Having played an instrumental role in initiating changes to player safety in NFL, Dr Chris Nowinski speaks to Deborah Johnson about the urgency to ensure that is replicated elsewhere in the world.
Having experienced concussion during his career as a high-profile WWE wrestler, and been left shocked by the lack of awareness of the issue at all levels of sport, Dr Chris Nowinski is now leading the charge for change for head injury in sport around the world.
Since 2007, Dr Nowinski has pushed the boundaries of what had become accepted as ‘the norm’ in sport – that there was ‘glory’ in players getting up and carrying on despite head injury; that there was no accepted correlation between multiple head impacts and longer- term neurological consequences; that sport was not taking more responsibility in protecting its players – and is helping to redefine the life-changing issue of player safety.
And through the efforts of Dr Nowinski and his Concussion Legacy Foundation, significant change has taken effect in the United States, particularly in the National Football League (NFL), which was “embarrassed into action” through his 2006 book Head Games: Football’s Concussion Crisis.
The book, which also became a documentary, examined the long-term effects of head trauma among athletes, and was described by The Lancet as having “sent shockwaves through NFL”.
The Foundation was also instrumental in the creation of the world’s first Brain Bank dedicated to the study of Chronic Traumatic Encephalopathy (CTE), which has led to the long-held understanding of brain trauma being revolutionised.
Through its pioneering research, the VA-BU-CLF Brain Bank remains the most significant CTE resource in the world, which has discovered the first cases of CTE in athletes whose primary exposure was soccer, rugby, baseball, ice hockey, and college and high school football.
“In the US our understanding of concussion has changed completely. When I was injured, they were still putting people who had been knocked unconscious back into the game, saying they’re fine,” Dr Nowinski tells NR Times.
“Through advocacy, we started to change the discussion and show how unethical it was to put someone back into the game. We focused on NFL because if we get them to change, then everyone would change.
“There are now laws in every state which mean medical clearance must be given to players with concussion allowing them to return, we now tend to talk about concussion in the right way – in European soccer we see players being knocked unconscious, like we did in the recent UEFA tournament, but that doesn’t happen in the US anymore without a massive outcry.”
And while such an ‘outcry’ has not been widespread in sport elsewhere in the world until more recently, happily change is starting to take effect, with the UK now seeing action like never before.
Both football and rugby governing bodies are introducing new protocols, spurred into action by the many former players who have revealed devastating diagnoses of neurodegenerative illness.
Dr Nowinski and his team have worked closely with the Astle family, who are campaigning for change in memory of footballer Jeff Astle, whose memory continues through the Jeff Astle Foundation which is dedicated to raising awareness of brain injury in all sports and offers support to those affected.
The willingness of the many sports professionals and families who have played their part in lifting the lid on the reality of brain injury in sport is crucial in bringing about change in sport, even where there may be resistance, says Dr Nowinski.
“I am amazed at the courage of families who are saying their loved one has dementia, without the steady drum beat of such stories this could be swept under the carpet again,” says Dr Nowinski, a Harvard graduate who later gained a PhD in neuroscience.
“People think this problem doesn’t exist because we don’t see it, but families previously chose to keep it private as nothing positive had ever happened before through going public.
“If we continue to push the rock up the hill and continue to fight for change, it will happen. To change a culture, you have to know the culture.
“I don’t recall any recent players being knocked unconscious and being put back in saying ‘I shouldn’t have been put back in the game’ and that needs to happen – but there is bad leadership within the football community and players feel without protection.
“There are a lot of studies in the US linking head impacts to brain disease which are well-known, but people outside the US tend to ignore them. There is always a scientist who will say they’re not sure about the findings, or we don’t know if the changes we’re seeing are permanent.
“In the US, there are some very outspoken doctors who represent professional sports leagues and they focus on minor criticisms to justify inaction, rather than the clear solution of preventing the hits to head that cause brain injury.
“While these doctors do their best to have their patients’ best interests in mind, even the most ethical doctors will be influenced by their professional position, this can lead to tremendous conflicts of interest.
“I’ve had threatening letters from UK football teams. In the US, it took journalists outside of sport to be willing to offend, and very powerful newspapers who don’t care if their reporters have been threatened to lose access to the teams they cover.
“Professional sports leagues are incentivised to minimise the the risks of concussions and CTE as they pose risks to profits, and that has unfortunately also played out in the UK.”
While the recent findings of the Parliamentary inquiry into brain injury in sport – where it was noted that governing bodies are effectively ‘marking their own homework’ – are encouraging, says Dr Nowinski, action must be taken and lessons learned.
“The Government has a huge role to play and the most recent hearings are a good start,” he says.
“In 2009, things started to change in the US when the NFL were embarrassed into taking action through public Congressional hearings, and we realised if we continue in this direction, we can help to get the change we need.
“One of the important things we did was to explore how the NFL’s Mild TBI Committee was doing terrible research and we got that committee to be retired.
“This issue needs to be looked at independently – it’s a public health issue and we are still only scratching the surface.
“This isn’t just an issue of dementia, where people lose a few years off the end of their lives but they got to be a hero as a sports player – we’re not recognising the danger of this disease to people in early- and midlife, and that limits motivation for people to change.”
A vital place to start is in protecting players from the very start of their experience of sport – from childhood.
The Concussion Legacy Foundation adopts a stance in the US of encouraging parents not to expose their children to tackle football or any repetitive brain trauma, including heading in soccer, until the age of 14.
“We need to stop hitting children in the head,” says Dr Nowinski.
“We have young children playing sport by the same rules as adults and that’s insane. We should be focused on what is best for children, they need exercise, not hits to the head.
“The odds of developing CTE are associated with how many years someone has been playing, and the correlation is extraordinary. We find it in boxing, we find it in American football, and we’re going to find it with soccer and rugby.
“If we want to eliminate CTE in sports, then we need to reduce the number of years when they’re experiencing repeated head impacts as children. It is not the time when they’re an adult and they’re being paid to play.
“If we reduce exposure among children, we can make it less likely they will get CTE. Right now, we assume we will only get better at dangerous activities by practicing those activities. That model, though well intended, is a mistake.
“The faster we act, and it’s very urgent we do that, the less we will see what is happening today in the next generation of sports people.”
Another important area is how concussion is portrayed in the forum where most people consume sport – via the media.
The creation of the Concussion Legacy Foundation’s Media Project has helped to change the language used around head injury in sport, and in turn the perception of millions of viewers, particularly among the younger generation.
“We have established the CLF Media Project in the US, which we’re now working on in the UK, we’ve done some work with professional journalists as well as students at university,” says Dr Nowinski.
“It’s very hard to reach a lot of people on this issue, and their understanding of concussion comes from watching sport on TV.
“This is an important moment in time. A few years back, the US media were still glorifying players playing through concussion, they weren’t using the word ‘concussion’ and broadcasters were pretending nothing was happening.
“We wanted to help them with the terminology that can describe what is happening without being seen to diagnose anything. In the UK and Europe, we see players playing through concussion, like in the recent UEFA tournament, and we don’t want these poor examples to parents and coaches to manifest into poor concussion care for children because the inappropriate medical care isn’t being criticised.
“There can be a backlash against commentators because television is a business like football, but we hope to give broadcasters the tools they need to cover concussion right.”
But underpinning the change is the research, which continues to be fundamental in greater understanding of, and action around, brain injury in sport.
Following the huge advances effected by the creation of the VA-BU-CLF Brain Bank, collaborations have since followed with the University of Sydney, which has collected 30 donated brains in the past three years, and the University of Auckland has just received its first donation.
And the pioneering impact is now coming to the UK with the creation of the Concussion Legacy Foundation UK led by Dr. Adam White of Oxford Brookes University, and a Brain Bank led by Dr. Gabriele DeLuca of Oxford University.
Dr. White recently completed a research project into athletes and caregivers’ experiences of CTE, working alongside the Concussion Legacy Foundation and Boston University CTE Centre.
The UK Brain Bank’s launch is accompanied by a 24-hour outreach hotline, education and peer support mentors and groups, with people also being connected with medics and clinics.
“When we first started the Foundation, goal number one was to start a Brain Bank,” says Dr Nowinski.
“Part of the reason concussion and brain trauma has been under the radar for so long is that there hasn’t been visual proof of damage. Without pathology, we can’t get this evidence.
“We want to create undeniable proof and show this unique disease under the microscope and show how it is destroying the lives of athletes now.
“We want the whole world to be working on this, the best scientists in the world, and we need this to be across the world if we want to have hope for treatment in our lifetime.”
