By Matt Chaney
For The Phanatic Magazine
National Football League officials may consider the issue of brain trauma as secondary in the labor standoff, or safely resolved for active players, but independent experts contend new detection tools are needed along with longer recovery time for head injuries.
Neurologist Dr. Randall Benson and forensic pathologist Dr. Bennet Omalu say the NFL still eschews deployment of a ready diagnostic set for brain trauma in football—advanced MRI and more radiology—which can prevent premature return of concussed players while also detecting harm of sub-concussive blows wholly missed by current assessments.
Benson and Omalu believe sub-concussive impacts to the brain over time, rather than episodic concussion, pose the greatest danger of permanent impairment in football players of all ages.
“The cumulative effect of these injuries seems to be the ‘Mike Webster’ syndrome and dementia,” stated Benson, of the neural-imaging research group at Wayne State University, in recent email. “Linemen are likely at risk the longer they stay in the league because of the thousands of hits to the frontal lobes. Damage to the frontal lobes results in slowed thinking, personality changes and poor judgment, among other things.”
Benson made the same argument more than a year ago at a congressional hearing.
“Advanced MR imaging techniques, I believe, including susceptibility weighted imaging, diffusion tensor imaging, and something called MR spectroscopy are able to reveal brain injuries where CT scans and conventional MRI appear normal,” Benson testified before the House Judiciary Committee on Jan. 4, 2010.
But as excitement grows over research findings of “functional” MRI, among imaging techniques, no expert consensus yet endorses such clinical monitoring of head injury in sport. The NFL recently funded a research group at the University of California-San Diego for further study.
“There are a lot of imaging modalities that are in research use right now, but have not yet gotten perfected to the point where they can be used in clinical practice, day in and day out,” said neurosurgeon Dr. Robert Cantu, member of the NFL’s head, neck and spine committee and co-director of the Sports Legacy Institute in Boston, which receives league funding.
The international group known as Concussion in Sport, meeting in Zurich during 2008, stated, “Alternative imaging technologies… while demonstrating some compelling findings, are still in the early stages of development and cannot be recommended other than in a research setting.”
Cantu also serves for Concussion in Sport, and last week the NFL adopted new guidelines from the group for its “concussion testing” components that independent experts denounce for inaccuracy, led by Omalu.
Omalu first discovered widespread cellular damage in the brain of a deceased NFL player, the retired lineman Webster, during autopsy in 2002. Webster was never diagnosed with a concussion during 17 years in the NFL.
Omalu argues that recent studies at Purdue University, Wayne State and in California support imaging scans for immediate employ in concussion management of athletes, particularly in the brutal NFL. Functional MRI is key in Omalu’s return-to-play proposal for concussed adult football players.
Omalu—chief medical examiner for San Joaquin County, Calif., and autopsy director for the Brain Injury Research Institute at the University of West Virginia—contends NFL players should be sidelined one to three months following a concussion, depending on severity and diagnostic technology.
“I have proposed, and I remain by it, that if anybody suffers an impact to his head that knocks him unconscious… he should be kept out of play for three months,” Omalu said in a phone interview. “For those who do not have loss of consciousness, they have dizziness, they cannot go back to play (too quickly). I don’t think (the NFL standard) two weeks is sufficient, in my opinion.”
Omalu rebukes current “concussion testing,” qualifying assessments like ImPACT software, widely used in American football, as invalid for diagnosis and unreliable for return-to-play decisions. He says such neuropsychological testing is best suited for periphery of concussion management, relegated to tasks such as indexing subjective symptoms for diffusion tensor imaging.
“When we move forward, DTI is emerging as a very useful tool, where we can now actually quantify in a more objective manner the amount of damage,” Omalu said. “We can now have a (return-to-play policy) where it should not be less than a month, in my opinion.”
Benson notes that imaging research shows assessments like ImPACT can misdiagnose both normal and concussed cerebral states in football players, including teen subjects of the Purdue study, and the point is corroborated by peer reviews that have panned computerized testing since 2005.
Loyola University neurologist Christopher Randolph concludes ImPACT baseline testing has unacceptable rates of false-positive and false-negative results. Randolph characterized utility of the tool as “clinical guesswork in most cases” for his new analysis published in Current Sports Medicine Reports.
Benson concurs, having told Congress, “Electrophysiologic data from an EEG… indicate that even after symptoms have abated from sports concussion, the brain has not normalized. Dr. Omalu mentions 99 days (rest)… Certainly, it raises the question of whether people should be returning to activity before that three-month period. This suggests that clinical symptoms are not a reliable indicator of recovery and that to rely on symptoms exclusively to guide return is to put the athlete at risk.”
Active NFL players may be involved with league imaging research at the University of California-San Diego, where details are sketchy. University PR director Debra Kain declined to discuss study participants of any type, citing HIPAA law as prohibiting release of personal information. Project leader and radiologist Mingxiong Huang was not made available for interview by phone or email.
Diffusion tensor imaging can expose brain trauma by picturing blood flow in real time, normal and abnormal transfer among cerebral regions through white matter composed of fiber strands of connecting conduit. Sub-concussive blows can shear white matter of a football player, causing liquid disruption and redirection, especially from battered fore regions of the brain.
Benson stated in email, “The microscopic structure of white matter, which is composed of long axon fibers which allow distant neurons to communicate with each other in the brain, is ideally suited for DTI which detects flow of water in three dimensions.”
“DTI methods have been applied to persons in motor vehicular crashes, falls and sports-related injury including retired NFL players. The long-term evolution of the imaging abnormalities is not known presently but it appears that the DTI abnormalities don’t change much over time even while clinical and neuropsychological improvement is observed.”
An undisclosed number of active NFL players participated with retirees in the recent imaging study at Newport Beach, Calif., currently published in The Journal of Neuropsychiatry and Clinical Neurosciences. Impairments of football players ranging in age from 30s to 70s were found to be multi-fold the rates of general population.
Dr. Daniel G. Amen is lead author of the study. “I think (MR) SPECT, PET, MEG, QEEG and fMRI are all candidates to scan (player) brains and help us understand long-term trauma,” Amen stated in email.
The study’s conclusion reads in part: “On SPECT, significant decreases in regional cerebral blood flow were seen across the whole brain (of players), especially in the prefrontal poles, temporal poles, occipital lobes, anterior cingulated gyrus, and cerebellum. This pattern is consistent with the lasting effects of TBI (traumatic brain injury). We also found significant decreases in the posterior cingulated gyrus and hippocampus, areas implicated in dementia.”
The ominous findings, coming lately amid a torrent of bad player news like suicide and neural damage of younger retirees, apparently have not deterred NFL management.
An active player, linebacker Scott Fujita, says brain trauma still ranks low on league agenda despite contrary proclamations of officials. The issue “is not being discussed on their end nearly as much as it needs to be,” the Browns veteran said by phone on Feb. 12.
Fujita, member of the union executive council, currently declines comment in accordance with a gag order on negotiations. But news reports and leaks confirm that money, or how to split billions in NFL revenues, remains foremost on everyone’s mind in the stalemate over collective bargaining.
Fujita insists players today view their immediate and future health as a paramount concern, considering modern news and research on brain trauma in football.
“Honestly, my biggest problem through the whole (bargaining) process, is that I don’t feel like the owners get it (brain trauma),” Fujita said. “They just don’t understand what we put our bodies through on a day-to-day basis, over the last 20, 25 years for some of us.”
“So for them to say they take concussions and our health and safety seriously? A lot of that to me is just PR stuff.”
Matt Chaney is a journalist, publisher, teacher and restaurant worker in Missouri, USA. Email him at mattchaney@fourwallspublishing.com. For more information, including about his 2009 book, Spiral of Denial: Muscle Doping in American Football, visit the homepage at www.fourwallspublishing.com.
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