American Football vs. Protecting our Brains.

Football season is over, Concussion is out of theaters, and most people are ready to forget about head injuries.

The big buzz word for the past few years (especially last year) has been CTE, or chronic traumatic encephalopathy.  It is a condition in which individuals who have experience repeated blows to the head develop an accumulation of Tau proteins.  This affects mood, emotions, and executive functions of the brain.  In other words.... if you hit your head over and over again, it can change your brain chemistry.  Later in life, this change can cause a rapid onset of symptoms similar to Alzheimer's disease.

Those somewhat familiar with the story might tell it like this.  "Mike Webster played enter for the Pittsburgh Steelers.  He was one of the greatest offensive lineman of all-time, and helped lead the Steelers to two Superbowl victories.  He was a hero in Pittsburgh, but shortly after retirement began a rapid downward spiral.  He suffered from severe dementia, and was homeless for years at the end of his life, despite having a network of former teammates offering him help.  After his death in 2002, Dr. Bennet Omalu and his colleagues diagnosed him with CTE following an autopsy. In the popular press, many now credit Omalu and his colleagues with discovering CTE (they were about 80 years too late to have been the discoverers).  This discovery suggested that repeated blows to the head during Webster's career, may have actually left him mentally disabled (this has been ruled to be the case in federal court).  This lead to the famous lawsuit where thousands of former NFL players sued the NFL claiming they were not properly educated on the risks of playing professional football.  The league agreed to $1 Billion settlement with the players and the details of that continue to be sorted out in the courts.  As part of the settlement, it was agreed that the league would not have to release any of their internal documents with regard to head injuries."

This narrative is inadequate in several key regards.

1. Football players suffering from CTE should not have been a surprise! - CTE was originally described in 1928 in the Journal of the American Medical Association by Dr. Martland, and was determined to be the cause of "punch drunkenness" in boxers.  Studies going back more than 20 years have suggested that "conditions similar to CTE may be present in athletes in other contact sports."

2. This has lead to reforms in football, but the reforms don't address what we know about CTE. - There have been changes to concussion protocols, but the most famous (or infamous) change to football rules have been rules meant to protect "defenseless receivers."  Essentially, the league made it illegal to lay a receiver out, who has no way to see the hit coming or protect himself/brace for the hit.  This was done out of fear for severe concussions.  They also moved kickoffs back to the 35 yard line so there would be fewer returns, and thus reducing the number of punishing blocks by the return team that result in concussions and other injuries to the kicking team.  This is good PR for the league, but some of the scariest data about CTE came after the league settled the lawsuit.  The PBS documentary team "Frontline" reported data from a study done by Boston University and the VA, in which the brains of 91 former NFL players were analyzed.  Of those 91 brains, 87 tested positive for CTE.  That is nearly 96%.  What is even scarier is that roughly 40% of those players were offensive linemen.  If you ever watch football, you know that offensive lineman bang heads with someone on just about every play.  You also know that they are not the high speed hard hitting impacts that "ring a player's bell" and get diagnosed as concussions.  What this suggests is that repeated sub-concussive blows are likely capable of causing CTE.  In other words, even if a player never experiences symptoms of a concussion, the player still may be causing permanent damage to his brain. Essentially, the league is containing the fires, but every player is still breathing the smoke.

3. This is not just a football problem and the leagues don't want you to know about it.  Roughly 20 years ago, a study was done comparing the cognitive function of soccer players and non-contact sport elite athletes.  The results of the study suggested that repeated "headers" could lead to long term neurologic impairment.  Two years later, an article published in the American Journal of Sports Medicine refuted this claim and in their own study showed that frequency of "headers" had no correlation with cognitive dysfunction.  Instead, they showed that cognitive function was only inversely correlated with acute head trauma (symptomatic concussions).  It is interesting to note, that this second paper, that essentially argues that "headers" are not dangerous was funded by the United States Soccer Federation.  I think it is totally appropriate for sport governing bodies to fund research that can help make their games safer, but it is totally inappropriate that no conflict of interest statement was given for this paper.  Moreover,  much can be inferred about the actual beliefs of the US Soccer Federation that this year, they made a rule against "headers" for players younger than 10 years old.  The NFL has recently been accused of funding research until it looks as though the results will not support their preferred narrative and then yanking funding.

4. This isn't just a problem for professionals.  It is easy to hear about athletes who spend 20-30 years of their life playing a sport like football having these problems and say "Well my kid isn't going to go pro, so I don't need to worry about this."  One might think this because they won't get hit as many times, or because in high school they don't hit as hard, but recent research suggests that even playing high school football may result in the accumulation of tau proteins associated with CTE. 

5. Head injuries are just one small part of the story of the risks of football.  We rightfully feel a strong attachment to our minds.  Our intact brains allow us to be who we are from an anatomical and physiological perspective, and the idea that a sport could cause its athletes to lose their minds is a frightening idea.  I won't go to deep into it here, but we are also concerned about staying alive.  I will only touch on it briefly in this article, but I was frustrated this year that during all the reporting of the number of deaths in football, that everyone seemed surprised.  In December, People magazine published an article titled, "Experts Alarmed Over 13 High School Football Deaths this Season."  The title implies that these experts are surprised, but if they are.... they are not experts in sports injuries.  According to the National Center for Catastrophic Sport Injury Research (NCCSIR), there were 16 total deaths attributed to football.  That is 3 more than this year.  Moreover, if you take the entire 84 year period for which they have data, there have been an average of 21.6 deaths due to football each year.   

I was a football fan up until this last season, and I even played high school football as a senior, but now when I see football on TV, I see 22 players on the field, and I see 21 that may get CTE.  These days I find it much tougher to cheer for a great block by a lineman, because I know that it is 1 of the 1400 head impacts he can expect to receive this season.  There is a lot that we do not know about CTE ( I address some of that below), but what is clear is that playing football makes an athlete less likely to remain cognitively intact, and more likely to die young.

Disclaimer: The results of the study showing that 96% of pro football players develop CTE likely overestimates the actual likelihood, because players and their families are probably more likely to donate their brains to research if they are worried about CTE.  Also, it is very difficult to know what exactly the risks are of long term sub-concussive blows to the head, because there are a number of confounding factors.  It is possible that these players have experienced concussions that they didn't recognize the symptoms of.  It is possible that players with many sub-concussive impacts are more prone to aggressive play and may also have had more symptomatic concussions.  It is also possible that there is a threshold effect, and that only blows to the head with sufficient impact may contribute to the development of CTE.