the NFL

Why don't we start with a few deep thoughts from NFL Pittsburgh Steeler linebacker James Harrison, following a particularly vicious hit on the Cleveland Browns' receiver Josh Cribbs:

The crown of Harrison's helmet slammed into the left side of Cribbs' helmet as the receiver was running a Wildcat formation play, causing Cribbs to crumple face-first into the turf. He appeared to be momentarily knocked out. Because Cribbs was a runner, such helmet-to-helmet contact is permissible. "I thought Cribbs was asleep," Harrison said. "A hit like that geeks you up, especially when you find out the guy is not really hurt, he's just sleeping. He's knocked out but he's going to be OK."

Awesome. Now, my first response upon reading this was to immediately Wikipedia James Harrison, because I was absolutely dying to find out the extent of his higher education. And, oh, man, I was so not disappointed. I had forgotten that this was the same guy who in 2009, after the Steelers won the Super Bowl, was the lone member to decline an invitation to the White House. At the time, he said, "This is how I feel — if you want to see the Pittsburgh Steelers, invite us when we don't win the Super Bowl. As far as I'm concerned, he [Obama] would've invited Arizona if they had won." Which, I suppose, is true.

Despite astute observations such as those above, Harrison somehow missed the plethora of medical studies linking serial head trauma to neurocognitive impairment. Many of these studies were published in the Journal of the American Medical Association, including the first description in 1928 by a pathologist from New Jersey, Harrison (ha!) Martland, who noted a "punch-drunk" personality change in long-term boxers. Many years later, a seminal report in JAMA from 1984 (pictured) demonstrated a clear association between boxers, cerebral atrophy on CT, and impaired neurocognitive and neuropsychiatric testing with an emphasis on poor memory performance.

JAMA continued to build on these reports, and began extending their observations to another sport rife with cerebral trauma: American football. In 2003, they published a report on collegiate football players that demonstrated an additive effect to head trauma; with progressive concussions, recovery time to full neurological function increased exponentially. This followed strong experimental data in which mice subjected to repeated mild trauma suffered progressive neurological damage as a result (J Neurosurg, 2001 Nov;95(5):859-70). Follow-up studies suggested that football players with 3 or more concussions over their careers were five times more likely to show signs of mild cognitive impairment, a frequent precursor of Alzeimer's Disease.

This correlative data was provided with a histopathologic correlative in 2005 when analysis of the brain of a recently deceased football player revealed "chronic traumatic encephalopathy with many diffuse amyloid plaques as well as sparse neurofibrillary tangles and tau-positive neuritic threads in neocortical areas. " As reported in the New York Times, five subsequent autopsies of NFL veterans who died between age 36 and 50 all revealed evidence of so-named "chronic traumatic encephalopathy," with tau and amyloid deposition that was otherwise never seen in brains of people this young. As the neuropathologist Daniel Perl from Mount Sinai School of Medicine noted,

"Something is clearly abnormal in these athletes' brains...in the most extreme cases the extent of tau pathology is just unbelievable."

An excellent review in The New England Journal of Medicine summarizes the pathophysiologic mechanism as follows: following head trauma, sudden movement produces rotational injury, damaging the long axons that connect different brain regions. This results in pathologic deposition of soluble amyloid-beta peptide as soon as two hours after injury. Ultimately, this results in accelerated formation neurofibrillary tangles seen generally in older patients with dementia as well as these patients.

This and countless other reports must have been part of the inspiration for a furious piece written by Malcolm Gladwell last year in the New Yorker in which he wondered if football and dogfighting were all that different. Gladwell speaks of the countless circulating stories of bizarre and ultimately self-destructive behavior of football players following retirement:

Mike Webster, the longtime Pittsburgh Steeler and one of the greatest players in N.F.L. history, ended his life a recluse, sleeping on the floor of the Pittsburgh Amtrak station. Another former Pittsburgh Steeler, Terry Long, drifted into chaos and killed himself four years ago by drinking antifreeze. Andre Waters, a former defensive back for the Philadelphia Eagles, sank into depression and pleaded with his girlfriend—“I need help, somebody help me”—before shooting himself in the head.

“There is something wrong with this group as a cohort,” Dr. Omalu [the pathologist at U. Pittsburgh who performed the first autopsy of an NFL player showing tauopathy] says. “They forget things. They have slurred speech. I have had an N.F.L. player come up to me at a funeral and tell me he can’t find his way home. I have wives who call me and say, ‘My husband was a very good man. Now he drinks all the time. I don’t know why his behavior changed.’ I have wives call me and say, ‘My husband was a nice guy. Now he’s getting abusive.’ I had someone call me and say, ‘My husband went back to law school after football and became a lawyer. Now he can’t do his job. People are suing him.’”

Gladwell goes on to note the data demonstrating the clear risk posed to football players due not only to their full concussions, but countless subconcussive head injuries. Ultimately, he, I think rightly, lays the blame at the feet of the NFL as an organization, which, despite claims to the contrary, applauds the tenacity of hard-hitting players such as Harrison, Ray Lewis, or Brian Dawkins and lionizes "warriors" who "play through injuries" and "never miss a start." A culture such as this, in which players are taught that approval (and salary) comes with masking or minimizing injury, betrays the best interest of the players. Gladwell concludes with anecdote of a young player during practice whose concussive symptoms are so severe that he is losing consciousness while sitting in a tub of ice-cold water, yet insists on returning to practice. He notes:

That moment in the cold tub represented a betrayal of trust. He had taken the hit on behalf of his team. He was then left to pass out in the cold tub, and to deal—ten and twenty years down the road—with the consequences. No amount of money or assurances about risk freely assumed can change the fact that, in this moment, an essential bond had been broken. What football must confront, in the end, is not just the problem of injuries or scientific findings. It is the fact that there is something profoundly awry in the relationship between the players and the game.

The mixed nature of the messages sent by the league could not be clearer than in the case I first mentioned, in which James Harrison was not flagged for the hit he put on Josh Cribbs, yet is being fined $75,000 for his actions. The league wants to permit the type of violent play for which fans clamor, yet have the appearance of chastising such choices. It's reminiscent of Obama's waffling on the "right versus wisdom" of the mosque at Ground Zero. It's no wonder that Harrison, 2008's NFL Defensive Player of the Year, now being subtly undermined as a dirty player, is considering retirement. He's the cuckhold, not the true villain.