Consciousness of concussions is growing, but issue of sports-related brain injury may be far larger

From Hollywood to the NFL, concussions have been the focus of the conversation around sports-related brain injuries.

But since the prevalence of traumatic brain injury among athletes has come to light, doctors and researchers studying the problem say it’s much broader than concussions or CTE, the degenerative brain disease associated with repetitive head trauma that’s been found in many former NFL players.

In interviews with The Spokesman-Review and KHQ this week, retired NFL quarterback Mark Rypien estimated he’d sustained “dozens of concussions and thousands of subconcussive injuries from playing this sport,” most of which went undiagnosed at the time.

“You say dozens, but you don’t really know,” he said. His first was likely in middle school.

A concussion is a very broad term for any blow to the head or violent shaking of the head followed by symptoms like a headache, dizziness, nausea or memory problems. A “subconcussive injury” is a blow to the head where no symptoms follow.

“We try to make it simple and it’s really a very sophisticated thing,” said Heidi Peterson, a licensed athletic trainer at the MultiCare Rockwood Sports Medicine Center who created a Spokane-area sports concussion committee last year.

The definition of a concussion has expanded over the past several decades as scientists have gained a better understanding of head trauma and the long-term problems it can cause. When Rypien played in the NFL, popular wisdom held that a concussion only occurred when a player was hit hard enough to black out.

That narrow – and inaccurate – definition meant hundreds of NFL players could go their entire career without a diagnosed concussion.

At all levels of sports, trainers like Peterson sent athletes with brain injuries back onto the field.

“If you weren’t knocked out, if you didn’t have a loss of consciousness, you were allowed to re-enter play,” Peterson said.

Mike Webster, the former center for the Pittsburgh Steelers who died at 50 after experiencing a rapid cognitive decline following his retirement, was never diagnosed with a concussion during his 17-year NFL career.

An examination of Webster’s brain led a then-obscure pathologist, Dr. Bennett Omalu, to diagnose him with a brain disease he named chronic traumatic encephalopathy, or CTE, in 2002. It was the first documented case of the disease.

Omalu went on to gain fame as one of the doctors facing down the NFL over its initial denial of a widespread problem among its players. The Nigerian-American doctor would later be portrayed by Will Smith in “Concussion,” a fictionalized retelling of his discovery.

Thanks in part to his work, and the research of dozens of neurologists, there’s a popular understanding that concussions can cause serious brain damage, and that repetitive head trauma leads to CTE.

But research suggests the problem is much more serious.

Boston University has become the leading national center on CTE research, with a brain bank program that examines the brains of former athletes and military members. They’ve published several studies in the past few years showing that blows to the head, not concussions, are the best predictors of CTE.

“In order to reduce CTE risk … there must be a reduction in the number of head impacts,” said Ann McKee, director of the CTE Center at BU, in a news release about the study. “The continued focus on concussion and symptomatic recovery does not address the fundamental danger these activities pose to human health.”

Some 20 percent of athletes who show early symptoms of CTE have never had a diagnosed concussion.

“That’s absolutely frightening,” Peterson said.

Omalu has also said the focus of injury prevention should be about brain trauma, not concussions.

“Every blow to the human head has the potential to cause brain damage. There is no safe blow to the human head,” Omalu wrote in his latest book, “Brain Damage in Contact Sports: What Parents Should Know Before Letting Their Children Play,” published earlier this year.

CTE is the most serious in a spectrum of brain disorders and diseases common in former athletes and military members. Currently, the disease can only be diagnosed after death.

The telltale sign of CTE is a build up of tau proteins in brain tissue, which cause the brain to shrink. That buildup can only be seen by cutting into the brain, hence the post-mortem diagnosis.

But living players can be diagnosed with a spectrum of other illnesses thought to be linked to repetitive head trauma, from early-onset dementia to the more generalized “neurocognitive impairment,” one of the conditions covered in the NFL’s concussion settlement.

These revelations have only heightened the debate about the future of football and other contact sports, especially for children. CTE has been diagnosed after death in an 18-year-old high school football player whose family donated his brain to BU for study. A 2015 Mayo Clinic study analyzing the donated brains of athletes who played contact sports in high school found CTE in one-third, compared to none in the nonathlete population.

And Omalu has reported receiving calls from the parents of middle and high school athletes whose families are noticing changes in behavior following blows to the head. Many eerily mirror the symptoms of retired NFL players: difficulty focusing, increased aggression and irritability, and poor performance in school.

Peterson said there’s been an effort in some leagues to reduce the number of plays where kids are likely to hit their heads, and flag football for prepubescent children is becoming popular.

Concussion protocols, like the one she helped develop, have become widespread, and young athletes who report any symptoms of concussion following a hit are removed from play. But those protocols do nothing to address the cumulative impact of hits to the head that don’t cause immediate symptoms.

And the helmets that many parents hope will protect their kids’ brains are designed to prevent serious injuries like skull fractures. There’s little to nothing they can do for concussions.

“It’s the brain bouncing around inside the skull, and the helmet doesn’t prevent that,” Peterson said.

Omalu suggests protective equipment like helmets can actually increase concussion risk by dulling the pain players would otherwise experience when hitting with the head.

“The absence of pain will make him more likely to lead and hit with his helmeted head and weaponize his head, increasing the number of blows to the head and the amounts of energy that reach the brain,” he wrote.

Omalu believes no parent should let a child under 18 play any contact sport. Not football, not rugby, not wrestling, not soccer unless headers are prohibited and rules are changed to minimize contact between players. Doing anything else, he writes, exposes children to certain damage before their brains are done developing.

“The glory of a few touchdowns is simply not worth it,” he wrote.

Daniel Amen, a neurologist and psychiatrist who has treated Rypien and about 200 former NFL players, said he sees little future for contact sports in children under 18.

“Most people now would say you shouldn’t let children hit soccer balls with their head and it’s a really bad idea to let them play tackle football,” he said.

Peterson said high school tackle football, with modifications, will likely continue for a while. But she believes tackle football will be phased out in middle school, and noncontact sports will continue to grow in popularity.

Knowing what he knows now, Rypien said he wouldn’t let his children play football. His wife, Danielle, said society generally recognizes that kids’ brains are still developing, leaving them too young to make choices about other harmful things like smoking.

“You wouldn’t let them drink alcohol, so why would you let them get their head pulverized?” she said.