NFL, NHL greats discuss concussions, CTE, PCPs’ role in concussion management
While the sporting world prepares for its biggest event of the year, many former players are still suffering from the after effects of their own pursuit of the Lombardi Trophy.
Although many players do not regret their decision to play football, they acknowledge their uncertain futures and frustration with how much is still unknown about how to manage concussions and their aftereffects, leading some to seek untested or unproven avenues to manage their ongoing symptoms.
Between them, former NFL linemen Randy Cross, Leonard Marshall and Matt Birk have six Super Bowl rings.
Each of these players has also suffered from several known concussions and countless hits to the head during their time as athletes, which according to the CTE Center, puts them at risk for chronic traumatic encephalopathy, or CTE.
The Brain Injury Research Institute estimates between 1.6 million and 3.8 million recreation- and sports-related concussions occur annually in the United States. Research in publications such as the Clinical Journal of Sports Medicine, the Journal of Athletic Training, and Orthopaedic Journal of Sports Medicine suggests not all concussions are reported.
According to the PBS documentary “The NFL’s Concussion Crisis,” the league created the Mild Traumatic Brain Injury Committee in 1994, regarded by some as the NFL’s first public acknowledgment that it would look into the impact concussions have on its athletes.
Several former NFL players who had already retired or were close to retirement at the time of that announcement told Healio Family Medicine they were not warned of the risks playing such a fast-moving contact sport would have on their long-term neurological health.
They shared their stories of injury, symptoms, treatment, and, in some instances, how their injuries still affect them to illustrate how the conversation on concussions has turned in the past 35-plus years.
Cross played 13 seasons with the San Francisco 49ers at guard and center, putting him in position for dozens of collisions with defensive lineman every game, and countless more in practices. He recalled the one time he said he was “knocked out cold” while playing for the San Francisco 49ers. An interception in a 1981 game against Dallas had occurred, and he was kneed in the forehead in the chaos that followed.
“The next thing I remember was talking to a doctor or trainer on the sidelines,” he told Healio Family Medicine. “I kept insisting that he let me go back in and he said he’d let me go in if I could tell him what the score was, and I told him it was 21 to 14. I [then] glanced at the scoreboard, and it was quite a bit more than that.”
It would be another 30-plus years before the NFL announced its first concussion protocol, according to the PBS documentary “The NFL’s Concussion Crisis.” The protocol, which has been modified and expanded several times since its 2013 introduction, comprises five steps: rest and recovery, light aerobic exercise, continued aerobic exercise and introduction of strength training, activities specific to football, full football activity and, ultimately, clearance to play, according to the NFL-affiliated website www.playsmartplaysafe.com.
This is a stark contrast to Cross’ treatment in 1981.
“You got an ice bag on the back of your neck and you got a smelling salt cap to sniff on. I was never taken inside the locker room to get the lights in my eyes to see if they were dilating. If you got headaches, and they persisted, they generally speaking would not let you practice until those cleared up.”
The diagnosis of concussions among NFL players have changed since that day, Cross said.
“Nowadays, what they consider a concussion, the number of times you get the shrinking room feeling, the peripheral vision starts coming in as a black, the being dizzy and seeing stars or bright floaters ... [I experienced that] a couple of times a week easily, since we did a lot of hitting in practice. The way things have evolved is a real positive.”
He said other research that also looks at repeated blows to the head, not just concussions, is also a step in the right direction.
“[The researchers] are going about it in a very methodical way. They’re going out there discovering how it happens and why it happens, but until they can figure out why you can get hit 100,000 times and I get hit 1,000 times and I’m the one that develops [symptoms] .... that’s probably the most frustrating thing out there about the subject.”
To him, a study in JAMA that showed that a convenience sample of 110 of 111 deceased NFL players’ brains had a neuropathic diagnosis of CTE, brought his decision to donate his brain to the Concussion Legacy Foundation upon his death into sharper focus.
“That study was good news [and] bad news,” Cross said. “The good news is they’re studying it. The bad news ... as a nonscientist, nondoctor, just a participant, speaking from the position of the lab rat ... I look at it as it’s just not a big enough, true sample.”
“If we can get to the point across the board, where you’re starting to study the brains of people who played in high school, but didn’t play a lick afterwards, or started playing at 6 and stopped playing at 15 and then at 53, 54 years old they started developing some problems, this is going to have to be more of a general population thing ... and one of the reasons I donated my brain is that you need as many brains as possible to get an accurate tell,” he continued.
There were developments on several fronts regarding the NFL, concussions and CTE following Cross’ retirement after the 1988 season.
Former Pittsburgh Steeler Mike Webster filed a disability application with the NFL Retirement Board, alleging his NFL career led to his dementia. Another former San Francisco 49er, quarterback Steve Young, retired, citing concussions. Terry Long, another former Steeler, committed suicide. An examination of his brain revealed CTE.
In addition, researchers published papers that, according to the PBS documentary, claimed slower recovery of neurological functioning after multiple concussions or neurological problems such as headaches, tingling or numbness in extremities, or speech and hearing problems.
However, “The NFL’s Concussion Crisis,” stated that it was not until 2009 that a NFL spokesperson told The New York Times: “It’s quite obvious from the medical research that’s been done that concussions can lead to long-term problems.” The television program went on to say that statement was the first time the NFL admitted a link between concussions and long-term effects.
Cross said the NFL knew about potential problems from repeated head trauma long before then.
“They knew a long time ago and this isn’t a guess, it’s a fact, they knew a long time ago, and didn’t tell players ... That wasn’t something that was ever talked about, or mentioned, or checked for in a physical.”
Since his retirement, Cross said he gets headaches but otherwise feels fine. He serves as football analyst for CBS Sports, and noted that working in the media on a weekly basis would put any cognitive issues or other lingering symptoms in the spotlight quickly. Although he is not showing symptoms now, he does worry about CTE.
“You have to,” he said. “The mental capacity side is the one thing you dread the most. I wish the worst thing that I could worry about was arthritis and a joint replacement — that’d be wonderful.”
Cross acknowledged he is one of the fortunate ones in both career choice and function afterwards.
“I’m very lucky to have [played professional football]. I’m very lucky to have achieved what I achieved, and those that I achieved it with, and damn lucky — knock on wood — that mentally and physically that things are fine.”
Marshall spent 12 seasons as an NFL defensive lineman, most notably with the New York Giants, with whom he won two Super Bowls. Although the most famous play of his career was knocking 49ers quarterback Joe Montana out of the 1991 NFC Championship game with a concussion, he was too familiar with being on the receiving end.
“I wish I could recall how many times I was concussed,” Marshall told Healio Family Medicine.
He did remember the first time he had one.
“I was as playing tight end my sophomore year [in high school] and I caught a pass ... across the middle. Shortly after receiving the pass I was hit smack in the face. I sat on the ground, with my eyes closed with brown spots floating around and semi-unconscious.”
Marshall said he had mixed feelings about his treatment during his playing time with the Giants.
“[Head coach] Bill Parcells had a thing. The first 20 minutes of practice in training camp, you lined up, mano-a-mano, man on man, and you knocked the living crap out of each other, and you tried to create a stalemate. And he did that across the line with 20 athletes for 20 minutes, nonstop,” Marshall said. “Every day, as a pro football player in training camp under Bill Parcells, I used a bottle of Tylenol the first two weeks of practice, because I had to go out there to compete. I knew the headaches were just part of the deal, and I had to accept it... When we look back on it, we laugh about it today, but that was the start of traumatic brain injury.”
“I actually feel that Ronnie Barnes, head athletic trainer emeritus, did a great job taking care of me and my teammates from 1983 through 1993,” he continued. “Do I think it could’ve been better? Absolutely. There was no such thing as an independent medical doctor on the sideline during games, there was no such thing as a brain specialist on the sidelines at practice, and [cannabidiol therapy] wasn’t available to us.”
In practically all cases, CTE is diagnosed posthumously, but Marshall may be an exception. In 2013, he was one of several former athletes who underwent a scan administered by the California-based company Taumark, in which a drug was injected that the company claimed bound to tau proteins in the brain.
According to The CTE Society, Taumark developed the first and only system to detect the presence of tau protein in the brain, which indicates CTE.
The validity of Taumark’s research has been disputed. In 2015, the company received a letter from the FDA regarding its drug [F-18] or FDDNP, saying “the claims and presentations in the website are concerning from a public health perspective because they make representations in a promotional context regarding the safety and efficacy of an investigational new drug that has not been approved by the FDA,” according to the FDA’s website.
The FDA further alleged that by doing so, Taumark was violating the Federal Food, Drug, and Cosmetic Act and ordered the company to stop violating that act. The company’s website has been taken down.
The scan indicated Marshall had CTE, so Marshall may be one of the few athletes alive today to know he has the condition. Regardless of the veracity of the company’s findings, Marshall’s concern is real. “After ... I learned what my future might look like, I was scared, scared as hell. I started to take proactive measures to towards finding people and products that could really help me, which is what lead me to hemp [cannabidiol therapy].”
Cannabidiol, one of the primary components of cannabis, has been shown to have benefit in several neurological conditions, including epilepsy and schizophrenia, and has been cleared by the FDA to be studied for the management of neonatal hypoxic/ischemic encephalopathy, glioblastoma and Dravet syndrome. A PubMed search did not find any clinical studies of its efficacy in patients post-concussion.
The therapy is not a cure-all, Marshall said, adding that though cannabidiol therapy has helped his short-term memory loss, depression, tolerance for sunlight and loud noises, he still has to deal with some of CTE’s effects.
“CTE is a real issue for me on a daily basis ... Over time, the amount of concussions has taken a toll on my total wellness and my ability to recall data clearly most of the time,” he said.
He acknowledged there were certain risks he accepted by becoming a professional football player, but not all were known to him when he first entered the league 35 years ago.
“I knew when I signed up to play professional football that there’s a potential chance of getting injured in the area of my knee, shoulder, neck, wrist, or forearms. Severe brain damage is not something I signed up for,” Marshall said. “It’s the unknown that I’m afraid of. But I feel extremely optimistic. I don't know what God has planned for me, in terms of my health. But I do know this, that if this disease continues to become more debilitating, I'm going to go down fighting and kicking and stomping, to try my damnedest to eradicate this from my body.”
Today, Marshall is under the care of a neurologist, and said he is “starting to feel good again.” Like Cross, he would choose football again as career if he could.
“It’s the greatest team sport of all time. It’s full of joy and pain. I wouldn’t want my kid to play tackle football until he is a teenager and tell him to learn how to tackle properly, play the game real safe,” he said. “Football itself teaches you a ton about life’s journey, its trials and tribulations, as well as forces you to take full assessment of your skills often as you compete.”
Birk played as a center from 1998 to 2013, spending time with the Minnesota Vikings and Baltimore Ravens. He told Healio Family Medicine he was concussed three times, but had no concerns about the treatment he received.
“Medical care was top notch,” Birk said. “I never questioned if the medical staff had my health as the top priority. Obviously, the docs in the NFL are among the best in the world.”
The mindset of concussions has changed over time, he said.
“We have learned a lot in recent years that the treatment [for concussions] has gotten better,” Birk said. “Certainly, the culture has changed to where players are more aware of and take brain health seriously.
He added he has no qualms about one of his five sons playing football if they made the decision to do so.
“Football is much safer today than when I played. [My sons] also play hockey, ride bikes, climb trees, dive into swimming pools, and 50 other things that normal boys do. I put football in the same bucket as all those activities,” he said. “Whatever my kids do, I tell them to be safe and I monitor them best I can.”
Even with the knowledge Birk has now, he would not change a thing about his career path.
“The rewards far outweigh the risks,” he said. “Football changed my life ... I’m grateful for the experience.”
Different sport, different mindsets
While headlines on the concussion issue have focused on NFL players, as athletes have gotten larger and the speed of action within games have increased, more players in all professional leagues have had to deal with the consequences of post-concussion syndrome.
Whereas the NFL eventually acknowledged the link between the CTE and concussions, and, according to a 2017 report in USA Today, has made donations to some of the most prominent facilities that research such neurological issues, NHL management has taken a different point of view.
USA Today also reported that at the time of its article, the NHL had not provided funding to any of the four medical centers that look into neurodegenerative diseases despite NHL Commissioner Gary Bettman’s insistence that the NHL wanted better data surrounding the possible link between concussions and long-term effects.
In 2016, responding to a letter from Senator Richard Blumenthal (D-Conn.), Bettman argued there is no definitive link between concussions and CTE.
“The science regarding CTE, including on the asserted ‘link’ to concussions ... remains nascent, particularly with respect to what causes CTE. and whether it can be diagnosed by specific clinical symptoms,” Bettman wrote.
He later wrote that the NHL was interested in promoting player safety based on scientific consensus while dismissing current research as “speculation and fear-mongering.”
Lindros, played for the Flyers and Rangers for most of his 15-year hockey career, which placed him in Hockey’s Hall of Fame despite being curtailed by at least six concussions.
He indicated that he is not completely comfortable with the NHL’s stance on concussions, and suggested that the results of studies involving concussions need to be more transparent.
“I just wish there was more research that we could rely upon for changes — to have a foundation for basic research that we can draw from. People working collectively to come up with some solution,” he said at a recent press conference where the Flyers retired his jersey number. “These will occur, it’s inevitable, but I really just [wish] the NHL would involve itself on the research side of things.”
Lindros, a former center, added that society is “nowhere near” diagnosing concussions sooner and treating them differently.
“I’m not so sure the research is occurring and [we’re] getting the most out of it,” Lindros added. “Are we sharing our results on time? Are we sharing them fully? Are we expressing some situations where our outcomes were poor? Let’s share [poor results] just the same as any gains, so people don’t have to duplicate them. Funds are hard to come by.”
Primeau spent most of his 15-year career as a center with the Detroit Red Wings and Philadelphia Flyers. He estimated he received “north of 10” concussions in his lifetime, four of which were documented.
“Each had their own set of symptoms,” he told Healio Family Medicine of the four documented concussions. “The last two, the most obvious [symptoms] were headaches, head pressure, sensitivity to light, I had some emotional duress but I always thought that was a byproduct of the symptoms. With my last one I actually had some double vision and sensitivity to light,” he said. “I knew I was off a little bit and I had been hit in the head. Part of me was hopeful, that it wouldn’t come to anything.”
Without any qualms, Primeau tried a variety of treatments under the supervision of his teams’ doctors: bedrest, stimulus therapy, exercise to see if the symptoms regressed, acupuncture, massage therapy, chiropractic care and even reiki, an alternative therapy intended to use touch to stimulate the body’s natural healing ability.
None of the treatments were effective and he was forced to retire in 2006.
Seven years later, Primeau said he tried prolotherapy, which, according to the website prolotherapy.com, is a regenerative injection therapy that “stimulates the body's own natural healing mechanisms to repair injured musculoskeletal tissue.”
Though this treatment helped Primeau regain what he called “some sense of normalcy,” the concussions have left an impact.
“I have concerns about my well-being and my long-term health. I trip over my words and I have short-term memory loss and I never used to. In addition, I sometimes have problems holding a combination of thoughts and that was never a problem for me before.”
“I’m always cognizant of the fact that I damaged my brain,” he continued. “I do worry and am concerned a bit about what the future holds, but I don’t live in fear of [CTE]... “I hope that my demise is of a more natural cause, but I can’t be completely sure I’ll escape it.”
Primeau said he was the first hockey player to choose to donate his brain to the Boston Brain Bank, the precursor to the Concussion Legacy Foundation, upon his death, to try and put what he called a positive spin on the situation. In its own way, he said, the decision helped in the healing process.
“There were days following my injury that I would sit in my office in the dark and be distraught... I found I had too much to live for, my friends, my family, my wife, my children, and I knew what normalcy felt like and I wanted to get back to that point,” he said. “But I also knew that getting back to that point would involve making a difference, making a change. Change comes from research and years and years of case studies, so if it meant sacrificing my brain posthumously to advance science then for me it was a no-brainer.”
Primeau said he has no regrets about his decision play professional hockey.
“Even as I went through my tribulations at the end of my career I didn’t think I had made the wrong [career] decision,” he said. “I would say that if I knew then what I know now I might have treated [my concussions] differently. Both my boys play, and the one has had a couple of concussions on his own, but we’re very confident and comfortable that he’s safe, and that we manage the condition differently than we did during my playing days.”
He added such changes make him comfortable watching his sons playing contact sports.
“It was once difficult for everyone — players, coaches, parents, trainers — to pull kids out when we weren’t even 100% sure they had had a concussion,” Primeau said. “Now, we err on the side of caution. Now it’s an automatic you’re out, you’re being evaluated, you’re not returning to play until you’re at baseline, all of these safeguards have protected both our youth and those who play the game for a living.”
“I don’t want to be so ignorant and say it’s an occupational hazard, or it’s a lifestyle choice that they’ve made, but as parents we get a tremendous amount of satisfaction watching them compete or doing something that makes them happy,” he continued. “I watch closely and intently with a slight reservation, but there is also the understanding that they’re in good hands. If this was 10 to 15 years ago I’d have a lot more reservations than I do today. I feel comfortable knowing that the issue is taken very seriously and is no longer being swept under the carpet.”
PCP’s role in preventing, treating concussions
While professional athletes depend on team physicians and specialists for the medical care, diagnosis and treatment for head injuries for many youth athletes starts in primary care. The athletes interviewed by Healio Family Medicine have all spoken on their experiences with concussions and have sought to raise awareness on the need for better education among youth athletes, their parents and their health care providers.
Cross said PCPs are the “impartial third party” when it comes to treating patients, and that these doctors need to recognize the critical role that they play in their patients’ lives in choosing to play contact sports.
“[The doctor] has an extremely important vote in what a lot of kids do,” he said. “They should not be afraid to [tell a patient] no and not be afraid to say if playing a really violent contact sport shouldn’t happen. There are people who may think no matter how much they’re suited for it, but they’ve got no business doing it.”
Lindros said uniform standards in teaching children about concussions would help diagnose and treat them.
“I’d prefer to start [teaching] at the grassroots levels and exposing kids to the issue,” he told Healio Family Medicine. [Tell them] concussions are going to happen and when they do happen, here’s what to look for. Start teaching them in grade 1, grade 3 and grade 5, but teach them the same thing, whether they’re in Illinois or Saskatoon. Everyone should be on the same page and everyone should use the same criteria.”
“To be up to date on concussions, in terms of what to look for, I’m sure the (medical community) can find a week in the medical calendar to be up to speed,” he added.
Primeau agreed that PCPs can learn more concussions to help them help their patients.
“Listen to your patients, help them through their situation,” he said, noting that no two concussions are alike, and what works for treating one patient, may not work for another.
“Educate your patient, educate yourself,” Primeau continued. “Doctors take concussions seriously, but not all of them completely understand them. It’s so important that they do. Education is vital and very important in this fight.”
Tomorrow, experts in the fields of sports medicine, neurology, orthopedics, and psychiatry will provide more information on the symptoms of concussions, tips on broaching the subject of concussions with patients, how to know when a player can return to the game, and more. – by Janel Miller. Gerard Gallagher and Chuck Gormley contributed to this report.
Disclosure: Healio Family Medicine was unable to determine relevant financial disclosures prior to publication.
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