Neurologists Weigh in on NFL Players' Settlement

Pauline Anderson

September 12, 2013

Many neurologists view the multimillion dollar settlement struck by the National Football League (NFL) and more than 4500 former players as a satisfactory compromise for all concerned parties, although some feel the settlement doesn't do enough for current players and the amount set aside for research into sports-related neurodegenerative disorders is lacking.

In what some saw as a surprise move during mediation, the NFL agreed at the end of August to pay $765 million to settle lawsuits from retired players who have developed depression, dementia, and other neurologic disorders they say resulted from head injuries incurred on the field.

The funds will be used to cover medical costs for documented severe cognitive impairment sustained by ex-players, to pay legal expenses, and to fund research. Awards will go to former players, or their families if the player is deceased, if they have clinical evidence of Alzheimer's disease (AD), severe cognitive impairment, dementia, or amyotrophic lateral sclerosis.

Retired players will receive a baseline medical assessment to establish a qualifying diagnosis either now or in some point in the future, a statement from the mediation firm notes. The baseline exam program will operate for 10 years, and any monies not spent during that time will be added to the monetary awards. The monetary awards fund is $675 million and will be paid according to the specific diagnosis and other factors, including age, numbers of seasons played in the league, and other relevant medical conditions. These determinations will be made by independent doctors working with the settlement administrators appointed by the District Court.

The settlement, which came a week before the start of the 2013 NFL season, was mediated by a court-appointed mediator, former US District Judge Layn Phillips. The agreement is subject to approval by US District Judge Anita B. Brody, who writes in a statement that she will "reserve judgement on the fairness, reasonableness, and adequacy of the settlement until the motions for preliminary and final approval of the settlement are filed."

In their suit the players, including plaintiffs Tony Dorsett, Jim McMahon, and the family of linebacker Junior Seau, who committed suicide in 2012, claimed the NFL concealed the long-term risks of concussions. In agreeing to settle, the NFL does not admit to any wrongdoing, and some say that the settlement relieves the NFL of having to release internal documents that would indicate how much information the league had on the dangers of head injuries and when it acquired that information.

One of the lead plaintiffs for the players was the family of Junior Seau, who committed suicide in 2012. (AP Photo/Denis Poroy)

"Win-Win" Situation

For Robert Cantu, co-director, Boston University Center for the Study of Traumatic Encephalopathy in Massachusetts, the settlement can be seen as a "win-win" situation.

"The fact that a great amount of money is changing hands is good for players and I think also good for NFL because they don't have to be exposed to what they did or didn't know," said Dr. Cantu. "As part of a settlement normally one doesn't have to admit any wrongdoing. And yet on the other hand, the players are receiving $765 million over some years, the great bulk of that going to players that have been, or allege they have been, brain injured while playing the sport of football."

The good news for the NFL, added Dr. Cantu, is that the settlement avoids a court case. "It's not necessarily a slam dunk that they would have won," he said. Furthermore, "I don't think science should be settled in court."

Whether or not the NFL knew about a possible relationship between football injuries and neurodegenerative disease, the settlement "certainly moves to the forefront the concerns of both the lay community and the research community that chronic mild traumatic brain injury [TBI] and mild concussions, or multiple repeated injuries, may have long-term consequence that are far more significant than we thought, say, 10 or 20 years ago," said Christopher C. Giza, MD, professor of pediatric neurology and neurosurgery, University of California Los Angeles (UCLA) Brain Injury Research Center, and UCLA Brain SPORT: Sports Concussion – Mild TBI Program.

Ramon Diaz-Arrastia, professor of neurology, Uniformed Services University of the Health Sciences, Rockville, Maryland, agrees that the settlement is "an important step in the right direction" indicating that the NFL "clearly recognizes that this is a problem."

Deal a "Vindication"

Charles H. Tator, MD, PhD, professor of neurosurgery, University of Toronto, Division of Neurosurgery, Toronto Western Hospital, Ontario, Canada, said the deal represents "a vindication" of the concept that repeated concussions ultimately lead to brain degeneration.

"This has gradually worked its way through medical science and medical practice, and now has been confirmed I think by this settlement," he told Medscape Medical News."To me, it's a wakeup call for all sports. It's another piece of evidence that society is faced with a major public health issue related to concussions, so no longer can we pass off concussions as just an inconsequential 'ding' or 'bell ringer'."

On the other hand, said Dr. Tator, as with all settlements this one is something of a compromise, "so both sides have given in."

The players' compromise, said Dr. Tator, is that they agreed to what may prove to be an insufficient amount of money. "It's not enough to compensate families for players who have already developed major brain degeneration and for those who are yet to develop it."

The costs — including those for lost productivity, medical care, and custodial care — related to repetitive TBI are in the ballpark of $10 million per case, said Dr. Tator. "That's what the 'market value' is; it's what they're asking for in court settlements for major brain injury."

Under the current settlement, he said, "if you do the math, that means only enough for about 76 players." Others point out that many of these football retirees played the game in an era when players weren't receiving the high salaries that many are paid today, and don't have the resources current players may have.

As for the reported $10 million earmarked for medical research, some experts think it's likewise not enough. While the money is welcome, it's "a drop in the bucket" for "a problem as complicated as this," said Dr. Giza.

It pales in comparison to the annual salary of an elite professional athlete or to the "hundreds of millions of dollars" handed out by the National Institutes of Health and various foundations to fund research into AD, he pointed out.

Current Athletes?

Furthermore, while some money was set aside for testing of current athletes, Dr. Giza didn't notice in the summary he saw any provision for benefits for current athletes.

"They're putting money into neurocognitive assessment of athletes playing the sport with the idea of trying to minimize possibilities for these problems in the future," he said. "But there's a bit of a crack that things can fall through for athletes who are currently playing and sustaining injuries who won't be retired at the time the settlement goes through, before our knowledge and understanding of this relationship [between repetitive football injuries and brain disorders] is strong enough to really prevent it."

 
But there's a bit of a crack that things can fall through for athletes who are currently playing and sustaining injuries … Dr. Christopher C. Giza
 

Dr. Tator is also concerned about the lack of provision for current players who, he said, may in a sense now be playing at their own risk. "It almost says that those who are playing now are warned that they're going to be on their own," he said.

"The league I think is saying that they're acknowledging that this condition exists and are putting $765 million down, not on the basis of possibility because we're now beyond possibility here and this is as close to a fact as you can get. This $765 million is one piece of evidence that we have a problem."

And what does the settlement say to players coming up through the ranks? "I think parents will really have further cause to be concerned about letting their kids loose to play the sport that caused this $765 million worth of brain damage," said Dr. Tator.

Considering the millions of athletes who are potentially at risk at all levels of football and other sports, Dr. Giza would like to have seen some resources set aside "to really determine whether those younger guys and girls are at the same risk."

Some in the field think the settlement may affect the popularity of the sport itself. Boxing was the second most popular sport in the United States in the 1960s and 1970s, but since questions have been raised about repetitive TBIs leading to neurocognitive deficits in boxers, the sport has fallen somewhat out of favor, overtaken in recent years by the sport of football.

Dr. Diaz-Arrastia acknowledges that steps are being taken at all levels to make football safer. For example, he said, there have been major changes in rules and regulations, with referees now calling penalties that before would not have been called before. And at the college level, he has heard that contact during practice is being phased out.

"A lot of hits occur during practice and if you can eliminate those, you probably eliminate 80% of the problem right there," he told Medscape Medical News.

"Political/Legal Affair"

Under the settlement, individual awards are capped according to diagnosis, the lead plaintiffs' lawyer Christopher Seeger told the Associated Press. Men with AD are capped at $5 million, those with dementia at $3 million, and those given a diagnosis of chronic traumatic encephalopathy (CTE) after their death at $4 million.

CTE is a progressive neurodegenerative disease found "in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head," notes a description of the condition on the Boston University's Center for the Study of Traumatic Encephalopathy website. "CTE has been known to affect boxers since the 1920s. However, recent reports have been published of neuropathologically confirmed CTE in retired professional football players and other athletes who have a history of repetitive brain trauma."

The repeated trauma causes progressive degeneration of brain tissue, including tau protein deposition, the description notes. "These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement. The brain degeneration is associated with memory loss, confusion, impaired judgement, impulse control problems, aggression, depression, and eventually, progressive dementia."

However, while players appear to be recognized in the settlement on the basis of CTE, the evidence linking repetitive trauma to CTE seems not yet sufficient for some concussion guidelines authors. The 2013 statement by the International Consensus Group on Concussion in Sport concluded that while CTE represents a distinct tauopathy with an unknown incidence in athletic populations, there is insufficient data to support a cause-and-effect relationship between concussions or participating in contact sport and the presence of CTE.

The American Academy of Neurology (AAN) took a similar stand in guidelines released in March. It excluded case reports of CTE from its evidence-based concussion guidelines, said Dr. Giza, who coauthored these guidelines. "We weren't even able to comment on CTE other than to say the evidence didn't meet the standard for us to review it."

Dr. Cantu, co-director of Boston University's Center for the Study of Traumatic Encephalopathy, disagrees with the International Consensus Statement on Concussion in Sport in this regard, even though he was one of the authors. "It's a consensus statement; that doesn't mean all the authors agree with it," he said."I vehemently disagreed with that statement, but the majority of authors believed the statement was reasonable."

 
It's a consensus statement. That doesn't mean all the authors agree with it. Dr. Robert Cantu
 

At the other end of the spectrum is Christopher Randolph, PhD, Department of Neurology, Loyola University Medical Center, Maywood, Illinois, who feels the agreement between owners and ex-players is purely a "political/legal" affair that's not based on a scientific link between football injuries and neurodegenerative disease.

After reviewing the related literature, he maintains that there's no evidence to suggest that retired athletes, including NFL players, are at increased risk for dementia or that they exhibit any type of unique neuropathology, specifically CTE.

He pointed out that retired NFL players have an all-cause mortality rate that is about half that of men their age in the US population and that their suicide rate is only 40% of that in the general population. As well, he said, clinical studies of samples of cognitively impaired NFL retirees have failed to identify any unique clinical syndrome.

"There is currently no credible scientific evidence that there is any increased risk of any neurological disorder from playing professional football," Dr. Randolph told Medscape Medical News.

His own research does show that there may be an increased prevalence of late-life cognitive impairment in retired NFL players, but this may reflect diminished cerebral reserve rather than CTE. He advocates a conservative approach to interpreting pathologic findings of uncertain clinical significant in case reports, until further studies are carried out.

Dr. Cantu and his research colleagues at Boston University believe they have documented evidence of CTE in the brains of former players. And he thinks that people who don't think that CTE exists are "very wrong."

"I think it's very difficult for people who don't really study the disorder itself and microscopically understand it, who just read the literature and pick and choose what they want out of the literature, to be authoritative," Dr. Cantu told Medscape Medical News.

Such selective review can pull out "very flawed publications" that raise doubt about whether CTE is a separate issue from, say, AD, he said. "Yet if you're a neuropathologist and/or are familiar with looking at the neuropathology of CTE, you understand that it is black and white different from AD, although the symptoms are similar.

"Neuropsychologists looking at predominantly psychological literature can't distinguish CTE from AD or, for that matter, from frontal lobe dementia or other dementias," he adds."They're similar but the neuropathology isn't the same; they are very uniquely different."

Dr. Cantu cited the numerous articles his group has had published on CTE over the last several years, the most recent coming out only a few weeks ago in Neurology. "I don't think you publish all these cases and in multiple peer-reviewed journals if there's really any debate about the existence of it."

Dr. Tator, who has a PhD in neuropathology, agrees that the evidence for CTE "is certain." His team in Toronto has investigated the brains of 6 retired Canadian Football League players and found that half had CTE, which supports the Boston findings.

"We think that the line can be drawn between repeated concussions and brain degeneration of a variety of types, and CTE appears to be the most common one, but we don't know exactly how common it is."

CTE, said Dr. Diaz-Arrastia, has been recognized in boxers for at least half a century. "There's no question that CTE exists. We've known that it exists for 50 years in boxers; the new recognition is that it also exists in football players."

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