This ever-evolving battle is the subject of a new Frontline episode that premieres tonight on PBS called League of Denial: The NFL’S Concussion Crisis, which had originally been a co-venture with ESPN before the sports network pulled its support of the documentary back in August.
In an effort to demonstrate that the league wanted to resolve the question of the relationship between concussions and long-term health issues for players, Tagliabue created the Mild Traumatic Brain Injury Committee, headed by rheumatologist Dr. Elliot Pellman, a team physician for the NY Jets, who shared the Commissioner’s belief that concussions were not a serious problem, but who was also not an expert in neurology nor had any background in brain research.
“If you’re going to put together a blue-ribbon committee to study brain trauma, it should have as its chair somebody who has that as a background,” contends neurosurgeon Dr. Robert Cantu of Boston University, who was the Sports Medicine section editor of the journal Neurosurgery when MTBI first began publishing the results of its research.
He tells Frontline that, at the time, he objected to publishing these papers, but that his boss — who also happened to work for the NY Giants — insisted the research be published in the journal.
Some choice conclusions from those papers…
On the safety of going back into a game after a concussion:
“Players who are concussed and return to the same game have fewer initial signs and symptoms than those removed from play. Return to play does not involve a significant risk of a second injury either in the same game or during the season.”
On the long-term effects (or lack thereof) from concussions:
“[T]he results of this present study support the authors’ previous work, which indicated that there was no evidence of worsening injury or chronic cumulative effects of MTBIs in NFL players.”
Advice for dealing with younger athletes, even though MTBI had not studied effects of concussion on players below the pro level:
[I]t might be safe for college/high school football players to be cleared to return to play on the same day as their injury. The authors suggest that, rather than blindly adhering to arbitrary, rigid guidelines, physicians keep an open mind to the possibility that the present analysis of professional football players may have some relevance to college and high school players.”
“They were making comments that were greatly at odds with prospective, double-blind studies done at the college and the high-school level,” says Cantu. “They just weren’t’ finding the same things, and that just didn’t make sense to anyone that’s a scientist.”
THE AUTOPSY HEARD ‘ROUND THE WORLD
While MTBI was ramping up its work, Hall of Fame Pittsburgh Steeler center Mike Webster was sinking into a morass of bizarre behavior and early onset dementia.
“He was supergluing teeth back into his head,” one of Webster’s sons tells Frontline. “I think dad’s the only person who could have a medical problem like that and decide to fix it with superglue.”
Despite nearly two decades in the NFL, nine Pro Bowl appearances, and an astounding four Super Bowl rings, Webster eventually ended up living in his truck and behaving erratically.
While he could still manage, Webster sought out legal assistance in 2000 to file a 100-page disability claim with the NFL. He was ultimately successful, even though the NFL insisted on hiring an outside physician to verify the claims made by the four doctors who had signed Webster’s claim. Sadly, Webster died not long afterward, in Sept. 2002, at the age of 50.
Medical examiner Dr. Bennet Omalu took one look Webster’s beaten, ravaged body and assumed that he’d find equally visible damage when he looked at the football great’s brain.
“I was expecting to see a brain with Alzheimer’s Disease features,” recalls Omalu. “But upon opening his skull, Mike’s brain looked… normal.”
Omalu felt compelled to figure out how on Earth this man could exhibit Alzheimer’s-like symptoms but have a brain that ostensibly looked okay.
“I saw changes that shouldn’t be in a 50-year-old man’s brain, and also changes that shouldn’t be in a brain that looks normal,” says the doctor. “I was convinced this was something.”
A peek under the microscope showed results that would shake the NFL for years to come: Chronic Traumatic Encephalopathy (CTE), a disease that had previously not been identified in the brains of NFL players.
SACKING THE PATHOLOGIST
CTE is a progressive, degenerative brain disease, resulting from repetitive trauma to the brain, that can have disastrous effects on a person’s memory, mood, and behavior. It can be diagnosed post-mortem by staining sections of the brain and identifying distinctive clustering of tau proteins.
Dr. Omalu consulted with several colleagues to confirm his finding. The doctors then published a paper on the case in Neurosurgery, the same journal where MTBI had published its research.
The implication, even from this one case of CTE found in a former football player was potentially damning to the NFL’s stance that concussions posed no long-term threat to players. But rather than just let this one paper about one player be published and forgotten about, the MTBI fired back with a vicious letter published in the pages of Neurosurgery.
Dr. Pellman and other members of the MTBI committee wrote that Omalu’s claims of finding of CTE in Webster’s brain tissue “are based on a complete misunderstanding of the relevant medical literature on [CTE] in boxers,” and that “there is inadequate clinical evidence that [Mike Webster] had a chronic neurological condition, a traumatically induced brain condition, or, in fact, a clinical encephalopathy.”
“They went after Dr. Omalu with a vengeance,” says ESPN’s Peter Keating. “They publicly said he should retract his findings… They basically told him to go away and never come back.”
Adds Pulitzer-winning journalist Steve Fainaru, “You don’t try to get a paper retracted unless there’s evidence of fraud or plagiarism or something like that.”
“The NFL has had this strategy of going nuclear every time it goes to court,” says Keating, “because the first time you ever lose, you open up the floodgates to potential billions of dollars of damage.”
GOING FOR TWO
In 2005, Terry Long, another former Steelers offensive lineman committed suicide by drinking antifreeze. He was only 45. Omalu tested Long’s brain for CTE and it also came up positive.
“When I saw Terry Long’s case, I became convinced that this was not just a statistical anomaly,” says the doctor.
Another paper in Neurosurgery followed, with more nasty pushback from the NFL MTBI committee.
“They insisted I was not practicing medicine, I was practicing voodoo,” recalls Omalu, who says that MTBI refused to meet with him, but that he did meet privately with one NFL team doctor to review slides of the two brains.
“Do you know the implications of what you are doing?” Omalu says the team doctor asked him. “He said ‘If ten percent of mothers in this country would begin to perceive football as a dangerous sport, that is the end of football.’”
Former Steelers neurosurgeon Dr. Julian Bailes says he was eventually won over by Omalu’s research.
“I didn’t want to believe it myself,” Bailes admits. “It was a hard message, a bad message, but it appeared to be true.”
In 2006, Tagliabue handed the Commissioner’s chair over to current commish Roger Goodell, who soon removed Dr. Pellman as head of MTBI and promoted an actual neurologist, Dr. Ira Casson, to head MTBI. But Dr. Casson was, at least publicly, even more staunch than Pellman in his denial of a link between head trauma and long-term health problems.
Casson’s most infamous appearance came during an interview on HBO’s Real Sports:
In the summer of 2007, Goodell and Casson hosted a summit in Chicago on the topic of CTE and its possible link to football. And while not everyone in attendance was of the same mind as the league, the Commissioner had deliberately omitted Dr. Omalu — the one who lit this fire — from the invite list.
However, former Steelers doctor Bailes was invited, and he’d since joined forces with Omalu to work together on CTE research.
By this point, Omalu and Bailes had found CTE in the brains of another former Steelers offensive lineman, Justin Strzelczyk, who was only 36 when he died in a car crash while in the throes of what he believed was bipolar disorder; and former Eagle Andre Waters, who had committed suicide in 2006 at the age of 44.
“It wasn’t met with any broad acceptance, to say the least,” says Bailes of his presentation to the group. “There was skepticism, there was dismissiveness on [Casson's] part. There was great doubt.”
NY Times reporter Alan Schwarz was on hand for the summit.
“There was clearly, among the NFL committee, a steadfast belief that this is not a problem, you guys don’t know how to do research the way we do, and thank you for coming.”
“Anecdotes do not make scientifically valid evidence,” Casson explained to reporters at the time. “I’m a man of science; I believe in empirically determined scientifically valid data and that is not scientifically valid data… In my opinion, the only scientifically valid evidence of a chronic encephalopathy in athletes is in boxers and in some steeplechase jockeys.”
So what came out of all of this? A pamphlet, titled “What Is a Concussion?”, that was handed out to players before the start of the 2007 season.
It included the following gem:
Q: If I have had more than one concussion, am I at increased risk for another injury?
A: Current research with professional athletes has not shown that having more than one or two concussions leads to permanent problems if each injury is managed properly.
BRAINS AND BRAWN
Chris Nowinski played football at Harvard and then went on to wrestle professionally, getting his bell rung on more than one occasion. He’s now concerned that he might have CTE and is doing what he can to help the research cause — wrangling brains for Boston University researcher Dr. Ann McKee and her team.
One of the brains gathered by Nowinski was that of another Ivy League bruiser, Tom McHale.
McHale had gone to Cornell then played for the Tampa Bay Buccaneers. In retirement, he began exhibiting new, erratic behaviors and spiraled down into drug addiction, ultimately dying of an overdose in 2008 at the age of 45.
Like other players with similar post-career symptoms, tests on McHale’s brain showed the tell-tale signs of CTE.
At the Super Bowl festivities in January 2009, Nowinski, Dr. McKee, and McHale’s widow Lisa held a press conference to present their evidence linking CTE to football.
“He is now the sixth confirmed case of CTE among former NFL players,” said Ms. McHale. “And bearing in mind that only six former NFL players have been examined for CTE, I find these results to be not only incredibly significant but profoundly disturbing.”
While the press conference was sparsely attended — certainly in comparison to the press-fest going on across the street at the actual Super Bowl — it did result in an invite for McKee to present her research to the NFL.
THROWING THE CHALLENGE FLAG
“I’m up against a lot of doubters,” says Dr. McKee of her trip to NFL HQ, “a lot of people who don’t think any of this holds any water.”
Objections to her research basically fell into two categories.
1. Causation — While every NFL player brain tested for CTE had thus far tested positive, researchers had not proven a causal link between football and the disease.
2. Prevalence — Given that nearly 1,700 players are active in the NFL at any given time and that researchers had only tested a very small sample of former players’ brains, it was impossible to extrapolate these results to the entire NFL population.
“We’ve seen only those that are having trouble, and we know there are thousands out there roaming around that are not having problems,” explains Henry Feuer, doctor for the Indianapolis Colts and a former MTBI committee member.
Others siding with the NFL on this issue point out that many of the players shown to have had CTE also had other health concerns like steroid and substance abuse, which may or many not have factored into the cause of the disease.
In 2009, the NFL commissioned a survey of former NFL players’ health issues. It wasn’t supposed to be made public, but someone leaked it to the Times’ Schwarz.
The survey asks respondents — who could also be a former players’ loved one — if the player had ever been diagnosed with “dementia, Alzheimer’s disease, or other memory-related disease.”
“What it showed was that former NFL players seem to have memory-related disorders at a much-much higher rate than people in the regular community,” says neuropsychologist Robert Stern.
The NFL publicly dismissed the very study it commissioned, saying that there were no formal diagnoses of dementia in the survey and that the scientific validity of the results was subject to the shortcomings of a telephone survey.
Later that year, Goodell was hauled before Congress to answer questions on the link between football-related trauma and brain disease. In a misguided attempt at deflection, the Commissioner chose to not give his personal opinion on the matter, instead repeatedly stating that the scientists were better equipped to respond.
The similarity between his empty responses and those given by tobacco executives more than a decade earlier was not lost on members of Congress or the media.
Following the fumble in Washington, Goodell did his best to brush off the stink by removing Casson as MTBI head, forming a new committee with actual brain experts in charge, instituting new safety guidelines, oh — and donating $1 million to the Boston University CTE Center where Dr. McKee works.
The NFL also made the BU Center the “preferred brain bank of the NFL, giving the researchers there even more access to the brains of deceased former players.
In 2010, McKee investigated the brain of Owen Thomas, a 21-year-old U.Penn football player who had unexpectedly committed suicide. But consiering Thomas had no history of diagnosed concussions, McKee wasn’t expecting to find any indication of CTE.
The concern with the Thomas case isn’t just that he was so young, but that perhaps his CTE was a result of the everyday, non-concussion collisions that are just part of playing football.
“Most people are keyed in on the big hit, but the little mini-concussions are just as dangerous because you might be sustaining six to ten, a dozen, of these hits during the course of a game,” says former NY Giant Harry Carson. “If you’re going up against top-flight players who are able to perfect those skills of hitting you upside the head… it’s one of those things, at some point you’re gonna pay for it down the line.”
Nowinski believes the NFL’s apparent inability to admit a link between football and CTE is having an impact on players of all ages.
“As long as the NFL dismissed this, that meant that parents were signing their kids up believing that there was no risk,” he explains. “That wasn’t fair to those kids or those parents, but especially those kids.”
SEAU’S FINAL IMPACT
When former San Diego Charger Junior Seau committed suicide in 2012, Dr. Omalu says he made a verbal agreement with the late player’s son to collect and research the brain.
But then the NFL told the son about its misgivings regarding the doctor and the son chose instead to donate his late father’s brain to the National Institutes of Health. The NIH later confirmed CTE in Seau’s brain, while also receiving a $30 million donation from the NFL.
One can easily look at this end result and say that it doesn’t matter who got to test Seau’s brain since the result still came back positive for CTE, but some believe this was a deliberate move on the part of the NFL to A) keep the brain out of the hands of vocal critics like Omalu and McKee, and B) give the NFL an opportunity to forge a high-profile relationship with NIH that may be friendlier to the organization’s brand-protection concerns.
“The NFL wants to come off as forward-looking,” says Keating. “The NFL wants to keep pushing these questions into the future… Make it seem like these questions that still need to be resolved are things the league is working with doctors and researchers on.”
Meanwhile, Omalu says the entire experience of the last decade has made him regret trying to bring CTE to the public’s attention.
“I wish I never met Mike Webster,” he admits. “CTE has dragged me into the politics of science, the politics of the NFL. You can’t go against the NFL, they’ll squash you.”
Finally, the NFL recently settled with thousands of former NFL players over allegations that it deliberately hid the dangers of long-term damage to players. The plaintiffs had originally asked for around $2 billion, but the proposed settlement is $765 million, about one-third of what ESPN pays the league to run Monday Night Football each season.
On the one hand, it does provide the plaintiffs with some money and the public may feel like the league has atoned for past sins. But at the same time, the NFL admits no wrongdoing in the settlement and it avoids having to go to trial, where league executives, coaches, doctors, and owners would have had to testify under oath.
“I don’t think we needed a trial to know the NFL conducted a lot of shoddy research,” says Keating. “What the trial would have done was bring out that evidence.”
The Frontline episode begins airing tonight, Oct. 8, on PBS. It will also be available for streaming on PBS.org, which also has a lot of supplemental material.