Love, Zac

by Reid Forgrave

  Dr. Shawn Spooner came back from Afghanistan with a continued interest in treating concussion.

  Spooner had to get Zac out of his “I’m broken” funk. “You’re broken,” Spooner told him, “but you’re not broken forever.” Spooner told Zac that he shouldn’t hope for recovery; he should expect recovery. Sure, he would struggle at times, like anyone with a chronic illness. But trust that you will improve, he told Zac.

  On June 16, 2015, around the time of Zac’s second appointment with Spooner, he scrawled an entry in his journal. His words hinted at optimism.

  “My 5 year class reunion is next month and I hope I at least got my shit together by then, so I can be social, plus I don’t really have any other friends,” Zac wrote. “I’ve been to 3 colleges and always felt to scared to be close friends with someone and for some reason I could never open up to anyone. Even when I would CrossFit, it was hard for me to become ‘close’ friends with someone. I feel like I try to avoid any situation to go out and meet new ppl. Often times when I’m running or listening to music I pretend I’m living a different life and it keeps me going. I always imagine having the girl I was to shy to talk to and hanging with the people I always wanted to. I’ve always been super self conscious and try to avoid public situations when my pic could be taken. I don’t even like to look at myself whether I look ripped or fat. O well—enough of the pitty party. I’m going to try and go for a run, maybe hopefully get my old self back!”

  Depending on your point of view, the setting for the Fifth Matthew Gfeller Sport-Related Neurotrauma Symposium was either incredibly tone-deaf—showing just how deeply in bed the football-industrial complex is with the medical and scientific communities studying brain injuries—or the only appropriate venue. I chose to see it as the latter. A couple of hundred brain scientists, athletic trainers, and other specialists, all of whom possessed knowledge of how contact sports affect the brain that far outpaced my own, strode into the third floor of Kenan Memorial Stadium at the University of North Carolina at Chapel Hill on a drizzly morning in March 2019. The college town had a special buzz because the next day North Carolina was scheduled to battle its Tobacco Road archrival, Duke, in basketball. The conference’s namesake, Matthew Gfeller, had been a do-it-all boy growing up in Winston-Salem, North Carolina, as comfortable singing onstage as he was lifting in the weight room as he pursued his goal of starting as a sophomore for his high school’s varsity football team. In August 2008, months after he’d become an Eagle Scout, Matthew was playing his first varsity game when he suffered a helmet-to-helmet collision. He died two days later. His parents lobbied for better concussion protocol for student-athletes and started this center to spur on concussion research.

  The day I walked into the symposium, a few things stood out: That the windows looked out on the yellow goalposts, where more than fifty thousand fans convened to watch the very sport at the forefront of the concussion crisis. That the symposium was sponsored by Riddell, the helmet maker that’s been sued by former NFL players with long-term health issues but every year introduces new helmets aiming to reduce concussions. That the previous football coach at UNC, Larry Fedora, had less than a year before created a firestorm by questioning the links between football and CTE, saying this: “I fear that the game will get pushed so far to one extreme you won’t recognize the game 10 years from now . . . I do believe if it gets to that point that our country goes down, too.” And that the keynote speaker, Dr. Allen Sills, the NFL’s chief medical officer, began his presentation, titled “Is there a future for football?” with a photograph of him with NFL Commissioner Roger Goodell.

  There are some who would stop right at Sills’s potential conflict-of-interest disclosure—that he is a full-time paid employee of the NFL—and dismiss this conference right off the bat. Science must be independent, these people say, and cannot be subject to pressures of moneyed interests. When I told Kimberly Archie, a California attorney and one of the foremost advocates for the rights of young athletes specifically relating to concussions in football, that I was attending this conference, she bristled. (Archie lost her son, posthumously found to have CTE, in a motorcycle accident.) These North Carolina researchers have taken millions of dollars in funding from the NFL, including a three-year, $2.6 million grant announced in 2017 to study postconcussion rehabilitation techniques, therefore they were dirty. She saved a special amount of disgust for Kevin Guskiewicz, a sports medicine researcher at the University of North Carolina at Chapel Hill who is the founding director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center. In 2018, Guskiewicz had served as an expert witness for the defense in a lawsuit from a former University of Texas football player whose widow sought to hold the NCAA responsible for his health problems decades after his playing career ended. “He is the devil,” Archie had told me about Guskiewicz. “The one place you can’t play both sides of the ball is in litigation. You’re either the plaintiff or the defense.” Archie and others like her believe researchers who take the NFL’s money are dirtied by it and cannot be trusted. Emblematic of modern-day America, even the science is politicized.

  I chose to take a different view, maybe because the different view—that these researchers, scientists, and doctors are working in good faith with an NFL that’s finally realized the threat of concussions—is the only view that offers hope for a solution. Sure, I would be skeptical of any broad conclusions about the future of football made by a paid employee of the NFL. But I also believe that you have to operate within the system to change the system. Guskiewicz and the Matthew Gfeller center certainly have close ties with football’s power brokers. He used to work for the Pittsburgh Steelers, for example, and he’s a member of the NFL’s head, neck, and spine committee. But he’s also an eminent scholar, a recipient of the MacArthur Fellowship “genius grant,” and the chancellor at UNC. If football is to be saved, it must start at the highest level, where the most money is, and then trickle down to colleges, high schools, and youth. If that means potential conflicts of interest, well, it feels inevitable.

  It’s hard to imagine a more accomplished scientist to lead the NFL’s efforts than Sills. He is a professor of neurological surgery at Vanderbilt University Medical Center in Nashville, and has served as a consulting neurosurgeon for Division I collegiate teams as well as NBA, NHL, and NFL franchises. He has been named eight times among America’s top doctors by the Castle Connolly guide. When it comes to acknowledging concussions as a problem in football, Sills is held in much higher regard in this field of medicine than Dr. Elliot Pellman, a rheumatologist who was the New York Jets team doctor and chaired the NFL Mild Traumatic Brain Injury Committee from 1994 until 2007, or Dr. Ira Casson, who cochaired the committee from 2007 to 2009. Casson became known as Dr. No after appearing on HBO’s Real Sports in 2007 and saying multiple head injuries caused no long-term health problems in NFL players. Together, those two became the face of the NFL’s denialism of the long-term impact of football’s head-jarring collisions. The NFL’s head-in-the-sand period of rejecting science has been analogized to the way tobacco companies once brushed away concerns that smoking could cause cancer.

  As ESPN reporters Mark Fainaru-Wada and Steve Fainaru put it in their seminal book League of Denial: The NFL, Concussions, and the Battle for Truth, those were “those strange years when the National Football League went to war against science.” Sills is the NFL’s flesh-and-blood admission that the science the league had railed against for so long was actually right. Or, as Guskiewicz stated: “CTE is real.” And the existential threat to football is real, too. You don’t have to look any further than the amount the NFL has invested in research—$235 million in brain injury research over the past five years, including $35 million in 2018 alone, for long-term studies about the consequences of playing football—for proof.

  Sills’s PowerPoint presentation about football’s future first looked at the sport’s past. He noted that concerns about the dangers of football are not a new problem, and he brought
up those 18 football deaths and 159 serious injuries, most of them involving devastating spinal damage, in 1905. He noted the NFL has made forty-seven rule changes in the past fifteen years to improve players’ health and safety. Kickoff rules in particular were dramatically changed after studies indicated those plays result in the highest number of head injuries. All players on the kickoff team now remain stationary until the ball is kicked, taking away the running start. There is now no blocking until the ball is caught, and no wedge blocks where the receiving team has two shoulder-to-shoulder blockers act as a two-person shield for the returner. The league now has thirty medical personnel at NFL stadiums on game days, including independent neurological consultants on the sidelines, support that was implemented in 2013.

  NFL engineers did video analyses of every in-game concussion between 2015 and 2018 and matched each hit against 150 variables, including how the player was hurt, where the contact was initiated from, where on the helmet the contact occurred, and the force factors involved. Then, the NFL ranked all thirty-four models of helmets players are permitted to wear; helmets that fell into the green category were the best helmets, while yellow helmets were decent, and red were substandard. For the 2018 season, the NFL Players Association banned all ten helmets from the worst tier, and about half of NFL players changed their helmet.

  “No player would sign up for a shoe that has a two times greater risk of an ACL tear,” Sills told the conference attendees. Ten new helmet models were introduced for 2019, he said, all in the best tier in terms of safety. The NFL’s efforts seem to have made a difference. The number of in-game concussions fell 29 percent from the 2017 season to the 2018 season, from 190 concussions to 135. And there was a 27 percent reduction in all injuries on kickoff plays alone.

  “Let me be very clear—we have to recognize CTE as a very real pathologic entity that’s best been characterized in autopsy,” Sills said. “Unfortunately, we’re still somewhat in our infancy in understanding some really important factors about who gets this disease, why they get it, what are the motivating factors, are there treatment implications, and what can we possibly do to diagnose or intervene in real life. This idea that you either believe in CTE or you don’t is a completely useless construct. Frankly, there is a disorder called CTE. We’re all aware of that. We just need to learn more about it.”

  If there’s one thing to take away from spending two days with a bunch of neuroscientists talking about things like how chronic pain alters brain plasticity, and how long it will take for blood-based biomarkers to move from research labs to clinical applications, it’s this: how far concussion science still has to go. The phrase I heard more than any other was “the infancy of the science.” Members of the media like myself want answers, and we want them fast—especially when we hear of suicides by athletic heroes like Junior Seau, who had a terrifying disease caused by the very sport we worshipped him for playing.

  But the desire for immediate solutions fails to take into account how young this scientific field is. The first-ever meeting about the treatment of concussion took place in 2015. Thirty-seven international experts convened in Pittsburgh and voted on sixteen statements of agreement, later published in the journal Neurosurgery. These statements weren’t exactly headline makers: The experts agreed concussions are treatable and characterized by diverse symptoms and impairment in function. But even these baseline agreements among scientists marked a major advancement. “If we have thirty types of knee injury, why would we think there’s only one type of concussion?” asked Micky Collins, director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center.

  In recent years, the media’s focus on the long-term effect of sport-related concussion as well as smaller repetitive subconcussive events has been omnipresent. Guskiewicz pointed out that the New York Times had published 333 articles on CTE between 2003 and 2017, yet in the world of scientific literature, there were only three hundred diagnosed cases of CTE during that same period. The media has “sort of sensationalized this at times,” Guskiewicz said. “At times, though, [the media has] gotten it wrong around the later-life neurodegenerative diseases such as CTE and Alzheimer’s disease, and painting this really ugly picture as if any athlete who plays contact sports for any period of time is highly likely to develop this. And that’s just not the case.” Science, by its very nature, is cautious. It wants to prove a hypothesis again and again before determining its value. And cautious means slow—much slower than the public, which expects a quick cure-all, can stomach. “It takes time for good research to happen,” Sills said. “What can we do until we have more information?”

  The good that has come out of the NFL’s concussion crisis is an increased visibility of this issue, which means more money and research, which together will ideally mean a sped-up timeline. Prior to 1990, PubMed, the search engine that has more than twenty-nine million citations for biomedical literature, had a total of seven publications on sport-related concussion in its database. This research field barely existed thirty years ago. In 2018 alone, there were 216 PubMed publications on sport-related concussion. “Fifteen years ago, we really couldn’t get anybody to talk about [sport-related concussion or civilian neurotrauma], and sure as hell we couldn’t get anybody to fund it,” said Mike McCrea, vice chair of research for the department of neurosurgery at the Medical College of Wisconsin and a leading researcher in the field. Federal funding over the past five years has surpassed $135 million. “When you think about where we started back in the late 1980s or early 1990s, believe it or not, this wasn’t even recognized as quote ‘injury,’ ” McCrea continued. “When I talked with my high school buddies, or the guys I played ball with in high school and college, it was like a subject of comic relief. It was the thing that we talked about over the summer or at our early high school reunions—‘You remember when you got your head knocked off on a kick return and you were in the wrong huddle? Ha, ha!’ It really had this lack of even a recognition as an injury. It was something, but not an injury.”

  McCrea has led research into blood-based biomarkers to diagnose concussions quickly. This is thrilling science: A biomarker is a measurable substance in the human body that can tip off scientists about diseases, infections, or, potentially, concussion. In time, the promise of blood-based biomarkers is a quick blood draw on the sideline to diagnose a concussion within minutes. But this science is, as McCrea put it, “not yet ready for prime time.” Now, those blood-based biomarkers can give accurate results months later as part of a research initiative. When researchers speak about the promise of these biomarkers, the timeline is measured in decades, not years. There is, McCrea said, a “long translational bridge” between research labs and clinical applications.

  But the science is real. Even as Sills was speaking at this symposium, there were four sites around the country collecting research-grade serum and plasma in potentially concussed patients and using a handheld rapid analyzer to figure out in real time if biomarkers indicated concussion. Even a decade ago, McCrea said, this would have been difficult to imagine.

  Today’s concussion research is almost elemental: the foundation upon which future scientific breakthroughs will be based. Collins and his group in Pittsburgh have identified six different clinical profiles for concussion, and they often overlap: vestibular, ocular-motor, cognitive, post-traumatic migraines, cervical, and anxiety/mood issues. The science of concussion has recognized that these brain injuries home in on the specific vulnerabilities of a particular brain. “Concussion fights dirty,” Collins said. “It decompensates certain systems of the brain. Patients with a history of carsickness are more likely to have vestibular issues following a concussion. Patients with a history of migraine are more likely to have migraine. People with a history of lazy eye are more likely to have ocular dysfunction. Patients with anxiety are more likely to be anxious, and patients with learning disabilities are more likely to have cognitive issues following a concussion. The point is, we’re starting to find that i
t may not be how hard you get hit in the head but what you bring to the table when you get hit in the head.”

  Meanwhile, treatment is becoming streamlined. An NCAA study from two decades ago showed that for 42 percent of concussed players, there was no symptom-free waiting period to return to play. Half of those players returned to play a day or two before concussion symptoms abated. That’s the worst possible thing to do after a concussion. But a joint study between the NCAA and the Department of Defense, conducted between 2014 and 2017, showed that 99 percent of concussed patients had a symptom-free waiting period before returning to play of more than one day, and 40 percent had a symptom-free waiting period of more than seven days. That means concussed players are being withheld for longer than their period of cerebral vulnerability.

  As researchers and scientists tackle what may be an existential question for football—How can brain trauma be mitigated in contact sports?—so too does the business world. Riddell’s newest technology involves a Carbon 3-D helmet, with the interior fitted to each specific head size and shape and then printed from a 3-D printer. Five years from now, Riddell hopes to be offering off-the-rack helmets tuned specifically to each player. The NCAA’s headache task force has focused on assertive and quick treatment from the moment after a concussion to avoid long-term problems. And the most recent research says that the proper treatment after a concussion is not to simply rest—not to cocoon people in dark rooms and limit physical activity. More effective is targeted physical activity like walking, jogging, or light lifting that doesn’t put the brain at risk.