Truth Doesn't Have a Side

by Bennet Omalu

  Bennet Omalu

  Lodi, California

  Appendix

  Questions from Parents about Brain Trauma and Contact Sports, Especially Football

  What are some recent discoveries affecting junior football play?

  A child can suffer permanent brain damage from playing football, even after only one season of football, without suffering any concussion. The cause of brain damage is less about concussions but more about repeated blows to the head—with or without concussions, with or without helmets. The younger you are when you begin to play, the greater the risk of permanent brain damage and the greater the risk of cumulative exposure to brain damage. Even a single documented concussion can cause brain damage. Studies have shown that if a child plays a high-impact, high-contact sport like football, that child stands a higher risk of dropping out of high school, not attending college, not doing well in life, becoming reliant upon the social welfare system and dependent on disability payouts as an adult, developing psychiatric and psychological problems later in life, receiving drug prescriptions for psychiatric illnesses, and even dying at a younger age.

  Just how much damage can happen and when? Even at an early age?

  Significant damage can happen any time and at any age. We do not know the exact blow—or how many blows—that will cause permanent brain damage. Anyone who plays football has a 100 percent risk exposure to permanent brain damage. There is no such thing as a safe blow or impact to the human head, just like there is no such thing as safe cigarette smoking. Every blow and impact to the human head can be dangerous. God did not intend for us to play games like football when He created our heads and brains. The younger a child is when he or she plays football or other high-impact, high-contact sports, the greater the risk of cumulative brain damage.

  What sports do make a lot of sense to play?

  Adults are free to play any sport they want to play, no matter how dangerous. It is within the rights, free will, freedom, and liberty of every adult to choose to play any sport and engage in any activity he or she wants to play or engage in. This is not about adults, but about our children.

  Children should engage in sports that are noncontact or less contact. For an enumeration of available noncontact sports that are brain-friendlier, visit the website of the International Olympics Committee (IOC) at www.olympic.org. I did that when it was time for my children, Ashly and Mark, to play sports. Today they play brain-friendly games that are noncontact, including track and field sports, badminton, volleyball, table tennis, baseball, basketball, swimming, and kick-only, less-dribble soccer. No contact sports for them. True sports are meant to be recreational and rejuvenating. True sports are meant to build up the child who plays them and not destroy that child and rob that child of what defines him or her as a human being—his or her mind and intellect. Having watched the Olympics every four years, I know that brain-friendly noncontact sports can be as entertaining and as exciting as contact sports. Moving forward into the twenty-first century, our children should engage in sports that build up their brains rather than destroy them.

  Less-impact, less-contact sports like soccer may be permissible. In these types of sports, incidental blows to the head do occur, but they are not intrinsic to the play of the game. I believe modifications should be made to these games as we play them today to make them safer for our children. Specifically, in soccer for children, we should eliminate heading of the ball; make the ball softer, lighter, and slightly bigger; and reduce the number of players on each team in order to reduce the number of players on the field at the same time—therefore reducing the risk of players running into each other by accident. Playing less-impact, less-contact sports like soccer requires adequate development of brain functioning for reflexes and coordination, which the brains of children have not attained developmentally. Therefore, we can increase the age limit for children to participate in these games. For example, children may not be allowed to play dribble soccer until they are twelve or fourteen years old to give them a chance to attain adequate development of brain reflexes and coordination. Before then, they may engage in less-dribble, less-contact kick-soccer.

  If I choose to put my kids in football, is there any advice you can offer based on what you’ve learned about sports?

  I really do not have any advice about what to do if your child is playing football. The only advice I have for a parent about football is that if your child is younger than eighteen years old, please do not let him or her play football or other high-impact, high-contact sports. It is not worth the risk. If your child plays football, he has a 100 percent risk exposure to brain injury and brain damage. There is no helmet on the market that will eliminate this risk. Your child can wait until he or she turns eighteen years old—just like your child can wait until he or she turns eighteen or twenty-one years old to smoke or drink or join the military. I do not let my children play, so if I were to advise other parents to allow their children to play, it would be unethical for me, and I would be falling short of my duties as a Christian and my call to love and treat my neighbor as I would treat myself. If your child is already playing football or other high-impact, high-contact sports, please stop them today. Stopping their brain from receiving the next blow may be the very thing that will save them.

  What about the whole effort to limit play to game tackling only, not in practice?

  It does not make any difference. Limiting tackling only to games still exposes your child to repeated blows to the head. The fundamental issue is not about concussions but about repeated blows to the head, no matter how seemingly innocuous those blows could be. Your child can still suffer brain damage, even after only one season of playing football, without suffering any concussions. In the management of risk, if you identify a risk, you mitigate exposure to that risk and eliminate that risk, if and when possible. Football is not an indispensable activity of daily living like transportation; we do not need sports like football to live, and therefore they should be avoided and eliminated for our children. There are so many other alternative sports for them to engage in. An analogy is cigarette smoking. We have identified cigarette smoking to be dangerous, just like we have identified blows to the head in any activity to be dangerous. We do not advise any child to smoke only one cigarette a day (or five cigarettes a day) as opposed to an entire pack. All cigarette smoking is dangerous, just like every blow to the head is dangerous. Repeated blows to the head over time can even be more dangerous for a child than smoking half a cigarette a day—yet we do not allow children to smoke, but we allow them to suffer traumatic brain injury. In most jurisdictions in the United States, the intentional and sometimes unintentional exposure of a child to the risk of serious bodily harm and pain qualifies as child abuse or neglect. The injury does not have to occur for you to be in violation of the law. For example, if you leave your seven-year-old child alone at home and you go to work, you can lose custody of that child solely because you left that child home alone. But in allowing your child to play football, you are even doing something worse for them. We are choosing to intentionally expose our children to the risk of permanent brain damage from high-impact, high-contact sports like football. This is simply not the right thing to do, especially if you love your children, like all of us parents do.

  Do studies show that concussion helmets, if worn throughout a player’s career, will help prevent concussions?

  No. Helmets do not prevent subconcussions and concussions. Helmets prevent abrasions, contusions, and lacerations of your face and scalp; fractures of your skull; and bleeding inside your skull. They do not prevent your brain from bouncing around inside your skull and impacting the inner surfaces. Helmets may actually increase the risk of your child suffering subconcussions and concussions. Your child is more likely to hit with his helmet because he feels less or no pain. There is no skin-to-skin contact. The helmet also increases the weight and size of your child’s head and increases the momentum of the impacts and the amounts of energy that reach your child’s br
ain and cause brain injury. Helmets are not the answer. The only answer at this time is prevention. The brain floats freely inside the skull, and nothing on the outside of the skull and scalp will stop the brain from moving and bouncing around the skull.

  What about flag or touch football?

  I do not know much about touch or flag football. If either involves the same blows to the head as regular football, they are not safe. As I understand them, touch and flag football are designed to be noncontact games, which make them a safe alternative to full-contact football. However, I do know that in touch and flag football, opposing teams line up against each other, and when they play, the players still do have collisions as part of the play. I caution parents against allowing their children to play football in any form. Noncontact forms of the game feed the illusion that football in all forms is safe while also building a stronger desire for a child to play full-contact football in middle school or high school. I have already addressed the dangers that this poses.

  At what age does CTE set in?

  CTE can set in at any age. Symptoms can begin at any age. Subtle symptoms may first manifest themselves while your child is playing and may go unnoticed. Sometimes it can take up to forty years for your child to exhibit serious and incapacitating symptoms. This can happen after your child has stopped playing and has long forgotten that he played. CTE is not the only danger. There is also another disease called PTE (Post-Traumatic Encephalopathy) that can also manifest during or after your child has stopped playing. One of the commonest types of PTE is Post-Traumatic Epilepsy. The long-term effects of blows to the head encompass a spectrum and continuum of diseases that involve physical brain damage, inflammation of the brain, and impaired functioning of the brain that may not always end up in either CTE or PTE, which are the more advanced and more permanent forms of this spectrum of diseases.

  Have you done studies on the college and high school level, and have you seen CTE take effect in younger athletes?

  Yes, I have seen CTE and PTE in teenagers and athletes in their early twenties. I have also seen ALS (amyotrophic lateral sclerosis—Lou Gehrig’s disease) in children who played football and developed the disease in their twenties and thirties. When they develop ALS, it is a form of CTE involving the spinal cord (CTE-ALS). The predominant symptoms are motor symptoms and movement disorders.

  Does the brain injury have to be repetitive to cause CTE?

  No, brain injuries do not have to be repetitive to cause CTE. CTE can occur outside of sports as a result of domestic violence, physical abuse of children, motor vehicle accidents, domestic accidents, other industrial and occupational accidents, physical assaults, and exposure to explosives, like in military veterans. But in sports, you are more likely to have the scenario of repetitive impacts to the head, which cause subconcussive and concussive injuries that can become cumulative over time. In subconcussive injuries, you will have injuries on the microscopic cellular level without any obvious and incapacitating symptoms. Concussive injuries display obvious and sometimes incapacitating symptoms, which can be transient. Subconcussive and concussive injuries are more prevalent in high-impact, high-contact sports, are cumulative in nature, and over time result in cumulative and permanent injuries. Therefore, every blow to the head is of a forensically consequential nature. This is why parents who have the habit of smacking or knocking their children on the head as admonishment should stop that—as well as all forms of domestic violence. Every blow to the head can be dangerous.

  How do you think the NFL changes will affect CTE? Have they gone far enough?

  No, the NFL has not gone far enough. The changes that have been made still do not remove the head from the game. In fact, I do not think that football as we play it today can ever be made safe, just like boxing cannot be made safe. The NFL has instituted new guidelines for concussion management, but the fundamental issue is not about concussions but about repeated blows to the head. The NFL guidelines should be about each and every blow to the head while playing football, but the league will not recognize that, because in so doing, they will have to admit that football is inherently dangerous. Even with the new concussion protocols and guidelines, once a player has suffered a concussion, the damage to the brain has occurred. The new guidelines cannot reverse that damage. There is no cure for a concussion—although the symptoms of a concussion may be treated. But the damage done to the brain by a concussion cannot be reversed or cured, especially within the context of repeated blows to the head. What do we have to do? We must recognize the truth for what it is, for there can only be one truth—and based on the truth, we become empowered and enlightened to discover solutions and cures. A solution cannot be derived if we do not recognize and accept the one truth.

  What is the safest position a child can play in football?

  There is no “safest” position a child can play in football. Debilitating brain injuries have been found in every position on the football field—from linemen and offensive and defensive backs to kickers and punters. Every position on the field puts a child at risk. Stating that there is a safe position a child can play in football is like stating that there are a certain number of cigarettes a day a child can safely smoke. Potentially dangerous activities should be left for adults who have reached the age of consent. Every position in football is dangerous for a child. A child is anyone under the age of eighteen, and this is when your child’s brain begins to become fully developed as an adult. The human brain becomes fully developed from about eighteen to twenty-five years old.

  Have you found any differences in positions played and the connection to CTE?

  Research data has shown that players who play certain positions are more likely to receive a greater number of blows to their heads. However, there are many more factors involved that have nothing to do with the position you play—for example, the style of play of the player. A more aggressive player, regardless of the position played, is more likely to be injured than a less aggressive player. Every player who plays every position in football has a 100 percent risk exposure to repeated blows to the head and to brain trauma—with or without a helmet, with or without concussions—and can develop permanent brain damage, CTE, and PTE over time.

  I thought that children could regenerate brain tissue. Can’t that help children be safe from CTE?

  The human brain does not have any reasonable capacity to regenerate itself. We are born with a finite number of brain cells. We can only lose our brain cells; we cannot create new ones. There has been an experimental proposition of limited stem cells in the brain—and that some of these stem cells may be instigated and programmed to create new brain cells—but these propositions remain at academic and experimental laboratory levels that have no reasonable applications in actual patients and in real life. As physicians and healers, we need to be empathetic, truthful, hopeful, and sincere with patients and not give false hopes to children and their families. We have more brain cells than we may actually need, so we have high compensatory and rehabilitative capacities for neurological functioning, especially in children, who are more likely to have greater temporal reserves. However, the brains of children are still developing and establishing the neural interconnectivity and architecture that developed adult brains have. Brain trauma affects this developing neural interconnectivity and architecture in children and makes their brains more vulnerable to brain trauma than the brains of adults.

  Is there a way to reverse CTE?

  As of today, given where we are in medical science and science in general, permanent brain damage from all types of brain trauma cannot be reversed. CTE and PTE cannot be reversed. The only cure is prevention. During and after brain trauma, medical care can control the degree and extent of damage, but it cannot reverse it or cure it.

  In what other sports have you found CTE?

  There is a risk of developing CTE in every high-impact, high-contact sport where repeated blows to the head are prevalent, where blows to the head are intrinsic to the play of the game.
The most notorious high-impact, high-contact sports are football, ice hockey, boxing, wrestling, mixed martial arts, and rugby. CTE has also been found in BMX bikers, as well as in soccer players as a result of headers and accidental collision injuries. That is why, in my opinion, headers should be removed from youth soccer, and children younger than twelve to fourteen years old should not play dribble-soccer or lacrosse as we play them today. Given the physiological differences between boys and girls, men and women, some of these contact sports may have to be modified for girls in order to lower the high risk of exposure to concussions like we have in women’s soccer.

  Is there any way to diagnose CTE while an athlete/person is living?

  A presumptive diagnosis of CTE can be made by a physician based on the constellation of symptoms and signs, medical history, and history of exposure to brain trauma. The key word is “presumptive” diagnosis, which means a reasonable degree (greater than 50 percent) of certainty. However, definitive diagnosis, with 100 percent certainty, can only be done after the patient dies and the brain tissue is examined. These standards also apply to dementias such as Alzheimer’s disease. So the answer is yes, if you believe you have symptoms of CTE, you should go see a physician who specializes in the diagnosis and treatment of all types of brain damage caused by brain trauma. These types of physicians include neurologists, psychiatrists, and physicians who specialize in physical medicine and rehabilitation. I must reiterate that neuropsychiatric testing—evaluating a brain trauma patient with psychological testing—should not be used to diagnose CTE or brain trauma. The FDA does not approve the use of neuropsychiatric tests for the diagnosis of brain trauma or CTE. Neuropsychiatric testing is used to monitor cognitive functioning, and it should stop at that. Parents have been systematically misled to believe that neuropsychiatric testing (imPACT testing, for example) is the answer to brain trauma in sports. This is not true. Once a child has suffered a concussion or another type of brain trauma in sports, there is actually nothing a neuropsychiatric test does for that child.