By Diane Carman
Dave Stalls is a burly guy, the size of a linebacker. He isn’t really a linebacker, though. He is a former NFL defensive tackle and defensive end. Since he retired his cleats, the affable president and CEO of Big Brothers/Big Sisters of Colorado has spent 17 years working with young people.
Despite his tough exterior, Stalls admits he’s “really scared,” both for himself and for young athletes.
“All of us (former NFL players) are used to dealing with the knees, bad shoulders and the back, but to have your brain threatened, that’s really scary,” he said.
Stalls has read the research. He’s talked to retired football players. He’s seen the news stories about dementia, depression, Alzheimer’s, insomnia, violent behavior, headaches, even suicides attributed to brain injuries from concussions and sub-concussive impacts. He’s listened to a neurologist tell him that the results of his tests indicate that he’s “on the cusp.
“He told me that the test results indicate I’m between OK and the beginning level of concern,” Stalls said. “It’s scary, really scary.”
One of the oldest studies of the impact of concussions on athletes was published in an obscure Texas medical journal in the 1970s. Dr. James Kelly, professor of neurology at the University of Colorado School of Medicine, said the bottom line of that research was that the longer a boxer fights, the smaller his brain gets.
Recent studies, which use the results of annual CT scans of the brains of all boxers who compete in New York, confirm the progressive brain atrophy in athletes who experience blows to the head. A whole range of studies has found characteristics of chronic traumatic encephalopathy in football, hockey and soccer players as well as other athletes who have suffered head injuries.
Among the high-profile researchers working to understand the mysteries of traumatic brain injuries along with Kelly are Ann McKee, associate professor of neurology and pathology at Boston University, and Kevin Guskiewicz, director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at the University of North Carolina at Chapel Hill.
McKee, who has done post-mortem examinations of the brains of persons diagnosed with dementia, Parkinson’s disease and Alzheimer’s for more than two decades, discovered in 2003 that the brain of a man who had been diagnosed with Alzheimer’s at the age of 58 showed no sign of the telltale beta amyloid protein of that disease upon his death at the age of 72.
Instead she found extraordinary evidence of the tau protein and other signs of chronic traumatic encephalopathy or CTE.
The man was a boxer. His condition was not Alzheimer’s; it was CTE caused by repeated blows to the head.
In testimony before Congress in October 2009, McKee described her research, which has found unmistakable evidence of CTE in the brains of football players ranging in age from 82 to 18.
Evidence of CTE also was found in the brain of Owen Thomas, the 21-year-old University of Pennsylvania football player who committed suicide last April. Thomas had no recorded history of concussions, leading researchers to conclude that repeated sub-concussive impacts likely caused the brain injuries.
Guskiewicz, meanwhile, has focused his attention on diagnosing and understanding concussion among athletes and the role the athletic trainer has in protecting players from complications resulting from repeated impacts. Guskiewicz, Kelly and several other experts on concussions co-authored a paper four years ago on the dangers of sports-related brain injuries, which was the basis for the revisions of the NCAA guidelines issued last April.
It has changed the way colleges and universities manage players who experience concussions.
Trainers follow new guidelines
The NCAA guidelines call for all member institutions to have “a concussion management plan on file.” The plan should provide for the removal from play of any athlete “who exhibits signs, symptoms or behaviors consistent with a concussion.” The athlete is to be “evaluated by an athletics health care provider,” and return to play is to be determined by the “team physician.” Student athletes “should be presented with educational material on concussions” and “must sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff.”
Athletic trainers at both the University of Colorado and Colorado State University say they are in full compliance with the NCAA recommendations. They also say that they are realistic about how much the young athletes are willing to cooperate.
“Some don’t want to be completely forthright with us about their symptoms,” said Terry DeZeeuw, head athletic trainer at CSU. “That’s why it’s so important for us to educate the student athletes about the risk of concussion, especially with the heightened sense of awareness nationally. We see a lot more parents involved in this as well.”
Miguel Rueda, head trainer for the CU-Boulder Athletic Department, said that all student athletes at CU have participated in an educational program about the risk of concussion and have signed statements saying they will bring injuries to the attention of the training staff.
“I think for the most part, they have embraced” the plan, which requires a minimum of four days off for an athlete after experiencing concussion symptoms, he said, but he admitted “if an athlete doesn’t come forth and tell you about an injury and the issues there, we can’t treat it.”
NCAA definition of concussion:
“An injury resulting from a blow to the head causing an alteration in mental status and one or more of the following symptoms prescribed by the American Academy of Neurology Guideline for Management of Sports Concussion: headache, nausea, vomiting, dizziness/balance problems, fatigue, difficulty sleeping, drowsiness, sensitivity to light or noise, blurred vision, memory difficulty and difficulty concentrating.”
Anyone who has worked with young athletes acknowledges the cultural pressures to conceal any injuries that might put them on the bench.
“It’s just part of the code,” said Stalls, the retired pro, who remembers what it was like to play in college. “If you get knocked out or knock somebody else out, it’s a badge of honor. You are sacrificing your body. You’re a man. You are better than the rest. Unless somebody removes you, you’re not going to remove yourself.”
All the incentives argue against athletes self-reporting head injuries, Stalls explained. College scholarships, performing on the field for scouts who are recruiting for professional teams – all that and the intensely competitive culture of teammates make it unlikely that athletes are going to reveal anything but the most severe symptoms.
“Unless an athlete is clearly woozy or goes to the wrong huddle or the wrong sidelines … there’s no way for a trainer to know about a head injury,” said Stalls. “Yet we know if the player thinks he’s not going to get back in the game for days and will likely lose his position because of it, he’s not going to say anything.”
Love of game prevails
Twenty-two-year-old Scotty McKnight disagrees. He said the culture on the field has changed dramatically since he was playing rough-and-tumble high-school football just a few years ago in Southern California.
“It was the getting-your-bell-run thing,” said McKnight, a wide receiver on the CU football team. “It’s what I grew up with, you know, ‘Shake it off, you got your bell rung.’ ”
Now, he said, players, coaches and, especially, parents know a lot more about concussions.
“My parents have done a good job of giving me literature to read. People have committed suicide because of it and have problems later in life. We all know we have to be completely honest with the team doctors.”
McKnight said he’s had “five or so concussions in the past two years.
“I’d get hit and then have a sense of blurred vision, confusion, the feeling like I’m lost – all followed with nausea,” he said. “I’d puke.”
The last concussion was the worst. “It was the first time I lost consciousness a little bit. I got hit at the side on my jaw. My body went numb. I don’t remember any of it,” he said, “or a lot of what happened after the game.
“The next day I had trouble controlling my emotions. One minute I’d be really angry and upset, and then I’d be crying.”
McKnight was out of action for six days that time “and they monitored me all the time,” he said. When he returned to play, he wore a special mouthpiece to help protect him from future concussions.
“If I didn’t feel comfortable with the doctors and everything involved, I wouldn’t keep playing,” he said.
Legal liability uncertain
Jack Mills, adjunct professor of sports law at the CU School of Law, said liability in collegiate sports has not been litigated extensively. Most likely the athletics departments only have legal exposure if they fail to adhere to the NCAA guidelines. “As long as they follow the accepted standards of care, I don’t think there would be anything like strict liability,” even if the athletes suffered long-term disability as a result of concussions or sub-concussive impacts.
“The No. 1 thing is don’t put a player back in contact too soon after a concussion,” he said. “Many times these players aren’t thinking very well and want to go back in the game too soon.”
The case of Preston Plevretes of La Salle University was particularly worrisome. He was allowed to return to contact a month after a concussion and suffered permanent catastrophic brain damage from a hit during the game. Plevretes, now 23, is wheelchair-bound and requires constant care. His parents filed suit against the university and won a $7.5 million settlement.
Mills said he has never represented collegiate athletes, but he has worked extensively with pros.
One of his clients, Ted Johnson, is a former CU football player who went on to a 10-year career with the New England Patriots. Since his retirement, Johnson has suffered headaches, depression, fatigue, and struggled with substance abuse – all, he says, as a result of the untold concussions he suffered playing football.
Proposals for protecting athletes from concussions
- Building better helmets
- Returning to light helments
- Outlawing head-to-head contact
- Increasing the speed of the game in football
- Outlawing fights in hockey
- Limiting the number of concussions any player can have and still play
“Ted had good legal cause for action against his coach,” Mills said, because he was returned to practice too soon against the team doctor’s advice. Ultimately, Johnson decided he didn’t want to proceed with the lawsuit, preferring instead to focus his energy on recovering from his severe post-concussion syndrome.
The standard for most civil lawsuits is whether the conduct goes beyond the bounds of what you could reasonably expect from the activity, Mills said. When it comes to football and hockey, that’s a hard line to find.
“Players expect to get hit,” he said. “That’s part of the game. If it was helmet-to-helmet and a guy developed a reputation for hitting hard, up until now that was considered a positive thing. The guy was a headhunter and more popular with the NFL.
“But as people begin to realize the consequences of this, it could diminish the popularity of those kinds of hits. They could become totally illegal.”
Playing it safe
Efforts are being explored to make the sports safer. The NFL is enforcing rules against “egregiously violent collisions” after a study it sponsored found incidence of Alzheimer’s and other memory-loss conditions among retired football players occurring at rates five times the national average or higher. The NFL Players Association has become actively involved in discussions about ways to protect the players’ health. At the high school level, states and municipalities have begun legislating to protect the athletes. Proposals for legislation are under consideration in Colorado.
While the NCAA has issued recommendations for handling concussions, for college athletes the protocols vary from school-to-school.
Kelly agrees with the strategy to make the sports safer. Boxing is the only exception. Kelly, who has served on the Colorado State Boxing Commission, has advocated for a ban on the sport for years. When it comes to football and other sports, however, he’d like to see the rules change to protect players.
The single biggest thing that could make the games safer is if the professional leagues stopped recruiting players who hit hard. Suddenly college and high school coaches would put a premium on players who emphasized skill and speed over size and toughness.
For now, though, tough play still rules and whether to participate presents a difficult decision for young athletes. They increasingly know the dangers that may lie ahead. But the glory of the game remains irresistible.
When Scotty McKnight graduates this month, he’ll continue his training regimen, hoping to land a spot in the NFL.
“It’s scary, but I love playing football,” he said. “I love what I do and I love my teammates.”
Dave Stalls loved it, too. But it was not without a cost. “I played nine years in the NFL, including three Super Bowls, and I can’t tell you one football play I was in.
“It makes me wonder.”