Play hard, die young

Recently, by coincidence, I have been reading the grimly-titled Play Hard, Die Young; Football Dementia, Depression and Death by leading forensic neuropathologist, Bennet Omalu.

Published in 2008, it helps provide some very interesting and relevant context to the currently unfolding events.

My post on Wednesday entitled 'applauding the NFL' should be taken within this context; I am fully aware that the league has been guilty in being too slow in both recognising the existence of brain damage caused by the sport, as well as in aiding those directly effected by it.

Here is an extract from the chapter entitled 'The response of the National Football League'. I encourage you to buy the full book.

'In 1994, Paul Tagliabue, the commissioner of the NFL, formed the Mild Traumatic Brain Injury (MTBI) committee to examine the issue of concussions in football. The committee later recommended that the NFL should sponsor independent scientific research into the causes, diagnosis, treatment and prevention of concussions. These independent research projects may not have been as independent as we would have wanted them to be, since the one who pays the piper dictates the tune.

A globally significant mistake was made when the six initial members of the MTBI committee were appointed; they included a neurologist, a neurosurgeon, a neuropsychologist, a bio-mechanical engineer and an epidemiologist. There was no neuropathologist or an expert in the genesis or cascades of developments of disease (pathogenesis). The focus of the MTBI committee expectedly drifted to the biomechanics and acute manifestations of sports-related brain trauma. They published many scientific papers on these subjects without paying any attention to the possible delayed effects of repeated concussions. Understandably, we are all human and we all make mistakes.

Following the diagnosis of gridiron dementia on the first NFL player in 2002, my colleagues and I were obliged to climb to the top of the mountain of science and announce the news to the scientific community. Our professional obligation and responsibility was to report the case in a reputable scientific journal since it would be the very first autopsy-confirmed case of dementia in a football player published in the medical literature. We chose to publish this first case in the journal Neurosurgery because the NFL published most of its brain trauma-related medical research in this journal, although the validity of some of the research findings has been questioned.

The case was finally published in July 2005 after a drawn-out and tiring struggle to convince the reviewers and editors of the journal that the case was scientifically valid. But thankfully, and with our deep appreciation to the editorial board of the journal, especially Dr. Donald Marion, a prominent neurosurgeon, the case was finally published.

Several months after the publication of the first case, I received an email from Dr. Marion requesting that I respond to an attached letter that the MTBI committee of the NFL had submitted to the journal. He called me later to discuss the NFL letter and gracefully advised me on what was expected from me. My initial response was that of fear and trepidation. I have sweated profusely out of fear only on several occasions in my life; this was one of them.

I felt very intimidated by the fact that doctors who represented the almighty NFL had submitted a letter requesting the retraction of our printed paper. After a gulp of my favourite whisky, I settled down, printed the letter, and perused it. First, I noticed that it was rather too lengthy for a letter to the editor in response to a published paper in a journal. Second, I noticed that it may have been even longer than the original paper that was its subject matter. Third, I noticed that it was rather too unfriendly and noncollegial, too confrontational and accusatory, and just too critical. I smiled, my heart beat much slower, and the profuse sweating stopped. Perhaps the whisky was taking effect.

I smiled because the letter from the MTBI committee was too defensive. It reeked of ulterior motive. I was surprised by this response and stance since I had presumed that the NFL would be happy with our scientific findings, which I had assumed would enhance their research and understanding of concussions. I was proven wrong.

I shredded the printed copies of the letter and went about my chores for the day, hoping to deal with it some other time. I forwarded copies of the letter to my coauthors. Two weeks later I composed a response and sent it to my coauthors, who made changes before we finally submitted the response to Neurosurgery in May 2006.

The letter from the NFL was written and signed by Drs. Elliot J.Pellman, Ira R. Casson, and David C. Viano, three of the most prominent NFL physicians. Dr. Pellman was actually the chairman of the MTBI committee. They essentially requested that our paper be retracted since it was scientifically invalid and flawed. The only papers that are retracted from publication are papers written by authors who lied or who have forged results and conclusions-that is, dubiously and intentionally falsified scientific papers. Ours was not the least bit falsified. We simply reported what we saw. These NFL doctors probably wanted to set a precedent that if certain powerful and influential doctors do not like a published scientific paper, they may have it retracted. Certainly, they weren't the first group to try.

Drs. Pellman, Casson and Viano attacked us, claiming that we seriously misinterpreted the neuropathological findings in the case and that we had a complete misunderstanding of the relevant medical literature. Neither Dr. Pellman, Dr. Casson, nor Dr. Viano was a neuropathologist. I wondered how doctors who were not neuropathologists could interpret neuropathological findings better than neuropathologists, especially when these doctors did not think that it was prudent to appoint a neuropathologist to their committee, even in an advisory capacity.

They extensively reviewed the neuropathological literature in their letter, arguing that our first case did not have gridiron dementia and did not meet the neuropathological criteria for such a diagnosis. I was extremely disappointed, for it seemed then that the NFL may have unfortunately adopted a stance of denial. I truly understand the embarrassment our report may have caused the members of the MTBI committee, but rather than adopting a stance of denial, they should have considered options more constructive than spurting a rather emotion-laden letter to the editor of Neurosurgery.

We replied with a more collegial and fraternal letter, recognised their "scholarly" letter, and suggested that the NFL should seriously consider our first case as a sentinel case that warranted further investigation by the NFL to confirm if there was a danger of professional football players developing chronic and irreversible brain damage. We reiterated that the NFL should begin examining the long-term effects of brain injury in its former players and volunteered to collaborate with the MTBI committee in developing and implementing an optimal research program that would address this important issue. At the time of publication of this book, almost five years later, the MTBI committee of the NFL has neither sent me a letter nor given me a phone call.'

What I have found most disconcerting reading various stories about how the NFL has dealt with the issue, as well as case studies of those former players now suffering at various stages of mental problems, is that the more you read, the more horrors appear.

It slowly unravels; more pieces of the jigsaw begin to fall into place. New names appear, new cases, and one begins to realise that the sport has, until now at least, done a remarkably effective job of pushing the issue clean off the agenda. Frankly, it's frightening.