Once more, with feeling...it's not just concussions

Well, for whatever amount of time I can retain my sanity and not be overwhelmed by despair, the blog is back. Conveniently, it returns on the day the NFL is staging its conference championship games.

If you want, blame my wife for sharing this article with me.

A study published in the peer-reviewed journal Brain drives home the point that has long been burbling under the surface of the ongoing attempt to sort out the link between brain injury and sport (mostly football, but some others too). This blog has made efforts to drive home this point before.

What is helpful here is a particularly strong effort at distinguishing between three terms that are sometimes thrown about rather loosely in the discussion and drawing a much clearer distinction than is usually the case. Evidently the article's author, Cindy Boren, felt it necessary (and got editorial consent) to draw out that discussion in detail, rather than hoping folks would click on the link in the online post (or go find the journal Brain and read it).

Many studies in the past have suggested that chronic traumatic encephalopathy, hereafter CTE, was not necessarily as connected to concussions as the common wisdom tended to assume, but those studies had not been set up to control for those factors and separate concussive hits from subconcussive hits (which are just what the name suggests, hits not hard or forceful or direct enough to provoke a concussion). This study deliberately set out to control for exactly those conditions.

Note the subject of the study: teenagers, specifically teenagers with head injuries. It shouldn't be a shock by now that early stages of CTE can show up in young athletes, not just grizzled veterans, so the choice of subject isn't out of reason at all.

The key is, not surprisingly, the repetitive nature of such hits. If you play one game of football and get banged up a few times, you could end up with a concussion. You are incredibly unlikely, barring other head injuries off the field, to end up with CTE. Conversely, you can play football through two or three years of middle school, four years of high school, and never get diagnosed with a concussion, and still end up showing signs of CTE. It's not necessarily the most common thing to happen, but it does happen.

The confusion of concussions, traumatic brain injury (TBI), and CTE has tended to hinder the public discussion about all of these subjects. Dr. Lee Goldstein, one of the study's authors, spells out those differences effectively enough that it's best just to let him do it, as quoted in the article:

When it comes to head injuries and CTE, Goldstein spoke of three categories that are being jumbled: concussions, TBI and CTE. Concussion, he says, is a syndrome defined “by consensus really every couple of years, based on the signs and symptoms of neurological syndrome, what happens after you get hit in the head. It’s nothing more than that, a syndrome. You take one [symptom] from column A, one from column B.”

A TBI is different. “it is an injury, an event,” he said. “It’s not a syndrome. It’s an event and it involves damage to tissue. If you don’t have a concussion, you can absolutely have brain injury and the converse is true.”

CTE is “a bona fide neurodegenerative disease. It will progress independently of whether you have future hits and a lot of people think that the injury is the disease and it’s not. There is an injury and then it goes on to spread in the brain, like other neurodegenerative diseases.”

And that being the case, eliminating the concussions (whether by "magic helmet" or some other technological marvel) doesn't necessarily eradicate CTE.

Presumably you can see where the problem lies: it's pretty hard to play football without getting hit, probably getting hit a lot. It's kinda baked into the nature of the game. It's what gets celebrated. It's basic. Other sports also have their issues with violent contact, but few of them (maybe rugby?) are quite so intrinsically based on large and fast men hitting one another as hard as possible as football is. (Soccer fans would probably celebrate enforcing rules enough to cut down on contact if only because it would cut down on the awful injury fakery that plagues that sport.)

But yeah, it's not going to be easy to do much about repetitive hits in a sport that is all about repetitive hits.

So, as the medical evidence continues to escalate, expect more distraction. Quite frankly the NFL and maybe even the NCAA will point to concussions more and more and hope you fall for it. High school athletic associations will frankly just hope you don't notice. After all, there's really not a lot of options otherwise.

Whether such distraction will work is up to you.

One other note: the authors of this study and this article do well to point out that football players are not the only sufferers of CTE affected by this information. Outside of athletics the most commonly afflicted are soldiers, particularly in those combat zones where improvided explosive devices come with the territory. Even beyond those, though, sufferers of repetitive hits include the incarcerated, the homeless, and victims of domestic abuse.

Yes, abused spouses and children can end up with CTE. Let that sink in.

In case you've forgotten...

Only Nixon could go to China

It is one of those stories where, well, you just have to wonder.

About a week ago, the University Interscholastic League, which is the governing body for high school sports in the state of Texas, announced a major effort to track brain injuries among athletes who compete in high school sports in that state. Twenty-four sports will be covered. While I assume some  boys' youth soccer does exist in Texas (girls' soccer is named in the article, you'll note), as a number of professional players have come from the state, the sport most likely to be up for closest scrutiny (by those observing and reporting on the study, if not in the study itself) is football, perhaps the most sacred of idols in that state (or perhaps only second to oil).

Note: while I am intensely curious about how the University Interscholastic League governs high school sports in Texas, I'll leave that discussion aside for now.

The study is inherently significant, as noted in the article, if for no other reason than the sheer number of youth who participate in sports in the Texas system. More than 800,000 athletes participate in sports in Texas public high schools (one assumes there are plenty of private schools with sports as well; whether they are covered in the study or not is not noted). That's the beginnings of a very large database tracking brain injury in young athletes.

The League is partnering with the O'Donnell Brain Institute at the University of Texas Southwestern Medical Center for the study. Its purported aim is to provide a more scientific means to judge whether rules changes, new equipment, or other measures are in fact having any impact in preventing or mitigating brain injury in young athletes, and whether new measures are warranted or needed.

This isn't the first case of a state organization trying to track youth sports on a large scale -- Michigan is noted as having been tracking such injury for some time now. In the 2015-16 academic year football produced the most reports of brain injury, with girls' basketball coming in second, trailing by a mere 1,453 reports.

One would like to be encouraged, wouldn't one?

It all seems very serious. The University Interscholastic League's spokesman acknowledges the lack of scientific usefulness in the current system, which only requires schools to report on a rotating basis. Whatever you may think of UT, its medical program is generally well-regarded. It all sounds like it should be a good thing.

But it's Texas.

It's freakin' Texas.

The book Friday Night Lights (or the movie or the TV series) wasn't set in Pennsylvania or Ohio or Michigan, or even California or Georgia or Florida. All of those states have strong, successful traditions in high school football, as do others. But this is Texas. "Worshipful" is not too strong a word for how that state views football, not by a long shot. The saying that gives this blog its name might as well have been invented there.

Can a state with such a reverence for, such an identity with a sport like football really pull off such a study, no matter where the results may lead?

Do they really want to?

Can the UIL really keep reporting numbers of they get large and out of hand, and nothing seems to help?

Can Texas high schools really be trusted to be scrupulous about reporting all such incidents of brain injury? Can coaches, assistant coaches, trainers, doctors really stick to the rules when the pressure is on and the star quarterback might have to be held out of the big game?

It all has the potential (as it might in any state to some degree) to become a big whitewash.

Or it has the potential to be, to use an overused sports cliché, a game changer.

A genuine and disciplined study can potentially point to what works, whether it be practice limitations, more scrupulous rule enforcement, rule changes or anything else. It could also, in the extreme, point to the conclusion that nothing really works, that football is just going to do this to some percentage of the people who play it when so much size and speed are in play.

On the other hand, a large study such as this could also become little more than a stall tactic, a cover for cries of "we don't have enough data" ad nauseam.

It may be that if a breakthrough of whatever kind is going to happen, it's only right that it comes out of Texas, the epitome of a state where the game really is "way more important than that." Rather like the historical event referenced in the title of this entry, maybe it has to be a state that so zealously embraces the game that has to the one that pushes forth the true nature of the game, or unveils whatever steps are necessary to keep it from enacting a macabre form of Russian roulette on the brains of those young athletes who play it.

It could be big, or it could be just a big sham.

Christian ethics, the human body, and football

Part of my responsibility in purusing this project is to put forth a coherent ethical response to the ongoing concern of football and the traumatic brain injury associated with it. Amidst the gathering of new stories and accounts of the experiences of former and now deceased players, the inability or unwillingness of football leagues or collegiate conferences to take the issue seriously beyond a basic CYA instinct, and possible changing attitudes among fans or players, I occasionally need to drop back and gather up some of the ethical foundation and procedure behind the project, to try to keep myself from getting too far off track.

So bear with me, please.

I have been reminded of two basic concerns underlying an ethical approach to this question; one concerning the possible audience for such concern, and another pointing to a basic reason why Christian ethics must (in my opinion, humble or otherwise) address the issue.

Note the choice of the term "Christian ethics." That is a significant limitation on whatever comes out of this pursuit. In trying to sort out what kind of Christian ethical position I'm coming from I've come to conclude that based on what I hope to be the outcome of such a project, my target audience is limited to what is theologically called the "body of Christ."

It isn't because I think the opinions and actions of those of other faiths are irrelevant or unimportant -- quite the opposite. It is simply that, in my role as a Christian (specifically Presbyterian) pastor, my most basic concern is to in some way provide spiritual guidance and direction so that the members of the body of Christ (we usually call them "Christians" though I am growing less and less fond of that word in its current state every day) are formed and matured into people who live rightly, more so than trying to direct individual actions so that individuals act rightly.* This might not sound like what you've perceived as the role of Christian ethics (or ethics in general), and there are certainly others who will disagree.

*Here one might look into Samuel Wells, Improvisation: The Drama of Christian Ethics (Grand Rapids: Brazos Press, 2004), especially his introductory chapters.

Christian ethical thought has at different times emphasized very different outcomes for the body of Christ -- sometimes emphasizing loyalty to the State as a means of guaranteeing the influence of the Church (and yes, quite a few nominally Christian leaders are clearly taking this approach today); sometimes propagating a canon of law or rules, adherence to which demonstrated one's faith; sometimes emphasizing the rationality of the faith, or its suitability to the improvement of the individual vs. the larger body. By staking out the position I have, I am certianly "showing my bias" -- the importance of community and "body of Christ" over individual supremacy, a preference for formation of habits and even "instincts" to respond ethically to situations that haven't necessarily existed before, rather than prescribing a rulebook and then trying to bend current situations to that rulebook (football is, after all, a relatively recent thing in history, though there are other activities that the Christian ethical response to which will be informative), and others I'm sure I'll hear about.

For the moment, though, the big concern that arises from this is that if my primary concern is with the body of Christ, then what I say should not be considered authoritative over those who do not claim membership in said body. It ain't because I don't care. And if a book or some other product eventually does hit the market, my Jewish or Muslim or agnostic friends (or anybody else) should certainly feel free to buy a copy. <grin> But all of this really does come out of a pastoral and theological foundation, and those who do not partake of such a foundation cannot be bound by my arguments from it.

So the language of this project is likely to get more and more faith-specific -- not with intent to offend, but simply trying to do the only job I can do here.


The second reminder to myself comes in a sideways fashion from the first -- specifically from my job being directed toward the "body of Christ," i.e. the Christian (there's that word again) church. Part of the reason is that I don't believe that followers of Christ, professors of an incarnational faith, can be indifferent to those activities in human existence that regularly and routinely cause harm to the physical body.

We are, after all, followers of a victim of torture. The scourging, whipping, imposition of a crown of thorns, and other abuses visited upon Jesus wouldn't even remotely pass muster under the Geneva conventions today, and I'm pretty sure crucifixion would fall under the ban on "cruel and unusual punishment" even for the most zealous defenders of capital punishment (on second thought, maybe not all such defenders). One of the key events in the narrative of Christianity is an act of physical destruction.

Not surprisingly, Christian ethics and doctrine have not typically looked kindly on activities that visit lasting harm on the body (leaving aside for the moment those who hold to soul/body dualisms of some sort, except to say that I'm not one of them). Capital punishment (usually) comes under criticism; abortion is sanctioned; harm to the body through drugs or alcohol or other foreign substances is decried; sports such as boxing have, eventually, fallen out of favor in many Christian circles. It certainly remains possible that football will similarly fall out of favor, although with such virulent attachments to it still in place in some corners of the church that doesn't seem likely any time soon, no matter how much nobodies like me might protest. But it's becoming harder and harder to ignore the degree to which the game produces an awful lot of broken bodies, even if the damage takes five or ten or twenty years to show. That can't be acceptable in an ethic that takes seriously the idea of human beings created in the image of God.  

Here's a case where our ancestors in the faith have provided some thought that can be applied to the modern case, albeit indirectly at best. The criticisms of Tertullian, Augustine, and the like against the gladiatorial combats and contests of the ancient world don't necessarily transfer directly to modern critiques of football (the spectacle of death is not immediate in the NFL, at least for now), but the concerns both about the aforementioned imago Dei and the impact such spectacles had on those who viewed them should not be dismissed. Augustine's account of his unfortunate friend Alypius at the spectacles sounds pretty mild compared to the total besotted intoxication fans display at the modern spectacles on Saturday afternoons (or nights, or now Thursdays or Fridays), or Sundays (or Mondays, or now Thursdays). That infatuation and saturation with the spectacle becomes an unavoidable part of teasing out a Christian ethical response to the seemingly intractable destructiveness of the game on some sizeable number of its players, and has inevitably to be answered and critiqued as part of the process of ethical inquiry.

In short; the destructive quality of football (which seems more intractable and less fixable than in sports like hockey) has to be addressed, but we're going to have to untangle some seriously dubious entwinement of football and religionesque ritual and worship while doing so. And yes, the "i" word (idolatry) is probably going to have to be invoked at some point.

I...I can't even...

The latest early retirements and alarming studies

I guess it's not really news any more when a player retires after only one year in the NFL, or I suppose it's less of a shock when the player has a history of four concussions instead of one or two, or if he's a Buffalo Bill instead of a San Francisco 49er, or a special teamer instead of a semi-regular to regular player. At any rate, the retirement of A.J. Tarpley was a more under-the-radar event than that of Chris Borland last year (the event that prodded me into more regular blogging after a bit of a lag).

Tarpley played in 14 of 16 games last season, including starts at linebacker in the season's two final games. In the Instagram post in which Tarpley announced his retirement, he is seen holding up the ball after picking an interception on what would be the last play of his career.

Tarpley is a Stanford grad, which might lead some to argue that his education puts him in a position to have a pretty good career outside of football, even after only one year in the league. Here he might bear some similarly to Borland, with a degree and means to forge ahead without the NFL.

Tarpley was frank about the role his four concussions played in his choice to retire. While Mike DeVito, a defensive end for the Kansas City chiefs, spoke of a more general injury history after nine years in the NFL, the two concussions he suffered this past season were also prominent in his decision to retire. DeVito weighed that injury history in light of being a family man; he spoke openly of the need to be there for his wife and children in future years (echoing a thought already expressed by Hussain Abdullah, another Chief who announced his retirement in March).

For D'Brickashaw Ferguson, the issue was less concussions than Concussion.

Ferguson also weighed his own perception of his lessened effectiveness last season, and also recalled a pretty sorry treatment of a former teammate who was strung along through an offseason only to be cut during the NFL draft -- yes, during the draft -- as soon as the Jets had drafted his replacement. There were certainly other issues at play for him. Nonetheless, Ferguson had also spoken out about the concerns the Will Smith movie raised for him after seeing it last fall. Ferguson's a thoughtful man, and showed enough intelligence not to be fooled by the movie's eye-catching title (more catching than Subconcussive Hit would have been, although to be fair the movie does acknowledge the role those play in CTE), expressing concern for the possibility that his future might be affected even though concussions were not a part (or at least an acknowledged part) of his career. He didn't miss a game and never even showed up on an injury report.

DeVito and Ferguson are less unlikely retirement candidates than Tarpley; each could have played a few more years, even if in lesser roles (though it seems clear that Ferguson wasn't interested in doing so), but it isn't completely unprecedented for players around age thirty (especially this offseason -- we see you, Calvin Johnson) or a little younger (you too, Marshawn Lynch) to retire.

The other striking news in the last couple of weeks involves another couple of new studies, focusing on the thing the NFL absolutely doesn't want to hear and more than absolutely doesn't want you to hear. A study out of Boston University specifically took as its focus the role not of concussions, but repeated hits over years of playing football. You can be certain that the NFL will do everything it can to distort whatever result it eventually comes out with (and the initial results, while not yet conclusive, don't look good). The study also doesn't specifically address CTE, the hot-button that the NFL doesn't want to talk about; rather, the study focuses more broadly on brain trauma of many kinds. (Reminder: CTE can only be diagnosed after death.)

Another study was released last week, prior to its presentation at a medical conference this week, concerning former NFL players and traumatic brain injury (TBI) -- again, living retired players, so CTE not a subject of discussion). The study, from Francis X. Conidi of the Florida Center for Headache and Sports Neurology and the Florida State University College of Medicine, tested forty retired NFL players both through sensitive MRI exams and tests of thinking and memory. (Full disclosure: I have a graduate degree from FSU, though obviously not in medicine.)

The results are fairly troubling; in those scans and tests, a full 40% of those players tested showed significant evidence of TBI, by a rate with less than one percent margin of error. That's a rate well beyond that in the general population. The article goes into more specifics on the rates of difficulty in the different mental functions measured by the memory, reasoning, and other tests; take a look for yourself.

That's disturbing enough. But here's the sentence I find most chilling. I'm just gonna quote it directly:

The more years a player spent in the NFL, the more likely he was to have the signs of traumatic brain injury on the advanced MRI. However, there was no relationship between the number of concussions a player had and whether he had traumatic brain injury based on the advanced MRI. 

No correlation to the number of concussions.

Again, this is going to be truly disturbing. Even if one assumes that one can do something about the number of concussions connected to playing football at whatever age or for however many years, it's going to be rather difficult to take hits out of football. Even the very idea is going to prompt the spewing forth of lame blather about putting players in skirts and other derogatory (and misogynistic, if you think about it) remarks from the mouth-breathing knuckle-draggers (hint: if you make such remarks, or even think about making such remarks, you are by definition a mouth-breathing knuckle-dragger even if you have a damn Ph.D).

And yet, as much as the media keeps not noticing, again and again things keep reminding us of something I've been saying for a while now (even about other sports).

It's not just concussions.

Repeat:

It's not just concussions.

Way to go out on a high note, A.J. Tarpley.