Steve James’ new concussion documentary overstates the evidence on head injuries in sports.
Still from Head Games © 2012 Head Games the Film LLC.
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Head Games, the new documentary from director Steve James (Hoop Dreams), begins on the sidelines of a football game at Near North Elementary in Chicago. It's a school for kids with special needs, mostly black and from poor families. The pint-sized players' coach barks out the story of David and Goliath: Your helmets are your rocks, he says, urging them to use their rocks to slay some giants. Ninety minutes later, we're at the last game of the season; Near North is down with seconds left to play. A score appears at the bottom of the screen: "David 28 / Goliath 35." Will the boys pull this one out?*
I bring up these scenes not because of what they say about the movie's theme—the apparent crisis of concussions in contact sports—but because of what they say about its method. The children’s struggle stands in for the team of underdogs at the center of the film, a scrappy crew of neurologists and advocates who are battling football’s businessmen and bureaucrats. But this nifty narrative deflects attention from some deeper facts. First, that the science of head trauma remains cloaked in anecdote, beset by suppositions, and hopelessly benighted when it comes to how to treat the problem. And second, that the panic over on-field head trauma has given rise to major business interests, some of which tie in to the movie's backers.
James starts his tale with Chris Nowinski, an ex-defensive lineman for Harvard's football team who spent some time as a pro wrestler and now helps run the Center for the Study of Traumatic Encephalopathy at Boston University. He's a natural showman, smart and charismatic, and we get to watch him re-enact a few of his greatest research moments. There he is in the library, poring over scientific papers and scrawling scary numbers in his notebook. He jots one down and then stares off into the distance. So much outrage in his eyes!
Another unlikely hero: the journalist who brought the dangers of concussions to a national audience. Acting on Nowinski's tip, the New York Times' Alan Schwarz linked the 2006 suicide of former Eagles defensive back Andre Waters to the buildup of tau proteins in his brain, a sign of repeated head trauma. The film paints Schwarz as a dogged, righteous nerd—we see the calculus books on his shelf—and savvy enough to call bullshit on the NFL's bogus science. "In a way, I was becoming the math teacher that I had always planned on being," he says of his early showdown with NFL commissioner Roger Goodell. He laid out for Goodell what it meant that the brains of four ex-NFL players had shown the signs of a rare, neurodegenerative disease. "All I wanted to do was get him to understand the probabilities at work here, that it wasn't just me being a pain in the ass. It was the fact that when you're four out of four, for a million-to-1 shot, something's up," he explains.
That's when another nerd might pause to ask a question: a million-to-1, really? A major obstacle for research on traumatic encephalopathy comes from the fact that no one knows its prevalence. The neurologists at BU have found signs of the disease in most of the brains they've studied, but it's still not clear how many other football players have it, nor what the rate is in the population at large. All that makes it very difficult to figure out how CTE affects mental health, or what else it means for sufferers. When Schwarz calls the disease a "million-to-1 shot," he's fudging.
No big deal, perhaps, but for the fact that concussion research is such a fudge factory from end to end. Does CTE lead to suicide, as the film repeatedly suggests? I don't think there's any reason to say it does. (Andre Waters, for example, suffered from many other risk factors: chronic pain, a protracted family dispute, and—most glaringly—chronic and untreated depression.) Does having one concussion make the next one more likely or more dangerous, as the film repeatedly suggests? Maybe, but the evidence isn't as strong as you might think; most comes from rodent work, and what we know from people suggests the added risk extends for about a week. Should people with concussions rest until their symptoms disappear, as the film repeatedly suggests? That's been the standard advice since the 1940s, but there's very little evidence to show it's more than superstition. The only real work to support the notion came out in June, with equivocal results. (Researchers found that a week of rest taken right after getting hit did as much good as a week taken several months later.)
Let's stick to this last point, since the idea that players should be barred from competition after getting dinged is seen as gospel by nearly everyone who appears in the film. It's the closest thing we have to a solid fact about concussion. It's also the central point of Concussions and Our Kids, the new book (out this week) from one of the major subjects of Head Games, BU professor and concussion expert Robert Cantu. "Rest is the hallmark of concussion therapy," Cantu writes. He advises parents and doctors to keep young athletes away from school for weeks or months, if necessary, after a nasty head injury. They should avoid all physical exertion and also mental overload—the kind associated with taking tests and reading books. They should also be prevented from using Facebook, sending text messages, and watching movies.
All that resting could be hurting more than it helps, however. A review published in the Journal of Head Trauma Rehabilitation this June points out that extended inactivity can cause depression, anxiety, headache, insomnia, and even balance problems, even in the absence of any head injury whatsoever. In other words, too much rest could itself produce the scary symptoms of "post-concussive syndrome." The authors of the review point out that "being sedentary after an injury or illness is one of the most consistent risk factors for chronic disability," and that the lasting symptoms of concussion (which affect a modest percentage of its sufferers) happen to overlap very neatly with the symptoms of depression. Could taking kids out of school or pro athletes off the field worsen their sadness and frustration?
Chalk that question up to nuance and uncertainty, concepts for which Head Games has only so much time. The film does great work to show how hard these issues can end up being for athletes and their parents, and Cantu, Nowinski, and Schwarz give some useful caveats about the science. But many of these warnings scurry past behind the wedge of anecdotes.
The long discussion of when and whether to pull a player from the game brings to mind another concern, one raised by concussion gadfly Irvin Muchnick. Blogging at length about the film's conflicts of interest, Muchnick notes that one of the film's executive producers, Steven Devick, devised a commercial tool for diagnosing the extent of head trauma on the sidelines. He also points out that Alan Schwarz, the film's avenging nerd reporter, is listed as an associate producer, and that Schwarz continued to work the concussions beat for the Times even after James began production.
Muchnick is also suspicious of the BU team for accepting a $1 million grant from the NFL in 2010. Robert Cantu, who does reveal on camera that he'd been drafted onto the NFL’s head, neck and spine committee, goes out of his way to praise the league commissioner in his new book. "Goodell exemplified how one person can have a huge impact on player safety if that person has the power and the will," he writes. And then: "Goodell is a doer, and at his direction the NFL has done a lot." And finally: "Goodell has a conscience, and that partly explains the pace of change."
All of these potential conflicts of interest were even more apparent in an earlier version of the film, one that was mistakenly sent to Slate by the firm that's handling publicity for Head Games. In a scene that was excised from the final cut of the documentary, there’s a lengthy product placement for the executive producer's concussion test. "We use the King-Devick test for removal from play," says the head athletic trainer at the University of Pennsylvania. "It's a quick sideline test that's completely objective." The unfinished cut also neglects to mention the $1 million grant to BU from the NFL.
I may be accused of denialism for harping on the flaws in Head Games while concussions maim and kill on the field. A study published earlier this month in Neurology revealed that ex-NFL players are dying from neurodegenerative disease about three times more often than matched controls in the general population. But the devil's in the details: Among the 3,439 people in the study, the expected rate of death from these conditions would be 0.1 percent; instead it turned up as 0.3 percent. That's a real effect and cause for concern. Still, the death rate across the study group was 9.7 percent overall, compared to an expected rate of 18.2 percent. In other words, the football players were about half as likely to have died from any cause as other people. Seen another way, the fact of their being ex-athletes was associated with some six or seven extra deaths from brain diseases like Alzheimer's, and 298 fewer deaths from all non-neurological causes. In terms of bodies in the ground, the benefits of playing football are more than 45 times greater than the risks.
That's no consolation for the players whose lives have been ruined by their head trauma, nor do we have the moral right to ignore the 0.3 percent whose disability might have been avoided. But the stats suggest that our obsession with concussions might be somewhat overblown. What of all the other lifelong risks that players face—the ones so obvious they rarely get a thought? I mean the chronic pain, twisted spines, steroid abuse, and opiate addiction that take their toll on so many athletes in contact sports. When Joe Theismann's leg snapped in half, an injury from which he says he never recovered, did any journalists announce they'd never watch the game again? Before we decide that concussions trump every other problem on the field, and start prescribing King-Devick tests to junior athletes across America, we ought to make sure we know what's going on. Head Games doesn't take that step. It hides more than it shows, and makes a cloudy story into something way too simple. At some point we'll have to learn that not everything can be David vs. Goliath.
Update, Sept. 22, 2012: This article has been modified in light of the fact that Slate was mistakenly sent an unfinished version of Head Games for review. In particular, a scene that showcases a concussion test devised by one of the film’s executive producers does not appear in the theatrical release, and the final cut of the documentary also acknowledges the NFL’s $1 million grant to Boston University. The text above was adjusted to reflect these facts after Slate received the theatrical version of the documentary.
Correction, Sept. 22, 2012: This article originally put the coach’s words “Your helmets are your rocks” in quotes. The exact phrase the coach used was “This your rock—your helmet.” (Return to the corrected sentence.)