Concussion Issue, Scientific Debate 'Eclipse' Doping in Football For Yesalis

Epidemiologist Yesalis Sees Game Threat, Questions Concussion Management

Neurologist Cantu Endorses Protocols But Says Breakdown Led to Teen’s Death

By Matt Chaney

As a foremost authority on sport doping, Pennsylvania epidemiologist Charles E. Yesalis identifies a public health problem of longstanding: athletes’ use of anabolic steroids, stimulants and more drugs that permeate amateur and pro ranks.

But Yesalis, professor emeritus of health policy at Penn State, sees a larger issue rearing now, brain trauma, to threaten all contact sports and particularly American football.

“This is going to eclipse the drug problem, and it probably already has,” Yesalis said in a recent telephone interview. “I think the whole drug issue is passé, to some extent. You don’t see any protests at moment about drugs in sports. … Steroid fatigue is all over the place, and I think people have just accepted it, deciding to go along.”

“But I really think that tackle football is in trouble (for concussions),” Yesalis continued. “Football is clearly the No.1 game in American sports, and it does not look good from an epidemiological standpoint.”

Yesalis believes that brain trauma in sport—ranging from common concussion to rare subdural hematoma—bears earmarks of a public health menace given the popularity of athletic participation in America. The issue is undoubtedly tackle football’s gravest threat in a century, since the institution turned back abolitionists of the Victorian Era.

Medical literature has long held head injuries to be inherent of contact sport, and contemporary neurological evidence conclusively links brain damage to football, the game that attracts millions of players every year, mostly juveniles, and causes serious injury for thousands and death for a few.  Expert estimates of football concussions range from 75,000 to 500,000 annually, with firmer numbers elusive because of assessment limits like underreporting.

“The (football) research has started and it will continue,” Yesalis said. “But I think it’s very fair to say, that given the research so far, on boxing alone, it doesn’t really present an optimistic picture for football as we know it. … The problem is not necessarily these major concussive events (for players), but what can be of great damage, the constant hitting short of concussion.”

While Yesalis is rather convinced of a scientific link between tackle football and long-term cognitive impairment, the epidemiologist is concerned for a muted but hot argument among neurologists—dispute over the advertised validity of protocols in so-called concussion management, tools currently employed in diagnosis and, most critically, return-to-play guidelines.

Neurologists and other doctors generally agree on the high risks of exposing an injured athlete to “second-impact syndrome,” before proper rest heals a previous concussion of volatile chemical reactions. One expert characterizes the brain, comprised of about 80 percent water, as a delicate “nerve cell.”

But the question over length of time for sidelining concussed athletes—including for schoolwork—remains open, especially regarding juveniles, and widely divides the medical community even if quietly, since media and politicians hardly address it.

One side says about 9 of 10 concussed athletes heal quickly and can return to sport—and classes, if applicable—within one or two weeks. Conversely, the other side says complete rest of diagnosed concussion should last much longer, one to three months.

Chasms within expert opinion for return-to-play guidelines, or clinical beliefs spanning the spectrum, only reflect the universe of unknowns about diagnosing and treating brain injury of the lightest impact, much less tackle football’s repetitive collisions of extreme force and torque, as recorded in studies utilizing helmet sensors.

American opinion generally supports status quo on concussion management, led by voices of the immensely powerful and popular football establishment, personnel and multi-industry associates of the NFL, NCAA, school federations and youth leagues, including concussion researchers. Supporters contend independent science has validated conventional protocols of diagnosis and return-to-play, such as written testing, baseline testing and more computerized neuropsychological assessment. 

Critics counter that research and development remains in early stage for concussion management, short of proper vetting or enough independent peer review and replication. In fact, the available literature has barely risen above clinical intuition and case studies, with quantifiable reviews progressing slowly for data on specificity and sensitivity in protocols. Moreover, the researchers who already sell assessments or aspire to market tools are typically authoring studies largely or in part, surely aware of blossoming lucrative demand in athletics.

Yesalis is frightened by any invalid science or faulty administering, because concussion management constitutes a precarious chain through the vast domain of American football, relying heavily on trained application by novices like general practitioners, trainers, coaches, parents and even juvenile athletes. As Yesalis begins to read available literature in abstract and full text, he doesn’t like the assumptions many leading experts stand on.

“For something that was really well-researched, you would see solid measures of sensitivity and specificity,” he said. “Every medical test, or the vast majority, has these measures and what percent of positives are truly positive, what percent of negatives are truly negative, and your false-positives and, conversely, your false negatives.”

Yesalis doesn’t yet dismiss existing research, pending his further review, but he regards what he’s seen thus far as low-level science. “There are various stages of scientific method above and beyond, all the way up to the random clinical trial, which determines whether tests or procedures or drugs are efficacious or not.”

That gold standard of scientific validation isn’t imminent for concussion management, but neurologist Dr. Robert C. Cantu, of the Boston University School of Medicine and the Sports Legacy Institute, believes the four primary protocols of present employ are sound and reliable.

Cantu confirms, however, that limitations or cracks cause false-negative results during injury assessment in tackle football, having led to a recent fatality: 17-year-old Nathan Stiles, a Kansas prep player who died on Oct. 29, hours after collapsing during game action for which he was cleared by a family doctor who reportedly followed return-to-play guidelines.

Stiles had sustained a diagnosed concussion four weeks previous and subsequently missed two games before returning to football. Media reports on the teen’s autopsy state a medical examiner determined the subdural hematoma originally occurred on Oct. 1, a finding rebuked by Cantu.

Cantu says his pathology team’s examination of brain samples from Stiles places the subdural hematoma as occurring during the Oct. 28 game for Spring Hill High School. The victim’s mother, Connie Stiles, has said CAT-scan imaging following the Oct. 1 injury missed the subdural hematoma, but Cantu disagrees.

“Subdural hematoma is definitely diagnosed with a high degree of sensitivity and specificity by CAT scan,” Cantu said during a telephone interview on Dec. 21. “(Stiles’) original CT was normal. … He was hurt, he was out a week-plus… and then he played the final game of the season, and in that one suffered a combined second-impact (injury) and a subdural, both.”

Connie Stiles and her husband, Ron, did not respond to an interview request.

Cantu suggests concussion-management protocols could’ve prevented the Stiles tragedy had the youth not acted as faulty link in the precious chain, triggering the notorious limitation known as underreporting. In other words, if for any reason the injured athlete does not accurately report lingering concussion symptoms, including many unseen signs, then others involved cannot prevent further brain trauma.

“I’ve talked with Mrs. Stiles, and she tells me that (Nathan) was not telling her he had (lingering) symptoms,” Cantu said. “I really wonder whether that’s accurate (no symptoms). … And when I see the evidence for second-impact, when I see the evidence for a re-bleed of a previous bleed, I have a very hard time really thinking he was asymptomatic.” 

Questions and debate surrounding concussion management will continue, fester, especially for outcomes such as Nathan Stiles’ and for tackle football, the sport that killed him.

Matt Chaney is a journalist, editor, teacher and publisher in Missouri, USA. E-mail him at mattchaney@fourwallspublishing.com. For more information, including about his 2009 book Spiral of Denial: Muscle Doping in American Football, visit the home page at www.fourwallspublishing.com.

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