The 3 C’s of the Season: Christmas, Concussions & CTE

Merry Christmas, from two elves and potential movie-goers this holiday season.

Today is Christmas, and I hope for all of you who celebrate the holiday that you and your family have a wonderful day.

Some of you, over this holiday season that will extend through New Year’s Day, will probably be viewing the movie Concussion, which opened yesterday across the country.  I know I’ll be writing down my thoughts on the movie itself after I have viewed it.

The central story has been told (and many of the characters in that story were portrayed) a couple of years ago in a wonderful PBS documentary called ‘League of Denial,’ which I reviewed in October 2013.  I am looking forward to the ‘Hollywood version’ of the story.  I am also looking forward to the robust debate about the topic of head injuries in football that will ensue.

In the buildup to the movie that has progressed over at least the last month, that debate has already, in fact, begun [in truth for those of us in ‘the business,’ the debate over issues such as the association of concussions and chronic traumatic encephalopathy (CTE) has been on-going for some time].  The New York Times has, in particular, seemed to make a point of publishing several articles and opinion pieces on the ‘concussion epidemic.’

As a pediatric sports medicine clinician and researcher, I have been particularly concerned and involved with the concern over the hypothesized association between risk of developing CTE and exposure to head injuries in youth sports such as football.  I am particularly worried that there has been a rush to judgment in the media, and proposed decisions (for instance, to banish youth contact sports) are moving way ahead of the science.  Many of the Times’ articles had me wanting to engage in a conversation with the authors, and so, in that spirit, I drafted a ‘Letter to the Editor (LOE).’

The Times’ word restrictions for their LOEs are pretty tight, and what I am sharing with you below far exceeds their limits.  I wanted to post it here and engage you, my readers in this discussion.

CJSM will be a leader in the on-going publication and dissemination of evidence-based research on the concussions, CTE, and other such issues in the world of sport.  Continue to follow us as we, along with you, wrestle with the questions.

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I have been reading with great interest the series of articles the NY Times has been publishing on the topic of youth football and contact sports, including the Op-Ed piece by Dr. Bennet Omalu[1] (“Don’t Let Kids Play Football”) and, most recently, the story of Peter Robinson, “How a Boy’s Concussion Death Changed British Sports.”[2]

One unifying thread in these two stories is the work done by two different neuropathologists, that of Dr. Omalu in the USA and that of Dr. Willie Stewart in Scotland.  The work they have been doing on the association of head trauma and pathologies including chronic traumatic encephalopathy (CTE) has been invaluable to advancing our understanding of youth sport safety.

I am concerned, however, that the stories being written in the NY Times pieces do not convey that the science of CTE, as it exists in 2015, is undecided.  The associations that are described in the articles, and in the work of the neuropathologists, are intriguing; they do not however demonstrate cause and effect.  This can be a tricky concept to fully understand even for the most advanced of scientists.  I am concerned that the stories that have been published do not convey the sincere debate that currently exists in the sports medicine community over the relationship of youth football (and youth rugby) participation and any long-term risk to these athletes.

I am a pediatric sports medicine physician, and I care for young athletes in clinics, training rooms, and on sidelines.  I am like many of the authors of the recently published American Academy of Pediatrics (AAP) recommendations on youth tackle football[3]:  we are clinicians as well as researchers, who have direct experience of managing concussions and direct experience of the value of youth sports participation.  The AAP recommendations chart a balanced and evidence-based course by which youth football can be made safer, and the recommendations do not endorse either an end to the sport or an end to all tackling.

I am, furthermore, concerned by comments attributed to Dr. Stewart:  i) “For all the small minds that are critical and obviously trying to deny the inevitable signs,” Dr. Stewart said, “there are a whole bunch of people who are having a positive effect on it,” and ii) “I don’t need to stand up in front of a conference of sports medicine and be personally criticized…..”

I can assure you there are many in the sports medicine community who have the overall, short- and long-term health of their young charges foremost in mind when they come to the same conclusions that the AAP has.  I would add in agreement with Dr. Stewart that there is no place for personal criticism or ad hominem attacks in a robust, evidence-based debate over an issue as serious as this. And I would caution him to know that there are many who are critical of his overall conclusions but who have open and not ‘small’ minds.

Finally, I would encourage him to, in fact, attend those sports medicine conferences, as there he will be exposed to countervailing arguments and engage in the true process of science, which is one of debate. This is a discussion that will continue for some time.  All stakeholders need to weigh in on these issues with mutual respect and with attention to the science.

[1] http://www.nytimes.com/2015/12/07/opinion/dont-let-kids-play-football.html

[2] http://www.nytimes.com/2015/12/14/sports/rugby/tragedy-forges-alliance-for-change-in-concussion-protocol.html?_r=0

[3] http://pediatrics.aappublications.org/content/136/5/e1419

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Merry Christmas and Happy New Year to you all.