiki/File:2011_Rugby_World_Cup_Australia_vs_New_Zealand(7296125200).jpg
[12] Browne GJ, Dimou S. Concussive Head Injury in Children and Adults. Australian Family Physician. 2016: 45(7)
[13] Netball Australia. Concussion Policy [Internet]. 2018 [cited 23 June 2021]. Available from: https://wa.netball.com.au/sites/wa/files/2020-01/Concussion-Policy-Netball-Australia-approved-2019%20%281%29.pdf
[14] Fuller GW, Tucker R, Starling L, Falvey E, Douglas M, Raftery M. The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study. Sports Medicine. 2020: 6(2)