Authors: Mark Fainaru-Wada
Cantu was a logical choice. One researcher called him the “
King of Concussions.” Cantu had been looking into the relationship between sports and head injuries for perhaps as long as anyone alive. When Apuzzo brought him in, Cantu was in his early fifties, a trim man with short red hair that he combed from left to right.
Cantu had grown up
in Santa Rosa, California, about an hour north of San Francisco, where his father owned a building supplies company. After pitching for two years at Cal, he blew out his arm, and so he decided to accelerate his entry into medical school at the University of California, San Francisco. Cantu moved to Boston in 1964 to do his residency at Massachusetts General Hospital and never left.
By the mid-1980s, Cantu was chief of neurosurgery service and chairman of the department of surgery at Emerson Hospital in Concord, Massachusetts; for fun, he worked the sidelines at high school football games. At the time, contact sports, especially football, were experiencing a wave of hysteria over something called second impact syndrome. The idea was that a first blow to the head might seem benign, but it primed the brain for the second blow, which killed you. The actual number of cases of second impact syndrome was, in fact, low, but the lack of understanding and the sinister nature of the injury led to a lot of media coverage. Cantu, who was watching teenagers collide every week, decided to start looking into the true nature of those collisions. He didn’t want to miss the concussion that preceded the concussion that wound up killing a kid.
Cantu quickly realized there were no guidelines for how long a player should sit out after a concussion, and so he decided to come up with some himself. There wasn’t a lot of research to draw on; Cantu admitted the exercise was a bit of a stab in the dark. One of his sources of inspiration was an experiment in which UCLA researchers had bashed rats in the head and then checked their glucose levels, glucose being the chemical that powers the brain. The levels stayed depressed for an average of 5 days but sometimes as long as 10, a possible indication of how long it might take to recover from a concussion. Later, the study’s author, David Hovda, ran into Cantu at a meeting and asked him how he had come up with his recommendation that athletes sit out a week after suffering a concussion. Cantu pulled out Hovda’s study. “You’re making
recommendations from rat data?” Hovda asked, grinning.
By the time Apuzzo tapped him as
Neurosurgery
’s sports section editor, Cantu had written dozens of papers on concussions and the criteria for returning to play. He had been named president of the American College of Sports Medicine. He was exactly the type of expert Lovell
had expected to see on the NFL’s committee. Cantu’s concussion guidelines were still somewhat arbitrary, but they gave coaches, trainers, and team doctors something to go on when assessing whether a player should be allowed back on the field. Cantu believed the NFL’s research was a perfect candidate for the sports section of
Neurosurgery
; it could help advance the science of an issue that had long been important to him. His doubts about Elliot Pellman notwithstanding, he was curious to see what the NFL, with all its resources, came up with. “I knew the work had been done; I thought the work was important and suggested they submit the first paper to
Neurosurgery
,” Cantu said.
The first NFL paper was accepted on May 27, 2003. It was published in the October 2003 issue under the title “Concussion in Professional Football: Reconstruction of Game Impacts and Injuries.”
To launch the unprecedented initiative, Tagliabue contributed
a bland guest editorial titled “Tackling Concussions in Sports.” He wrote that the NFL’s research already had “contributed to advancing our understanding of the science of concussions, which is a concern for everyone involved in competitive sports and recreational activities. The accompanying article confirms the groundbreaking character of this research.”
Apuzzo was
more effusive and colorful in a manner befitting his avant-garde publication. In an editor’s note, he compared Elliot Pellman’s MTBI committee to Galen of Pergamon, the Greek philosopher and medical researcher who studied the wounds of the Roman gladiators. “Football’s participants dwarf Rome’s gladiatorial combatants in number, and, in its most sophisticated form, the game’s pageantry matches or exceeds the spectacle of Roman-designed events,” Apuzzo wrote. “As in the ancient contests, modern football is attended by myriad injuries, the most frequent of which involve the brain.”
“As in the past,” Apuzzo continued, “the modern arenas of sport offer laboratories for the study of the mechanisms and events attendant to multiple injury end points in athletes, and they offer a substrate of important information for our general comprehension of the problem of human trauma in general.”
Apuzzo described the research by “Pellman et al.” as “highly responsible NFL-sponsored studies” combining field analysis with lab work and offering “significant new insights” into concussions, including “important
data for consideration in the development of new directions in helmet design and testing.”
The NFL’s era of scientific exploration had begun.
The early reviews were glowing. In its first paper published in
Neurosurgery
, in October 2003, the NFL (Pellman et al.) not only had brought science to the question of why the lights were going out for so many players, it also had addressed an issue on the minds of many researchers who thought deeply about the subject. The paper suggested that the standards used to measure the effectiveness of football helmets in preventing head injuries had to be reassessed. The standards were set by a body known as the National Operating Committee on Standards for Athletic Equipment; everyone called it NOCSAE (pronounced NOC-SEE). It had the ring of a government agency—maybe part of the FTC or the Consumer Protection Agency—but in fact, NOCSAE was a private nonprofit organization funded mostly by the sporting goods manufacturers it regulated, including the helmet companies.
Not surprisingly, NOCSAE hadn’t changed the way it tested and certified helmets for years. But now here was the NFL, with all its power and authority, using science as a catalyst for reform. NOCSAE focused primarily on the ability of helmets to withstand blows to the periphery and crown of the helmet, but the NFL’s study indicated that many injuries occurred when players got hit in the face mask and the side and back of the helmet. This was progress. Cantu, who served as a consultant to NOCSAE, knew that the standards needed updating. In a review appended to the article, he called the NFL’s first paper “the most extensive study to date on the biomechanics of athletic concussion in football” and praised “Pellman and his collaborators for this exciting, innovative and unique study and the NFL for funding this research on a topic very critical to its athletes.”
Three months later, the NFL published
another study in
Neurosurgery
. This second paper—“Concussion in Professional Football: Location and Direction of Helmet Impacts”—drilled down on where the concussive blows were delivered. Again it was illuminating. Pellman received credit as lead author, but most of the heavy lifting was done by Biokinetics, the Ottawa biomechanics firm brought in by the NFL, and
Dave Viano, a biomechanical engineer at Detroit’s Wayne State University who had done crash-test studies for the auto industry. This time the NFL divided the human head into quadrants. The league found that 71 percent of the concussive blows were being struck on the side and back quadrants of the helmet, another repudiation of NOCSAE standards.
Again
the reaction was positive. Julian Bailes, the neurosurgeon whose work with Barry Jordan had indicated that alarming numbers of retired football players had signs of dementia, wrote that the NFL had “ushered in a new era in the study and analysis of the many nuances of these high-speed bodily collisions.” Alluding to the concussion videos, the NFL, Bailes wrote, was “studying by darkroom analysis an important laboratory for head injury, the football field.”
An aura of good feeling settled over the Mild Traumatic Brain Injury Committee. The NFL had revealed itself as a force for good. Yes, the commissioner had appointed a rheumatologist to oversee scientific research into brain injuries, and yes, most of the doctors had ties to the league, but the science was the science. The NFL had resources that no other researchers had at their disposal: a vast library of videotape, an army of willing research assistants, a closed pool of subjects (the players), and, of course, gobs of money. The concussion research community stood by and waited to see what the Mild Traumatic Brain Injury Committee would produce next.
The wait lasted only a month. In the next issue of
Neurosurgery
, the league published
NFL Paper Number 3.
This one was different; that much was clear.
The much praised biomechanical studies were over. This time, Pellman et al. had taken the statistics from the NFL Mild Brain Injury Surveillance Study and used them to paint a panorama of concussion in professional football.
It was in many respects a very pretty picture. The NFL didn’t have much of a concussion problem, the study concluded. The injury occurred at an extremely low rate—about one every three games—a rate strangely similar to the statistics spouted by Tagliabue and the NFL’s PR department for a decade, long before the study had been put in place. When concussions did occur, 92 percent of all players returned to the field in less than seven days—that is, they never missed a game.
Pellman and his fellow authors interpreted this as an indication not that players were being rushed back on the field or hiding their injuries but that concussions were minor events whose symptoms went away quickly with few, if any, long-term consequences. “More than one-half of the players returned to play within 1 day, and symptoms resolved in a short time in the vast majority of cases,” they wrote.
The
response from the scientific community this time was guarded, even puzzled. Many researchers noted the obvious flaw that blew an enormous hole in the NFL’s claims that concussion rates were low: the reluctance of players to report their injuries to coaches and team medical personnel.
Nine months later came
yet another NFL study in
Neurosurgery
. This one dealt with
repeat
concussions. Numerous previous studies had shown that one concussion left the brain vulnerable to another concussion if the brain wasn’t given time to heal. Guskiewicz had taken it a step further: Repeat concussions, he’d found, appeared to increase the probability of dementia later in life greatly. But that wasn’t a problem in the NFL, according to Pellman et al. The league looked at how quickly players went back on the field and concluded that they were at no greater risk than if they had never been concussed at all. The logic was that because players returned to the field so quickly, they must have been okay or the medical staff wouldn’t have cleared them. This flew in the face not only of previous research but of widely known realities on an NFL sideline. First, players often didn’t report their injuries. Second, they hid their symptoms whenever they could. Third, NFL doctors often deferred to the wishes of coaches and players, just as Pellman had deferred to Parcells. As Steelers doctor Tony Yates had said: “Only a head coach can pull a player off.” The entire NFL culture was incentivized toward risk.
For the first time, the NFL also took on the issue of football and brain damage, a growing concern among researchers. The league’s scientific opinion? This wasn’t a problem in the NFL either. Boxers got brain damage. Football players didn’t. It was as simple as that. “This injury has not been observed in professional football,” Pellman and his colleagues wrote.
That was technically true: No one had yet cut open the skull of a
dead football player to examine his brain for signs of neurodegenerative disease. But after the findings of researchers such as Bailes, Jordan, and Guskiewicz, few doubted that day was coming. Pellman and his colleagues noted that the NFL’s study was “admittedly not the best vehicle to search for evidence” of long-term brain damage in football players. Why? Because the league, in fact, hadn’t studied the issue. But that didn’t stop Pellman and his colleagues from offering an opinion. Yes, there were players who left the game with long-term symptoms after suffering repeated concussions. “They clearly did not have [brain damage] as that seen in boxers,” Pellman et al. wrote.
The response to NFL Paper Number 4 was like a cannon going off in the tightly knit concussion research community. Before the paper was published, Cantu, as sports section editor at
Neurosurgery
, sent it around for peer review. Bailes and Guskiewicz were among the reviewers. The two researchers could hardly believe what they were reading. Not only was the NFL dumping on their research, but the league had taken a giant deductive leap by essentially declaring that pro football players were impervious to brain damage, as if they were superhuman. Bailes and Guskiewicz informed
Neurosurgery
that
they were rejecting the paper’s major findings. They weren’t alone. Even
Cantu, the editor, had misgivings about the NFL’s conclusions and the paper’s scientific underpinnings.
In most peer-reviewed journals, rejection by a preponderance of reviewers—particularly the assigning editor—is usually more than enough to prevent a paper from being published. Many scientists feel that’s exactly the point of the peer-review process: to prevent science of questionable origin or credibility from making it into the literature—the engine of scientific progress. But
Neurosurgery
, at Apuzzo’s direction, used a different process. Reviewers could raise their objections in a comments section appended to the paper, but the paper itself would stand.
Even in the
stilted language of science, the comments on NFL Paper Number 4 were scathing. Guskiewicz called the NFL’s conclusion that repeat concussions were of no real consequence “potentially dangerous.” Bailes stated that the concussion rates calculated by the NFL do “not indicate a true ongoing incidence.” In other words: wrong. Cantu wrote: “At first glance, the NFL’s experience with single and repeat concussion
(no difference) and management (more than 50% of players return to the same game, including 25% of those with loss of consciousness) seems to be at odds with virtually all published guidelines and consensus statements on managing concussion.”