Sometimes we are unaware. Sometimes we are unsure. Sometimes we don't know what the future will bring. Yet, if anyone could see a glimpse of the future, we can only speculate Dave Duerson could. As a member of a six-man volunteer panel that oversaw applications for the NFL's disability plan, he had listened to the retired players' or their wives' stories. Duerson worked for the 88 Plan, a fund created to help provide some care for more than 150 players with dementia. The 88 Plan is named after the jersey number of Hall-of-Fame tight end John Mackey, who was diagnosed with dementia when he was 59.
The Repetitive Trauma Spectrum
As more expert studies have emerged, more coaches and players are viewing football's collisions and impact on the brain as a spectrum of hits over time, beginning with their play in youth football through high school, college and possibly the NFL. These repetitive head traumas may be spectacular such as John Carlson's in the NFL playoffs where he flipped in the air, landed on his head and shoulder on a frozen sideline in Chicago and was carted off the field in a stretcher. Carlson described what he remembers: "I hit my head, got knocked out for about a minute. I’ve recovered really quickly. I had a concussion, but the memory’s come back, and I feel really good....I remember the play, I remember getting flipped up in the air, but I don’t remember hitting the ground and I don’t remember anything from hitting the ground to halfway through the ambulance ride. I don’t remember them putting me on a stretcher. And the doctors say I probably will never remember that."
Ryan Grant, who became dizzy and wobbly after a hit in the Packers' preseason game, almost regrets his actions that led to being diagnosed with a concussion: "Maybe it would've been a little different if I'd have stayed on a knee and said, 'I just got the wind knocked out of me, let me take a couple plays off and come back....I'm going to do everything I can working with them to get back, because I don't want to be out. But at the same time, I know it's severe and you've got to be smart about it."
Dan Wenger suffered two concussions in less than a month last year, sidelining him for almost the entire year, but has petitioned the NCAA for a sixth year of eligibility with the Irish.
High School Hits
Dr. Aaron Dalan is not your typical pediatrician at 6'7" with the built of a former offensive lineman. Dalan played at the University of Washington and then with the Oakland Raiders. Dalan understands the mentality, "As a lineman, 75% of my hits were helmet-to-helmet. That’s just the way it was. I spent eight years of my life engrossed in the gladiator mentality, so I understand it pretty well. The question was, were we tough enough to give and take hits, stay in the game, and play through it." Now a pediatrician in Seattle, Dr. Dalan has taken on the challenge of educating parents his young patients as to the subtleties of concussion symptoms. He wants those patients in organized sports to let an adult know if noise bothers them, lights are suddenly annoying, or they feel like they’re "in a fog" after a hit - not to just "take a few plays off".
Also in Washington state, a near tragic incident has inspired legislation to help prevent Second Impact Syndrome, which descibes a second brain trauma before the first one is allowed to heal . Zachary Lystedt, who played both ways on his middle school football team, was hit and his head struck the ground. In obvious pain, he went to the sideline, stayed out for about 15 minutes and then returned for the rest of the game.
Zachary forced a game-winning fumble on another hit at the end of the game and collapsed. The second hit caused a brain hemorrhage that resulted in coma for almost three months and the removal of both sides of his cranium. The Zachery Lystedt Law prevents football players who have had head trauma are prevented from returning to a game until they have been examined by a medical professional. Similar versions have been adopted in many other states and is being considered at the federal level. (link for state laws)
One study of American high school and college football players demonstrated 94 such catastrophic head injuries (defined as significant intracranial bleeding or edema) over a 13-year period with only two at the college level. Seventy-one percent of the high school players suffering such injuries had a previous concussion in the same season, with 39% playing with residual symptoms. While the metabolic mechanisms of traumatic brain injury are still being learned, it is apparent that the brain needs time to heal, otherwise a second trauma can be catastrophic. The incidence of football-related concussions involving loss of consciousness is estimated at 300,000 annually by National Center for Catastrophic Sport Injury Research and the American Association of Neurological Surgeons. Since two studies have shown only a 8%-19% of concussions involve loss of consciousness, the incidence of all sports-related concussions is from 1.6-3.8 million a year. (link) It is estimated 20% of football players will have a concussion each year.
Removing players from play and practice until the brain heals will help reduce catastrophic Second Impact Syndrome, but the problems of concussions, subconcussive impacts and cumulative, repetitive impacts remain.
Who Protects the Players
Kurt Warner, who retired after two concussions, said: "The unfortunate thing in our business, more times than not, is that either guys don't know it or don't let somebody know it and continually play through those kinds of situations, where it's week after week, it's hit after hit, where they're not coming out of games and they never get healed. And I think that's probably -- and I'm just guessing -- where the biggest effects are down the road, is guys that may not have a record that they had 10 concussions but probably had that or more so and just played right through it." Dallas Cowboys quarterback Troy Aikman retired after suffering a documented 10 concussions in his 12-year career. San Francisco 49er quarterback Steve Young quit after his fourth concussion in three years.
Anthony McDonald's post-concussion behavior after the hit in the Washington game in 2009 was dramatic, as Charlie Weis describes: "He gets up off the ground ‑‑ you know that old thing, 'He's going the wrong way!' That was him. He was actually running the opposite way from where everyone else was going. I'm yelling for a trainer. I'm not even watching the kickoff now because I see him dazed and confused. I'm almost wanting to go out on the field myself because I'm yelling for the trainers, because you knew this is a guy who was knocked out on his feet at the time."
A study of 393 college football players from four FBS universities (Michigan State University, the University of Florida, the University of Pittsburgh, and the University of Utah)showed that 34% reported experiencing 1 concussion of any grade, and 20% reported a history of 2 or more sustained concussions of any grade and 46% reported no prior history of concussion.
A significant relationship was found between total years participating in football and total number of concussions sustained. Quarterbacks (like Warner, Aikman and Young) and tight ends (like Mackey and Carlson) had the the highest rates of prior concussion (68% and 65%, respectively in the study). Running backs–fullbacks (11 of 33) and kickers-punters experienced the lowest rates of prior concussion (33% and 46%, respectively). NFL tight ends besides Carlson that suffered concussions last year included Dallas Clark, Heath Miller, Kevin Boss, Chris Cooley, Todd Heap to name a few. Jeremy Shockey has recently retired from the Saints after recovering from a concussion while a Giant and reportedly having a subsequent seizure weeks later. NFL concussion incidences were up 21% last year over the prior year and up 34% in two years.
Multiple Concussion Data
A prior history of concussion no matter at what level puts a player at greater risk for severe symptoms in a subsequent concussion. Only 9.4% of players without any history of a concussion had prolonged post-injury mental status changes at the time of a concussive injury compared to 31.6% of those with a history of multiple concussions, according to a study. Also, 3.7% of those with no history of concussion exhibited 3 or 4 of the four severity markers used in assessing concussions (loss of consciousness, anterograde and retrograde amnesia, and confusion) while 26.3% of those with a history of concussions exhibited 3 or 4 of these severe symptoms.
In short, players with multiple concussions were 9.3 times as likely to have severe symptoms.
Football used to only track the catastrophic injuries - the death and disabilities caused by impacts. The brain injuries due to concussions are becoming more alarming as the research emerges. However, the spectrum of repetitive subclinical, subconcussive injuries over time is just as significantly alarming.
Chronic Repetitive Trauma
Repetitive subconcusive brain trauma "takes from five to 20 years to manifest itself. And then the brain cells start dying. And that’s when the people crash,’’ says Neuropathologist Bennet Omahu, a major researcher looking at the relationship of athletes and chronic traumatic encephalopathy (CTE). CTE is a progressive neurological disorder found in people who have suffered some kind of brain trauma, which has many of the same manifestations as Alzheimer’s. CTE symptoms begin with behavioral and personality changes, followed by disinhibition or depression and irritability, before moving on to dementia.
"There is something wrong with this group as a cohort. 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.’ " reports Robert Cantu of Boston University's Center for the Study of Traumatic Encephalopathy (CSTE).
So many of the ex-players who have been given a diagnosis of chronic traumatic encephalopathy (CTE) were linemen -- line play lends itself to lots of little hits that traumatize the brain over time. People with CTE, Cantu says, "aren’t necessarily people with a high, recognized concussion history. But they are individuals who collided heads on every play—repetitively doing this, year after year, under levels that were tolerable for them to continue to play."
Cantu said studies have shown a first-string college football player in a given year experiences between 800 and 1,500 blows to the head of a G-force greater than 20. That's the equivalent of about a 20-mph car crash each time.
Matt Birk, the All-Pro center and graduate of Harvard who plays for the Baltimore Ravens describes the inherent risks of play in the current NFL, "Players are bigger, faster, stronger. It's simple physics: Force equals mass times acceleration. It is a violent game, and there are inherent risks to the game itself. ... Collisions are becoming more intense." Plus the NFL is the end of the cumulative time spectrum for players' careers. Birk has donated his brain posthumously to BU's CTSE.
A thirteen-year NFL veteran like Birk, when you bring in his college and high-school playing days, could well have been hit in the head twenty thousand times equivalent each time to a 20 mph car crash. Clearly, Birk is a smart, experienced, talented NFL-caliber player who knows the risks and has chooses to play for the love of the game though he realizes the possible consequences.
Ted Johnson, a linebacker on the New England Patriots championship team, testified in the Massachusetts legislature for a state bill similar to the Zachery Lystedt Law in Washington state. Johnson had had two concussions within days of each other in 2002. Johnson said, "I know the hazards of football, but I didn’t know what repetitive hits to the head could do. I am terrified about what can happen in the long run.’’
Stun and Separate
Johnson learned a tackling technique from his former linebacking coach, Brian Cabral, called "stun and separate". "Stun and separate" brings down larger players, hitting them with your forehead to their chinstrap. Cabral reflects, "You know, sometimes I wonder if [stun and separate] isn't to blame for this mess. I wonder sometimes if I didn't help do this to him." Cabral had perfected the technique when he was with the Chicago Bears during the mid-80s, when he was a teammate of Duerson's.
Alicia Duerson, who kept in touch with her ex-husband, said that he developed a word-finding difficulties in writing and in his conversation. He also had developed short-term memory loss that, she said, "got worse as time went on." Duerson knew the stories of John Mackey, Ted Johnson, and many others through his work on the NFL retirees disability panel and the 88 Plan. "I think David knew that inside of him there was something wrong.... Somebody has to step up and acknowledge that."
Duerson loved football, Notre Dame and the Chicago Bears. At Notre Dame, Dave was a two time All-American, MVP and Captain in his Senior year, an honors graduate in Economics, winner of the Moose Krause Distinguished Service Award, past President of the Monogram Club and past member of the Board of Trustees. He was 50 years old when he died and had been out of football for 17 years.
His family will scatter his ashes over the fields at Notre Dame and at Soldier Field. Yet his spirit may loom over football fields asking each of us if we have done all we can for the game we love and the players we admire and who may have been our fellow students. We cannot plead ignorance anymore.
We offer our heartfelt condolences to his family.