Military vs. Football: A Study In Concussions

Doc Bear looks into the correlation between traumatic head injuries suffered in military service and that of football.

For years, I've written about concussions and their effect on the lives of professional football players. In the last six years, we've gone from the NFL decrying the idea that traumatic brain injuries were a constant part of the sport, or that they affected the lives of the players for many years to reach full acceptance (without taking full responsibility).

That changed in March of this year when the NFL’s Health and Safety Director said that concussions were ‘certainly’ related to post-football health problems, contradicting the NFL’s earlier statements. It’s about time and it’s good to see.

When we talk about researching brain injuries, there is a far more extensive database than football’s available to us. I'm referring to that of the US military. Gerard Riedy, together with Walter Reed Veteran’s Hospital’s imaging Center, examined the brains of victims of blast-related brain injuries that were diagnosed as ‘concussions’. Another, very loose way to say it is ‘mild to moderate brain injuries’. In reality, many of the concussions were/are quite severe.

None the less—300,000 service men and women were examined In the study. Most of these were blast oriented. The outcome suggested that our current methods for diagnosing concussions are woefully inadequate in detecting brain damage. That’s a problem that I’ve fought since the 1990s.

http://www.scout.com/nfl/broncos/story/1656540-nfl-not-doing-enough-for-...

These results, part of the largest ever imaging study of traumatic brain injuries (TBI), provide strong evidence that even brain injuries commonly classified as mild often lead to long-term damage.

The modern images—what’s now used is light years beyond 2000—showed scar tissue in over half the patients.  That’s far above what was expected. In the percent without blast relation to the TBI, scar tissue still showed up. Regardless of cause, concussions will develop scar tissue. 

Researchers at Walter Reed National Medical Center also observed anomalies in the white matter (the part of the brain responsible for transmitting signals between different regions) of more than one half of the participants, most of whom had been diagnosed with at least one concussion. The anomalies equated to scar tissue, supporting the above conclusion.

Gerard Riedy, the radiologist from Walter Reed who led this research, said that the large number of abnormalities seen in this study was surprising.  It underlines the point that a person with one traumatic brain injury traditionally was thought to have normal brain images—but that has not been the case. There is more danger to concussions than we had any idea.

Obviously, more than 300,000 individuals diagnosed with traumatic brain injuries that were often from blast-related trauma is substantially more than you would ever see in the National Football League. However, despite the varied causes of each, concussions are concussions, in degree.

They have certain common attributes—short term memory loss, emotional outbursts, lack of focus, speech aphasia—regardless of how they happened.  As a result, by making use of this knowledge, we have a far more substantial research database to work with.

In many TBI cases, neither a CT scan nor an MRI showed any signs of brain damage. That’s essential to note because in the 1990’s, this was one excuse the NFL (and a lot of insurance companies) used to claim that the players—even if knocked unconscious—weren’t ‘really’ injured.

The clinical tools available for assessment, including the patient's history and his/her baseline evaluations of cognitive skills such as memory and attention, as well as tests of certain motor skills, require a large degree of subjective interpretation. We keep getting closer to an effective, ‘moment of injury’ tool to diagnose a concussion, but we don’t have one yet.

Those assessments can also be seen in conditions such as post-traumatic stress disorder, which can cause many of the same problems. In other words, there’s a lot of ‘clutter’ when you’re trying to establish whether there’s a brain injury and if so, how severe it is.

Traditionally, the NFL used that as a lever to avoid responsibility. Used in conjunction with the results seen at the Walter Reed Brain Injury Center, we’re learning increasingly fast tools to diagnose a TBI.  

We’re learning to look for tiny scars in the areas affected by a concussion. The army study showed that they’re there. By definition, scar tissue is a tougher tissue that fills in an injury. It gets less blood flow and is less conducive for electrical signals. In other words, it’s a spot that doesn’t work as well in the way we need our brains to work.

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In high school football, we have just begun to see that MRI imaging that shows heat exhaustion often overlaps that of the imaging from concussion. Since high school students die at a rate three times that of Pop Warner football or college football, any information that we can develop to slow or end the onslaught of concussions for them is well worth exploring.

This possibility is being studied by obtaining MRIs of both conditions and comparing the two. It’s slow, right now. Good results will take time. Yet there are things that we can state with clarity. For example, certain positions in football will sustain concussions at a higher rate. Here is the breakdown in an average season:

Running Back: 11 TBI

Quarterback: 11 TBI

Wide Receiver: 20 TBI (that holds true for all three common wide receiver positions)

Tight End: 15 TBI

Right Tackle: 12 TBI

Left Tackle: 12 TBI

Guard: 7 TBI

Center: 6 TBI

Defensive End: 9 TBI

Defensive Tackle: 4 TBI

Linebacker (All positions): 20 TBI

Cornerback: 37 TBI

Safety: 13 TBI

There are two other aspects of this that need to be clarified. The first is that the offensive line commonly suffers multiple and additional ‘compression’ concussive impacts per game that are not listed. They comes from blows to the crown of the helmet.

They can occur from making contact with the defender's arms, pads, chin guard or chest pads. Remember Ben Hamilton? He had a full blown concussion in addition to the compression blows. He was never the same afterward and was out of football in a few years.  

The second clarification is that every concussion is a TBI. Not every TBI is a concussion—there are many types. The TBI may be of greater or lesser severity, but they all bear the danger of long-term results.

The University of South Dakota did an excellent study on the effects of concussion on adolescents. The study interacted with seven school districts to create its data:

“Conclusions: Sport-related concussion can negatively influence physical and emotional function, academics, and interpersonal interactions as perceived by adolescent student-athletes and their parents. Education of parents and their children, school professionals, coaches, and teammates remains critical to effectively recognize and manage sport-related concussion. Secondary school districts also play a critical role in the concussion-management process by establishing and implementing accommodation policies that alleviate student concerns about falling behind while ensuring a healthy return to normal school routines. Furthermore, adolescent support systems must be considered throughout the recovery process.”

It sounds like a sensible plan. Add the Pete Carroll tackling system or a better one. Get the  physician parents of players to volunteer at games. Appeal to every college, junior college and charitable organization, as well as raising funds in-house, to get the best current equipment you can find. Talk to the NFL—some players have outfitted entire high schools on their own dime. A lot of those players give back constantly.

Pay for the coaching/management staff to learn the current concussion protocol. Never practice if the air temp is above 90 degrees. Make sure each player rehydrates fully, every practice. Their health is job No. 1, above sharing your life, religious or personal convictions. After all, they can’t carry those out if they’re dead.

Each change is a minor step. Together, they could save some lives.

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Doc Bear is a Featured Columnist for MileHighHuddle. You can find him on Twitter @DocBearOMD.

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