Hidden Injuries and Concussions:  The Direction of Healthcare for Players

"A man's own observation, what he finds good of and what he finds hurt of, is the best physic to preserve health." Sir Francis Bacon

It isn't news that football is a rough, hard-hitting sport. Our modern combination of the stratagems of chess and the violence of unarmed territorial warfare has a bare-knuckle history, in which simply being willing to use the forward pass was once considered a sign of weakness; in which playing hurt was and is a mark of excellence rather than a failing and which sometimes pits the health of the players against the financial and strategic considerations of the teams and the league itself. Football is still constantly finding and reinventing itself, just as it has over the past 100 years. One thing that has changed over those scores of years is the perspective of players and fans alike: We are discovering that while we will cheer on anything that brings victory a step closer, fans and the league increasingly also want the best for the health of the players. It's leading to a sea-change in the way that we observe and handle the issues of injury in the NFL.

The owners and players alike are also embroiled in a burgeoning snare on the subject of healthcare practices by the teams. The NFL has been guilty of fighting a rear-guard action against the rights of the players to obtain a fair and unbiased diagnosis when problems don't respond to the normal or entrenched processes of diagnosis and treatment. This has long been a serious concern within the league, but both the owners and the players' sides have generally avoided any actions that could threaten their own situations. While I'd prefer to see an even higher level of leadership on the issues of player healthcare, certain steps are being taken, and I don't minimize that fact. It's a welcome change, and it is getting more central to the situation each day.

In the past year, the AFC has brought forth a couple of prime examples of the difficulties and the contradictions that are created by this problem. Denver fans were treated to this up close as Brandon Marshall, last summer, chose to vent in the media about his issues regarding his hip injury. In San Diego, Antonio Cromartie also dealt with the subject of a hip injury that tainted his last season. The two cases, while similar on the surface, seem somewhat different as we dig deeper.

Marshall's case tells us something that is often hard for fans to understand. In medicine, even if everything is done properly there is no assurance that the league's doctors (or any others) will ever be able to spot and treat every problem, every time. Marshall complained of pain in his hip during the 2008 season, but despite two series of MRIs (magnetic resonance imaging, one of the most advanced diagnostic tests currently available) nothing appeared on the films. Marshall felt betrayed by this turn of events. While Brandon's disquietude about last year's injury is understandable, he was also ignoring something that people may misunderstand: Our current levels of diagnostic testing simply don't show all injuries. The magnetic resonance imaging process is a remarkable and valuable tool most of the time, but there are many kinds of joint injuries that simply don't show up on that scan. He received two such scans, and both came back 'clean', making it impossible for the team doctors to make a further diagnosis at that time. Marshall is expecting all tests to show accurately and fully the problems that he experienced, and that just isn't reasonable. But there is a precedent here that entitles him to wonder and to need reassurance on this subject: The NFL has been complicit in the past regarding poor diagnosis and care of injuries.

As is sometimes the case, Marshall should also reflect on the fact that he has a history of being less than fully concerned with his practicing and playing time. Ironically, this time he was actually injured.  In 2007, Mike Shanahan had to threaten him to get him back to practice during training camp. It seems likely that his previous incident influenced the coaches inappropriately but understandably. Moving forward, it's worth noting that neither side was at fault when he had physical issues last summer, and that's exactly what both sides want.

It was a very different case regarding Cromartie's hip-injury situation. As Michael Silver noted in his June 2, 2009 column, Cromartie suffered a broken hip in the second quarter of SD's Week 2, 2008 game against Carolina, yet he played out the season on that fracture. Cromartie's performance suffered greatly that season, and he's been on record as feeling that the hip injury was at the heart of that drop-off. The team, in degree, countered that it was up to him to make it clear how bad his situation was becoming. While it's fair to say that he needed to step up and be more proactive regarding his health, there are at least four reasons why that wasn't done:

Concussions and the Players

The most most important coverage that the players have been receiving of late has centered on the issue of head injuries. Long misunderstood, traumatic brain injuries have been a thorn in the side of healthcare because we have tended to take a particular position regarding them. In medicine, we have often been guilty of trying to apply 'scientific' standards that are contrary to common sense and personal respect. We have often claimed that if our testing doesn't clearly show a particular symptom or disease state, the problem doesn't exist. Because our testing abilities have lagged behind the severity of the problem in the past, we lacked a definitive test for head injuries.  Doctors have too often used this as a crutch to claim that we can't observe the symptoms and believe the patient regarding them. Problems with pain have presented us the opportunity to avoid the problem, rather than a chance to improve our diagnostic abilities. That has led to problems, since we like to claim that the players are 'faking' their problems. It's been a neat way to avoid accepting responsibility to the damage that the game has done to thousands of retired players. Finally, testing and research have improved, and the problem is being approached more directly. We are beginning to see that change.

Dr. Ira Casson has become a lightning rod for anger on the part of the players and the public. He was formerly the co-chair of the concussion committee. Casson has consistently taken the perspective that we can't diagnose mild-to-moderate traumatic brain injuries, that the major concussions are not the problem that many now feel that they present and that the NFL has done everything possible and reasonable under the circumstances. The only problem with his position is that he reached it before sufficient research was done and he has maintained that position despite mounting evidence that he's wrong. He's the problem in miniature, a perfect example of why not enough has been done, but things are happening that show people like him for the paid shills that some of them are. As a result of public opinion and even congressional distaste for their position, the owners are accepting of the fact that the status quo won't stand. On Tuesday, Casson and another doctor, Dr. David Viano, both offered their resignations. Goodell has promised to replace them with individuals whose agendas are based in medicine, rather than politics.

Even with the improvement offered by the replacement of these two men, it's important to note just how it was that they came to be heading this committee. They were brought in to replace Dr. Elliot Pellman, who resigned in 2007 after strong criticism of his work and indications that he had exaggerated several aspects of his medical education and professional status in official biographical sketches and a résumé prepared for Congress. Since the NFL let him go to bring in two more doctors whose professional ethics seem less than optimal, you can understand if the players don't embrace the new hires with open arms..

The Concussion Dilemma

When treating a problem, the first thing that you have to do is to be able to diagnose it. One of the problems in doing so is the crying lack of understanding of the concussion problem on the part of the coaches and players. Consider these quotes from AP, posted on nfl.com:

What these quotes show concerns me deeply: There is still a great deal of misinformation out there. Contrary to what Roy Lewis and others believe, everyone cannot see that you have a concussion. Quite the contrary - one of the great problems with concussion is that many of them have hidden perils. People who know you may not understand why you've begun to become less focused or more irritable, but the symptoms may be hard to separate out from day to day life. Players believe that if they had a concussion they'd know it, but the reality is that most concussed individuals really can't tell at all. As the number of concussions - and this includes the so-called 'minor' concussions, which can easily become cumulative - the player himself may not have a clear way to tell if he's not improving or is getting worse.

One part of the solution has been identifying cutting-edge clinical environments like the University of Pittsburgh, where first Michael Westbrook and then Clinton Portis went to have their concussions checked and their future play considered. There is no lack of good facilities that can help the NFL with this problem. The problem has been getting the NFL to make use of the independent programs that are already in existence. By adding their expertise to the formula, the players can be assured of getting high-quality, independent healthcare advice. That provides a precedent that should be widely applied.

A Word from The Dude: Gambling, Fantasy Football, and Injury Reports

The NFL is no stranger to gambling. Even its founders had links to legal gambling with the likes of bookmaker Tim Mara (grandfather of Giants owner John Mara) and Art Rooney, who, in part used his winnings from gambling to buy the Pittsburgh Steelers (http://online.wsj.com/article/SB124511421029417367.html). The recent NFL, however, has tried to distance itself from the gambling industry, while at the same time benefiting outrageously from the NFL's popularity with gamblers. In any given year, there can be in upwards of $100 million wagered on the Super Bowl alone. And there are hundreds of millions more being wagered during the season.

The somewhat recent popularity of fantasy football has also provided a boon to the NFL. It's estimated that almost 20 million people play fantasy football and it's annual revenues are somewhere in the range of $3 billion (http://www.informationweek.com/news/internet/showArticle.jhtml?articleID=201804513). Fantasy football encourages fans to watch more games until the final whistle, and follow more teams and players--all in turn benefit the NFL's lucrative TV deals.

Which brings us to the weekly injury reports each team puts out during the season. Have you ever asked yourself why they exist at all? Sure, on one level, they exists to make sure each team has a "level playing field" as they prepare for each other. But that's hardly the real reason. The real reason injury reports exist is for fantasy football and for gambling, not for player safety.

Before we assume nefarious behavior on the part of the NFL, there's a legitimate reason for this. As Mike Sliver points out in his excellent column from Yahoo Sports from June 2nd, 2009, "...the NFL's [injury] policy isn't a principled stand for truth and transparency. Rather, the league is looking out for the interests of gamblers - not altruistically, but in an effort to keep them at bay. If injuries are reported in a uniform and reasonably accurate manner by all teams, there is a far lesser chance that high-stakes gambling interests might be empowered to purchase inside information from, say, an assistant equipment manager in the know."

In other words, the NFL is the ultimate want-your-cake-and-eat-it-too league. On one hand, they are happy to gorge themselves on the TV deals, advertising revenues, and merchandise sales that are driven by a gambling and fantasy football crazed populace, but at the same time, they don't want to be influenced directly by these powerful concerns. Unfortunately, player safety hasn't been included with the cake. That is slowly starting to change. - TJ

NFL Spine Centers

There are good steps being taken that I want to support and publicize. In one, the NFL has opened a series of what are being called Spine Centers. Spinal impacts also can have extended neurological effects. Given the nature of the sport, that is going to happen in some cases, but such problems have to be expertly diagnosed and extensively monitored. I wanted to take this opportunity to extend my thanks and appreciation to the new NFL Spine Centers. These centers may end up providing a partial template for addressing concerns like the one's listed here.

The NFL Spine Centers are a response to the adage that an ounce of prevention will save a ton of greenbacks, not to mention a life of pain. Early diagnosis and treatment is the cornerstone to an effective approach to minimizing the difficulties of living with long-term spinal damage by the retired NFL players. Each medical center provides an orthopedic spine surgeon who serves as a program director and coordinates the services of a team of healthcare professionals in the evaluation and treatment of the former players. The team includes a neurosurgeon and a physiatrist as well as a wide spectrum of other professionals. While the next step can and should be the formation of similar centers for current players, I want to applaud all sides for putting together and funding this project.

It's a good first step and it may provide a template for a way to improve the situation. Each team currently maintains its own staff of paid doctors who are responsible for decisions regarding the players' health. Since those physicians are paid by the teams, questions of conflict of interest are inevitable. Anytime you see a situation like Marshall's or Cromartie's, you have to question whether or not the doctors involved let their loyalty to their source of income overcome their oath to the profession. Since you cannot fully discern where such a line gets drawn, it becomes necessary to consider the possibility of having a neutral party in on the decisions. In this case, the Spine Centers provide that party. Congratulations, folks. Well done!

Solutions

There has been considerable movement on this group of subjects, those that involve the health and healthcare of the players. Rodger Goodell has been making an attempt to be fair in his handling of this circumstance. A committee of current and former coaches, led by legendary former coach John Madden, a master of malapropisms, speaks by phone with Goodell every three weeks about safety issues and reports to the league's competition committee. Madden's group will make formal recommendations in February.

Tony Dungy has also stepped in -- The league selected the former player and coach to coordinate the Player Advisory Forum. Dungy, who brings an instant air of respectability, will select players to attend meetings in various cities around the league to receive input, comments and criticism about various league matters, including the NFL's player conduct policy and player safety issues. Among those whose knowledge he is drawing on are Broncos safety Brian Dawkins, linebacker Ray Lewis and quarterback Kurt Warner.

USA Today's Jarrett Bell has reported that the NFLPA has formed its first committee on head injuries just in the past few weeks. While long overdue, I applaud the steps that are being taken. Their committee is being headed by Arizona Cardinals special teams ace Sean Morey. The NFLPA has identified head injuries as a priority that they will continue to address during the new CBA negotiations. The recent congressional hearings also have shown a public spotlight on the problem and that makes it less likely that the owners and management group will be able to sweep this under the mat any longer.

The plight of retired NFL players has drawn increased scrutiny as well. Former Chicago Bears head coach Mike Ditka has been instrumental in getting this problem into the public spotlight. Punch-drunk ex-players, many (most) of whom are also suffering rheumatic and degenerative physical conditions are a substantial and growing problem and that has now been accepted as fact by all but the most recalcitrant doctors and authorities. Funding the solutions will be a constant fight, but the simple agreement that a problem exists is a step in the right direction.

All parties will now agree, at least in principle, something needs to be done to address this. The NFL has drawn a lot of well-deserved flack for the fact that they battled against admitting this problem to exist, but they have been exposed recently. House committee hearings served to remind the owners that they have an anti-trust exemption at the whim of Congress and that violations of the public trust can lead to changes in that exemption.

Where Do We Go from Here?

As the Collective Bargaining Agreement lapses, this is a good time for the NFLPA to bring the subjects to the bargaining table. Otherwise, fully funding insurance, health care costs and retirement for players whose bodies have been decimated by the game of football could eventually bankrupt the sport. Look at the situation with General Motors for a down-the-pike, real-world example of the issues that the NFL may end up facing. It is essential to the long-term health of the sport as well as its players that the situation be looked at objectively and that steps must be taken to solve this growing problem.

Making sure that players have access to outside, neutral second opinions is a minor step in this process. Establishing protections for players who admit to the severity of their injuries will at times be difficult, but initial steps in that direction should be considered. The game is tainted when players are forced to play when dangerously injured. Giving them a chance to deal appropriately with their injuries when they occur (rather than after the site of injury has been increasingly damaged by playing through them) would save big dollars down the road. It would also permit those athletes the recognition of a measure of decency and humanity.

Since the dollars are going to be spent on doctors and equipment which have the responsibility for giving unbiased diagnosis and rational treatment to players when the players are injured, it behooves the sport to lock into the next agreement a provision that will establish a system that is independent of the owners purse strings. We know from history that such system are flawed from their inception: healthcare has to be independent of financial rewarding of the doctors by one side or the other if it is to be accurate and fair. Whose pockets this comes from is an important question: the players will benefit the most from such a change and they should look at their own responsibility in funding part of the costs. The owners now cover such costs and they should not be permitted to foot-drag in donating a similar percentage to the solution. Again, the Spine Centers have provided a basis to discuss this further. We also have the growing influence of Sean Morey's group, Dungy's group and John Madden's committee. Ditka and other have brought the problems of retired players into the public eye. There is a growing sense of optimism regarding the direction the circumstances are going it.

Whatever the final solution or solutions may be, it should live up to the following standards: It must be financially independent of either side. It should take advantage of facilities, clinics and programs that already exist and which are considered at or near the top in their fields. There must be a high level of transparency, with the results available to all appropriate parties. Last, all new research must be openly explored and embraced in an attempt to continue to improve the quality of care for the players, past, present and future.

You can see the change beginning. The NY Times had this to say:

In addition, Commissioner Roger Goodell has agreed that bringing in more outside specialists is in everyone's best interest. These are decisions that are going in the right direction for the players and for the sport.

On Monday, November 23, 2009 Thom Mayer announced that 1/2 the NFL teams, plus the players union have agreed upon independent specialists (up from 1/3) to evaluate head injuries. While the other half of the teams need to get on with their obligations, this is a wonderful step in an important direction. Using this same approach to redesigning the medical system in the NFL is an ongoing challenge, but moving in the direction of independent examination and treatment is a huge step.

Whatever decisions are made will influence the lives, health and happiness of generations of NFL players. For their sakes, the sake of their families and for our own moral responsibilities, we have an obligation to get this one right. The enjoyment that we receive from watching this dynamic and remarkable sport should not be diminished by a realization that we are skimping on the quality of care that the players receive.

Finally, we have to see this as an opportunity as well as an imperative. Individual opinions will vary in different situations, but the overall road map to the future should not be drawn, as it often has been, in the blood of the players themselves. Our willingness to demand, as fans, a quality system for caring for the players will influence Congress, balance the preferences of the ownership and management groups and provide an impetus for the improvement of the current system to improve and to emphasize an openness to future changes as well. The field of healthcare is moving rapidly and many changes are being made that will provide a higher level of care for everyone in the future. We must demand that such advances be implemented whenever they are discovered.

Finally, the players themselves must see that they are a great resource for further research into the problems created by trauma and impact. They should make themselves available for such testing as may provide clues to better methods of diagnosis and treatment as time unfolds. This hasn't been employed sufficiently to date, but the demise of the Collective Bargaining agreement will inevitably create an opportunity for improving the lives and care of the players and for the rest of society, which may benefit from what we learn by studying the problems that players experience.

Fans, doctors, owners, management and players all bear a responsibility in this circumstance. Each group needs to step up and to provide the best effort they can, so that the game can be enjoyed for generations yet to come. I salute their efforts.

Many thanks to The Dude for his contributions to this article

Poll

Is the NFL doing enough to protect its players' health?

9%

Yes

42 votes

40%

It's hard to achieve, but they're trying

176 votes

32%

They're dragging their feet, but they're starting to move forward

140 votes

17%

No, they're not doing enough

76 votes

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