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Why should football care about brain injuries?

In our first two posts on brain injuries and football we covered the consequences of brain injuries and how and when they happen during a football game. Today, we’ll answer the question of why people who care about, participate in, or own and run football teams should care about brain injuries. We’ll focus on the National Football League (NFL) in particular. The question may seem almost rhetorical to anyone who has a heart and has seen first (or even second) hand the terrible effect of brain injuries on a person but it’s not. Think about it this way. The cigarette and alcohol industries are still going strong and those products are usually harmful and sometimes fatal to their consumers. Football is only usually harmful and sometimes fatal to its workforce!

The first reason for why football should care about the damage it does to its workforce is the most obvious one: it’s unethical to employ people to do something as dangerous and unnecessary as football. Football is an entertainment product. If Hollywood actors were disproportionately suffering from early onset dementia and dying premature deaths, you can bet that Paramount pictures executives would be stumbling over themselves trying to solve the problem. Football is no different. That said, it’s probably unrealistic to expect that real change could come from this reason alone. There are too many convenient and legitimate rationalizations available to football decision makers: the science is unclear, players know what they’re getting into, life-changing salaries are a good enough reward to offset the risk, etc. We need more persuasive reasons.

If hitting football in the heart isn’t enough to create change, how about the wallet? This process has already begun. In the fall of 2013, the NFL settled in a class action lawsuit with 25,000 retired players and 9,000 relatives of deceased players. As part of the settlement, the NFL agreed to spend $765 million dollars on health care and compensation for retired players with any signs of dementia. That’s a lot of money and it may not be over. Just this week, Sports Illustrated ran a story about a group of around 220 retired players and their families who have opted out of the settlement. Why would they do that? According to Michael McCann, who wrote the story, the potential benefit is that “the NFL might offer improved settlement terms as a way of inducing the players to drop their new lawsuits. Or, should these lawsuits go to trial and juries hold the NFL liable, the potential damages assessed by jurors could be massive and far eclipse settlement payments.” The NFL is a powerful organization with an immense ability to represent themselves in all aspects of legal and political conflict but as long as these concussion lawsuits continue, they are vulnerable. Brain injuries are expensive.

Facing a threat from one end of the football spectrum, retired players, the NFL cannot lose sight of an equal threat from the other end: youth players. Unlike professional soccer teams in Europe, the NFL does not get most of its players through team-run youth academies. Instead, they rely on the many youth football leagues, like Pop Warner and American Youth, to get young football players started on the path to the NFL. Later, academic institutions take over as kids go through high school football and then through the virtually semi-professional ranks of major college football. This all costs a lot of money and the NFL doesn’t have to spend any of it. Using ESPN’s remarkable collection of expenses from major college football programs in 2008, we know that the top 119 college football teams cost a total of 5.4 billion dollars. Of course, they make almost that much in revenue today but the NFL could not expect that side of things to stay the same if they ran college football as a minor league developmental program. Youth football programs find great football players, train great football players, and they make celebrities out of them and the NFL benefits from all of this without paying the players or the organizations a single cent. Brain injuries are a real threat to all of this free player development that the NFL relies on.

In the past few years, lots of very public figures, influenced by the news about brain injuries, have stated that they would not let their sons play football: President Obama in 2014, sports writer Michael Wilbon in 2010, hall of fame NFL player and coach (and SNL subject) Mike Ditka in 2015. Even some NFL players have gone on record saying they wouldn’t let their kids play football. This has begun to have an effect. Steve Fainaru and Mark Fainaru-Wada reported for ESPN that “The nation’s largest youth football program, Pop Warner, saw participation drop 9.5 percent between 2010-12, a sign that the concussion crisis that began in the NFL is having a dramatic impact at the lowest rungs of the sport.” When the well starts to run dry, you bet the barons are going to worry about what’s stealing their oil.

The last reason why the NFL should care about brain injuries is purely speculative and far more anticipated than observed. Eventually, people will tire of watching the NFL if nothing is done to fix its brain injury issues. So far, television ratings do not support this thesis one bit but it’s hard to imagine that the popularity of football could continue forever without being damaged in some way by the growing popular understanding of the damage the game does to its players. The court of public opinion sometimes has a long appeal process but eventually the jury’s ruling will sink in if nothing can be done to fix football’s brain injury problem.

Tomorrow we’ll continue our series of posts on how to fix football with a discussion of the NFL’s history of rule changes and which elements of the game are most or least open to future changes. If you want to read more on today’s subject, I recommend Kevin Greir and Tyler Cowen’s essay in Grantland called “What would the end of football look like?”

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What do we know about brain injuries or concussions?

The sight of a football player knocked senseless or woozy during a game is common. For years, the culture of football was to celebrate the roughest elements of the game, including those that caused concussion symptoms like these. Of course, the word concussion wasn’t used, players were “dinged up” or “had their bells rung.” Concussed players rarely left the field, and if they did they were back as soon as they could walk straight. Today the way we observe, comment on, and handle brain injuries in football is very different. Now when a player goes down, we gasp, avert our eyes, and talk in hushed voices. We know now that brain injuries have serious short and long-term consequences. They can cause the toughest football players to seize up, be unable to tolerate sunlight, or vomit uncontrollably. In time, they can cause personality changes, aggression, and dementia.

What has changed? Well, we know more about brain injuries and their effects thanks to some powerful investigative reporting and promising scientific work led by the New York Times and Boston University respectively. The twin forces of knowledge and focus shifted public opinion but have not necessarily conveyed the full story in an easily understandable way. If you’ve ever wanted to understand what’s really going on when a brain is injured and how that pertains to football players, here is a summary.

Brain injuries are generally categorized into two groups: concussions and subconcussive events. Both are caused when a person’s head moves rapidly enough for the brain inside to scrape or hit the inside of the skull. In football, this is often the result of a blow to the head from another person’s body or the ground, but it can also happen if the head moves fast enough, even without impact. Of course, every injury is unique but it helps to classify them.

Concussions are injuries that have recognizable short-term symptoms that may not be present immediately after the impact. A concussed player may have a headache, loss of memory, and confusion. They may experience visual symptoms like blurred vision or seeing stars (this actually happens! it’s not just in cartoons). In some cases concussions may cause vomiting or loss of consciousness. Some symptoms of concussions are usually experienced with a short delay of a day to a week. These insidious symptoms include sensitivity to light, trouble sleeping, difficulty with concentration, and depression. Concussion symptoms may dissipate after a few days or may stick with a person for months or even years.
Subconcussive events are simply a description of any head trauma that does not cause a concussion. It’s not a very satisfying definition but subconcussive blows are an important concept because of how frequently they occur in football and their potential impact on the long-term effect of football on its players.

It’s hard to know how many concussions there are in the NFL and in other levels of organized football. Estimates range widely mostly because players and teams both have incentives to not report concussions as they happen. The NFL reported 228 concussions in the 2013-14 season, down slightly from 261 and 252 in the previous two seasons. That means every time a player steps on to a football field, (and 96 do, per game) he has a roughly 1 in a 100 chance of getting a concussion. Just from having watched a lot of football, that frequency feels about right. That would mean there is one reported concussion (too obvious to hide) in almost every game.

Football players certainly suffer concussions at a greater rate than normal people. They also suffer broken bones and torn ligaments at a significantly higher rate than normal people. Broken bones and torn ligaments never have and never will be seen as a pernicious element that could conceivably bring down football. The real problem is that a statistically significantly higher percentage of football players experience another set of physical and psychological symptoms that are almost definitely tied to brain damage. We are now morally certain that these symptoms are the result of a neurological disease called Chronic Traumatic Encephalopathy, or C.T.E., and that it has been caused by concussions or other brain injuries suffered while playing football. The New York Times, which did a lot of the earliest and best reporting on C.T.E. thanks to the work of Pulitzer Prize nominated journalist, Alan Schwarz, described C.T.E. as “a degenerative and incurable disease”. Here is the best description of the four stages of the disease from an article by Schwarz’ colleague Ken Belson:

Those categorized as having Stage 1 of the disease had headaches and loss of attention and concentration, while those with Stage 2 also had depression, explosive behavior and short-term memory loss. Those with Stage 3 of C.T.E…. had cognitive impairment and trouble with executive functions like planning and organizing. Those with Stage 4 had dementia, difficulty finding words and aggression.

The popular science author Malcolm Gladwell has also had a big influence on this issue. Gladwell wrote an article about brain injury in football which was published in the New Yorker in 2009. This article was the first one to shift my thinking about the game and it is well worth reading despite its relative age. Here is a quote from the piece which builds on the description of symptoms above:

C.T.E. has many of the same manifestations as Alzheimer’s: it begins with behavioral and personality changes, followed by disinhibition and irritability, before moving on to dementia. And C.T.E. appears later in life as well, because it takes a long time for the initial trauma to give rise to nerve-cell breakdown and death. But C.T.E. isn’t the result of an endogenous disease. It’s the result of injury.

Scientific and medical understanding of C.T.E. has come a long way but it’s still not entirely clear whether concussions or subconcussive events are the main cause of the disease. It’s understandably difficult to figure this out given that almost all football players will experience both types of brain injuries during their careers and that until recently even concussions with fairly dramatic symptoms were largely treated as an unavoidable consequence of playing football which was best ignored.

One of the biggest obstacles to learning more faster about C.T.E. and the brain injuries that cause it is that the disease can only be conclusively diagnosed by examining the brain after death. During a special autopsy, scientists are able to see if the brain shows the degeneration and accumulation of a protein called tau that are characteristic of C.T.E.. As heart-wrenching as it has been to read stories about the handful of football players who have shot themselves in the chest and left instructions for their brains to be studied, they and other players whose families have donated their brains posthumously, have been responsible for virtually everything we know about the disease so far. Luckily, there is some movement on this topic. Researchers at the Semel Institute for Neuroscience and Human Behavior at UCLA have been able to detect evidence of C.T.E. in living brains through the use of a particular dye and a “routine positron emission tomography scan.” In a 2013 Wired article on the topic, Sean Conboy writes that this test “also could help settle the debate over whether CTE is exacerbated by a few major concussions or years of exposure to subconcussive blows. And it could answer the most important question of all: How much tau is too much?

Another facet of testing that is rarely talked about is genetic testing. David Epstein explains in his book, The Sports Gene, that there is a single gene called ApoE that is predictive of Alzheimer’s disease as well as “how well an individual can recover from any type of brain injury.” There are three variants of the gene and everyone has two copies, one from their mother and one from their father. One variant, ApoE4, is particularly bad. People with one copy of ApoE4 are four times more likely than the general population to develop Alzheimer’s, and people with two copies are eight times more likely. Nothing has been proven about any connection between ApoE4 and C.T.E. but, given that people with copies of that gene variant “take longer to recover” from brain injuries and “are at a greater risk of suffering dementia later in life,” it seems likely.

As it stands today, the only sure thing is that C.T.E. is horrible and deadly. Until we know otherwise, I am going to assume that all blows to the head or which cause the brain to hit the skull contribute to the potential development of C.T.E. and that the more violent the impact, the larger its negative consequence. Until the day (and that day may never come) when science can definitively predict which injuries and which players are on the road to C.T.E. and medicine can prevent those players from getting the disease, football has a responsibility to understand how players are injured and to find ways to reduce or eliminate the danger.

This is the first post in a series of posts about brain injuries in football and how to fix the sport. In our next post, we’ll discuss how brain injuries or concussions happen. What kinds of hits cause them? Why do players escape some collisions unscathed and stumble away from others?

Football brilliance and its price, but is there hope?

Football, football, football. It’s mid-fall and my brain is still full of football. Soon, basketball, and hockey will creep in. Once in a while, a blip of tennis or soccer or volleyball pops up, but for the most part, it’s football, football, football. The sports media is equally obsessed and luckily for all of us, its producing a ton of great stories about football. Here are three from the past week that I want to share with you because of their great writing and impressive subjects.

Odell Beckham Jr.’s Catch Was A Culmination: A Former WR Explains

by Nate Jackson for Deadspin

Nate Jackson is a retired NFL player and the author of an insightful book about life in the NFL called Slow Getting Up. In this article for Deadspin, Jackson gives his thoughts on the incredible catch made by Odell Beckham last week that has widely been called the (or one of the) best catch in the history of the NFL. Jackson describes how difficult playing receiver is and also how little leeway the NFL’s obsessive coaches give players to practice the incredible.

But you can’t just play catch and call yourself a receiver. You have to get open. To get open on a route, you tell a lie with your body. This is harder than it seems. You may think you are leaning one way, but you’re not. To pretend to go one way when you really plan to go another way is counterintuitive. To do so at top speed requires a full-scale deception perpetrated against yourself. Every muscle, every bone, every ligament must be in on the lie, lest the defensive back see through you, and crush you.

But let’s think about something here, for one moment. ODB, a man with the football skills we just witnessed, is not allowed to trust his football instinct UNTIL the ball is in flight. He must stick to the PLAN until the ball is let go. …in the NFL, the freedom to improvise exists only for the quarterback. And even for him, it is rare. Our finest football players, men who would make Batman blush, must adhere to the small-minded tactics of a bygone era. And the arbiters of that era, uncoincidentally, are the men who also cannot conceive of such a catch being made in the first place.

Real Life or Fantasy?

by Joe Posnanski for NBC SportsWorld

It’s probably worth noting that Odell Beckham, the player who made the amazing catch described in the first article, didn’t finish the game he made it in. He left the game hurt although he did play in the next game. That’s the life of an NFL player — play, get hurt, play, get hurt. Rinse, repeat, until it’s time to retire. This is the story of a player who, in his day, scored more touchdowns and took more hits than almost anyone else and what his life is like now.

Housewives wrote thank you notes to him. Office workers built desk shrines to him. People around America would spend more time in the fall thinking about Priest Holmes than they would about their families. They named their fantasy teams after him – “Holmes Wreckers” and “Judas Priests” and “The High Priest of Touchdowns” – and they moved their lineups around him and they spent their Sundays shrugging when opponents took a big lead because nothing mattered, nothing at all, until Priest Holmes stepped on the field and began his weekly fantasy football scoring spree.

The greatest fantasy football player of them all looks for cracks in the ground when he walks now. “Cracks,” he says. “Divots. Unlevel ground. A shift in the pavement. A crack in the hall.”

He looks for these things because the tiniest variation in elevation can throw his body now. If he hits one of those cracks just a little bit wrong, his ankle turns. His hip jolts. “I can blow out a knee,” he says. The body that once bounced off the ground after the most savage crash went dark now teeters with the slightest incline or dip.

Each week took a terrible toll on him. He would remember Friday nights when he still wasn’t sure if he could play. That’s because: The feeling happened every Friday night. “Something would happen between Friday night and Saturday night,” he says. “I guess it was the mental training of it, I’d just done it so many times that my body would come together. “But I would know that the minute that game ended on Sunday, I wasn’t going to be healthy Monday, Tuesday, Wednesday or Thursday. It would be back to Friday, and me saying: ‘Come on body, I need you one more time.’”

Concussions, by the New Book

by Bill Pennington for The New York Times

Times have changed in the NFL since Priest Holmes played. Sure, his career would have been ended by the knee and hip injuries that ended his career anyway, but perhaps, thanks to a new comprehensive policy on head injuries, the mood swings and scary loss of feeling that Holmes suffers from may have been lessened or prevented. There is some hope.

Once, the treatment of players with head injuries varied from team to team and could be haphazard. Beginning last season, all players suspected of having a head injury — should they lose consciousness from a collision or experience symptoms like a headache, dizziness or disorientation — were required to go through the concussion protocol system. It features a broad cast: a head-injury spotter in the press box, athletic trainers on the bench, doctors and neuro-trauma specialists on the sideline and experts in neuro-cognitive testing in the locker room.

Each doctor interviewed for this article said a consensus in the “Go or No Go” moment is usually reached easily and without disagreements. No one recalled discord. “Ninety percent of the time, it’s pretty obvious,” Kinderknecht said. “It’s not a whole lot different than talking to somebody who is intoxicated. You can tell.”

It is becoming more commonplace for players to self-report a head injury… Players are also policing one another, tipping off the trainers that a teammate acted oddly in the huddle. Gossett said he had seen game officials alerting medical personnel as well.

The benefit of learning toughness from sports

You have to be tough to play sports. That’s a central message of most sports cultures that gets hammered into athletes brains from a very young age. Sports culture is fairly unyielding on this principal. “Walk it off.” “There’s a difference between being hurt and being injured.” “Rub some dirt on it.” These common phrases are just some of the ways that parents, coaches, and peers all reinforce that core tenant of sports, playing through pain. We also honor professional athletes who play through pain. Michael Jordan’s flu game, where he scored 38 points despite being visibly ill is legendary. Willis Reed coming out to play in game seven of the 1970 NBA finals despite having a torn thigh muscle is equally famous. In baseball, Kirk Gibson’s hobbled home run in the 1988 World Series remains one of the most famous plays ever. Football players make playing through injury so routine that you needn’t look farther back than a few weeks ago when quarterback Tony Romo broke two bones in his lower back and came back to finish the game. No sport lives its injury ethos more diligently than hockey. In the 2013 playoffs, Gregory Campbell broke his leg during a penalty kill and played on it for more than a minute before getting to the bench. In that same playoffs, Campbell’s teammate Patrice Bergeron played through broken ribs, torn cartilage around the ribs, a punctured lung, and a separated shoulder. Just this season, Olli Maata, played with a cancerous throat tumor. He played until his scheduled surgery, which doctors think was successful, and is now back skating, ahead of schedule to return for his team. Not only does hockey culture demand this of its players, but it demands that they play through injury immediately (thus the phrase, “player A [suffered this injury] and didn’t miss a shift”) but without complaint.

Playing through pain isn’t always a good thing. We now know that ignoring the effects of brain injuries is a very, very bad thing to do. The culture is slowly shifting to be more permissive of players who voluntarily report injuries or who choose to sit out a game or two to get healthy. This is almost definitely for the best but it’s easy, when in the midst of a cultural shift, to forget the benefits of the element of the culture that is changing. There are real benefits to the principals of toughness that sports instills in its participants. Most of us who play sports don’t become professional athletes. We’ll never need to play basketball while unable to properly walk or hockey while in intense pain but all of us are people who, at some point in our lives, will face intense challenges. Whether it’s fighting through a flu to watch your child perform in something important to them or suffering from a disease or handling the anguish of a loved one’s death or giving birth, no one makes it through life without being faced with a painful situation. The benefit of learning toughness from sports is that it’s there when you need it.

Nowhere is the benefit of having learned toughness from sports more clear than in the amazing story of Mikey Nichols. Brought to us by Steve Politi of NJ.com, this is a truly inspiring story. Nichols was playing hockey for his high school team from Monroe, NJ, when he suffered an injury to his spine which left him paralyzed:

He was chasing a puck in the corner when he was checked from behind. “I remember sliding into the boards and thinking, ‘Oh (shoot), I’m going to get a concussion. I don’t want to miss a shift.’ And then I hit the boards.”

He knew something was very wrong.

“Mikey, you good?” his best friend asked.

“I’m fine, bro. I just can’t move anything.”

Hockey culture informs its players that they should respond to all injuries with casual indifference. Yes, he’s fine. He just can’t feel his body. But he’s fine. Viewed from afar, the fact that the sport Nichols loves might have informed how he responded to a catastrophic injury he suffered while playing the sport may seem like not nearly enough to balance the scales in favor of hockey and sports culture. But when you read Politi’s article, you get a sense for how amazing Nichols is and how having grown up a hockey fan and player doesn’t just inform the moments after the injury, that it’s going to be a part of who he is forever, no matter what challenges he faces, then you start to think about things differently.

“To play in the NHL, of course,” is what Mikey will say when you ask him his goals. But then he’ll get serious. He’ll talk about his parents and the sacrifices they’ve made. “I want to be able to do everything I used to take for granted, and now I wished I had back.”

Maybe it’s The Big Idea that’ll give him that. Maybe it’ll be some other promising research. But, after spending the past 10 months meeting other people with spinal-cord injuries and benefitting from their help, he hasn’t lost hope.

“I want everyone who’s ever had to be in a wheelchair to walk again,” he said. “And to get a second chance.”

Getting paralyzed during a sporting event is horrible and I wish it never happened. There are some common-sense things hockey could change to avoid more of these injuries and they should absolutely do them. They are rare though. Nichols is one of the small percentage of people who suffer a life-changing injury playing sports but his attitude is an inspiring reminder that the lessons taught in sports can help all of us overcome (the hopefully smaller) the challenges that life presents to us. Just remember, if Nichols can figuratively say of himself, “hockey player becomes a paraplegic, doesn’t miss a shift” we can do it too.

What does probable or questionable mean on the NFL injury report?

Dear Sports Fan,

First time playing fantasy football here. What does it mean when someone is listed as Probable or Questionable? If someone (say Andre Ellington) has a Sunday game and has not been seen in practice till Wednesday, is it a sign they won’t start that week? Also, what kind of injuries are the worst? Ankle?

Best regards,
Mengster

— — —

Dear Mengster,

It sounds like you’ve really caught the Fantasy Football bug! As I wrote in my recent post about what it means to start or sit a player in fantasy football, predicting which players on your fantasy team are most likely to play well in their real games is a big part of playing fantasy football. A player who is too injured to play is 100% positive to not score any points for your team, so researching and following your players’ injuries is important business. Luckily for us, NFL teams are required to put out injury reports every day which file all of their players as either healthy or under one of the four possible standard injury designations: out, doubtful, questionable, and probable. It’s actually not luck, the NFL requires teams do this because having this information makes gambling on football and fantasy football games possible. Oh, the NFL wouldn’t say that if you asked it^[1] but it’s true nonetheless.

NFL injury designations are officially tied to percentages. Out = 0% likely to play. Doubtful = 25% likely to play. Questionable = 50% likely to play. Probably = 75% likely to play. In reality, that’s not actually the case. The Wall Street Journal ran an article a few years ago about what the real percentages for these labels were. In it, they discovered that Doubtful players played less than 3% of the time, Questionable was closest to its “proper” percentage, just a little higher than 50% — around 55%. Probably players played more than 90% of the time. Although the article is from 2011 and the stats go back to 2006, I don’t think much has changed. I wrote my own qualitative descriptions of what each designation means in an answer to similar question last year from someone who asked about the injury report:

Probable — if a player is probable, he’s almost definitely playing. The team is either following the requirements and reporting that the player did not practice because they are suffering from some minor ailment or the team is trolling the system by obscuring real injuries with fake injuries to avoid giving their opponents the advantage of knowing who is actually hurt. This is a classic move of Bill Bellichick and the New England Patriots who once listed quarterback Tom Brady as probable for a few years despite him not missing a game.
Questionable — this designation is the only one that’s legitimate. A player listed as questionable might play or might not.
Doubtful — a player who is doubtful for a game is almost definitely not playing, the team just isn’t willing to admit it yet. According to this article about how bookmakers should use injury reports, only 3% of NFL football players listed as doubtful, play.
Out — nothing to see here, a player listed as out is definitely not playing in the upcoming game.

When thinking about fantasy football, I generally assume that players listed as “probable” are fine. For players listed as “questionable,” I dig in and do some research about their specific situation. Have they, like you said, been practicing? What kind of injury do they have? Did it knock them out of the last game or were they able to finish? You can generally learn a lot about a “fantasy relevant” player’s injury. For example, in Andre Ellington’s case, I can tell from Rotoworld.com that he “remains on track to play in this week’s game against the 49ers.” So, he’s probably fine for this week. A lot of players, especially running backs (who take the most hits) and veterans will regularly skip a day of practice. It’s not necessarily a bad thing. What you want to watch out for is someone who’s designation gets worse during the week (moves from Probably to Questionable) or someone who wasn’t on the injury at the start of the week but is by the end. Those are both bad signs for their likelihood of playing on Sunday.

In terms of what injuries are the worst, that’s probably worth its own post. I can say from having played fantasy football for years and followed a lot of sports in general, that the injuries which seem to keep players out for the longest are (excluding obvious things like broken bones, torn ligaments, and concussions): high ankle sprains, turf toe, and foot sprains. I know, those things sound less serious than rib or hip injuries, but an athlete lives and dies by his or her ability to plant off one foot and switch directions. You need your ankles, toes, and feet healthy to do that!

Good luck in your fantasy game this weekend,
Ezra

Footnotes (↵ returns to text)

It would probably say, “AHH!! A talking league??!”↵