Rush to judgment
To those who have read any of the countless articles about head injuries in sports in the national and local media or watched in recent years any of the concussion documentaries on CNN, HBO or PBS, Head Games: The Movie plows already familiar ground. Here again are the stories of athletes who have been forced to retire from their sport - or are one concussion away from retirement - after suffering multiple concussions (Andre Waters says he "stopped counting at 15"). All of the athletes featured in Head Games candidly admit that they did not tell anyone about their initial or lingering symptoms, were allowed to keep playing despite such symptoms, or returned to the field or rink before their brains had fully healed.
Needless to say, the adverse effect on their health is predictably negative. All of the brains in which Drs. Ann McKee and Bennet Omalu found the dark stains of tau protein characteristic of CTE were, with the exception of Penn football player Owen Thomas, of professional athletes who played for many, many years longer, and presumably sustained many more diagnosed and undiagnosed concussions and sub-concussive hits than the average high school football, hockey, lacrosse, or soccer player. Yet there is only the briefest of mentions of this vitally important fact.
Despite quick disclaimers at various points through the movie, Head Games is intent on reinforcing in the viewer's mind a link between playing contact or collision sports and CTE, and between CTE and suicide. For every statement that the research on CTE is in its early stages, or that connecting some of the dots "isn't supported by the science," it seems there are ten heart-rending and emotional stories about athletes who have committed suicide and later found to have suffered from CTE (Andre Waters, Mike Webster, Owen Thomas, etc.), or, like Mr. Nowinski and some retired NFL players, are at high risk of CTE. The scenes of Thomas's father visiting his grave, of Penn head athletic trainer and MomsTEAM expert, Eric Laudano, holding back tears in talking about Thomas, and of Mr. Nowinski, Drs. Cantu, McKee, and Stern telling the widow of a former boxer that his autopsy was positive for CTE, pack an emotional wallop, to be sure.
At the same time, Dr. Cantu admits in the film that, tragically, there is a "huge gap" between that hype and the science, that the brains Dr. McKee has been slicing and examining under her microscope represent a "very selective sample," and that, we have "no idea" of the prevalence of CTE." As an excellent recent article on ESPN.com reported, most of those involved in the study of CTE caution against a rush to judgment and are unwilling to connect the dots quite yet.
"I've seen [CTE research teams] present their data at meetings and they talk about the limitations of it," says Kevin Guskiewicz, PhD, ATC., Kenan Distinguished Professor at the University of North Carolina, and head of its Center for the Study of Retired Athletes and Director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center. He blames the CTE hysteria, not on the researchers, but on the media. "I'll just be honest," he told ESPN.com's Mike Fish, "they sensationalize it, and it all is about ‘Every former player that plays for more than five seasons must have this.' ... We have been moving a bit too quickly. We need to get more prospect[ive] studies that are going to really identify whether there is a cause-and-effect relationship. Because right now all we are doing is looking at a cross section of a relatively small group of players that are based on case reports and not scientific studies," he observes.
To his credit, Dr. Cantu, both in the ESPN article and in Head Games, also urges caution in drawing conclusions from the "very skewed sample of brains" that his group has been looking at. The problem is that, when Dr. Cantu, like Dr. Guskiewicz, blames the media for over-hyping the possible links between concussion, CTE, and suicide, his words ring hollow, because his restraint is not shared by his colleague, Mr. Nowinski, who is only too happy to connect some of the dots in order to paint a much, much more one-sided and scary picture, one in which, he suggests, we can "create 500,000 cases of CTE" and, somehow, "everybody's okay" with that. It is Mr. Nowinski's overheated rhetoric, I believe, which viewers of Head Games are much more likely to remember, not Dr. Cantu's more qualified, cautious and careful approach.
Is anybody listening?
One of the things Head Games does well is dramatizing (and in one particular instance, perhaps over-dramatizing) one of the major challenges faced every day by those involved in concussion education, as MomsTEAM and I have been for the past 11 years: educating parents, coaches, athletic trainers, administrators, and players to take the health risks that concussions pose seriously.
I know first-hand, as Alan Schwarz of the Times says, that too many people simply "don't want to believe" the problem is as serious as it is, and that this stick-your-head-in-the-sand attitude is pervasive at all levels of sport. It should come as no surprise to anyone involved in youth sports that even Chayse Primeau, the 14-year-old hockey-playing son of Keith Primeau, whose NHL career was cut short by concussions, says he "would rather not know" about concussions, and that even such NHL veterans as Danny Briere of the Philadelphia Flyers say that concussions are something players don't really "want to talk about."
For anyone who has been involved in concussion education as long as I have, the scene in Head Games in which Mr. Nowinski is shown giving a lecture to a half-filled high school auditorium - half-filled, he notes, because the football coach had decided to schedule a mandatory weight-training session for his players at the same time as the lecture - is apocryphal. When the school's head athletic trainer accuses him of engaging in scare tactics by failing to mention that many athletes don't suffer adverse long-term health consequences from playing contact and collision sports, Nowinski's frustration boils over. He chastises the AT for a "terrible argument" (likening it to those who used to complain that all the talk about cigarette smoking causing lung cancer didn't recognize that lots of people who smoked didn't get the disease), says he fears for the AT's job because of his blasé attitude about concussions, and walks off the stage in a huff mumbling "I'm going to go back to Boston."
Leaving aside for the moment whether the scene is all that flattering to Mr. Nowinski, as it puts on display a darker side to his personality that we don't see anywhere else in the movie, leaving the impression with the viewer that he may be more bully than educator, the problem once again is that, unlike the link between cigarette smoking and lung cancer, which is now clear beyond peradventure, the link, at least between concussion and CTE, has not yet been proven. The result is that Mr. Nowinski's curt dismissal of the athletic trainer's statement as a "terrible argument" rests on drawing a conclusion from the data that the data simply doesn't support.
Culture club
The movie does an excellent job of driving home the message that the very culture of violent, contact and collision sports such as football, ice hockey, lacrosse, and, yes, even soccer, leads many athletes, when they suffer hits that leave them disoriented and seeing stars, to respond by deciding to be tough, hide their symptoms from everyone, and keep playing. What is on full display in Head Games, and is a point made clear by virtually every athlete and former athlete who appears on screen, is the "warrior" culture of contact and collision sports, a culture which undoubtedly represents one of the biggest single obstacles to tackling the concussion challenge before us. As Gene Atkins, a former New Orleans Saints' player, tells us, when he suffered concussion symptoms, he simply didn't want to come out of the game. The sad result, as the movie shows us, is memory problems so severe that Mr. Atkins can no longer even correctly recite in order the months of the year.
Mr. Nowinski admits that he was "seeing stars" all the time he played football, and later as a wrestler in the WWE. Knowing what he knows now, he is amazed that he was "gladly exposing myself" to repeated concussions for 19 years. We learn that it isn't just football and hockey players who hide their symptoms. Former Olympic and World Cup soccer player, Cindy Parlow Cone, admits that she probably suffered over 100 concussions (if "seeing stars" is considered a concussion), while 15-year-old soccer player, Mary Rounce, tells of her determination to continue her pursuit of Olympic and World Cup glory, despite having suffered 4 concussions. "I'm pretty good at being tough," says Rounce.
Here, once again, the problem with Head Games, in my view, is that it highlights athletes who are outliers, who are better than most at hiding their symptoms, who have a higher pain threshold, who so competitive that they continue to play despite - or is it because? - their brains are scrambled.
More troubling is that while the movie identifies the problem - chronic under-reporting of concussions by athletes and the difficulty sideline personnel often face in spotting concussed athletes, especially at the youth and high school level - it doesn't offer any real hope for a solution to that problem. Instead, Mr. Nowinski simply wonders "how can we let kids play" when most school and youth sports programs don't have observers on the sidelines and in the booth like the NFL whose sole job is to look for athletes with signs of concussions, and Dr. Cantu says that it could be argued that sports programs that can't afford to have athletic trainers or other trained medical personnel on the sidelines perhaps shouldn't be fielding teams in contact or collision sports at all.
Completely missing from the movie is any mention of the advances in technology, particularly products designed to alert sideline personnel through the use of accelerometers (e.g. hit sensors) embedded in helmets, chin straps, mouth guards, or sweatbands, or even put in an athlete's ears, to hits hard enough to possibly cause a concussion so he or she can be checked out.
Nor does Head Games include any mention of the King-Devick Test (KDT), co-invented by one of the movie's Executive Producers, Steve Devick, a simple two-minute test of rapid eye movement which has been found in two studies (one of college athletes, and another that included both high school- and college-age rugby players) to be a an accurate "remove-from-play" sideline concussion assessment tool, so much so that no less an authority than Dr. Cantu himself recommends use of the test as part of the battery of baseline and post-concussion tests in his new book, Concussion and Our Kids.
As first reported by Slate.com, and confirmed in an e-mail from Mr. Devick, one of the early rough cuts of Head Games did include footage on KDT, which was not included in the final version. While I understand that leaving the KDT footage on the cutting room floor was the decision of the director, Mr. James, who, according to an email from Mr. Devick, had "complete creative control" over the movie, and while inclusion would undoubtedly have exposed Messrs. James and Devick to charges of conflict of interest (which the Slate reviewer made anyway, based on the rough cut that it was mistakenly sent), it was, in my view, unfortunate that viewers were deprived of the benefit of knowing about the test, and the progress being made towards reliable sideline assessment of concussion. I am left to wonder whether the real reason it was not included is that it detracted from the message the director sought to convey. A concussion might be a little less scary to parents if they knew that there was a test that a trained health care professional could administer on the sports sideline to determine whether an athlete should be allowed to continue playing or be sent for a more complete assessment.
